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The routine use of postpartum Pitocin is a part of the active management of placental birth (third stage of labor) to prevent postpartum hemorrhage, even without signs of postpartum hemorrhage.
How Much Blood Loss is Considered a Postpartum Hemorrhage?
The average amount of blood loss for a vaginal birth is 500mL, and for a cesarean, it is 1000mL.
Postpartum hemorrhage is considered greater than 100mLs of blood loss for a vaginal birth. However, it is now being redefined based on research showing that healthy birthing people are usually unharmed by blood loss up to 1000 mL [1]. And for a cesarean, postpartum hemorrhage is typically considered greater than 1000mL of blood loss.
For perspective, blood loss of around 500mL is like a routine blood donation which is about 2 cups of blood. And the blood that is lost after birth is sometimes also diluted with urine and amniotic fluid. Additionally, there’s already an increase in blood volume during pregnancy (by about 1250 mL) that helps to protect mothers against the harmful effects of blood loss after birth [2].
What is Active Management of the Placenta with Postpartum Pitocin?
Active management is also called “hands-on” management, where the practitioner uses different interventions to try to prevent postpartum hemorrhage.
This management approach came about in an attempt to reduce PPH, the leading cause of maternal deaths in countries defined as “low-income” and accounts for more than a quarter of all maternal deaths around the world [3]. The U.S. Centers for Disease Control (CDC) estimates that PPH accounts for about 11% of maternal deaths.
Additionally, one survey from the U.S. and one from the U.K. found that physicians are much more likely than midwives to use active management [4, 5].
Traditional use of active management from hospital-based practitioners include:
- Giving postpartum Pitocin in the third stage of labor (the birth of the placenta) or another uterotonic drug just before, with, or after the birth of the baby to help the uterus contract more.
- Clamping the umbilical cord early, before the cord has stopped pulsating. For the research on delayed cord clamping, check out the blog post: Unexpected Ways Delayed Cord Clamping Can Make Your Baby’s Life Better.
- Using traction by pulling on the umbilical cord with counter-pressure on your uterus to aid the birth of the placenta and typically make it happen more quickly.
What is Expectant Management of the Placenta
Contrasting active management, “expectant management involves supporting the birthing person’s natural release of oxytocin, waiting to clamp the umbilical cord until it has stopped pulsating (or has gone “white”), and using gravity or the birthing person’s own pushing efforts to birth the placenta. Providers skilled at expectant management use many techniques to support the birthing person’s own natural release of oxytocin” [6].
One study from 2010 looked at all healthy women and compared groups who had an actively managed placental birth vs a holistic placental birth and found that the risk of postpartum hemorrhage increased from 1.7% to 11.2% [7]. Any healthcare professional who knows the physiology of birthing the placenta would say this is an obvious finding.
What Causes Postpartum Hemorrhage?
The placenta is attached to the uterine wall during pregnancy. After your baby is born, your placenta naturally detaches from the uterine wall but is still attached by blood vessels. These blood vessels go horizontally and vertically from the placenta, and you will continue to have uterine contractions that naturally cut off these blood vessels.
During active management, postpartum Pitocin is given, increasing the strength and frequency of these contractions as your provider pulls and guides the placenta out. However, if the provider pulls too hard and rips the placenta from the wall, breaking a blood vessel or multiple, this could lead to extra bleeding. If there are any disturbances to this physiological process, there is a risk of postpartum hemorrhage occurring from the hands-on intervention.
Furthermore, it’s invalid for a practitioner to express concerns about your cervix closing before the placenta is born, as the cervix doesn’t even begin to close after birth until 1 week postpartum.
Tone
Lack of tone in the uterus or uterine atony is when the uterus isn’t contracting as much as it should be to effectively constrict the blood vessels and allow the placenta to detach from the uterine wall.
Uterine atony may be treated with Pitocin, a different pharmaceutical uterotonic, uterine massage, and/or herbs if you are in your home or a birth center.
However, in most cases, uterine/fundal massage is contraindicated if you had Pitocin in labor for induction or augmentation. A systematic review (the highest level of evidence) found that fundal massage is effective when needed if Pitocin was not used, but there was no added benefit for fundal massage when Pitocin was already used during labor or after [8].
The risk of uterine atony increases with Pitocin use in labor because your uterus could become hyperstimulated from excessive or prolonged use of Pitocin in labor. However, research has shown that an injection of Pitocin is still effective even if Pitocin was the cause of the issue.
The risk also increases if you have polyhydramnios (extra amniotic fluid), pregnancy with twins or multiples, or have had many previous pregnancies.
trauma
Such as cervical tears, torn blood vessels, etc. Depending on the trauma, it may need to be treated with surgery.
