Be vigilant for retained placental products …and more

Don’t mess with the placenta!

My approach to the prevention of postpartum hemorrhage is simple: Don’t mess with the placenta! The less manipulation, the better. I give oxytocin when the placenta appears at the cervical os in vaginal deliveries and when the cord is clamped in cesarean deliveries.

Ramon H. Gonzales, MD
Madisonville, Kentucky

Misoprostol is the key

I administer misoprostol 400 μg rectally after delivery of the placenta. I have used this trick for 3 years and more than 700 deliveries without one case of postpartum hemorrhage.

Richard P. Benedict, MD
Fort Mohave, Arizona

Postpartum infusion of oxytocin averts the need for postpartum hysterectomy

I was surprised to learn, from Dr. Barbieri’s editorial, that postpartum use of a uterotonic is not routine in the United States. I trained at Travis Air Force Base here in California in the early 1970s and was taught to give 10 to 20 U of oxytocin in 1,000 mL of IV solution following delivery of the placenta. I have continued that regimen, adding carboprost tromethamine (Hemabate) to the regimen about 10 years ago when hemorrhage persists. Most recently, I started adding 1,000 μg of rectal misoprostol. (Misoprostol is very inexpensive.) I also do not hesitate to administer uterine massage, sometimes placing a hand inside the uterus to facilitate massage, removing it when the uterus contracts around it.

I guess I am lucky because I have never had to perform postpartum hysterectomy after more than 10,000 deliveries.

Doug Tolley, MD
Yuba City, California

IV infusion of oxytocin has worked for 20+ years

For more than 20 years, I have administered oxytocin by IV infusion immediately after delivery. I give 20 to 30 U of oxytocin in 1 L of saline at a rate of at least 125 mL/h. This approach has reduced the incidence of immediate and delayed postpartum hemorrhage due to uterine atony to virtually nil without increasing the incidence of retained products of conception.

Henry Moon, MD
Sanford, Michigan

Any information on injecting oxytocin into the cord?

I once had a student who suggested that oxytocin be injected into the umbilical cord after clamping. I decided to try this approach and started injecting 10 U into the cord. I have been unable to find any information on this method, but it seems to reduce blood loss. It would be a fairly easy study to conduct—and I’d love to see the data. Until then, I will continue injecting oxytocin into the cord. It seems to work!

Patricia Boullie, CNM
Astoria, Oregon

Dr. Barbieri responds Kudos to our community of expert clinicians

As these letters demonstrate, the readers of OBG Management are a community of outstanding clinicians who have vast clinical experience and broad and deep knowledge about optimal approaches to obstetric problems.

I agree with Dr. Alonzo that having a large “banjo” curette available in all birth units provides a quick and effective tool for finding and removing retained placental products, which are a common cause of postpartum bleeding. In an unanesthetized woman, this approach might cause some discomfort.

Dr. Semchyshyn elegantly describes the integration of oxytocin infusion with a multistep birth process. He agrees with Dr. Nassar that the optimal timing of oxytocin administration is with the delivery of the anterior shoulder.

I appreciate the innovative report from Dr. Benedict on the use of rectal misoprostol as the primary agent to enhance uterine contractility. Ms. Boullie provided another innovative description of the injection of oxytocin into the umbilical cord and asks about the evidence for or against this practice. A Cochrane systematic review concluded that the injection of oxytocin into the cord is not more effective than the injection of saline and recommended against this technique.¹

As Dr. Tolley and Dr. Moon note, the most common approach to active management of the third stage of labor in the United States is to start an IV infusion of a solution containing 10 to 30 U of oxytocin per liter at a rate of about 125 mL/h.

Dr. Gonzalez and Dr. Druzin provide very useful advice: Avoid unnecessary manipulation of the placenta until it begins to deliver, and turn on the lights to ensure that we can employ all our senses optimally when an obstetric problem arises.

I share Dr. Franger’s advocacy for individualized care and simultaneously wonder if quality and safety can best be improved by reducing variation and by standardizing processes.

The quality of the clinicians in our obstetric community ensures that pregnant women will receive the exceptional care that they deserve and need.