I’ve written in other pieces about physiological vs managed third stage of labour. This piece will look at the drugs used for a managed third stage and when syntocinon or syntometrine is preferable for routine third stage use (i.e. used to prevent rather than to treat post-partum haemorrhage).
Approximately 99.5% of women birthing in Irish maternity units will receive a drug for the third stage of labour. This is where the placenta is delivered, following the birth of the baby. An actively managed third stage is a two-step process usually. Firstly, a drug is given via injection into the woman’s thigh, causing the uterus to contract, helping the placenta to peel away and reducing the risk of a post-partum haemorrhage. The second step of the process is controlled cord traction – the midwife checks that the placenta has separated and gently draws it out of the uterus.
The drug that is given via injection is an oxytocic-drug – it contains a synthetic version of the hormone oxytocin. Currently, our maternity units in Ireland use one of two drugs routinely – syntocinon or syntometrine. Syntocinon is synthetic oxytocin and often referred to simply as oxytocin. Syntometrine contains both syntocinon and another drug called ergometrine. But which is better?
Irish clinical practice guidelines for the prevention and management of primary post partum haemorrhage (written in 2012, you can access the document here), recommend that syntocinon be used routinely, and given intramuscularly (IM). They cite the research of Cecily Begley from Trinity College who, in a review of 5 trials involving 6,477, found that active management of the third stage was associated with an increased incidence of nausea, vomiting and raised blood pressure. These side effects are usually related to the use of ergometrine containing uterotonic agents, of which syntometrine is one.
Another review found that, while syntometrine was not more efficacious than syntocinon at preventing post partum haemhorrage of greater than 1000ml, it carried a five-fold increased risk of unpleasant side effects such as nausea and vomiting and elevation of blood pressure. It’s therefore contraindicated in women with already elevated blood pressure.
Older research by Cecily Begley showed a correlation between the use of ergometrine and shortened duration of breastfeeding, but recent reserach shows this correlation also exists when syntocinon is used. Ergometrine is also known to suppress lactation, although it seems that this is a risk associated with repeated rather than single use.
Listed below are the maternity units still using syntometrine. If you are booked into one of these units and would prefer to have syntocinon for third stage management (if you are planning a managed third stage or should one become necessary), then you will need to include a birth preference to state this.
- National Maternity Hospital, Holles Street
- Waterford General Hospital
- Limerick General Hospital
- Midland’s General Hospital, Mullingar
- Sligo General Hospital
- Letterkenny General Hospital
- Tipperary General Hospital
HSE guidelines for prevention and management of post partum haemorrhage: https://www.hse.ie/eng/about/Who/clinical/natclinprog/obsandgynaeprogramme/postpartumhaem.pdf
Cochrane review on active versus expectation management for the third stage of labour: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4026059/
Active management of the third stage of labour may reduce breastfeeding duration: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4026059/
Third stage of labour: http://birthtobaby.ie/why-the-third-stage-of-labour-should-be-more-than-an-afterthought/