pitocin to induce placenta delivery?

alath wrote:
I never used to use prophylactic pitocin in the 3rd stage, but recently
more evidence has emerged that it appears to be beneficial and I
started doing so for all patients who already have IV's. I realize this
is not systematic, but I have been impressed with the shorter duration
of second stage and especially the reduced maternal blood loss. In my
experience the difference has been quite dramatic. In many of my
deliveries now, I am seeing essentially no bleeding at all.

There is another Cochrane review underway now, with the somewhat
broader scope of "active versus expectant management of 3rd stage" -
active management encompassing medications, fundal massage, and/or cord
traction. I will be interested to see these results.

I do not consider the evidence completely established on this issue,
but it is definitely worth looking at when one considers that
postpartum hemorrhage accounts for a large portion of all maternal
morbidity and mortality.

What's your sense of what the difference might be
between routine immediate use of pitocin and some sort of
compromise like liberal use when things aren't moving along
smartly? From everything I've read, it seems like routine
use does have better outcomes than not using it, but I
don't recall having seen much that looks at liberal vs.
conservative use or something like that.
From just my individual experience, I had very
short 3rd stages and very little blood loss all three
times, so I sort of wonder why I should have been jabbed
(no IV in place) for what obviously wasn't a problem for
me. Still, I don't know if there's a way to easily
separate out the clearly-don't-need-it folks from the
wish-we'd-given-it-to-them folks before undesirable
consequences have already happened.

Best wishes,
Ericka

I never used to use prophylactic pitocin in the 3rd stage, but recently
more evidence has emerged that it appears to be beneficial and I
started doing so for all patients who already have IV's. I realize this
is not systematic, but I have been impressed with the shorter duration
of second stage and especially the reduced maternal blood loss. In my
experience the difference has been quite dramatic. In many of my
deliveries now, I am seeing essentially no bleeding at all.

sometimes, alath, I wish you were my OB! It seems like you actually think
about things, which isn't always true! Where is it that you practice?

What is your opinion on ergometrine?

What implications does this have on the timing of cutting the cord?

From the maternal point of view, why do you want to shorten the 3rd stage (I
hope 2nd stage was a typo), that time after delivery, where the baby is
stuck on your tummy and no one can take them away as they are still
attached, is very precious! I can see once you are getting over half an hour
you might be getting fidgity, but before that, I'd have been annoyed that it
had been speeded up (FWIW, 23 min 3rd stage, 250ml blood loss).

It would be also interesting to see what the results were when breastfeeding
was initiated at that time, the problem is that it is difficult to say what
really happened, I bet anyone watching thought I'd initiated breastfeeding
at this stage, I tried, she opened her mouth over my nipple, but didn't
suck, so there probably was no stimulation and relase of oxytocin.

Cheers

Anne

From just my individual experience, I had very
short 3rd stages and very little blood loss all three
times, so I sort of wonder why I should have been jabbed
(no IV in place) for what obviously wasn't a problem for
me.

well what alath is suggesting is that he wouldn't have given it to you as
you didn't have an IV in place, he admits that is not very systemic, but if
there is minimal side effect and no unpleasantness (IV inserted, or IM
injection), it doesn't seem a particularly bad protocol, though I hope he is
telling women what he is doing. I haven't found the answer for sure, but it
seems a lot of the risks we are told about in the UK are due to the
ergometrine componenent, I've got a real downer on using ergometrine
automatically, it's such an unpleasant drug, my decisions on natural 3rd
stages were based on the administration of this and it turns out that all
the negatives were due to this and not the syntocinon component, I think I'd
accept syntocinon alone if I had an IV in, which as it happens means my
unpleasant managed 3rd stage would have been the managed one, IV was in
syntocinon was going into it, but they still insisted on the syntometrine
jab and my 2nd would have been as it was, as the IV had fallen out!

I'm going to look into this ergometrine thingy, can't see why thousands of
women in the UK are suffering unpleasant side effects, hundreds are going to
theatre for retained placenta, when syntocinon alone seems to have just as
good a result.