Tissue
Such as a retained placenta, where a part of the placenta doesn’t come off and out of the uterus with the rest of it.
thrombin
Thrombin refers to either a blood-clotting disorder or if you’re on medications that cause your blood to have fewer blood-clotting factors.
This would be treated with a blood transfusion that contains blood clotting factors.
What is Postpartum Pitocin, and What are the Risks?
Pitocin is synthetic oxytocin that blocks the release of oxytocin. Both Pitocin and oxytocin causes uterine contractions that help birth the placenta and prevent PPH. However, only oxytocin is released from the brain, which helps reduce anxiety, stress, and pain [9].
Oxytocin is also responsible for breastmilk letdown while breastfeeding and is a strong factor in maternal and infant bonding.
Additionally, mothers who have Pitocin during or after labor have an increased risk of postpartum depression or anxiety by 36% [10].
“If it ain’t broke, don’t fix it”
I say, “if it ain’t broke, don’t fix it” because that’s when you’re adding risks to a potentially perfectly fine situation. And recently, despite routine postpartum Pitocin, we’ve still seen an increase in postpartum hemorrhaging.
Researchers in Canada looked back at over 100,000 births to single babies (no multiples) between 1978 and 2007 to try and explain their recent rise in PPH [11].
Overall, 2.3% of the participants had a PPH during the study period, and the rate rose between 1978 and 2007. In addition to the increase in PPH, there was also an increase in labor induction, labor augmentation (speeding up the labor with Pitocin use), and prior Cesarean section over the study period. The researchers concluded that these three risk factors (induction, augmentation, and prior Cesarean) appeared to largely explain the increase in PPH.
Conclusion
There is a time and place for every effective medical intervention. Just because Pitocin use has been proven to help in life-threatening situations doesn’t mean it’s a good idea to then practice this on all women. In fact, that’s not a good idea, as we can see in the research.
Additionally, when looking at the research on postpartum Pitocin use, in some studies using active management improved outcomes in women, but they were only in settings of medicalized birth where many of the women had one or more factors that were increasing their risk of postpartum hemorrhage. On the other hand, when women have a physiological birth without medical interventions, their risk of postpartum hemorrhage is decreased with holistic placental birth (expectant management) compared to active management.
Sources:
[1] Anger, H., Durocher, J., Dabash, R., et al. (2019). How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin? PLoS One, 14, e0221216. Click here. Free full text!
[2] Erickson, E. N., Lee, C. S., and Emeis, C. L. (2017). Role of Prophylactic Oxytocin in the Third Stage of Labor: Physiologic Versus Pharmacologically Influenced Labor and Birth. J Midwifery Women’s Health, 62(4), 418-424. Click here.
[3] Vogel, J. P., Williams, M., Gallos, I., et al. (2019). WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one?. BMJ Glob Health. 4(2), e001466. Click here. Free full text!
[4] Schorn, M.N., Dietrich, M.S., Donaghey, B., et al. (2017). US Physician and midwife adherence to active management of the third stage of labor international recommendations. J. Midwifery Women’s Health 62 (1), 58–67. Click here.
[5] Farrar, D., Tuffnell, D., Airey, R., et al. (2010). Care during the third stage of labour: a postal survey of UK midwives and obstetricians. BMC Pregnancy Childbirth 10 (1), 23. Click here. Free full text!
[6] https://evidencebasedbirth.com/wp-content/uploads/2020/06/Pitocin-Handout.pdf
[6] Fahy K, Hastie C, Bisits A, Marsh C, Smith L, Saxton A. Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study. Women Birth. 2010 Dec;23(4):146-52. doi: 10.1016/j.wombi.2010.02.003. Epub 2010 Mar 11. PMID: 20226752.
[7] Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2013 Jul 1;(7):CD006431. doi: 10.1002/14651858.CD006431.pub3. PMID: 23818022.
More Sources:
[8] Meisenberg, G. and Simmons, W. H. (1983). Peptides and the blood-brain barrier. Life Sciences, 32(23), 2611–2623. Click here.
[9] Kroll-Desrosiers AR, Nephew BC, Babb JA, Guilarte-Walker Y, Moore Simas TA, Deligiannidis KM. Association of peripartum synthetic oxytocin administration and depressive and anxiety disorders within the first postpartum year. Depress Anxiety. 2017;34(2):137-146. doi:10.1002/da.22599
[10] Kramer, M. S., Dahhou, M., Vallerand, D., et al. (2011). Risk factors for postpartum hemorrhage: can we explain the recent temporal increase? J Obstet Gynaecol Can., 33(8):810-819. Click here.
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