“Give a uterotonic routinely during the third stage of labor,” by Robert L. Barbieri, MD (Editorial, May)
I agree with Dr. Barbieri’s assertion that a uterotonic should be given routinely in the third stage of labor, but I recommend one very important proviso: A sonogram should be on file.
My advice comes from experience. I once took care of an unregistered patient who had not had prenatal care and who came in with cervical dilation to 8 cm and was progressing rapidly. After delivery, I did a digital exam and discovered an undiagnosed twin (vertex). Just think what would have happened if I had given a “routine bolus” of oxytocin!
I trained with people who gave oxytocin when the anterior shoulder was delivered. I have found that the cervix can close down very fast if the uterotonic is given after the baby is delivered but before placental delivery.
John Lewis, MD
Dr. Barbieri responds: Uterotonic can wait until delivery of the placenta
I appreciate Dr. Lewis’ astute clinical comments about administering a uterotonic at delivery, which are clearly based on significant clinical experience. In the case of multiple gestation, it is preferable to wait until both fetuses are born before giving a bolus of oxytocin. The undiagnosed multifetal gestation presents a significant challenge for the obstetrician.
Many clinicians have noted that administration of oxytocin after the delivery of the infant’s anterior shoulder stimulates cervical contraction and may increase the rate of retained placenta. In response, these clinicians prefer to administer a uterotonic after delivery of the placenta. This practice is perfectly acceptable and has been demonstrated to reduce the risk of postpartum hemorrhage.1