# Necessary? Uterine massage and pitocin shot after delivery



## SeekingJoy (Apr 30, 2007)

I have been looking for research about hemorrhaging and why the current hospital standard of care is uterine massage and a shot of pitocin. Since I have/will have none of the risk factors for hemorrhage (induction by pitocin, multiple fetuses, first pg, etc) is are these preventive measures really necessary? Is it enough to check my own? Are there additional risks of pitocin and active management of the third stage of labor (cord traction for delivery of placenta)?


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## Smalls181 (May 12, 2006)

This happened to me and let me tell you it was by far the most excruciating pain Ive ever felt. Worst than labor. Worst than delivery. Worst than the tear. Worst than the ovarian cyst that weighed down and twisted by ovary and fallopian tube resulting in surgery. In fact, thinking about it makes me want to puke. So, Ide be interested in hearing some info on this.


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## SublimeBirthGirl (Sep 9, 2005)

Of course it's not necessary. If it were, the species would have died out before it was ever truly begun as women bled out after giving birth. Breastfeed your baby. There are lots of bad things about cord traction. Is your HCP talking about this stuff? If these things are mandatory I'd be switching!


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## RachelGS (Sep 29, 2002)

I HATE uterine massage. I had it the first time when my uterus was still boggy a good while after giving birth, and the second time as a matter of course. But it's awful. I'd be all about skipping it next time. It's incredibly painful and I'm not convinced that it's necessary.


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## MeepyCat (Oct 11, 2006)

I wound up with uterine massage and the pitocin shot not as preventative measures but because I was hemorrhaging. Had I not been actively bleeding, I would have told the OB to shove it (in fact, I tried to do just that before she told me what was going on). My understanding is that these are active management techniques that are most appropriate when problems are actually present. I can't think why they'd be part of the standard of care for someone with a normal delivery.

Uterine massage was really painful (even with the epidural), and prevented me from holding the baby right away. I was lucky to give birth in a baby friendly hospital where they gave DS to DH to hold instead of taking him to the nursery while they did this, but there are only 58 of those in the U.S. It was, in short, the suck, and was only acceptable to me on the understanding that that it was intended to address something going very wrong. (I would be fascinated to hear it if anyone has any info on how uterine massage addresses hemmorhagic post partum bleeding and whether it does any good or just annoys the fuck out of the patient.) (Sorry for the cussing, my L&D experience kind of brings that out.)


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## Romana (Mar 3, 2006)

Quote:


Originally Posted by *SeekingJoy* 
I have been looking for research about hemorrhaging and why the current hospital standard of care is uterine massage and a shot of pitocin. Since I have/will have none of the risk factors for hemorrhage (induction by pitocin, multiple fetuses, first pg, etc) is are these preventive measures really necessary? Is it enough to check my own? Are there additional risks of pitocin and active management of the third stage of labor (cord traction for delivery of placenta)?

No, it's not necessary unless you're hemorrhaging, in which case the first line of defense should be BF anyway.

I think the best management of 3rd stage is as follows (and all of these minimize the risk of PPH):

Allow cord to stop pulsating before clamping or cutting.

Immediately after birth, place baby on mother's chest. Encourage mother to nurse baby, if mutually desireable. Do not separate mother and baby.

Allow placenta to be delivered naturally, without any augmentation. Wait for it if it isn't delivered within 15 minutes. Wait at least an hour, unless the mother is bleeding heavily.

Those steps maximize the chance of the placenta coming out in one piece, on its own. If there is a piece of retained placenta or the placenta is still in there and there's a lot of bleeding, manual removal may be the next best step.

Once the placenta is out, nothing should be done unless mother is having a PPH. Some bleeding is normal. No pitocin shot, no massage, no reaching in there for clots or anything else. Again, encouraging some breastfeeding will help the uterus clamp down and stop bleeding.

If the placenta is out and the mother is bleeding heavily, after breastfeeding (or in conjunction) shepherd's purse is a good first line of defense. Some midwives also use cayenne tincture. You can follow that up with pitocin if the herbs don't work, or methergine, or both, or cytotec rectally. Also can try fundal massage at that point or bimanual compression. At the end of the list, those options are for severe PPH with mother about to die. They are not necessary by any stretch of the imagination for an ordinary second stage with minimal, average, or even a bit above average bleeding.

Cord traction, of course, drastically increases the risk of PPH by pulling the placenta away from the uterine wall before it's ready. This can lead to retained pieces of placenta or simply the uterus not getting the "message" to clamp down prior to removal of the placenta, so the blood is being pumped to the site of attachment and there is no placenta, hence the hemorrhage.

HTH. None of those (cord traction, pitocin shot, fundal massage) should be standard procedures.

