In my hospital: oxytocin before placenta expulsion 10UI by injection, we don't delay cord clamping more than 1 minute.

Same in our clinic. We perform 10 UI before controlled umbilical traction

For bloodless delivery and to shorten third stage it is now in practice to give 10IU oxytocin in umbilical cord before expulsion of placenta.

There is substantial evidene supporting intra umbilical oxytocin with even higher doses (50IU) which gives improved outcome in terms of reduced duration of retained placenta as well as reduction in blood loss...

I believe that the best evidence support administration of oxytocin before expulsion of the placenta and in fact, right after the baby's delivery. It reduces the 3rd stage of labor and the risk of postpartum hemorrhage. I believe that there is not enough evidence to support intra-umbilical oxytocin administration at this time outside a good research protocol or special circumstances.

My reading, research and practice leads me to the conclusion that artificial oxytocin should not be used when the birth has been normal. It actually creates extra PPH due to blocking the release of natural oxytocin. See 3. Fahy, K. Hastie, C. Bisits, A. Marsh, C. Smith, L. & Saxton, A. (2010) Active management of the third stage labour compared with holistic physiological care for women at low risk of postpartum haemorrhage: a cohort study. Women and Birth. 23 (4): 146-52

You Should apply oxytocin after de delivery of the baby. Some reasons and guidelines with good evidence: Am Fam Physician. 2007 Mar 15;75(6):875-882.

Active management of the third stage of labor decreases postpartum blood loss and the risk of postpartum hemorrhage (number needed to treat=12).

Oxytocin (Pitocin) is the first choice for prevention of postpartum hemorrhage because it is as effective or more effective than ergot alkaloids or prostaglandins and has fewer side effects.

One of the first cause of maternal death in low income countries is PPH.

More information about the complications during delivery can be accessed in the Advance Life Support in Obstetrics Course

Dear Galo, I invite you to read the article I referenced, above, and then form your own opinion; do not just assume that any published research is actually 'true' for all women.

It is advisable to administer oxytocin after parturition because it enhance involution of the uterus and prevent postpartum hemorrhage.but prior to parturition if the cervix is not properly dilated it may rapture some of the blood vessels and course complication.

Not always, only if needed. If birth has been normal and articifcal oxytocin is added it actually seems to increase the rates of PPH (please read the cohort study above which had large numbers and compared the effect of syntocinon on PPH for woman at low risk of PPH i.e. normal birth. The women who did not have Syntocinon had a PPH rate below 4% compared with over 11% for those who did.

Colleagues, I personally believe that one should refrain from giving personal opinion and also providing reference of low quality research. There are specific guidelines laid down by WHO for this specific topic based on Cochrane database reviews; which are more in favor of Natural Birth as suggested by Kathleen.

Administration of oxytocin before or after placental expulsion does not significantly influence the major clinical outcomes such as the incidence of PPH or duration of the third stage of labour. This is an important finding because a previous systematic reviews had found a trend towards an increased rate of placental retention following active management of the third stage of labour in which uterotonic drugs had been administered prior to or at the beginning of the third stage of labour in women at low risk of haemorrhage. The administration of oxytocin after expulsion of the placenta has the advantage of reducing the risk of over-infusion of placental blood to the baby. There is already evidence to show the beneficial effects of delaying cord clamping and of cord drainage.

Ref: The WHO Reproductive Health Library 2011

There should not be one rule for all. Normal birth, that is a normal physiological process of which there has been no intervention, should not require a drug to expel the placenta. providing the woman is in good health, able to take fluids and put the baby to the breast a physiological 3rd stage should occur. however where there is poor health and circumstance and intervention this is another matter.

I am looking for practitioners to try and study my third stage protocol which uses oxytocin only at 10minutes after delivery of placenta, in the event of excess bleeding

http://www.greenmedinfo.com/blog/how-eliminate-postpartum-hemorrhage

Great idea Judy but it would be hard to get approval from maternity units to do that study.

Kathleen Fahy: I would be interested in a pilot study of 5 women in 10 different locations. I have had no PPH>1000 cc. This is not a claim that any other protocol has made. I think this is enough to warrant a pilot study. Dont you?

