Valerie Gommon Midwife’s Blog

Archive for the ‘syntocinon’ Category

This is a guest blog written by Sarah Ward.

 Homebirth & PPH

Women often worry about what would happen if a woman bled heavily after a home birth. Throughout history, severe blood loss has been one of the main causes of women dying in childbirth, and it remains the most common cause of maternal death in the world [WHO, 1994].

Efficient management of postpartum haemorrhage is one of the wonders of modern obstetrics. The key is the availability of oxytocic drugs, which make the uterus contract down and normally stop bleeding.

You can choose to have either a ‘managed’ or a ‘physiological’ third stage, at home or in hospital. A ‘managed’ third stage means you have an injection of syntometrine as a precautionary measure. A ‘physiological’ third stage means you take a ‘wait and see’ approach to the delivery of the placenta, and only have drugs if you are worried about bleeding or if the placenta is taking longer than you want to wait for it to turn up

Sometimes one hears of doctors trying to dissuade women from home birth because of the risk of postpartum haemorrhage yet in fact severe bleeding after a home birth in the UK is rare, and postpartum haemorrhage is usually managed at home or by transfer to hospital. Despite the fears of some doctors, you would be very unlikely to bleed to death after a planned home birth in a developed country.

A famous review of quality studies of home birth (Olsen, 1997) looked at outcomes for over 24,000 women and found no maternal deaths. The National Birthday Trust Fund study looked at around 6,000 planned home births in the UK, and found no maternal deaths.

Where treatment for postpartum haemorrhage is needed, there are two elements. Emergency treatment focuses on stopping the bleeding, and in severe cases, keeping blood volume up while the bleeding is stopped. The other element of treatment is helping you to recover from blood loss, by administering a blood transfusion or iron supplements, this usually occurs several days after the bleed after blood tests have been performed.

What can a midwife do about heavy bleeding at a home birth?

Your midwife would follow exactly the same steps that she would take in hospital. Oxytocic drugs to manage blood loss are part of the basic kit that midwives take to every home birth.

If these did not bring the situation under control quickly then an ambulance would be called, and the midwife would take other steps if necessary, such as manually compressing your womb to stop bleeding.

In the UK most midwives can put an intravenous drip in at home while they are waiting for an ambulance to arrive.

What if the midwife isn’t there?

In the rare circumstances that a baby is born so quickly the midwife has not arrived yet, or the bleed has occurred after the midwife has left (also extremely rare), then you can do the following:-

  • ·       Call 999 if you can’t get hold of your midwife immediately
  • ·       Massage the uterus firmly – this often stops the bleeding immediately
  • ·       Pass urine
  • ·       Bi-manual compression – only if bleeding is extreme – involves someone continually massaging uterus externally and internally until help arrives

When the midwife arrives…

  • ·       She considers what we call the 4 T’s: Tone, Trauma, Tissue and Thrombin (clotting) factors.
  • ·       She can make sure the woman has passed urine and does not have a full bladder.
  • ·       She can use massage of the uterus, syntometrine or ergometrine medication to try stem bleeding. These medications induce a sustained uterine contraction. The massage of the uterus will sometimes expel any tissue obstructing good uterine clamp-down.
  • ·       The midwife can check for a tear, sometimes we can tear internally and it be less obvious
  • ·       Bi-manual compression will be used and transfer to hospital will happen as soon as an ambulance arrives if bleeding is not slowing.
  • ·       If bleeding has been easily stopped and woman feels fine then she may end up declining transfer to hospital. However in hospital they can offer a number of extra helpful interventions for anyone who has experienced or is experiencing a life-threatening PPH.

Placental Problems

  • ·       Occasionally the placenta doesn’t separate properly and obstructs, the midwife can manually remove it allowing the uterus to contract down and stem the bleeding

Can more be done in hospital than at home?

  • ·       The answer is yes, but only because there are more staff on hand, however the chances of having a life threatening PPH are far far greater in a hospital than at home in the first place.
  • ·       The most common reason for PPH is to do with atonic uterus, where the womb fails to contract down properly. At home, this is dealt with in the same way and with mostly the same drugs that would be used in hospital.
  • ·       It’s important to mention that PPH at home is reasonably rare, by the very nature of the fact that the major risk factors for PPH are things which only happen in hospital (instrumental deliveries, long hours on syntocinon drips, caesarean section etc).
  • ·       The last confidential enquiry into maternal deaths listed approx 5 deaths from PPH, all of which were in hospital, four of them were following instrumental deliveries and one following caesarean.

