Objective To compare the effect of intramuscular Syntometrine and Syntocinon in the management of the third stage of labour.Design A randomised double blind prospective study.Setting Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Hong Kong.Subjects One thousand consecutive patients with singleton pregnancy and vaginal delivery in February and March 1993.Results The use of Syntometrine in the management of the third stage not only reduced the blood loss after delivery but was associated with a 40% reduction in the risk of postpartum haemorrhage (odds ratio 0.60; 95% CI 0.21–0.88), and the need for repeat oxytocic injections (odds ratio of 0.63; 95% CI 0.44–089). The two drugs did not differ in their effect on the duration of the third stage. However, the incidence of manual removal of the placenta was higher when Syntometrine was used (odds ratio 3.7; 95% CI 1.03–123), although the overall incidence remained low. Side effects from both drugs, such as nausea, vomiting, headache and hypertension, were uncommon.Conclusion Intramuscular Syntometrine is a better choice than Syntocinon in the management of the third stage of labour.

A case of secondary infertility, dysmenorrhoea and menorrhagia due to retained fetal bone is presented. Retained fetal bones should be considered in all patients with infertility, dysfunctional uterine bleeding, dysmenorrhoea or other symptoms dating from a pregnancy or pregnancy termination. Ultrasound is an excellent modality for evaluating these patients. Ultrasound is also very useful for the follow-up of patients after surgical removal of the bony fragments. Some bony fragments may be embedded in the endometrium or myometrium and may not be identified at curettage. Hysteroscopy is valuable in both establishing the diagnosis and the removal of bony fragments. A crucial aspect of the procedure involves reintroduction of the hysteroscope to document that the cavity is clear after attempts at bone removal are complete. After removal of bony fragments, restoration of fertility and improvement of symptoms are expected.

EDITORIAL COMMENT We accepted this paper for publication because there are surprisingly few papers in the literature about how best to deal with vaginal lacerations and pelvic haematomas. It is generally agreed that postpartum haemorrhage from the uterus cannot be dealt with effectively by packing the uterus because the uterus distends, bleeding continues and the pack becomes dislodged. However bleeding from vaginal lacerations, with or without an associated episiotomy, is a different matter because the vagina lies within the bony basin of the pelvis and this can be effectively packed to give rapid haemostasis, i f the blood is clotting normally, although the ribbon gauze pack must be long and wide (200 x 10 cm) and in the editor's experience 2 such packs need to be tied together to do the job properly. The pack should be moistened with obstetric cream so it can be introduced without causing trauma to the vagina. Since such packing occludes the urethra, an indwelling (Foley) catheter is required until the pack is removed, usually 12 hours later; healing of any unsutured vaginal lacerations is usually quite satisfactory (A). The editor has the indelible memory of a patient who in 1964, following a dificult mid-forceps delivery, was seen to have large bilateral vaginal tears which bled profusely. There was no possibility of dealing with the problem with sutures and 2 packs as mentioned above were quickly inserted, together with an indwelling catheter; and the patient was given a 2-pint blood transfusion. The pack was removed the next day without any further problems. At the 6 weeks postnatal visit the vagina was well healed but somewhat distorted, However at the patient's first antenatal visit in her next pregnancy, the vagina appeared normal and she proceeded to term and had an uneventful, safe delivery. Following this experience and throughout his obstetric lifetime, the editor always used a gauze pack in any patient who had a large episiotomy as a prophylaxis against a paravaginal or vulval haemutoma. Cases of vulval haemutoma reoccurring after an episiotomy has been repaired, suficient to take the patient to theatre, as described in the 5 cases reported here, is a major surgical exercise which can probably be avoided, in many cases, by routinely packing the vagina when a large episiotomy repair has been necessary, as outlined above. During the subsequent 30 years of obstetric practice the editor was certainly not taking I in every 290 patients he delivered, the incidence herein reported, to theatre to deal with a vulval haematoma. This pack, catheter plus antibiotic regimen avoids serious morbidity and probably also mothers' lives. (A) Beischer NA, Mackay EV, Colditz PB. Obstetrics and the Newborn, An Illustrated Textbook, Thjrd Edition, Saunders 1997: p 545. AUTHORS' REPLY TO EDITORIAL COMMENTThe frequency of cases of perineal haematomas at the Sutherland Hospital has been much less since the audit of cases reported here.