I am regularly contacted by individuals and practitioners enquiring about the routine prophylactic administration of 10iu of intramuscular (IM) Syntocinon (synthetic oxytocin) following the birth of baby.
Recommended to reduce maternal blood loss and facilitate the delivery of the placenta, there are questions regarding the timing of administration of Syntocinon and whether this interacts with placental transfusion through delayed or optimal cord clamping.
**Note**
This blog is not intended to advocate against human physiology which is, within our medicalised model of care compromised through many complex factors such as: hospital setting, birth spaces, multiple caregivers, induction of labour, augmentation, epidural, medication and much more. Women should be supported in their choice for physiological placental birth if they wish, this means the options for third stage of labour should be discussed properly so women can make an informed decision based on their individual circumstances and risk factors. And most importantly, the midwife should advocate to optimise physiological hormonal processes.
NICE guidelines (2014) recommend all woman to have active management of the third stage, because it is associated with a lower risk of a postpartum haemorrhage and/or blood transfusion. For active management NICE suggest 10 IU of Syntocinon by intramuscular injection with the birth of the anterior shoulder or immediately after the birth of the baby.
Despite the rigorous research undertaken by NICE prior to producing the recommendations, practitioners continue to query whether oxytocin immediately after birth is the ideal time to administer the injection. Some practitioners have concerns about whether this impacts of the amount of blood the baby receives through DCC.
A recent randomised control trial (RCT) by Satragno et al., (2018) provides answers to this question. Their primary outcome to measure weight gain (by blood transfer) using two groups:
Group A- where Oxytocin (10 IU) was given IV within 15 sec. of birth
Group B - where Oxytocin (10 IU) was given IV after clamping the umbilical cord 3 minutes after delivery.
In their study babies were weighed soon after birth at the level of the vagina using a 1g precision scale and then placed on the mother's abdomen or chest. At 3 minutes, in both groups, the cord was clamped and cut and weight was obtained again on the same scale. There were no differences in the primary outcome.
Infants in group A (n: 70) gained 86g and in group B (n: 74) 87g. Haematocrit was 57% in group A and 56.8% in group B. No differences were found in any secondary outcomes including jaundice, polycythaemia and maternal postpartum haemorrhage. In their research they conclude that the volume of blood is not impacted by routine use of synthetic Oxytocin.
This new research helps to alleviate the concerns over the variations in timing of Syntocinon administration in clinical practice. Some midwives prefer to give the oxytocic early and others prefer to wait until umbilical cord pulsations have ceased. Either way, blood volume transition to the newborn is not shown to be compromised.
Maternal Outcomes
It is important for midwives to practice autonomously, if active management is strongly indicated (previous PPH, induction of labour) then early administration may be preferable.
However a Cochrane review by Soltani, Hutchon and Poulose (2010) which discusses the timing of prophylactic uterotonic administration (synthetic oxytocin) and maternal outcomes such as postpartum haemorrhage, retained placenta and length of third stage of labour found that oxytocin administration either before or after birth of the placenta was not shown to have have any clinically significant difference on outcomes.
This being the case and given complexities of human physiological processes, research limitations and gaps in our knowledge, it seems logical to defer administration of the oxytocic until after delayed or optimal cord clamping.
In this way protecting the newborn from unnecessary exposure to synthetic hormones, protecting the physiological process of the third stage of labour and potential impacts on the immediate postpartum period such as breastfeeding.
Summary
Concerns that early administration of synthetic Oxytocin (with anterior shoulder) may either enhance or diminish placental transfusion have, in this study, shown not to be significant. Placental transfusion to the newborn is unaffected by routine uterotonic administration either with the anterior shoulder or administration after delayed cord clamping of 3 minutes.
#DCCoxytocin