HI it deponds on your protocol and your country that you live. in my country post partum hemmorhage is the first cause for maternal morbidity and i prefer to do active management.of course in high risk pregnancy written by james steer you can see more about it volume 2 chapter 75

Dear Juliana, even if you use active management the most important thing is to promote immediate skin to skin contact between mother and baby and spontaneous nuzzling at the breast to promote maximum natural oxytocin. If you really insist on using artifical oxytocin then please delay it until one minute after the birth to allow the mother's body to do what it will naturally do if the woman is surrounded by love, not fear.

I tell you how I work: I never use active management of the third stage of labor because I prefer to delay cord clamping. I only use oxytocin after placental expulsión If I consider it necessary and I never have had any problem. But I think that each country and even each institution is different.

That is great Lola and exactly what I would recommend based on the research I have read and conducted in the area of the causes of PPH. In relation to Narij's comment I note that there has been no RCTs where the researchers have had control of the intervention of interest i.e. physiological third stage care (which is assumed to be pretty much the same as not giving Syntocinon) when it is much more holistic than that. The aim is to help the woman feel warm, safe and loved so that her own physiology functions optimally. What is the explanation as to why obstetrics recommended that all women need artificial oxytocin?

Recommendations that "all" patients be given this or that usually stem not from physiological studies but from biosocial statistics of 'risk' (that is, the rule of the majority case).

I once read a paper from Sweeden that attributed the use of oxytocin to calculations doctors made about birthing baby being late (unrelated to PPH). They said that it was the calculation that was inadequate, based on 'most' cases, often not the actual baby or mother. The statistics caused damage to both.

Also, as ot 2009, I could not find any longitudinal study of the effects of Syntoncin or bioidentitcal oxytocin use on the baby's long-term health, especially female.

The "Should" of the question: Does it relate to a habitual medical intervention or Does it relate to actual signs of emergency looming being observed?

Spot on Marika. Physiology is the key. Uterine atony happens under sympathetic stimulation or anaesthetics or drugs. Otherwise we can trust physiology.

But even at the term of gestation over 36 weeks uterus has no innervation. So the key is not autonomous regulation.

I do not understand it what is the relation of uterine innervation in respect of gestation ?

The uterus is under the control of the autonomic nervous system. Under sympathetic stimulation the uterus relaxes. The body needs to be in parasympathetic mode (relaxed, peaceful, warm) in order for the uterus to contract effectively. Check this out in a text book.

Reference re autonomic control of uterus Tortora, 10th Edition, 2003, p. 569

Autonomic system does not have any relation with atonicity or atonic PPH. If so, then why we use oxytocin in atonic PPH.

There are certain risk factors associated with atonicity

Hi Prabhat, I am saying that most uterine atony is 'caused' by the way we treat women in labour; we put them in a state of alertness and fear. Thus, the uterus relaxes. The more medicalised the environment, the higher the rate of PPH. In a birth center the PPH rate will be below %5 but the same low risk women in an obstetric unit will have PPH rates of over 12%. Also consider how other mammals are not bleeeding to death during birth; women are mammals. We know not to distrub dogs and cats during labour and birth; the same respect should be given to women.

oxytocin acts on smooth muscle and blood vessels, I believe, governed from the hypothalamus (which is an osmostat center). I seem to remember this is not mediated via autonomic nervous system, but a hormonal effect, via blood.

Apologies to Niraj for the following extensions, but the use of OXT in birthing seems an important issue.

Some further speculation and questions:

So the autonomic control (parasympathetic warm, peaceful, re-laxed) would then a higher-order reaction if OXT is not effective? The hypothalamic osmostat is considered a 'first stress system', the autonomic must then be 'second', and the CNS (‘higher’ function) would then be third in line of reaction. These cascades can be induced by many factors, including plain food. The hypothalamus is also a center of body temperature control, which fails early in ageing post-menopausal women if not treated medically. Is it effective in the birthing situation?