 How likely is post-partum haemorrhage after a home birth?

  • ·       PPH is significantly less likely to happen after a home birth than after a hospital birth.. This is probably because home birth reduces the risk of interventions which can contribute to PPH
  • ·       For more info, see the National Birthday Trust Fund study in the first instance, but numerous other studies have also found a reduced PPH rate in planned home births.
  • ·       Part of the reason for higher rates of blood loss after hospital birth is that PPH is statistically more likely to occur after intervention such as caesarean section, assisted delivery (forceps or ventouse), or medical induction or augmentation of labour (having a drip to speed labour up). None of these things will be happening at home. If you were to have any of these interventions, you would already be in hospital.
  • ·       There are some ways in which planning a home birth actually reduces your chances of having a PPH. Simply planning a home birth significantly reduces your chances of ending up with a caesarean or an assisted delivery – labour just seems to progress more smoothly at home, leading to less call for intervention. As these interventions increase the risk of PPH, by reducing the risk of the intervention, you are reducing the risk of PPH.

Can you have a home birth after having had a PPH with a previous baby?

  • ·       To try to work out the chances of a PPH recurring, and whether this is ‘safe’ for a home birth, you’d need to know why the PPH occurred, and if the same circumstances were likely to recur.
  • ·       Much depends on how you felt after the PPH.  Some women feel great even after losing a considerable amount of blood whereas others may feel terrible only losing 300ml.
  • ·       Its often hard to accurately measure the amount of blood loss. In the UK we call a loss of 500ml a PPH, but Europe don’t record a PPH unless over 1000ml.
  • ·       What were the circumstances the PPH occurred in? Were there known risk factors for PPH which would not apply this time? For instance, PPH is more common after assisted deliveries, first babies, large babies, induction or augmentation of labour.

o      If she needed an assisted delivery this time she would transfer to hospital, so that shouldn’t affect her status as regards home birth.

o      Likewise, her labour is not going to be induced with prostaglandins or augmented with syntocinon.

  • ·       Was the PPH a ‘true’ PPH in terms of being blood loss from her uterus, or was it associated with perineal tearing or episiotomy? Blood from both sources ends up in the same measuring jug, but the difference is significant.
  • ·       Did she have a retained placenta, or did the bleeding occur after the placenta was delivered – some ‘uterine atony’ involved?

Conclusion

All in all the risks of a PPH are lower in a planned homebirth than in a planned hospital birth.

However if one should occur, there are many ways it can be treated successfully at home, or by transfer to hospital.

It’s also important to realise that a negative outcome from a PPH can also occur in a hospital situation as well as at home.

Having experienced a PPH following a birth is not an automatic barrier to home birth in the future, it would depend on the reasons why it occurred. In fact planning a home birth may significantly reduce the chances of having a PPH in the future.

 

I have just found an interesting article which says that drugs which are often routinely given to women immediately after birth could reduce their chances of breastfeeding.

www.walesonline.co.uk/news/health-news/2009/09/02/life-saving-childbirth-drugs-could-reduce-ability-to-breastfeed-91466-24586076/

The article is so interesting that I will copy it complete below.  My only query regarding the research is to question whether women who choose not to have syntocinon/syntometrine/ergometrine (the drugs routinely used to speed delivery of the placenta, and which many believe help to prevent haemorrhage) may be better informed – perhaps choosing homebirths or waterbirths where the use of these drugs is less frequent – and therefore more likely to breastfeed.

It should also be pointed out that whilst the vast majority of doctors and midwives believe the use of drugs to deliver the placenta to be beneficial there are others who do not believe that they should be used routinely (see Delivering Your Placenta www.aims.org.uk).

“A study of 48,000 new Welsh mothers has suggested the drugs, which can be life-saving, could also be linked to reduced breastfeeding rates.

Researchers from Swansea University believe the drugs, which are used to prevent bleeding after childbirth, may be the reason why so few mums breastfeed, with only 45% continuing within a week of the birth.

The analysis of the records of women who gave birth in South Wales found the use of the blood-clotting and other drugs were associated with a 7% decline in the proportion who started breastfeeding within 48 hours of giving birth.

Researchers believe the drugs may impede a woman’s ability to produce milk and say new mothers may need greater time and support from midwives if they wished to breastfeed their baby.

