Management Of Third-stage Labor Research Articles

Investigating active versus expectant management of third stage labour in a midwife-led unit

Little is known regarding third stage management approaches and the incidence of and treatment of postpartum haemorrhage in women giving birth solely in midwife-led units. This systematic literature review identified nine studies of varying quality that investigated active versus expectant management of the third stage of labour and any related blood loss in women, who had a normal physiological birth and gave birth or intended to give birth in a midwife-led unit. The results identified a need for further research studies into this area of practice, as birth settings are becoming increasingly more important. This is because of research studies that have reported many beneficial outcomes for healthy women at low risk of obstetric complications, who plan to give birth in midwife-led units.

Frequency of retained placenta in patients presenting with postpartum haemorrhage after active management of third stage of labour

Background: Postpartum haemorrhage (PPH) is a potentially life-threatening complication. PPH is defined as blood loss of more than 500 ml in vaginal delivery or 1000 ml in caesarean delivery. The most frequent causes are uterine atony, genital tract trauma followed by retained placenta. Active management of third stage of labour reduces the risk of postpartum haemorrhage and should be offered and recommended to all women.Methods: It was a descriptive (cross sectional study) conducted to determine the frequency of retained placenta in patients presenting with postpartum haemorrhage after active management of third stage of labour, conducted in ward 8, Jinnah Post Graduate Medical Centre, Karachi from October, 2013 to April, 2014. A total of 189 patients with postpartum haemorrhage after receiving active management of third stage labour were included in this study. All patients were subjected to detailed history and vaginal examination to confirm retained placenta. Data was recorded in a pre-designed proforma.Results: Frequency of retained placenta presenting with postpartum haemorrhage after active management of third stage of labour was observed in 20.11%.Conclusion: It is concluded that active management of the third stage of labour has proved beneficial compared with expectant management based on the decrease in the PPH rate, use of additional uterotonic medication and cost of the care.

Process Evaluation of Skilled Delivery Service in Hadiya Zone in Southern Nations, Nationalities, and Peoples Region, Ethiopia.

Pregnancy-related death is a cause for maternal and newborn mortality and morbidity as well as an obstacle for economic growth. Three-quarters of mothers' lives can be saved if women have access to a skilled health worker at delivery and emergency obstetric care. This evaluation was conducted to assess skilled delivery service implementation level by using three dimensions (availability, compliance, and acceptability) and identify major contributing issues for underutilization of the service. The evaluation design is cross-sectional. The study included 846 mothers who gave birth in Hadiya zone within one year prior to study period, using one year delivery records. Epi Info 3.5.3 and SPSS version 16 were employed for data analysis. Based on selected indicators, resource availability was inadequate for health facilities, human resource medical equipment, and rooms. On the compliance dimension, skilled delivery service coverage (34.8%), active management of third stage labor (32.7%), and health information at discharge and in postnatal care (PNC) visit (7.1%) critically complied with or poorly agreed to the guidelines and targets. Regarding skilled delivery service acceptability, welcoming, privacy keeping, reassurance during labor pain, follow-up, baby care, comfortability (rooms, beds, and clothing), cost of service, and episiotomy (without local anesthesia) were not acceptable.

Physiologic childbirth and active management of the third stage of labor: A latent class model of risk for postpartum hemorrhage.

Postpartum hemorrhage (PPH) is a threat to maternal mortality worldwide. Evidence supports active management of third stage labor (AMTSL) for preventing PPH. However, trials of AMTSL include women at varying risk levels, such as women undergoing physiologic labor and those with labor complications. Counseling women about their risk for PPH and AMTSL is difficult as many women who appear low-risk can still have PPH. This study uses outcomes of 2322 vaginal births from a hospital midwifery service in the United States to examine risks for PPH and effectiveness of AMTSL. Using a latent class analysis approach, physiologic birth practices and other risk factors for PPH were analyzed to understand if discrete classes of clinical characteristics would emerge. The effect of AMTSL on the PPH outcome was also considered by class. A four-class solution best fit the data; each class was clinically distinct. The two largest Classes (A and B) represented women with term births and lower average parity, with higher rates of nulliparity in Class B. Class A women had more physiologic birth elements and less labor induction or labor dysfunction compared with Class B. PPH and AMTSL use was higher in Class B. In Class B, AMTSL lowered risk for PPH. However, in Class A, AMTSL was associated with higher risk for PPH and delayed placental delivery (>30minutes). AMTSL may not be as beneficial to women undergoing physiologic birth. Further study of the etiology of PPH in these women is indicated to inform preventive care.

