active management

[homemademomma]

talk to me about "active management" of the 3rd stage. opinions, research, experience, etc.

[SublimeBirthGirl]

I don't believe in active management, period. Do you have specific questions?

[onlyboys]

I guess for me, it would depend.

I've read that it's very effective at preventing PPH, while still very intrusive and wrong feeling. If I had a woman who I intuitively thought might hemorrhage, or had hemorrhaged badly with her last births and couldn't or wouldn't improve her health, iron levels, etc., then perhaps I might consider it.

I think active management as a prophylactic measure for every woman is ridiculous.

This is all coming from my relatively uncolored personal perspective. I've only seen 1 pph. I'm still a baby at all this.

How does your practice feel about active management?

[homemademomma]

well, i just read an article in the journal of midwifery about active management being more effective at preventing pph than expectant management, basically because it shortened the 3rd stage, and a 3rd stage over 30min seems to be correlated with a higher risk of pph.

active management does not sit right with me, but i dont know if that is because i am being reactionary, or what.


my practice has no official opinion re: active management.

[onlyboys]

We read the same article! I also seemed to have some across it many times in a short span of time, so I spent some time looking into it from a theoretical standpoint. It does feel wrong, doesn't it?

[pianojazzgirl]

Sorry, not a birth professional, but this is just the question I was coming to post (my dr believes in active management and I want to do my own research). Could you link me to that article if it's available on-line? Or any other on-line research? Thanks!

[BeckiCNM]

Originally Posted by pianojazzgirl

Sorry, not a birth professional, but this is just the question I was coming to post (my dr believes in active management and I want to do my own research). Could you link me to that article if it's available on-line? Or any other on-line research? Thanks!

Other on-line resources (these all support active management):
http://www.aafp.org/afp/20060315/1025.html
http://www.path.org/projects/prevent...hemorrhage.php
http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.06_eng.pdf (note that this one supports delayed cord clamping during active management)
http://www.internationalmidwives.org...ith%20logo.pdf (so does this one)

If you really want the above mentioned article (which is really good, as is that whole issue), PM me and I can email you a PDF. It's not available online.

[amyro]

I'm working on the next edition of Obstetric Myths versus Research Realities with Henci Goer and she just finished the draft of a (new to this edition) chapter on management of 3rd stage. We searched all of the literature and, in a nutshell,

Active management reduces the likelihood of bleeding more than 500cc but is much less effective at reducing blood loss at other, more clinically meaningful thresholds such as 1,000 and not effective at all at reducing likelihood of transfusion or long-term consequences. (Note: 500cc is the same amount of blood that nonpregnant people lose when they donate blood, so it is certainly disingenuous to call this a "hemorrhage," especially since pregnant women have an excess of blood volume compared with nonpreg.)

All studies of active management of third stage are flawed in that not a single study includes a "physiologic" control - i.e., where there was no intervention in the control group women. The only study that looks at completely physiologic management of 3rd stage (which did not include a group that underwent active management) had rates of PPH and transfusion much lower than those reported in active management trials.

You can get the same benefit of active management by not intervening in labor in ways that increase the likelihood of PPH. For example, avoiding episiotomy is equally effective at decreasing the likelihood of PPH as doing active management.

These findings and more in our book which is coming out toward the end of next year!

I hope this helps.
-Amy

[amyro]

I just remembered that Henci herself answered a question about this recently on the Lamaze forum she moderates. She breaks it down a little more clearly than I did, I think. Here's the link:

http://www.lamaze.org/NormalBirthFor...1/Default.aspx

[Peppamint]

Awesome Amy, thanks! I might have to print that to add to my placenta booklet.

I am curious, have any studies been done to show if early cord clamping/cutting affects PPH? I noticed Henci mentioned in the post that Amy linked to, that it helps the placenta detach when baby is receiving the blood they need. Hmm.

[homemademomma]

wow, great responses everyone! thank you!

[pianojazzgirl]

Originally Posted by BeckiCNM

Other on-line resources (these all support active management):
http://www.aafp.org/afp/20060315/1025.html
http://www.path.org/projects/prevent...hemorrhage.php
http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.06_eng.pdf (note that this one supports delayed cord clamping during active management)
http://www.internationalmidwives.org...ith%20logo.pdf (so does this one)

If you really want the above mentioned article (which is really good, as is that whole issue), PM me and I can email you a PDF. It's not available online.

Thank you so much for the links! I'm going to read through them now.

[amyro]

Originally Posted by busybusymomma

I am curious, have any studies been done to show if early cord clamping/cutting affects PPH?

Yes, it does decrease bleeding to "drain the placenta". The way researchers studied this, unfortunately, is to clamp immediately, cut, and then unclamp the placenta side of the cord and drain the blood into a bowl. But an unclamped cord delivers that blood to the baby (return blood to the placenta ceases well before blood flow from the placenta to the baby).

Also, active management protocols used to call for immediate clamping and that has been dropped from the active management "cocktail"

Glad you found the info helpful!
-Amy

[etoilech]

Originally Posted by amyro

I'm working on the next edition of Obstetric Myths versus Research Realities with Henci Goer.

OT: Have any idea when this is going to print?:

[amyro]

We're looking at late 2008 or early 09. We're chugging along, but it's a huge project.

Thanks!
Amy