Dr Sue Jordan of the university’s school of health science, who led the study, said: “Our results highlight the need for further research and clinical trials. What we would like to see is extra help for new mothers trying to establish breastfeeding by making sure to allow enough time for the effect of drugs given in labour to subside.

“Our new findings could contribute to meeting the government targets of reaching that extra 2% of women breastfeeding per year.”

The study is the second link the research team has drawn between breastfeeding rates and drugs given during or after labour. Their previous research confirmed the link between epidurals and reduced breastfeeding rates which prompted revised guidelines for the NHS on the use of the drugs in labour.

Dr Jordan, however, supported the current medical practice regarding the use of the drugs saying: “The potentially life- saving treatments to prevent bleeding after birth must not be compromised on the basis of this study, but further studies are required to establish ways to minimise any effects on breastfeeding rates.”

Of the women involved in the study, who all gave birth between 1989 and 1999, 65.5% of those who did not receive drugs to prevent bleeding after the birth started breastfeeding their baby within 48 hours of giving birth.

This dropped to 59.1% among those given an injection of oxytocin, a hormone that stimulates contractions and plays a natural role in labour, and to 56.4% of women given an additional injection of ergometrine, given to stop bleeding after the birth.

In the study 79% of women received either oxytocin, ergometrine or both, as is routine in the NHS.

“The decline of 6-7% in those being breastfed could lead to up to 50,000 fewer British babies being breastfed every year than might otherwise be possible,” said Dr Jordan.

UK health surveys claim the results of bottle-feeding can lead to obesity and asthma as youngsters are not getting the natural benefits of a mother’s milk. Bottle-feeding has also been linked to an increased number of mothers being affected by breast cancer.

Rosemary Dodds of the National Childbirth Trust said: “Women need more support to start breastfeeding soon after giving birth and this study adds weight to that. A lot of women are not given enough information about the medications that might be given to them during childbirth, and women at low risk of bleeding may not need to take these drugs.”

Helen Rogers, leader of the Royal College of Midwives in Wales, said: “We welcome studies like this as it shows the important part midwives can play in breastfeeding. Unfortunately, with staffing levels on maternity units, midwives are looking after mums who need more medical care and attention rather than those who have breastfeeding problems and have no other ill effects from the birth.

“Also, mums are now keen to leave hospital, sometimes within six hours of the birth, and as a result they lose the midwife contact and support they may need if they have problems breastfeeding.”

Dr Jordan said the next step in her research was to seek funding for further research and clinical trials to measure the real effect of medications given during labour and the uptake of breastfeeding.”

ENTONOX

Also known as “gas and air” (50% oxygen and 50% nitrous oxide).

Self administered through a mask or mouth piece

Used to breathe in and out during contraction

Helps you cope with the pain and also acts as a distraction by giving you something to focus on

ADVANTAGES

Helps take the edge off the pain

Does not affect baby

Can not overdose

Can stop using it at any time

DISADVANTAGES

Can make you nauseous or vomit

Can make you feel “drunk” or out of control

MEPTID

A pain killing drug similar to pethidine.  It is given by injection either into your bottom or thigh.  It usually relaxes you a bit and takes the edge off the pain.  This drug has to be prescribed.  We give an amount proportionate to your weight.

ADVANTAGES

This drug helps some women

The effects on the baby are probably slightly less than pethidine

The nausea/”drunk” feeling may be less than pethidine

Can be given again after 2 hours

DISADVANTAGES

It can make some women feel nauseous and vomit

Some women do not to feel “out of control”

It may affect the baby’s breathing/ability to breastfeed if given shortly before the baby is born

Can not have meptid if having a waterbirth

PETHIDINE

A pain killing drug, given by injection into your bottom or thigh.  It takes about 20 minutes to take effect and lasts for up to four hours.  It usually takes the edge off the pain and relaxes you.

ADVANTAGES

Effective pain relief for some women and relaxing if nervous

Can help you to sleep

DISADVANTAGES

Some women do not like the “out of control” feeling

Can cause nausea and vomiting

For some women it has no effect at all

Pethidine crosses the placenta and can affect baby’s breathing/ability to feed (antidote is available)

Can not have if having a waterbirth

DIAMORPHINE

Similar to Pethidine – A pain killing drug, given by injection into your bottom or thigh.  It takes about 20 minutes to take effect and lasts for up to four hours.  It usually takes the edge off the pain and relaxes you.