Cheers

Anne

Anne Rogers wrote:
From just my individual experience, I had very
short 3rd stages and very little blood loss all three
times, so I sort of wonder why I should have been jabbed
(no IV in place) for what obviously wasn't a problem for
me.

well what alath is suggesting is that he wouldn't have given it to you as
you didn't have an IV in place, he admits that is not very systemic, but if
there is minimal side effect and no unpleasantness (IV inserted, or IM
injection), it doesn't seem a particularly bad protocol, though I hope he is
telling women what he is doing.

But as he says, that's rather a sample of convenience.
If, in fact, pitocin is good for everyone, then presumably once
there was real evidence to support that, one would seriously
consider it for everyone, IV or no. My question was whether
there was known to be a group that clearly *didn't* need it,
even if it was beneficial to most, and whether that group
could be accurately distinguished by some criteria.

Best wishes,
Ericka

But as he says, that's rather a sample of convenience.
If, in fact, pitocin is good for everyone, then presumably once
there was real evidence to support that, one would seriously
consider it for everyone, IV or no. My question was whether
there was known to be a group that clearly *didn't* need it,
even if it was beneficial to most, and whether that group
could be accurately distinguished by some criteria.

oh, I see what you mean, trying to pick out the women that are at risk of
PPH in advance, I'm sure there are some risk factors, unlike shoulder
dystocia, which has pretty clearly been shown to be almost entirely
unpredictable (http://www.shoulderdystociainfo.com, though there is a new
predictor this year, which is showing very good results, this is a badly
structured webpage to read through, but is very thorough in it's coverage of
SD), but PPH also seems to be something that strikes fairly randomly.

There is also a line where bleeding might technically be a PPH, but not
require further intervention, but be enough to make you feel grotty, I feel
rough giving a pint of blood, with the increased blood volume in pregnancy,
I didn't notice any effects from losing the same amount in childbirth, but
there must be a point somewhere where you can end up feeling grotty, but it
not having been a problem otherwise.

I think when it comes to third stage, it's always going to be a choice
issue, but to me this line that alath has drawn seems quite sensible, give
it if it easy to give, it appears to be benefical, otherwise practice
expectant management. I couldn't draw out a factor from the study alath
mentioned, but the figure generally thrown around in the UK is syntometrine
decreases risk of PPH 20 fold, and I think, but am less sure about this
figure, increases the risk of retained placenta 7 fold, now to me that isn't
a very good trade off, particularly when you add in being violently sick.
I'm content with the "risk" of going without that, so clearly I'd be content
with the risk of going without pitocin alone, but on the other hand, if I
knew I could reduce the risk of PPH 20 fold without the other side effect,
then if it was an easy thing to do, I'd do it, whether that be giving
pitocin through an IV that was already sited, or clamping my hands 7 times
in some kind of wierd ritual, but it were something difficult to do like
standing on my head or having an IV inserted for no other reason, then I
wouldn't, which isn't at all scientific reasoning.

I suppose the one other thing it would be good to have research on would be
how this effects breastfeeding rates and PPD rates.

Anne

If, in fact, pitocin is good for everyone, then presumably once
there was real evidence to support that, one would seriously
consider it for everyone, IV or no.

We're in a funny place now where the evidence is emerging, and a fair
read on the direction of the evidence is possible, but not all the
evidence is in yet. At this stage, I think there is enough evidence to
administer prophylactic pitocin in the third stage, but I don't know if
the benefit is great enough to justify placing an IV in a patient who
doesn't already have one.

There are occasional adverse outcomes with IV's, though very rare. It's
a judgement call. If further research demonstrates a large effect size,
enough to justify IV's for people who otherwise wouldn't need them,
then I guess I'll be advising those folks to get IV's.

Anne alluded to "I hope he's explaining this" - and I have to admit not
to everybody. If I had a patient who had a birth plan and expressed
generally strong opinions about care practices, I would. But, frankly,
most patients really don't care. When I first graduated from school I
had been strongly indoctrinated with the need to explain the pros and
cons of every single decision. Feedback from patients has made it clear
that the vast majority are not interested in clinical minutae and are
quite often distrubed when presented with 500 options at every step.
The trick lies not in explaining every single detail to every single
patient, but rather, in finding out which decisions are particularly
meaningful to which patients and eliciting their participation in
those. Once in a blue moon I will have a patient who has the level of
interest and concern that is common on this board. It's fun to have
patients like that every once in a while and I certainly try to
accommodate them when I run into them, but you guys should know that
you are real outliers - somewhere in the 97+%tile by my experience.

