Thoughts on active vs passive mgmt of 3rd stage (delivery of placenta)?

[MamaKickyPants]

I'm having to make a decision on this at some point soon - I am 35 wks and planning a homebirth w my 2nd. We did active mgmt w my son, and everything was fine, but I'm leaning toward passive this time b/c well, why intervene if u don't need to plus, my midwives carry oxytocin and would administer it at the first sign of hemorrage. It acts fast is my understanding. Also, the idea of (even gentle) cord traction freaks me out.
To complicate things, my mom is an experienced midwife and I know that she thinks active mgmt is better. I know she will respect my decision regardless, but I really trust her judgement and it makes me 2nd guess myself...

[kltroy]

Pros: active management significantly reduces risk of hemorrhage by 65% and maternal low hemoglobin (>9, due to blood loss) by 50%.  (see this excellent summary of the best available evidence on the topic:  http://www.ncbi.nlm.nih.gov/pubmed/20614458)

Cons: Active management reduces birth weight of the baby (because less of the cord/placenta blood flows into the baby), and increases after pains and need for pain relief due to after pains. 

I decided during my last birth to not have active management - this was a hospital birth (though generally intervention-free).  I was told that the only disadvantage to doing it that way was that if I did hemmorhage they would have to give me oxytocin in the thigh (ie I would get stuck with a needle).  If they did it "actively" they could put it in through the saline lock that was in my hand.  Since you're a home birth you probably won't have a saline lock anyway, so this is not really a consideration I would think.

I will say that, while I did not come close to hemorrhaging, I did feel pretty light headed after my birth - daughter was born at 3:26 AM and it wasn't until around 12 hours later that I could really stand up for long enough to take a shower without getting dizzy.  (and I was pretty gross - I needed one!!).  If I had to choose again, I'm not sure whether I'd care too much one way or the other.  I didn't feel like I "got anything" out of the experience....

Best of luck with your choice.

[CookAMH]

There is a good thread on the homebirth board discussing pit specifically in homebirth which helped me think it through, at least as far as pit goes. I don't feel comfortable at all with cord traction, needing the placenta to come out sooner than it really needs to, or massaging before it's necessary. But I have written on my birth plan that I consent to prophylactic pit if my midwife felt it would prevent a hemorrhage, depending on how the second stage of labor is going. I felt that preventing anemia or weakness for hours after the birth, or a possible need to transfer, would be worth it. She errs on the side of wait and see though, but getting a shot in my thigh after the fact isn't a huge deal to me.

ETA: link to thread I mentioned http://www.mothering.com/community/forum/thread/1295548/pit-after-the-birth

Edited by CookAMH - 3/28/11 at 9:47pm

[mwherbs]

I think much of this has to do with the skill and training of the provider.
In Austrailia they did a fairly recent study on low risk for hemorrhage population and the active management group were 7-8 times as likely to have hemorrhage .Additionally the majority of the active management studies were in clinical settings before the delayed cord clamping studies showed benefit to babies to delay cutting the cord.
Perhaps have ypur mom look at this study and the review.


br />Women Birth. 2010 Mar 10.
Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: A cohort study.
Fahy K, Hastie C, Bisits A, Marsh C, Smith L, Saxton A.
The School of Nursing and Midwifery, The University of Newcastle, University Drive, Callaghan, 2308, Australia.
>>>>>>>>>>>>>>>>>skipping to the end of the abstract>>>>>>>>>
"CONCLUSION: This study suggests that 'holistic psychophysiological care' in the third stage labour is safe for women at low risk of postpartum haemorrhage. 'Active management' was associated with a seven to eight fold increase in postpartum haemorrhage rates for this group of women. Further prospective observational evaluation would be helpful in testing this association."

---

I think it takes quite a while for research to alter practice on a world wide level so in recent years the older studies influenced WHO to recommend active management, but there have been problems in having pitocin on hand to accomplish this,and not enough trained professionals to do it as recommended in the older studies, so they have been experimenting on 3rd world populations
Trying to figure out if no pit will work they are also looking at using misoprostol for this, to confound this movement is the info about delayed cord clamping being healthier for babies. No absolute newer protocols have been figured out. I do think there are more studies underway in OZ like the one above. So keep checking pub med.

Here is one Review reference, they included 4 studies, their conclusions were things like babies weighed less in active management group due to quick cord clamping and there were more returns to the hospital for bleeding( which means over all blood loss probably not any better, but they would have stopped measuring blood loss)

Cochrane Database Syst Rev. 2010 Jul 7;(7):CD007412.
Active versus expectant management for women in the third stage of labour.
Begley CM, Gyte GM, Murphy DJ, Devane D, McDonald SJ, McGuire W.

School of Nursing and Midwifery, Trinity College Dublin, 24, D'Olier Street, Dublin, Ireland, Dublin 2.

[MamaKickyPants]

Thanks all - I've talked it over with my second midwife and she had some good insight about the research (ie: it doesn't necessarily apply to the way midwives practice in Canada and that expectant mgmt is totally fine) and we're going with expectant mgmt with go on the oxytocin at the slightest indication of an issue. I'm happy with that. 

[anne1140]

Can Pitocin and delaying cord cutting go hand in hand? I am okay with consenting to Pitocin, but I would like to delay cord cutting for a few minutes, and no cord traction.

[CookAMH]

Originally Posted by anne1140 

Can Pitocin and delaying cord cutting go hand in hand? I am okay with consenting to Pitocin, but I would like to delay cord cutting for a few minutes, and no cord traction.

I believe it can. In my consenting to prophylactic pit at my upcoming homebirth, it would be taking place after delayed cord cutting.