ADVANTAGES

Effective pain relief for some women and relaxing if nervous

Can help you to sleep – long lasting

DISADVANTAGES

Some women do not like the “out of control” feeling

Can cause nausea and vomiting

For some women it has no effect at all

Diamorphine crosses the placenta and can affect baby’s breathing/ability to feed

Can not have if having a waterbirth

EPIDURAL

An epidural is where painkilling drugs are passed into the small of your back via a fine tube. It is called a regional anaesthetic, which means the drug is injected around the nerves that carry signals from the part of your body that feels pain when you’re in labour. The result will be that your belly feels numb, giving you very effective pain relief

ADVANTAGES

Good pain relief – especially if labour is long, or instrumental delivery is required

It can be used during a caesarean section and therefore avoids the use of a general anaesthetic

DISADVANTAGES

You need to remain very still whilst epidural is being sited

It causes a drop in maternal blood pressure:

You will need an intravenous drip to counter this drop in blood pressure

Drugs used pass through the placental barrier

Your baby will need to be continually monitored – in extreme circumstances the baby can become distressed necessitating an urgent caesarean section

You will usually need a urinary catheter to empty your bladder

It can slow the labour necessitating a syntocinon drip to get contractions going again

It restricts your movement – usually you will be confined to bed and it can be harder for the baby to get into the best possible position for birth, this can make the labour longer, and make it more likely that you need help (ventouse, forceps or caesarean section)

It may not be 100% effective and you can have “break-through” pain

There is a lack of sensation to ‘push’ in the second stage and this leads to an increased need for ventouse or forceps deliveries

The effects can take some time to wear off



There has been quite a bit of debate this week about whether women should have access to an epidural in labour.

Of course in the majority of cases women do have access to an epidural in labour if this is what they choose, however many maternity units cannot GUARANTEE that a woman will get an epidural when she requests one.  This may be for several reasons.  A woman who has an epidural needs to have one to one midwifery care to ensure the safety of both the mother and her baby.  If a unit is particularly busy or poorly staffed a midwife may not be available to give this level of care (it is well documented that midwives are often caring for two or more women who are in active labour), secondly, an anaesthetist may not be immediately available.

The debate occurred because there have been several articles in the media recently regarding the National Childbirth Trust’s (NCT’s) views on women’s access to epidurals following the publication of a guidance document, “Making Normal Birth a Reality”, drawn up by the NCT with the backing of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. www.appg-maternity.org.uk/resource/Normal+Birth+Consensus+Statement+NEW+LOGO.pdf and www.nct.org.uk/press-office/press-releases/view/128

There was a very interesting debate on Woman’s Hour this week when Belinda Phipps, the Chief Executive of the National Childbirth Trust was interviewed opposite Smriti Singh.  www.bbc.co.uk/radio4/womanshour/02/2009_10_thu.shtml and

The programme highlighted that epidurals are extremely safe (and I say thank goodness for the fantastic medical care we have if it is needed), but I personally do feel that there are very good reasons for avoiding an epidural if possible.

Epidurals are not recommended until a woman is in “established” labour, that is that she is having regular, strong contractions and that her cervix is dilated (usually to 3cm).  The reason for this recommendation is that if the epidural is given earlier the labour could stop as labour may not be fully established.

By having an epidural, a woman is usually confined to bed.  She will need to have her baby continuously monitored by a cardiotocograph machine (CTG) as the epidural can affect the baby, she will also need an intravenous drip because the epidural can significantly lower her blood pressure and she may well also need a urinary catheter to keep her bladder empty.  Being confined to bed will not allow the normal active behaviour of the mother which will help the baby into the optimum position for birth, nor will she have the affect of gravity.  Epidurals occasionally allow the labour to progress more quickly, but more likely the labour will slow and an oxytocic drug (syntocinon) will be needed to increase contractions, and so the “cascade of intervention” continues.  It is also true that women are slightly more likely to need assistance from either a ventouse or forceps to deliver their baby as it is more difficult to “push” out the baby when you have an epidural.

Whilst being an advocate for my clients, and if (given this knowledge) a woman chooses an epidural I honestly believe it is my job to support her in this choice; this said, I believe that far fewer women would actually choose an epidural is they received appropriate one to one support, preferably from a known midwife during their labour.


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