"alath" wrote and I snipped:
Anne alluded to "I hope he's explaining this" - and I have to admit not
to everybody. If I had a patient who had a birth plan and expressed
generally strong opinions about care practices, I would. But, frankly,
most patients really don't care. When I first graduated from school I
had been strongly indoctrinated with the need to explain the pros and
cons of every single decision. Feedback from patients has made it clear
that the vast majority are not interested in clinical minutae and are
quite often distrubed when presented with 500 options at every step.
The trick lies not in explaining every single detail to every single
patient, but rather, in finding out which decisions are particularly
meaningful to which patients and eliciting their participation in
those. Once in a blue moon I will have a patient who has the level of
interest and concern that is common on this board. It's fun to have
patients like that every once in a while and I certainly try to
accommodate them when I run into them, but you guys should know that
you are real outliers - somewhere in the 97+%tile by my experience.

It's very interesting to hear a doctor's perspective on this. I wonder if
you or anyone else has suggestions for how to clue in a doctor (of any
specialty) who isn't sensitive enough to figure out that a patient is one of
those outliers. I don't want to be treated as if I'm not interested in the
options. Sometimes I get doctors who explain everything, which I love.
More often I get docs who don't. I can't seem to tell if they prefer it
that way or if they're just treating me the way they've learned that most
(vast majority of?) patients want to be treated.

Thanks,
-Patty, mom of 1+2

Anne alluded to "I hope he's explaining this" - and I have to admit not
to everybody. If I had a patient who had a birth plan and expressed
generally strong opinions about care practices, I would. But, frankly,
most patients really don't care. When I first graduated from school I
had been strongly indoctrinated with the need to explain the pros and
cons of every single decision. Feedback from patients has made it clear
that the vast majority are not interested in clinical minutae and are
quite often distrubed when presented with 500 options at every step.
The trick lies not in explaining every single detail to every single
patient, but rather, in finding out which decisions are particularly
meaningful to which patients and eliciting their participation in
those. Once in a blue moon I will have a patient who has the level of
interest and concern that is common on this board. It's fun to have
patients like that every once in a while and I certainly try to
accommodate them when I run into them, but you guys should know that
you are real outliers - somewhere in the 97+%tile by my experience.

perhaps I'm odd, but if I have an IV in and drugs are going into it, I want
to know exactly what, not just "here's something for the pain and something
for the sickness", which is usually what nurses say and I guess it makes
sense, if the nurse came along and said, here's x mg of buscopan and y mg of
metoclopramide, how many people would know that was the same thing? I wish
when I'd been under a general anaethsetic the anaethetist would hand me a
list of what went in whilst I was under!

If I have another baby and if as we currently expect, it's by c-section I'll
want an explaination every step of the way, being honest here, I'd be liable
to panic otherwise, I'll warn people in advance though.

Anne

PattyMomVA wrote:
"alath" wrote and I snipped:
Anne alluded to "I hope he's explaining this" - and I have to admit not
to everybody. If I had a patient who had a birth plan and expressed
generally strong opinions about care practices, I would. But, frankly,
most patients really don't care. When I first graduated from school I
had been strongly indoctrinated with the need to explain the pros and
cons of every single decision. Feedback from patients has made it clear
that the vast majority are not interested in clinical minutae and are
quite often distrubed when presented with 500 options at every step.
The trick lies not in explaining every single detail to every single
patient, but rather, in finding out which decisions are particularly
meaningful to which patients and eliciting their participation in
those. Once in a blue moon I will have a patient who has the level of
interest and concern that is common on this board. It's fun to have
patients like that every once in a while and I certainly try to
accommodate them when I run into them, but you guys should know that
you are real outliers - somewhere in the 97+%tile by my experience.

