SimonMommy:
In the Kashion article, I would like to point out that the control group was not managed expectantly. Everyone in the group received prophylactic pitocin after the birth of the placenta. It's considered "mixed management". Also the cord traction management occurring "immediately following the uterotonic" sounds very aggressive- no mention of looking for signs of separation? In my opinion it's possible that overly aggressive cord traction could have led to the higher rate of blood loss in the intervention group. The most recent research on cord traction supports that. By the way, the Cochrane review you listed next excluded this study from its analysis "because of the high rate of exclusion after randomization (48%)".
From Begley:
"Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. In the subgroup of women at low risk of excessive bleeding, there were similar findings, except
there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours)...
Overall, active management reduced the risk of severe bleeding, but it would be important to investigate if this benefit arose from the uterotonic component of the active management alone. The negative effects of active management appear, in the main, to be due either to 1) the administration of a specific uterotonic (e.g. hypertension due to ergometrine-containing preparations and hypotension due to IV oxytocin boluses (Lewis 2007)) or 2) possibly to controlled cord traction leading to retained shreds of membrane or placenta, thus causing the increased incidence of return to hospital due to bleeding or 3) early cord clamping leading to a 20% reduction in the baby's blood volume. Different uterotonics will have differing effects, and clinicians will need to assess the optimum one for use in their circumstances. Recent international guidelines have turned to IM oxytocin as a uterotonic that provides effective prophylaxis but without the associated side effects (ICM-FIGO 2003; NICE 2007; WHO 2006). The increased incidence of women in the active management group having to return to hospital due to bleeding is of concern, as such bleeding takes place away from immediate access to medical assistance. This would, again, be of greater significance for women in low-income countries."
For some reason, the reviewers considered "severe and very severe hemorrhages" to be a primary outcome while plain-old >500ml hemorrhage is considered secondary. Do you know how hemorrhages are prevented from becoming severe or very severe? Administration of one or more uterotonics, for one. So you've got your first line, pitocin, which has very few adverse effects in terms of management of PPH, and then if that doesn't work you've got cytotec, either buccal or per rectum (per rectum HURTS btw), methergine, hemabate- all of these have very unpleasant adverse effects, but they are considered preferable to uncontrolled hemorrhage/hysterectomy. VIGOROUS fundal massage. This hurts like holy hell but again, better than bleeding out and losing your uterus. Manual removal of the placenta, if it's still in there and not coming with cord traction. This also hurts like holy hell. All of these things hurt like holy hell by themselves, but put together, it's truly awful. It leads to those delightful adverse effects the studies refer to. Labor was nothing compared to management of my postpartum hemorrhage following expectant management; the initial significant pain and then the day of feeling shitty and nauseous as result of PO cytotec given as a result of continued heavy bleeding after the official hemorrhage ended. This thread began with the OP wondering why something that hurt so much was done with no apparent reason, so I wanted to specifically address the alternatives. The other alternative is, of course, a relatively discomfort-free third stage. Most women do not hemorrhage. Some do. As one of the ones who did, with no previous intervention or risk factor, I will tell you that it sucks.
Another issue I have with this meta analysis is that what they consider an integral part of "active management" includes immediate to up to 1 min cord clamping and cutting. This is not the recommendation of the WHO:
http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/cd004074_abalose_com/en/index.html Delaying the clamping of the cord for up to 3 minutes (that may not sound like much, but the research on delayed clamping and cutting has found the benefits in effect by that time- see academicobgyn.com for his grand rounds on the topic).
Athalbe: This was a PILOT study, with a tiny n. It looked at one aspect of active managment, cord traction. Both groups received prophylactic pit, perhaps the most effective aspect of active management.
That's my take on these studies.
Just to throw it out there, I would still support a woman who wanted a hands-off third stage, with the explanation of what reasons would cause me to want to deviate from that plan. There's no way I would fire a patient for that.