I did read TWO birth stories recently where a woman was subjected to all three. In both stories, there was ZERO indication for any of these procedures being done. In one of them, cord traction was performed _six minutes_ after the baby was born.

ETA: I'm not a HCP. This is my opinion based on pretty extensive research and experience.


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## CEG (Apr 28, 2006)

It's called "Active Management of the Third Stage" and is promoted by WHO to prevent deaths from postpartum hemorrhage.

One of the interesting things is that it is practiced very widely but actually early cord clamping is not really part of it, although many practitioners believe it is and cut the cord early.

I hate performing uterine massage but it actually is effective in firming up a boggy uterus. Most of our moms do breastfeed immediately after birth but occasionally there is a uterus that will not stay firm. It's often related to a full bladder but not always. We also have to check the height of the fundus with each assessment to ensure the uterus is involuting properly and that can be uncomfortable. I guess an unexpected fundal height could signal an issue like retained placenta but it doesn't seem to be a super good indicator of anything in a woman with no other symptoms.

So, active management of the third stage is considered to be effective at preventing postpartum hemorrhage but is probably not necessary for the vast majority of healthy US/ other well-fed women.


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## lyttlewon (Mar 7, 2006)

Quote:


Originally Posted by *CEG* 
It's called "Active Management of the Third Stage" and is promoted by WHO to prevent deaths from postpartum hemorrhage.

One of the interesting things is that it is practiced very widely but actually early cord clamping is not really part of it, although many practitioners believe it is and cut the cord early.

I hate performing uterine massage but it actually is effective in firming up a boggy uterus. Most of our moms do breastfeed immediately after birth but occasionally there is a uterus that will not stay firm. It's often related to a full bladder but not always. We also have to check the height of the fundus with each assessment to ensure the uterus is involuting properly and that can be uncomfortable. I guess an unexpected fundal height could signal an issue like retained placenta but it doesn't seem to be a super good indicator of anything in a woman with no other symptoms.

So, active management of the third stage is considered to be effective at preventing postpartum hemorrhage but is probably not necessary for the vast majority of healthy US/ other well-fed women.

How long do you wait before you determine a uterus is boggy? A friend of mine had uterine massage before she had even birthed the placenta. It didn't appear they were checking her for anything just rubbed it automatically. I didn't see them mesure fundal height so how would they know if it was unexpected?

OP I had pitocin to control my hemmorage and it was very painful as the PP mentioned. I don't remember uterine massage though. I had read somewhere that giving pitocin to a tired uterus can actually increase hemmorage. Does someone have an article they can share on that?


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## QueenOfThePride (May 26, 2005)

If the newborn baby is left skin-to-skin on mama's belly, wouldn't his/her feet naturally do uterine massage as he/she crawls up to find a nipple?


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## MMGerard (Oct 26, 2005)

My last child was born at a teaching hospital and they did not do the uterine massage. They said it was not necessary because I was breast-feeding.


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## CEG (Apr 28, 2006)

Quote:


Originally Posted by *lyttlewon* 
How long do you wait before you determine a uterus is boggy? A?


The hospital policy is to check the fundus about every 15 minutes after the placenta was birthed for an hour, then every half hour after that for two hours. If at any point during that the uterus was boggy then it would be reason to do uterine massage. This is for nurses, the provider would do their own thing prior to birthing the placenta (usually they choose to yank
on the cord for awhile







)

I think a lot of people confuse checking the height of the fundus with uterine massage. This is simply feeling to see if the fundus is above/even with/below the umbilicus and how far. There are certain expected levels at different times after birth. Although you do sometimes have to apply a little pressure to feel the fundus it shouldn't be really painful- just a quick hand on the belly. Mama should not have to put down the baby or stop nursing.

I've never waited after feeling a boggy uterus- just a boggy uterus is a boggy uterus. Really it's pretty rare- I think one lady I saw birth naturally was boggy following delivery and ended up with higher order meds. Massaging her uterus would cause it to firm up and bleeding to slow but once massage was discontinued she would bleed again. With the epidural mommies it seems to happen a little more often but still not too much and usually it is not really painful for them because they are still feeling the effects of the epi.

This was all in the hospital which I do not love. I do think that if you explain properly to the mom what you are doing ("your uterus is not as firm as we would expect and this is causing you to bleed. We would like to massage your uterus which may be painful but will can help us avoid needing medications or more drastic measures later."). It certainly isn't nice to just start mashing on a woman's belly after giving birth for no good reason. I remember it well from my own births (before I knew any better) and dreading it.


