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Re: active management of the placenta or third stage From: Barbara Nicol MD (blnicol@ix.netcom.com) Thu Mar 16 10:28:17 2006 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: igold@cox.net: "GBS testing for repeat ceserean" Previous message: Anna Meenan, MD: "Re: Informed Refusal - VBAC" In reply to: Jamie: "Re: active management of the placenta or third stage" Next in thread: Raymond Stephen: "Re: active management of the placenta or third stage" Check the Cochrane database. There are at least 3 well done RCTs on this issue. This makes it one of the relatively few interventions that we actually _know for sure_ does something positive. Decreased blood loss, no increase in retained placenta. (The "increased retained placenta" thing is a good example of something we know that ain't so, at least if you avoid ergot alkaloids. It's a traditional obstetric teaching - an old doc's tale, if you will, not very well supported by the evidence.) However, you must be certain of fetal number! If the patient hasn't had an ultrasound (rare these days) I wouldn't recommend giving oxytocin until you are sure that there isn't a second twin. Otherwise, I recommend it for every patient around the interval from the last baby's anterior shoulder to cord clamping, depending on logistics (there's a lot going on in those moments <g>). Your mention of immediate breastfeeding brings to vivid recollection a birth I did during residency. All was going along swimmingly until there was a mild PPH which I was managing with massage and oxytocin, with a slow initial response, though I could feel a gradual increase in tone. Suddenly, grandma, who'd been a traditional midwife in her home country, and who spoke no language in common with me or the RN, charged over and began doing extremely vigorous and painful nipple-stim. (Let's just say: 720 degrees. YOW!) It was nearly impossible to stop her, and very difficult to explain that we were trying to get the baby to latch and that we had other, less painful, means of getting oxytocin going and stopping the PPH, especially as the patient, the only one present who could speak grandma's language, was screaming too much from the nipple-stim to translate our attempted calming explanations. Take home message for me: traditional midwifery can be more uncomfortable than current obstetric care - though I admired grandma's willingness to step in and help out with the PPH! (Everyone eventually settled down and did fine, and we saved grandma's face with the patient by explaining the potential role of nipple-stim in PPH when you don't have other uterotonics available.) - Barb t Thu, 16 Mar 2006, Jamie wrote: > >I've been looking for the study showing active management decreases risk >of PPH and can't find it, though I've seen the info quoted everywhere. >Did it compare active management to immediate cord clamping and pitocin >given after the placenta, to immediate clamping and pitocin not given at >all, or to delayed clamping (with or without immediate breastfeeding)? > >At Thu, 16 Mar 2006, Raymond Stephen wrote: >> >>In theory oxytocics given after delivery have a slightly higher >>incidence of PPH, but whether you give it with crowning, with the >>anterior shoulder, or after delivery, the clinical difference is >>minimal. The later it is, the more PPH there is, but, the earlier, the >>more retained placentae, so you pays your money, you takes your choice. >>Personally, I like it given with the anterior shoulder, but our midwives >>are very relaxed about it and it rarely happens that way. >> >>Steve >> >>-----Original Message----- >>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of S >>Osterling M.D. >>Sent: Thursday, 16 March 2006 2:57 PM >>To: Multiple recipients of list OB-GYN-L >>Subject: active management of the placenta or third stage >> >>here's a link to a family practice article about active management of >>the third stage of labor. >> >>it recommends: >> >>oxytocin IV at delivery of anterior shoulder rapid cord clamp traction >>on the cord >> >>I am one of the few docs at my hospital that gives oxytocin after the >>baby is out. >> >>What do the rest of you think? >> >>http://www.aafp.org/afp/20060315/1025.html >> >>S. Osterling M.D. >>California > >-- >JFields, RN, BSN > -- Barbara Nicol MD St. Luke's Health Care Center San Francisco CA USA Next message: igold@cox.net: "GBS testing for repeat ceserean" Previous message: Anna Meenan, MD: "Re: Informed Refusal - VBAC" In reply to: Jamie: "Re: active management of the placenta or third stage" Next in thread: Raymond Stephen: "Re: active management of the placenta or third stage"

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