The management of the third stage of labour—A national survey of current practice

Abstract

Active management of the third stage of labour is currently recommended by the National Institute for Health and Clinical Excellence (NICE) (2007) and the Royal College of Obstetricians and Gynaecologists (RCOG) (2009). In 2007, NICE recommended that active management should comprise the administration of oxytocin, early clamping and cutting the umbilical cord, and controlled cord traction. Since the publication of these guidelines, however, there has been continued debate within the literature about the optimal standards for active management considering both maternal and neonatal outcomes. This debate is reflected in the findings of our survey, which showed that practices with respect to active management of the third stage is not uniform in England despite the recommendations of NICE. Key findings were that Syntometrine was used in 67% of units and most commonly administered with delivery of the anterior shoulder in 60% of units. This survey showed that irrespective of which oxytocic was used, early cord clamping was practiced in 74% of units. The majority of units (72%) awaited signs of placental separation before initiating controlled cord traction. Thirty-two percent of units who had changed to using syntocinon following the publication of the NICE (2007) guidelines had reverted back to using Syntometrine citing concerns over perceived increase rates of haemorrhage. Contrary to the recommendations of NICE (2007) and RCOG (2009), only half of the units surveyed currently recommend active management of the third stage to all women. In view of the findings of this survey, more recent evidence with respect to early and delayed cord clamping and the findings and recommendation of the Cochrane review by Begley et al (2011), we believe that national policy with respect to the management of the third stage should be reviewed.