Other things go in the same direction: some diseases and syndromes are now suspected of starting with a circulatory problem (eg fibromyalgia). OXT acts on smooth muscle, including circulatory... In some syndromes, also, the spine has no tonus because the discs are dehydrated, muscles are weak because they are dehydrated, cellular energy is suppressed by dehydration. In some women, pregnancy induces swelling... My knowledge is limited, I'm just connecting the dots, but with this, the "necessity" of OXT-induced reactions either to initiate birthing or stop PPH looks like it might be more effectively addressed by searching, earlier than birth time, for reduced osmostic tonus (cellular water pressure) anywhere in the body, including uterus but not only, for example in circulation. Particularly starting at puberty, when 'bad circulation' and cold-hands-&-feet starts in many women. This localisation in circulation is the basis also for cellulite, a female problem that has now spread to nearly all women says a recent text book about it. Dry mouth is a typical symptom in cancer as well as less critical syndromes...

Then smaller doses of OXT (bioidentical would be better than syntocin) might support the mother's body better than a later and larger dose, with less risk to the baby? (No longitudinal studies on this). Food might have a role, and living conditions: the whole Ecology of Health. There is something undermining women's tonus of health, and it is not being researched. I cannot find any physiological knowledge in papers or textbooks about this most basic, local-tissue or systemic role of OXT that it seems to have. I asked a question here, in ResearchGate, but no one replies. . If you know something, please respond to my question:

Spot on. We are mammals, with wildlife needs that are not being met and that upsets our whole ecology of health.

Exactly Marika, you understand.

Dear Kathleen Fahy,

My thesis was regarding management of third stage of labour. I searched many articles. Midwifery Jornl helped me many ways. At night, oxytocin release is often better. When mother sees her baby first time it causes release of more oxytocin. Humans are mammals but they have the improved brains where maximum threats are stored. Another point is man are always in standing position. The autonomic system has improved role in sperm transportation. Some authors believe that during sexual excitement rhythmic contraction causes transportation of sperm though it is debatable. I hope I have explained it in my own way.

Hi Prambhat, I understand you and agree that the oxytocin is released in the brain as well as travels in the blood. In addition the autonomic nervous system is involved. Additionally adrenaline blocks oxytocin at the receptor sites.Oxytocin is released in optimal amounts and received at the receptor sites in the reproductive organs in both men and women. Certainly being in a parasympathetic state is necessary both for easy birth and good sex (as well as for breastfeeding).

Dear Kathleen Fahy

Thanks mam. We the clinician don't feel your feelings. This is too academic. Thank you mam.

HI Prabhat, I am a clinican too. Knowledge is not about 'feelings' what I am quoting to you is biological fact. You can choose to ignore it, of course, but that means that you cannot understand uterine atony and the factors that cause it.

Can't resist - it's just too widespread... the ideas and theories are twisting what is talked about in medicine.

1- --> so why are women laid on their back to give birth, against gravity? (robbed of the help gravity offers to other mammals)

2-

Choose to ignore...

Has the basic physiologic knowledge, local in the body, lost any scientific value?

One example:

Nobody knows anything about the local action of oxytocin in the tissues with respect to osmosis and diffusion. OT action is researched, as mediated by ADH/AVP.. mostly in the brain, in terms of aggression, What does it do in the tissues? What role does it have in breaking waters before birth, or the flow of blood (PPH or cord). What does it do to a baby's physiology and stress-adaptation when injected into the mother in a violent large dose?

What are the intellectual frameworks that preside to the determination of which doses of OT to give and when? Do they include the possibility of birthing at ease, like wildlife? This may not seem important to men, of course, but specific questions like this one are embedded in a general Culture: the bible mentions that god punished women with difficulties in birthing. That seems to be spreading in the popoulation. They also cop much weaker health, and a lot more pain and fatigue (other cultural texts). Why?

I thought medicime was not to harm... but Choose to ignore... is at the expense of women and children; that's harm.