It's very interesting to hear a doctor's perspective on this. I wonder if
you or anyone else has suggestions for how to clue in a doctor (of any
specialty) who isn't sensitive enough to figure out that a patient is one of
those outliers. I don't want to be treated as if I'm not interested in the
options. Sometimes I get doctors who explain everything, which I love.
More often I get docs who don't. I can't seem to tell if they prefer it
that way or if they're just treating me the way they've learned that most
(vast majority of?) patients want to be treated.

We got lucky with both the OB and the chief neonatalogist who treated
A. Perhaps because the OB knew we'd come from a homebirth, she did take
the time to tell me everything she was doing, which is why I'm sure I
wasn't jabbed without my knowledge (and post birth I would have
noticed). Also, my midwife was following everything very closely and
explaining the details if I missed any. Tho things were in emergency
mode, the OB still managed to tell me what was going on - and spent a
great deal of time with me the next 2 days going over it all.

The chief neonatalogist was excellent in that regard, in that he
explained all the minutiae of A's care. However, he had also taken the
time to read the charts about *us* and knew we were scientists, myself
in health (he also made a point to always call me "Dr" which was nice
tho I told him first names were fine), so knowing we understood more
than the avg joe - and likely wanted to know more, he didn't hesitate
to go into detail. Some of the nurses did the same (all knew about the
homebirth, but only a few knew our backgrounds) and were quite
responsive to our questions. Others just acted perturbed and put on the
superior attitude.

"alath" wrote:
Once in a blue moon I will have a patient who has the level of
interest and concern that is common on this board. It's fun to have
patients like that every once in a while and I certainly try to
accommodate them when I run into them, but you guys should know that
you are real outliers - somewhere in the 97+%tile by my experience.

Yup, right on the money.

And it would be a real drag to have all your patients be like us;
explaining
things in detail takes a lot of time and is hard mental work too. On
the
other hand, perhaps many of us already know so much that you would be
able to skip most of the routine discussion your "normal" patients
require.


PattyMomVA wrote:

It's very interesting to hear a doctor's perspective on this. I wonder if
you or anyone else has suggestions for how to clue in a doctor (of any
specialty) who isn't sensitive enough to figure out that a patient is one of
those outliers.

I am so far off the scale that physicians who do see a lot of
want-to-know
outlier type patients tell me *I* am an extreme case in their
experience.
But I already know that about myself. I simply tell the physician I
want to
know the details. I'd like copies of relevant technical papers,
please. I'd
like copies of my reports as we go along, not years later. Often,
they'll
want to talk about my "control issues" (never mind their own, eh?). I
say
I know I'm a control freak but I have it under control,
thankyouverymuch.
And knowing more gives me confidence. I am capable of thinking of all
manner of extremely bad outcomes. So, the more information I have, the
more bad outcomes I can rule out and the calmer and more cooperative
I am. I tell physicians this. If this disturbs them, I find another
physician.

I had a crisis of confidence last week when the neonatal surgeon I
chose
months ago to remove my baby's tumor a few weeks from now, was not
prepared to answer my technical questions with much more than generic
reassurances. I don't want to be told you're the best there is and
you'll
do your best. I don't even require that you be the best! I do require
that
you *show* me you are good at what you do. Your knowledge of a topic
you should know all about, and your willingness and ability to explain
very
technical details, are important to me. I cannot distinguish unwilling
from
unable to explain, but a surgeon unable to explain what they do, and
why,
probably is not competent. So I absolutely require a surgeon who will
at
least try to explain, try again and again if necessary, until I
understand.

After several followup phonecalls with the surgeon, including a long
one
on Labor Day, we finally managed to communicate. The surgeon (poor
thing) did resort to saying "you just have to trust me", but in the end
was
able to answer all my questions fully. I think we both saw the problem
was that we had too little technical vocabulary in common, which made
communication slow and difficult. I found it helped to give a lot of
"this
is where I'm coming from", and "according to such and such" background
information. That showed the surgeon some holes in my information,
holes which I had not seen for myself. Filling those holes helped me
to
understand why the surgeon could not answer some of my questions,
and at the same time enabled me to answer those questions myself.

Know what I mean? (Ha ha.)