Re: [ozmidwifery] question

Sat, 19 Feb 2005 22:04:09 -0800

Thanks for this, and for the feedback so far - I'm sure more is on the way!
The situation is that I am contesting another practitioner's management of a delivery. One aspect of this delivery was that he commenced CCT on a friable cord (small baby- IUGR - scrappy cord) almost as soon as the oxytocic had been given (we use sytocinon not syntormetrine by the way Mary).  The cord, not surprisingly, separated.  And a chain of events ensued.... :-(
I challenged the fact that CCT had been commenced before signs of separation, and was told that the only factor needed to be ascertained was that the uterus was contracted.
I know that I was taught to await signs of separation before commencing CCT, even given that in those days we always used syntometrine,so this surprised me.
As this situation is now being taken further (there is obviously a lot more to the whole story)  I need to have my facts and evidence to back up my opinion before the next stage.  Unfortunately it still seems to be that this issue is unclear with most centres recommending waiting, and some recommending immediate CCT with the first uterine contraction.  'Active management' is a term used frequently with, it seems, an assumption that people know what it entails.  I would be very interested to hear from student midwives on this - what exactly are you being taught nowadays?
The second point of contention in this issue is what defines a retained placenta - I would have thought this was patently clear with most authorities agreeing that a period of 60 minutes is acceptable in the absence of bleeding.  As you will have guessed by now - this time was not given!
Just for clarification, the patient had an empty bladder, an IVI with syntocinon infusion and was not bleeding.
 
Thanks again all
Sue
 
----- Original Message -----
Sent: Sunday, February 20, 2005 12:06 PM
Subject: Re: [ozmidwifery] question

A useful link re third stage management pros & cons.
 
 
Jenny
Jennifer Cameron FRCNA FACM
ProMid
Professional Midwifery Education  Service
0419 528 717
----- Original Message -----
Sent: Sunday, February 20, 2005 1:22 PM
Subject: Re: [ozmidwifery] question

Active management of third stage using controlled cord traction.
Beischer, N. Mackay, E. Purcal, N. 1989, 2nd edition. Care of the pregnant woman and her baby, W.B.Saumders/Balliere & Tindall, Sydney.
 
1) Administer oxytocic, Syntocinon 10 units IMI or IVI after the birth of the baby.
 
2) Await signs of separation.
 
3) The cord is reclamped near the vulva and steadied with one hand while the other hand is used to gently push the uterine fundus upwards. This will indicate if the placenta has separated since the cord will not follow the upward movement of the uterus. If separation has occurred, a combined movement is made of downward and backward traction on the cord and upward displacement of the uterus, provided that the latter is firmly contracted.
 
If the placenta does not advance there are usually only 2 possibilities - it is still attached to the uterus or it has become trapped in the tightly contracted uterus (unusual if using Syntocinon, usually only occurs with Ergometrine). In such cases be patient and repeat the procedure at intervals. Resist the temptation to massage the uterus unless bleeding is excessive. If the umbilical cord vessels are congested, remove the clamp and drain the cord blood out. This will reduce the size of the placenta.
 
Once the placenta appears at the vulva you can stop steadying the uterus and gently 'rock' the placenta out taking care not to tear the membranes. If they begin to tear, the placenta should be rotated to cause a bunching up of the membranes near the vulva; a wide clamp is then applied and the membranes eased out with steady traction (pp 252-3).
 
It is generally recommended to always use an oxytocic with controlled cord traction, however it can performed without an oxytocic as long as you await separation and ensure the uterus is firmly contracted before applying any traction. Hope this helps. Cheers
Jenny
Jennifer Cameron FRCNA FACM
ProMid
Professional Midwifery Education  Service
0419 528 717
----- Original Message -----
From: Ken WArd
Sent: Sunday, February 20, 2005 8:41 AM
Subject: RE: [ozmidwifery] question

You must wait for placental separation, otherwise you risk inverting the uterus    Maureen
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]On Behalf Of Susan Cudlipp
Sent: Wednesday, 9 February 2005 2:55 AM
To: [email protected]
Subject: [ozmidwifery] question

Dear ozmid list-ners
I have not been on the list for a while but have a question that I would welcome your input on.
 
When performing active management of the third stage, is it routine practice to await signs of placental separation before commencing CCT, or to simply ascertain that there is uterine contraction?
 
Also, what is the current recommendation for management of retained placenta, or situations when the cord separates during CCT?
 
I know this may sound odd, and I know what I was taught and have practiced, but I am in the midst of a "difference of opinion" and I need to check what are the actual guidelines given.  I have attempted to search this out myself but have not been able to find much in the way of actual step-by-step instructions for active management of the third stage.
 
With respect, I do not need to know people's preferred methods or  opinions on the rights and wrongs of active management, simply the actual guidelines for active management and when to commence CCT.  I would be grateful if anyone can post this or lead me to it.  I have tried many sites on the net without success and do not have easy access to up to date manuals.
 
Thank you in advance, I have been "off list" for quite a while due to being very busy!  Looking forward to listening in again now that life is a bit quieter.
 
Susan  Cudlipp

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