Variation in adherence to recommendations for management of the third stage of labor

Abstract

Severe bleeding is a major cause of maternal morbidity and mortality worldwide, and postpartum hemorrhage (PPH) rates are reportedly increasing [1,2]. Active management of labor reduces PPH and widespread implementation could reduce the burden of disease associated with obstetric hemorrhage [3,4]. A joint statement from the International Confederation of Midwives and the International Federation of Gynecology and Obstetrics (ICM/FIGO) recommends that “active management of the third stage of labor should be offered to women since it reduces the incidence of PPH due to atony” [3]. Active management is defined in the ICM/ FIGO statement as: (1) administration of uterotonic agents (10 units of oxytocin intramuscularly is recommended); (2) controlled cord traction; and (3) uterine massage after delivery of the placenta as appropriate [3]. Notably, Prendiville et al. [4] include early cord clamping and cutting as part of their active management protocol, rather than uterine massage. However, a recent systematic review did not find that early cord clamping reduced the risk of PPH [5]. We report a population-level assessment of the management of the third stage of labor, methods of PPH reporting, and procedures used to control PPH as documented in the medical records. We used data collected in a statewide review of the delivery admissions of 1200 women in Australia in 2002. Data were abstracted by 3 clinicians experienced in obstetric chart review. The methods have been described elsewhere [6], but probability sampling with over-representation of severe hemorrhage allowed us to estimate population rates of the extreme measures used to control PPH. Table 1 indicates the significant practice variation in the documented use and timing of prophylactic oxytocics, controlled cord traction, blood loss reporting (especially by mode of delivery), and PPH rates depending on the criteria used. Early cord clamping was not reported in any record. Data were not collected on the use of uterine massage because local health policy defines active management according to the Cochrane Systematic Review [4], and recommends 5–10 units of oxytocin [7]. Among the women who had PPH (using blood loss or diagnostic criteria, Table 1), 6.9% had a blood transfusion and 2.6% had manual removal of the placenta following vaginal birth. Population estimates (per 1000 PPH cases) of extreme measures used to control bleeding were: 32.7 for dilatation ⁎ Corresponding author. Department of Obstetrics and Gynecology, Level 4, Wallace Freeborn Building (26), Royal North Shore Hospital, St Leonards, 2065, Australia. Tel.: +61 2 9926 7013; fax: +61 2 9906 6742. E-mail address: clroberts@med.usyd.edu.au (C.L. Roberts). ava i l ab l e a t www.sc i enced i r ec t . com