Active Management of Third Stage

[AmieV]

Well, color me shocked and ignorant because I had no clue that A guide to Effective Care in pregnancy and childbirth advocated active management of third stage labor, stating that it creates a 70% reduction in PPhemorrhage, and that the WHO endorses this as well.

Does someone want to explain this to me as well as point me in the direction of research that proves the contrary? Because this seems completely counterintuitive and backwards to me and it's weird because the WHO and AGTECIPAC have historically backed up my opinions not refuted them!

[sapphire_chan]

Question. What is the definition of "active" management?

I suspect that it might be more "pro-active" and less "aggressive".

[AmieV]

It's pretty damn aggressive IMO.

*prophylactic IM pit
*cord traction
*early cord clamping/cutting

The definition of AM in the book is all three components though they mention that most providers aren't strictly AM or expectantly managed...most use some elements of both.

[olive&pimiento]

Active management of the third stage entails giving oxytocin with the birth of the baby's shoulders, early clamping of the cord and controlled cord traction. It has been shown to prevent PPH and the reason that WHO would endorse it is because their are areas in the world where women cannot stand to lose one extra drop of blood. (check out baby catcher africa's blog) Due to extreme famine and disease, they are severely anemic. I agree that is an aggressive approach for all births, though it is evidence based and that is probably why it is in the book.

Here is an older study:

BMJ. 1988 November 19; 297(6659): 1295–1300. PMCID: PMC1834913

Copyright notice
The Bristol third stage trial: active versus physiological management of third stage of labour.
W. J. Prendiville, J. E. Harding, D. R. Elbourne, and G. M. Stirrat

[BeckiCNM]

Originally Posted by AmieV

It's pretty damn aggressive IMO.

*prophylactic IM pit
*cord traction
*early cord clamping/cutting

The definition of AM in the book is all three components though they mention that most providers aren't strictly AM or expectantly managed...most use some elements of both.

WHO's definition of active management is actually:

*immediate oxytocin (usually defined as sometime after the birth of the baby and before the placenta is delivered)
*controlled cord traction
*uterine massage

Neither the FIGO (international version of ACOG, but more likely to pay attention to the evidence) or the ICM definitions of active management include early cord cutting either. WHO recommends delayed cord clamping, even with active management.

http://www.who.int/making_pregnancy_...aemorrhage.pdf

[AmieV]

found this w/ regards to the Bristol study
http://www.midwiferytoday.com/articles/bristol.asp

I understand why it would be recommended in certain demographics, but for everyone? as a standard practice? I'm pretty sure most of mws on mdc (pamamidwife in particular) don't use any of the components routinely and have good results.

[AmieV]

oh, and the 5 studies referenced in Effective Care use the 3 criteria I listed above, including early cord clamping.

[BeckiCNM]

Both the Guide to Effective Care and the Cochrane review of active management date back to 2000 - which is practically an eternity in the world of evidence based practice and research. Newer guidelines do not include the cord clamping as a necessary part of active management, because newer studies show the benefits of delayed cord clamping.

Edited to add another link:
http://www.pphprevention.org/files/I..._Statement.pdf

This clearly states clamp the cord after pulsation stops in a normal birth.

[Turquesa]

Originally Posted by AmieV

Well, color me shocked and ignorant because I had no clue that A guide to Effective Care in pregnancy and childbirth advocated active management of third stage labor, stating that it creates a 70% reduction in PPhemorrhage, and that the WHO endorses this as well.

Does someone want to explain this to me as well as point me in the directionof research that proves the contrary? Because this seems completely counterintuitive and backwards to me and it's weird because the WHO and AGTECIPAC have historically backed up my opinions not refuted them!

Sorry if non-pro's aren't allowed in here.... : I'm just intensely interested in the topic. It may not be entirely accurate to say that the WHO backs it 100%; rather, it backs it with some notable caveats.

I found a 1997 statement from the WHO, although I'm not sure if it's based on obsolete data: http://www.who.int/reproductive-heal...apter5.en.html

"In conclusion, oxytocin administration immediately after delivery of the anterior shoulder, or after delivery of the infant, seems advantageous, especially in women with increased risk of postpartum haemorrhage or in women endangered by even a small amount of blood loss, for instance women with severe anaemia. Doubts remain about the combination with controlled cord traction, and about the routine application in healthy low-risk women. Recommendation of such a policy would imply that the benefits of this management would offset and even exceed the risks, including potentially rare but serious risks that might become manifest in the future. In our opinion it is too early to recommend this form of active management of the third stage for all normal low-risk deliveries, although we note the earlier recommendations made by WHO (1990, 1994c). If for various reasons active management is employed, a number of questions remain unresolved, particularly regarding the optimal timing of prophylactic oxytocin injections."

And there's some ambiguity on the cord clamping issue:

"If controlled cord traction after oxytocin administration is practised, as is the case in many obstetric departments worldwide, early or relatively early clamping of the cord is mandatory. However, where late clamping is taught and practised, i.e. after the pulsations of the cord have ceased, usually after about 3-4 minutes, adverse effects have not been recorded. In addition, recent research supports late clamping, because it may prevent iron deficiency anaemia in childhood, which might be of special importance in developing countries (Michaelsen et al 1995, Pisacane 1996). Although at present there is insufficient evidence on which to decide between early and late clamping, this issue clearly deserves more attention."

[AmieV]

Well, barring the age of the book, and the cord clamping, the WHO is still advocating for cord traction and prophylactic oxytocin. Not for high risk populations, mind you, but for everyone, stating that there are clear benefits.

If the rationale is that the research is so old BeckiCNM, where is the new research that refutes this? That's really what I'm most interested to know.

As midwives, CBE's, doulas, etc. we claim to pratice and educate based on evidence. I'm just trying to make sense of this "evidence". How many times do we talk about how the WHO recommends breastfeeding till 2? Isn't it then a bit contradictory to say, without new evidence, that we don't agree with what the WHO says on something else evidence based?

So maybe I wan't clear, what I am MOST interested in is to find things like the midwiferytoday link I posted that refute the policy of actively managed third stage. My guess is that it's more helpful in actively managed BIRTHS, because there is less natural oxytocin flowing, but I would really like some information on the outcomes of expectantly managed third stage at homebirths or physiological natural hospital births (of which I suspect there is little). Clearly a woman who has been on Pit all day long is at a greater risk of hemorrhage, so were the studies looking at women like that? And was expectant management, like the midwifery today article states, really just sitting on your hands doing nothing even in the face of a potential hemorrhage? These are the kinds of questions I have that haven't really been addressed.