We are become away from the simple topic. There are so many studies regarding mode, action of oxytocin. The simple question here is whether oxytocin can be used before or after placental expulsion. I don't understand why autonomic system is coming here. Modern obstetrics is evidenced based. According to cochrane review of active management of third stage of labor, oxytocin is given IM or IV before placental separation. There is no increased incidence of trapped placenta. You have to feel the each component of AMTSL. If you use Oxytocin without CCT there may be trapping of placenta however it does not cause any serious problem. 5 trials have been meticulously reviewed in cochrane review where same technique was not used. If you want to use oxytocin after placental expulsion, it does not harm the general outcome of the mother except it causes slight amount of blood loss in third stage of labor. It solely depends on the physiological procedure of placental expulsion which is practiced in many countries (in UK also). Grossly, the incedence of PPH in physiological management is about 12-20 % whereas in AMTSL it is 4 %. However, if you want to use it after placental delivery there will be increased blood loss that is not statistically significant. PPH definition depends on blood volume of mother not amount.

Hi Prabhat,

I understand that the conversation has drifted but the first premise needed to be challenged i.e. that all women need artifical oxytocin. The research upon which medicine bases AMTSL is flawed in that no researchers controlled the critera for who was eligible for physiologial 3rd stage care nor how it was defined or delivered.

Dear Kathleen Fahy

This is not the time to go back. AMTSL has been proved to be safe and life saving. As I told PPH definition depends on preexisting blood volume not the amount. It is always helpful in rural low BMI women like our country. Then why will we go back?

AMTSL is not effective in reducing PPH rates. If it was then PPH rates in Australia would be lower than they were before AMTSL was made mandatory (i.e. about 5%). Now PPH rates are more like 12% with AMTSL so clearly, it is not working. We need to really understand how medicalised environments and the fear of women and clinicians creates sympathetic stimulation in the woman which causes uterine atony and PPH.

Let me me an intermediary here, and a devils' advocate. You both may be both right and wrong. Apologies if I offend anyone or my 2 bobs' worth is unneeded because the question was specific - it obviously can't be resolved on a specific basis. (or there would be no comments here, apart from a yes or no).

@ Kathleen "proven effective" or not... in what context? Prabhat works in India it seems, Kathleen talks about Australia.There could be different degree of emergency, different baseline health parameters (eg diet and bodily integrity), different birthing conditions etc.. Time to take into account orders of gravity and the baseline health.

@ Prabhat "not go back"... If humans were smart they would look at the consequences of high-developments (eg hi-tech) where they are (in developed countries) and see for themselves that developed countries do not have better health or all-round conditions of life than 'in-development' countries, even though 'basic' development brings many benefits.Again, time to look at orders of 'development' and the baseline.

I live in Australia and have seen it reproduce the errors of Europe and get the same results - no better life.

Westerners look to tradition and 'natural' living for improvement, but traditions included many constraints too, and devaluation as well, plus nature is not always clement [this goes against my experience of it, it is what others say and I respect it, see it in the news about India and other countries]. Traditional cultures look to the West luxuries & medicine for improvement, but "we got cancer & diseases of the century" and a lot of mad behaviour.

Baseline and deploying sympathetic-parasympathetic. Stress is well connected to sympathetic, but parasympathetic can weaken and cause malaise; yogic breathing into the belly can weaken over many years of breathing that way.... The 'balance' notion has been challenged; many just cannot reach it.

What is under West-East or North-South views? We are back to the debates that existed 2000 years ago! What is under that baseline? What is under the generalisations and the fragmented specific questions? After all, both were suppposed to aim at help in humans to live more 'at ease', not 'easier' and dependent on medicine(s) or CNS-mind-brain-head drive, no? Is human life a lot easier than then, as a whole? (altogether?)

Time to look to a truly 'different' way of looking at things in my view. Such debates on specific points and generalisations just lead to ... more of the same... treatments generalised to 'good for everybody'.

