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Articles, Birth preferences, Third stage of labour

Syntocinon or syntometrine?

Posted on September 9, 2016 at 2:01 pm by / 0

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

 

Further reading:

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/

 

 

 

 

 

 

 

 

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Birth preferences, Birth Stories, First baby, GentleBirth workshop, Rotunda

A wonderful birth experience in the Rotunda

Posted on April 24, 2016 at 4:53 pm by / 0

I just wanted to let you know that our GentleBirth baby arrived on 12th April (2 days after due date given to me by hosp)! It was a really wonderful experience, I went into labour Monday night around 9.30pm and did some ironing, watched a movie, listened to my tracks and used the TENs machine. We went to the Rotunda at 7am Tuesday morning (my surges were pretty strong and every 3 mins at this stage and I felt I needed a bit of help).

 

Got to the hospital and was 3cm so went to the labour ward, we had a wonderful midwife Shauna who left me alone but was there if I needed her, I just breathed my way through the next few hours and used my affirmations (My body can do this/My baby is the right size for my body etc) and my husband was a star- reaffirming same and putting cold facecloth on my head! My waters broke spontaneously around 11am and at 1.05pm with no intervention, not even gas and air, little James entered our world and took our breath away!! All 7lb 13oz of him! I honestly don’t think I would have had such a positive birthing experience if it hadn’t been for the Gentlebirth workshop and tracks. Even now as I try and establish breastfeeding and how to look after a newborn I find myself calm and using the gentlebirth mantra! My husband agrees that it was such a worth while exercise doing it too!

 

Elaine and Michael

 

Read more fantastic GentleBirth stories here.

To book your GentleBirth workshop with Melanie from BirthToBaby.ie, visit www.gentlebirth.com/melaniemcardle.

Limited space so early booking is advised!

Download the GentleBirth app today – there is a free week of full access when you register.  https://www.gentlebirth.com/
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Articles, Birth preferences, First baby, GentleBirth workshop, Placenta, Third stage of labour

Why the third stage of labour should be more than an afterthought

Posted on January 27, 2015 at 6:55 pm by / 0

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How many of us spend time considering birth preferences for the third stage of labour ? Very few, and yet what happens between the birth of baby and the expulsion of the placenta can have a significant impact on our birth experience.  During the third stage of labour, the placenta separates from the uterine wall and the uterus contracts to expel it. As the placenta separates, there is some bleeding from the area of the uterus where it was sited. The amount of bleeding varies from woman to woman – blood loss greater than 500ml is considered a post partum haemhorrage.

Currently, the policy in all Irish maternity units is to carry out a managed third stage of labour. This involves giving an intramuscular injection, of either syntocinon or syntometrine, into the thigh.  Many women will not even know they’ve had this – they are so engrossed in their newborn that it doesn’t even register. Once the injection has been given, a strong surge usually follows and the placenta is often expelled quickly. Your midwife will feel the uterus to see if the placenta is separating from the wall of the uterus and may use what is called controlled cord traction (pulling the placenta out) to hurry the process along, or may encourage you to push it out.  If you have a managed third stage, your risk of  a post partum haemhorrage (PPH)  is reduced.

The alternative is to have a physiological third stage.  The placenta is left to separate itself, without drugs to speed up the process. It should be expelled using maternal effort, rather than being pulled out. Although a managed third stage is recommended based on current research which shows it lowers the risk of PPH, a study comparing physiological third stages in settings that do not fully support that mode of birth and settings that do is not available. It has been observed by midwives that women who have a physiological third stage may bleed more immediately after birth but then bleed less post partum than those who have a managed third stage, but this is anecdotal rather than backed by evidence.

The vast majority of women will have a managed third  stage, as part of the standard package of hospital based maternity care. In a home birth setting, most women will have a physiological third stage and have no problems with blood loss. In the midwifery led units (MLUs), physiological third stages are far from unusual. But how can you decide what is right for you?

Dr. Sarah J. Buckley believes that we should resist intervening in the third stage of labour, if all has been well up to that point.  The birth process is driven by hormone interactions which, when disturbed by some routine hospital procedures, can have negative consequences for mothers and babies. The drug given in the third stage of labour is an oxytocic drug – it is a synthetic version of the naturally occurring oxytocin in our bodies, which is at its highest level just after the birth of our babies.  Oxytocin is released as we gaze at and touch our wondrous newborn, and yet more is released if baby makes her way to the breast and nuzzles and latches on. The levels peak around the time that the placenta is expelled. So if our body already has everything it needs to do the job, why do we need an injection to help?