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## cottonwood (Nov 20, 2001)

Quote:


Originally Posted by *QueenOfThePride* 
If the newborn baby is left skin-to-skin on mama's belly, wouldn't his/her feet naturally do uterine massage as he/she crawls up to find a nipple?

Yes, the weight and movement of the baby is a natural kind of uterine stimulant, as is breastfeeding as others mentioned, and just being near the baby, smelling the baby, focusing on the baby. Also mothers who are not distracted with discussion and awareness of others during third stage very often instinctively lightly massage their own bellies. Any mother could do this consciously as well, of course.

The most important thing is that the mother not be distracted. There is so much activity usually at birth and immediately after -- even if there is no emergency, the baby is thrown on top of the mother (or taken away), rubbed down with towels, suctioned, people are talking, the mother's being stitched up, the baby is being weighed, dressed, etc. There is just a lot going on. But the birth process isn't over and it is still crucial that the body continue to release the proper hormones, and it won't do that optimally with all that going on. Hence, the "need" for prophylactic treatment.


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## Nan'sMom (May 23, 2005)

I had uterine massage with dd1 with a mw who had assured me that she didn't do active management of third stage...I guess she didn't think it important to inform me about the uterine massage (she called it "fundal support"). I found it intensely painful, made her stop, although she said that my uterus could fall out so I agreed to do it myself, which was awful too but not quite as bad. I researched it a lot before my UC, and experimented afterwards. It felt so horrible that I felt certain it was the wrong thing for me to do. It was SO wonderful to bond with my baby and not have anyone fretting about uteruses falling out, placentas taking "too long", etc. I was so happy!


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## kerikadi (Nov 22, 2001)

I had massage with #1 and pitocin and massage with #2, of course both were hospital births and there was no indication of hemmorage.

My next three were born at home and I had neither and no bleeding issues. I actually bled less with my homebirths.

Keri


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## wombatclay (Sep 4, 2005)

I had SD followed by a 4th degree tear (so plenty of bleeding) followed by a "stuck" placenta (it was "caught" a little on my c/s scar). They didn't do fundal massage but did use pitocin. They didn't ak but I was ok with it...the blood loss was scary and I wasn't in a position to discuss it! They did wait about 8 minutes to cut the cord since I was breathing for dd while they resusitated her (on my belly).

I think pit on hand is a good idea for any birth, but certainly not necessary in most cases!


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## guest9921 (Nov 3, 2005)

Its absolutely unnecessary.
I had the whole array of unnecessary interventions.

Pitocin to birth the placenta.
Cord traction.
Immediate cutting of cord.
Uterine Massage while birthing the placenta.
Uterine Massage afterwards - by many different nurses, at many different points.

Never was I asked, or asked to consent, nor was I told what was happening - it was a "this is happening to you now, lay down" bit - and unfortunately I was foolish enough to let it continue.
It is unbelievably painful, and I will add that it topped pitocin labor, stitching and everything in between.

I had no indictation of PPH, nor was I bleeding heavily. It was 'standard care'.


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## pinksprklybarefoot (Jan 18, 2007)

I had both the pit injection and massage. They waited to cut the cord, placenta came out naturally, bf'ed right away.

I did have pre-e and was hemhorraging.


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## mwherbs (Oct 24, 2004)

in a hospital setting with a room full of busy other people- it might be a necessary couple steps-- I have no idea how to prevent hemorrhage in that setting given what they are working with and doing- I was massaged and given shots and still hemorrhaged at the hospital-- I know what I do at home to help prevent a hemorrhage- including dietary and supplemental advice in pregnancy- then try to help feed, hydrate and have mom empty her bladder in labor- mom pushes a baby when she gets the urge and starts pushing- we ask for mom to not use a cell phone before the placenta is out -- and we talk about the importance of just really taking the time to look at pay attention to and get to know the baby as well as take care of herself and settle in to what she feels, this may or may not include nursing a baby ,we respond to the appearance smell and sounds of a baby as much as to them suckling- notice how breastfeeding women will have a let-down when they hear a baby crying, not all babies latch and attach in those first bit of time --- when the placenta is ready to separate there is usually a gush of blood and mom feels uncomfortable- wants to move or knows she wants the placenta out- the placenta comes and that is that- now if a room full of family is the distraction I watch more, a light hand on a fundus can be stimulation enough and sometimes it does take something more- if I firmly grasp a uterus it is with the intent of stopping a hemorrhage- in which case it would be pretty much a firm grasp in 1 or 2 hands- not just to rough it up- too rough of handling will actually congest a uterus and increase bleeding in the long run- and we will give a pitocin shot if the other things are done then these last ones don't need to be done very often- but sometimes it just does... so they aren't the first things I do but they have their place on a continium to protect a mom


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