Efficacy of mindfulness based stress reduction (MBSR) on the sense of wellbeing of healthcare staff: A pilot study

active management of third stage labour. The medical model for understanding the causes of PPH based on the four T’s (tone, tissue, trauma, and thrombin) will be critiqued as incomplete and inadequate. We will argue that the high rates of PPH in obstetric units reflect the reductionisticmedicalmodelof labourphysiologywhich ignores the impact of the environment and the emotions. This study poses the question: does immediate skin to skin contact and early breast feeding affect the rates of postpartum haemorrhage (PPH) and if so why? Institutional ethical approval was obtained. Following extraction from the Obstetrix data base the records of over 10,000 women were analysed. Descriptive statistics provided information on frequencies and percentages and logistic regression and odds ratio (OR) were conducted to identify and predict relationships. When a woman had skin to skin contact with her baby at birth she was less likely to have a PPH (p<0.0001, OR2.704, CI-2.217–3.297). When a woman breastfed her baby after birth she was less likely to have a PPH (p<0.0001, OR-1.578 CI1.334–1.866). When a woman had continuity of midwifery care at the standalone birth centre or at home she was less likely to have a PPH (p<0.0001, OR-2.563, CI-1.640–4.005).The cascade of endogenous oxytocin occurs most and acts most effectively when physiological care is provided in labour.It is best practice for physiological care to continue into the 3rd and 4th stages of labour and thereby minimises PPH rates.

Management of third stage labour following vaginal birth in Iran: A survey of current policies

Objectivethis study was aimed to provide information on policies for the practice of managing the third stage of labour in Iran, including discussion of related systematic evidence. Designthis survey used a standard questionnaire to obtain information about prevention and early treatment of postpartum haemorrhage from all geographical areas in Iran, in 2010. Settingthe survey included maternity units from 23 provinces, covering 129 out of a total of 560 maternity units in Iran. Participantsat least one public hospital, one private hospital and one rural birth facility unit were included from each province. Questionnaires were completed by the unit's senior midwife with support from the unit's lead obstetrician. Findingsall the units who were approached responded to the study including 69 public hospitals, 32 private hospitals and 28 rural birth facility units. The rate of active management of the third stage of labour was 57 per cent, although answers to individual components of management indicated a higher rate for active interventions than expectant management. Ninety-four per cent of the responding centres indicated oxytocin administration, 71 per cent apply early cord clamping and 65 per cent apply controlled cord traction. A lack of standard definition for postpartum haemorrhage was reported in 18 per cent of units. Key conclusionsa high rate of active management was reported in Iran with variation in its different components which is in line with the international findings. These policies were mainly congruent with the existing systematic evidence except for timing of cord clamping. Implications for practicethere is a need for improvement in locally sensitive policy development, continuing education, establishing accurate auditing systems and ensuring access to facilities such as blood banks and products in rural units. Efforts to reduce maternal mortality and morbidity and investigations into their causes should be extended to factors beyond the third stage of labour care clinical components.