Midwife Rachel Reed, author of the Midwife Thinking blog, explains here why the hospital environment is not always conducive to a physiological third stage of birth.  Many women arrive at the third stage after having interventions along the way – birth has not been physiological up to that point. Furthermore, the third stage of labour is a time when mother and baby should be left undisturbed, to get to know each other. Uninterrupted skin-to-skin should be facilitated, to allow oxytocin levels to reach their natural peak – no weighing or other checks that separate mother and baby should be carried out. There can also sometimes be fear in the room if staff are not used to facilitating a physiological third stage – this stress, and the time pressure (sometimes hospitals will put a limit of 1 hour on a physiological third stage) can cause adrenaline release in the mother, which can suppress oxytocin release. My own experience, as a doula in Irish hospitals, is that some staff can become nervous as the hour approaches and the mother begins to feel pressure to perform and produce the placenta – not the ideal environment.

So if a managed third stage means less chance of a post-partum haemhorrage, why would you consider a physiological third stage?  Well, a recent study suggests that breastfeeding duration may be affected by administration of drugs for the third stage of labour.  Women who had had oxytocic drugs for the third stage of labour were significantly less likely to be breastfeeding at 2 and 6 weeks and were more likely to have stopped due to pain or difficulty breastfeeding.  More research is needed to examine why this might be the case.

Another risk is that after the administration of the drug, the uterus may clamp down and start to close, trapping the separated placenta inside. This is why controlled cord traction is used, to help the placenta be expelled quickly. If the placenta is trapped inside, it will need to be removed manually in theatre.

Some women can feel sick, dizzy and too unwell to hold their babies after administration of the third stage drug. This is generally due to syntometrine rather than syntocinon being used. Syntometrine is a combination of syntocinon and another drug called ergometrine, and while effective at preventing haemhorrages, it somes with a list of unpleasant side effects. For this reason, Irish Obstetric Guidelines for preventing PPH recommend that syntocinon be used routinely, where the woman is not at increased risk of PPH. It is worth noting that the manufacturer instructions for syntometrine state that it can “inhibit prolactin secretion and in turn suppress lactation”.  If you are attending a maternity unit where syntometrine is used routinely (Waterford and National Maternity Hospital being two), then you may want to have a birth preference that requests syntocinon, should you be planning a managed third stage or in case it becomes necessary.


If you have had a physiological or minimal intervention birth up to the third stage, then you may feel it makes sense to try for a physiological third stage.  GentleBirth women often have confidence that their body, which has grown their baby from two cells and then launched it into the world with no conscious effort on their part, can finish the job on its own.  The injection can be drawn up and ready to go, in the event that you begin to experience significant blood loss. This lovely article describes facilitating a relaxed third stage of labour. Midwives in Irish hospitals are thankfully now becoming more familiar with physiological third stage, as more women are deciding that this is the best option for them and their baby.  As suggested in the article, maintain the ‘mood’ in the room, whether you birth at home or hospital. Leave phonecalls and texts until after the birth of the placenta. Stay together with your birth partner and supporters and marvel at the new being who has just come into your life. Examine your baby’s face, those teeny fingers and toes. Let baby crawl to your breast and familiarise herself with the new territory. Forget the clock – as long as there is no significant blood loss, the third stage of labour should not be time-limited.  If there is a delay, getting into an upright position such as on the toilet can encourage the placenta to plop out. Most women will deliver their placenta within the first hour after birth, that magical period when you are getting to know the new and wonderful person you have brought safely into the world.

As with all birth preferences, there is no right or wrong answer. Being informed and having decision-making tools will mean that you can make the best possible choice for you on the day.

Further reading
Dr Sarah J Buckley on third stage physiology: http://www.birthspirit.co.nz/leaving-well-alone-third-stage-labour/
Midwife Rachel Reed discusses why a managed third stage may be the best option: http://midwifethinking.com/2012/05/05/an-actively-managed-placental-birth-might-be-the-best-option-for-most-women/
Gloria LeMay on the 30 minute third stage: http://www.glorialemay.com/blog/?p=161
How the placenta grows, functions and is birthed: http://42weeks.ie/2013/08/28/the-mysterious-placenta-and-the-third-stage-of-labour/

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Birth Stories, First baby, GentleBirth workshop, Pregnancy after miscarriage, Rotunda, Third stage of labour

Amazing first birth in the Rotunda

Posted on August 3, 2014 at 12:06 pm by / 1 Comment

Cleo, my first baby, was born on 23rd February 2010, and I suppose that was the real start of my journey towards being a GentleBirth Instructor.