Most cases of PPH have no identifiable risk factors. RCOG 52. AMTSL reduce4s the risk of PPH. Definition or cut off value according to WHO it is 500 ml. RCOG cannot deny it but they are continuously saying that up to 1000 ml blood loss, take all precaution for homeostasis as most of the women in Britain tolerate blood loss up to 1000 ml . RCOG also saying that every obstetrician should know the risk factors of PPH those are 4 T’s – tone, tissue, traction and trauma. In RCOG guideline, it is also written that in sympathetic blockage, condition of bleeding women become worst. It is simply ridiculous that sympathetic overflow causes atonicity of the uterus. One of the definitions of PPH is “any amount of blood loss causes hemodynamic instability of the mother is called PPH”. It has been well explained that average blood volume in a nonpregnant women is 70 ml per kg body weight. So in a pregnant woman of 40 kg it would be 2800 ml. when she goes to 32 weeks, it increases to 40 % if proper nutrients are given. The blood volume would be about 4000ml. Just calculate the scenario in case of a pregnant women whose pre-pregnant weight is 60 to 70 kg. (Latest version of Munro Kerr's Operative Obstetrics). Nobody will except the explanation that sympathetic stimulation causes atonocity.

Hi Prabhat, I love it that you continue to think and debate. It is not ridiculous that sympathetic stimulation causes uterine atony; we use Salbutamol, a beta stimulator to stop preterm labour because it relaxes the uterus. So does natural fear.

Madam,

Salbutamol can not relax uterus more than 48 hours.

I must congratulate Dr. Prabhat for debating on the very important and basic topic in childbirth. WHO has clearly mentioned from the review of various RCT's 'Administration of oxytocin before or after placental expulsion does not significantly influence the major clinical outcomes such as the incidence of PPH or duration of the third stage of labour."

Dr. Prabhat you have also read this in ur literature search. The topic we are discussing is very basic in obstetrics. We still after more than 100 years of modern medicine are not sure what is best treatment for the basic in obstetrics. I had already voted Dr. Kathelin's answer purely b'cos she endorsed the natural way. We humans took more than million years in evolution. And at the end of it god has created 1st hand organ with one hormone for two important physiological processes (Lactation and Uterine contraction for delivery and also control of PPH). There has to be some reason behind it. And evolution cannot create a thing (i.e. uterus) which is second hand or which is not best in the business.

Maybe after years of experience everybody will understand the meaning of natural. It is for everybody to see that evolution of medicine for prevention of PPH is going back to the natural. I hope Dr. Prabhat I have made my point clear. For all practical purpose we have to follow what WHO says in recent guidelines which keep changing every now and then. Which is a evidence enough that what we are practicing now may not be correct. And WHO or ACOG or FIGO guidelines from the asserts of various level I evidence studies.

Dear Niraj Mahajan

I like your comment. Without level I evidence we cannot go back (RCOG, ACOG, ICM/FIGO). My thesis was about AMTSL of about 500 partuating mothers. Honeshtly, I completed it. I fell it not read anything about third stage.

Have worked in the UK where the norm is at delivery of the Anterior shoulder and now in North America where the norm is after delivery of the baby. To date have not really seen any difference in PPH or any other sequelae - so I think its personal preference really.

Oh Richard, how can you say taht based on your experience there is no difference in PPH rates! I thought all contemporary health care providers were committed to evidence-based practice. If it is personal preference then how about letting women make an informed decision instead of a clinican having a preference.

In Nigeria the norm is to routinely give an oxytocic after the delivery of the anterior shoulder.

I am currently unaware of any centre that practices post placental oxytocic administration

Comparing the odds of postpartum haemorrhage in planned home birth against planned hospital birth: results of an observational study of over 500,000 maternities in the UK.

Nove A, Berrington A, Matthews Z. BMC Pregnancy Childbirth. 2012 Nov 19; Free full text:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570310/

1% severe PPH at hospital birth, 0.38% at homebirth including transfers.

Interesting read.

Again, no matter what your location, I urge all practitioners to try Judy's 3,4,5 protocol once.

http://www.youtube.com/watch?v=zX1FEJ9SMEw

http://www.youtube.com/watch?v=LOp6Z4mahvA

3-4-5 PROTOCOL: Delivering the placenta in Squatting method at 5 minutes: Required Equipment: Digital watch with seconds displayed (must be digital), Optional: bowl.

