My CPMs employ a protocol for PPH that involves one shot of Pitocin, possibly a follow-up shot, and then methargine.  If none of those are doing the trick, they administer Cytocec rectally.  I understand that this is an off-label use for the drug, so I asked them if they had any safety data on this particular use. 

From what they provided me and the limited amount I found online, it looks like there is a lot to support how effective it is, but not much in the way of safety.  Since I don't have access to most of the medical journal articles, do you know of any studies attesting to the safety of Cytotec in the third stage of labor?   (I know that it has a horrendous record for induction and augmentation, but that could be a different ball of wax!)

The bottom line is that I'm trying to decide whether or not to consent to them using it one me.  (For the record, I'm not under any pressure to consent).  Thanks for sharing your opinion on this! 

According to a Cochrane systematic review covering the routine use of Cytotec (misoprostol) to prevent PPH, misoprostol does no better than injectable agents to reduce bleeding, and it is associated with more side effects: nausea, vomiting, diarrhea, shivering, and fever. It also takes longer to work. Pitocin, by the way, also has fewer side effects than ergometrine.

It isn't clear from your e-mail whether your midwives' protocol is routine (active management of 3rd stage) or the protocol they use to treat women who are bleeding too heavily after the birth. If it is routine, get back to me. The chapter on 3rd stage management forthcoming in the new edition of my book Obstetric Myths Vs. Research Realities details all the logic problems and flaws in the research on this issue.

-- Henci

If I don't have my baby before I next see them, I'll be sure to ask about 3rd stage management.  In the meantime, it is in my birth plan not to take any steps unless there is a clear indication of PPH.  Thank you for the reply!