I really wanted to have a natural birth and used GentleBirth during my pregnancy from about 26 weeks, doing home study and attending the workshop with Tracy. My concerns were avoiding an assisted delivery or a Caesarean, but I suppose I mainly wanted a positive birth experience, and I thought that keeping things as low intervention as possible was the way to go.  The only person I had ever heard describe birth as “wonderful”  had had a home birth, obviously with no epidural.  My mother had described my birth as great once she’d had the epidural – “like being at the hairdressers”. I didn’t want to feel like I was in the hairdressers, I wanted to experience birth in all its primal glory, if I could. I devoured Ina May Gaskin’s Guide to Childbirth and felt that, after all, I was born to birth, so I could do it. My husband was super confident that he could support me, once we attended the workshop, and assured me he’d seen hundreds of births and could probably manage the delivery himself (he’s from a dairy farm!). I had a great pregnancy and felt so well and energised as I approached my guess date and then went over it.

I went into labour at my EDD + 6 days. The surges started at 7am and were only 7 mins apart. After an hour, they were 3-5 mins apart but I knew that there was no point going to hospital yet because they were not that intense. From the first surge, I knew this was it, so told Peter there was no point in going to work. We hung out at home for the day and just chatted. From an hour or so into my labour the surges were uncomfortable enough that I had to breathe through them. The hard bit was only one breath long, in and out and I would say to myself, this will pass quickly. They were sore if I sat down, but fine if I stood and swayed so I spent many surges bending over the table or the mantelpiece, reciting that affirmation. About 10 hours of this carry on, (the time really does pass so quickly!) and I started to get impatient that things weren’t going anywhere so went for a walk. On the way back, I had a waaaay more powerful surge and looked down and there was water coming out.  The same happened on the next one so I assumed the waters had gone (tip: have a sniff if this happens to you…urine smells like urine, amniotic fluid is sweet-smelling!). It was about 7pm at this stage so we had dinner and went into the hospital. As I was very calm and relaxed, I was left in the waiting room for about an hour, during which time I was able to sit quietly and listen to GB on the headphones. I was totally relaxed between surges and just closed my eyes and breathed when I had a surge.

So now came the first difficult bit. I was examined and was only 2cm (felt like punching someone after 14 hours or so of labour!) and it seemed the waters hadn’t gone at all – I had probably peed myself (I now think her head engaged at this point). But the midwife was insisting I stayed there and be admitted to the prelabour ward, while they’d send Peter home because it was out of hours. It made far more sense to us to go home and keep on as we were, when there was no medical reason for us to stay – especially when she said that my labour might slow down and they’d have to speed it up with drugs. Which was the reason I didn’t want to be admitted in the first place!  We were most definitely going home! She said no, we said yes, eventually she got a doctor down who scanned me and told us there was no problem if we wanted to go. She said she worked in England where people were a bit more vocal about their wishes so it seemed pretty normal to her for me to want to be at home and I’d be better off. I was so proud of Peter as there was no way he was going to budge and be convinced to stay there, we were going home, and that was that.

All that lying around getting the trace on the heartbeat and being scanned threw out my focus though and when we got home I could feel things were harder to cope with. After about an hour, the surges were 4 long breaths out and in at the peak and very little break between them. They were radiating from front to back and it felt like my pelvis was going to explode.  I got a bit panicky and I started to feel like I really needed the epidural and I wasn’t coping. So back to the hospital, this time I wasn’t very calm and couldn’t sit in the waiting room, could only lean over the reception desk, but was examined very quickly and was 6cm. I got the gas and air at this point as I couldn’t lie down for them to do the trace on the baby without it. Then went straight to delivery and got the gas again. The gas was like being really drunk, you can still feel everything but you don’t give a sh*t! Plus it helps focus your breathing. Was great because it meant I could lie down and rest and just flake out between surges which was a godsend because I’d been on my feet most of the day.