At the 36-week prenatal visit, the midwife squats in front of the client to demonstrate how the woman will deliver her placenta 5 minutes after the birth. The client’s consent is obtained. Immediate continuous skin-to-skin contact with the baby is initiated for the first 3 1 ⁄ 2 minutes postpartum. At 3 minutes, using 2 fingers other than the thumb, the cord is checked to see if it has stopped pulsing. A pulsing cord feels like a heartbeat is going through it; 99 percent of cords checked by index and middle finger have stopped pulsing by 3 minutes. The nonpulsing cords are cut at exactly 3 minutes postpartum, if the mother consents, while the baby is in her mother’s arms. The midwife keeps hands off the fundus. At 4 minutes: The midwife directs the mother into a good deep squat with her bottom almost touching the floor or on the floor of an empty bathtub, or over a low plastic bowl if midwife wishes to measure blood loss. If the mother has agreed to the cord being cut, the mother hands the baby to someone. The midwife waits until 5 minutes postpartum for the placenta to be born without intervention other than verbal encouragement to push. Do not wait for the woman to feel a contraction. She pushes without feeling a contraction If the placenta is not born, the midwife assists the cord to come further out by gently pulling it down about 5 cm in length in order to bring the placenta low enough to give the woman an urge to push. The woman is in a low squat while she pushes out and births the placenta. The time of delivery is noted. Immediately after delivery of the placenta, the mother is assisted to put on an absorbant pad and underwear(optional), assisted into bed, and immediately given the baby. The uterus is then immediately massaged to check for clots. If bleeding fills an absorbant pad during the next 5 minutes, a shot of either 10 u Pitocin IM, 0.2 mg methergine IM (intramuscularly), or both is given at 10 minutes postpartum. Early suckling at the breast is initiated, which generally takes place between 10 and 45 minutes postpartum. In the case of a woman with a history of PPH>1000 mL, on previous birth(s), or delivering twins, prophylactic methergine 0.4 cc IM is given as soon as placenta is delivered.

If we manage the 3rd stage with active management we use oxytocin infusion(20 unit+1000cc ringer)after anterior shoulder deliver and clamp the cord afterr birth but in phisiology management we dont use oxytocin and we do cord clamp with delay of course pph risk factor for how to manage the labor is very important for me.

It should be administered before placental expulsion, not only would it act to prevent post partum haemorrhage, it would also facilitate placental separation

• After a long time and reading the answers, it has been seen that issue is controversial.
• I believe that if oxytocin is given im (iv infusion) before separation of placenta and after delivery of baby, It would only contract the uterus. Palm is placed over the abdomen to feel the uterus. When uterus is contracted, give CCT to deliver the placenta without waiting for the signs of its separation. This will decrease the third stage blood loss. 
• If you wait for placental separation and deliver it, it is not associated with increased incidence of PPH, but associated with insignificant amount of third stage blood loss.
• If you give oxytocin before placental separation and don't apply CCT, there is insignificant number of trapped placenta. So, if you use oxytocin, you have to apply CCT when uterus is contracted.
• Cochrane review included six studies from developed countries and found it is beneficial. WHO and other guidelines are  in favour of AMTSL (misinformation given by Niraj N Mahajan). Even it has been clearly expressed that AMTL should be incorporated in each and every women delivering baby in every country. They are also not against it.  
• AMTSL decreases the incidence of PPH from 12% to 4%. Reverse is not correct which has been suggested several time by Kathleen Fahy. This should not be told as every society is in favour of decreasing MMR.
• If you want to practice physiological management, then you have to be positive of BMI, Iron prophylaxis, hemoglobin level, duration of labour and other risk factors of PPH.
• There is no difference between injecting oxytocin before and after placental delivery.
• It has been observed that incidence of uterine inversion have been increased following incorporation of AMTSL (I am saying just observing the incidence before and after the adoption of AMTSL. It could be due to CCT before contraction of uterus. 
• At least, this is a simple issue, there is little scope to avoid or distort the evidenced based guidelines by WHO, ACOG, RCOG and SOGC. 

All the explanations given above are evidenced based. Just follow the methods of AMTSL of the studies included in the 'Cochrane review'.