It was a quiet night in the Rotunda and there were two midwives in my room plus a senior midwife popping in and out, as well as a medical student. When I was admitted, I asked about the epidural and the senior midwife looked at my birth preferences and said I was doing brilliant, that it was absolutely amazing to be admitted at 6cm on your first baby, and that I still had time for the epidural if I wanted it so to see how I got on. Was hilarious when they asked me if I had birth preferences and moaned, ‘Yes, but I don’t think I want to stick with them!’. They just told me to hand them over, helped me out of my clothes and handed me the gas.

The whole time I was in the delivery room, I listened to my GB tracks on my ipod over and over (just as well, as there was a good bit of chat from the others. If I had my time again, I’d tell them all to STFU and stop polluting my birthing space with their shite talk).

All of a sudden, a bit more than an hour after we arrived, I could feel myself lifting up and turning over onto all fours like it wasn’t me doing it (poltergeist!) and the midwife looked and said, there go the waters, your baby will be here soon. I gave up the gas as I couldn’t use it on all fours and I just had to be on all fours to be comfortable. My body started pushing the baby out and it was like throwing up after waaaaay too much drink, really really forceful but it was throwing down instead of up! In between surges, I just flopped, listening to my GB and when a surge came, I just let my monkey do it and allowed my body to completely take over. Totally switched off the intellect. I could feel her head coming down and it just felt so hard, like a little cannonball. Eventually I just knew I had to get out of the bed and stand up and I did and then she was really coming. As she crowned, it stung like billy-o and I saw my sex life flash before my eyes and felt fear….and just thought, this can be over now. So for the first time, I listened to the midwife telling me to push and I pushed…..and out she came! The perfect birth!

Straight away the midwife said, oh look, it’s a velamentous cord insertion. And she said the cord wasn’t pulsating when we tried to stop her cutting it – and she cut it. So when my baby was passed to me, she was passed from the side, sort of enter stage right rather than up through my legs, which made it a little strange. She was also mostly pink and had her eyes open, wasn’t crying and looked for all the world like she was taking it all in. She was the most beautiful little thing – I just exclaimed “Oh my God, she’s gorgeous”. But I have to say I didn’t feel a rush of love – amazement, awe, relief, pride, strength, empowerment……. The love came after I sat down on the bed and had a good rest! It was less than 3 hours after we arrived back at the hospital.

I was so wrecked as I lost “more blood than normal” – have discovered since the birth of baby no 2 that I seem to bleed quite a bit at the birth but have very little lochia afterwards. My bleeding both times was pretty much done after day 3. So I was given syntometrine to stop the bleeding and deliver the placenta. However, as the midwife was carrying out controlled cord traction, she snapped the cord (she shouldn’t have been pulling it at all due to the fact it wasn’t a “normal” cord), said “oh shit” and that’s where the fun started. The world and his wife came down to try to retrieve the placenta and when they couldn’t I had to be brought to theatre, where I was given a spinal and had it removed manually. I was also stitched while I was there as pushing through the crowning meant I had a second degree tear (which was very minor, and healed brilliantly and very quickly and mostly painlessly).

The funny thing is that while all of that was going on, I was fine. I breastfed my daughter and then when I was separated from her for an hour and a half, I was on such a high, I laughed and chatted to the staff in theatre. I felt like superwoman!!!!

The memory of feeling my daughter enter to world, to feel her come down and out of me is so special. I am so glad that I got to birth her actively, my way, as really all the midwife did was catch her.

Although it didn’t end well, I still look back on the whole thing as amazing – because up until the placenta fiasco it was the perfect birth. And I think the affirmation “I accept whatever path my birthing takes” helped me stay super relaxed when it all happened – when I look back, I just can’t believe how calm and happy I was while it was all going on. It was much worse for Peter who was left holding a newborn and wondering if I would come back….

Cleo was a very easy baby and fed well from the start. Amazed all the staff in hospital with her expert breast crawling! No sore nipples, no milk supply issues, just baby bliss. We took Early Transfer Home from hospital so I was home within 30 hours of giving birth. The ETH team were fab, but I can’t say they they were great with breastfeeding help because we really didn’t need any. It felt completely natural, I think due to confidence from the breastfeeding mp3.

Despite the turn it took at the end, I had a wonderful, empowering birth that for me was transformative. When we get in touch with our primitive selves, we are powerful and all conquering 🙂

Download the GentleBirth app today – there is a free week of full access when you register.  https://www.gentlebirth.com/

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