Effects of Syntocinon use in active management of third stage labour

Following the publication of guidance from the National Institute for Health and Clinical Excellence (NICE) (2007) , Syntometrine was withdrawn in practice for routine use as part of the active management of the third stage and replaced with Syntocinon 10 international units (iu). While it was recognized that these guidelines related to the care of low-risk women, from the evidence reviewed there did not appear to be any reason not to recommend the use of Syntocinon for the majority of women. Concern about perceived increase in major postpartum haemorrhage (&gt;100 ml) resulted in a retrospective comparative study of primary postpartum haemorrhage (PPH) rates and blood transfusion rates. This study found a statistically significant increase in estimated blood loss (EBL) above 1000 ml from 2008 to 2010 (0.59% vs. 1.74%). Nevertheless, there was no statistically significant increase in blood transfusion rates. Possible reasons for this increase are suggested, including: the limitations of the present study compared to previous studies; the experience of staff using Syntocinon 10iu; as well as the attitude of staff toward this practice change. In view of these issues, the researchers do not believe that these results provide robust evidence to revert to using Syntometrine, contrary to the recommendations of the Centre for Maternal and Child Enquiries (CMACE) (2011) .

Third Stage of Labour Care for Women at Low Risk of Postpartum Haemorrhage

In normal birth there should be a valid reason to interfere with normal processes. Yet, active management of third stage labor is being imposed on women who have no known risks of postpartum hemorrhage. This article examines the evidence from existing randomised trials comparing active and physiological third stage care for its relevance and validity to the effectiveness of physiological third stage care for women who are at low risk of postpartum hemorrhage. Consideration is given to midwifery and medical perspectives of the following definitions: 'postpartum hemorrhage'; 'low-risk status'; 'active'; 'expectant' and 'physiological' third stage care. A systematic search of the research literature regarding the third stage of labour is described. Four randomised trials and a meta-analysis by Cochrane were considered. These studies are examined in terms of their potential generalisability to women who are at low risk of postpartum hemorrhage. All trials included women who were at high risk of postpartum hemorrhage. The existing research does not provide relevant and valid evidence about the effectiveness of physiological third stage care, as defined by midwives, for women who are at low risk of postpartum hemorrhage.

Cost-effectiveness analysis of active management of third-stage labour in Vietnam

Active management of the third stage of labour (AMTSL) using oxytocin substantially reduces postpartum haemorrhage (PPH), a leading cause of maternal mortality. An economic analysis of the use of AMTSL was conducted as part of an intervention study in Thanh Hoa Province, Vietnam. A spreadsheet was used to calculate various scenarios and estimate the costs and outcomes of the routine use of AMTSL with oxytocin in Uniject compared with oxytocin in ampoules, and AMTSL compared with no AMTSL. We estimated the health outcomes from probabilities that were generated from the effectiveness portion of the AMTSL intervention project. The study also estimates the costs of treating PPH and the net incremental costs of AMTSL (costs and savings); examines the impact of different scenarios of PPH rate and Uniject cost; and estimates the potential cost per PPH case and PPH death averted. The additional net cost per woman of providing AMTSL with ampoules was just US dollar 0.20 in the base case; using Uniject devices added only US dollar 0.08 more per woman to the ampoule cost. Varying the rate of PPH had the biggest effect; if the underlying PPH rate were 8%, the incremental cost of AMTSL drops to just US dollar 0.07 per woman with ampoules and the cost to avert a case of PPH is US dollar 2.10 with ampoules and US dollar 4.52 with Uniject. The low net incremental cost of AMTSL suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women's health without adding much to national health care costs.

How Do Physicians and Midwives Manage the Third Stage of Labor?

Current practice guidelines recommend active management of the third stage of labor. We compared practices of three maternity care provider disciplines in management of third-stage labor and the justifications for their approach. This study is a cross-sectional survey of maternity practitioners in usual practice settings in British Columbia. All 199 obstetricians, all 82 midwives, and a random sample of family physicians practicing intrapartum maternity care (one-third, or 346) were surveyed The three main outcome measures by discipline were the method preferred in managing third-stage labor, the reasons given for the chosen method, and views on the appropriateness of the current third-stage labor guideline. The overall response rate was 57.8 percent. Response rates indicating that the participants were "aware of guideline" were the following: obstetricians, 85.3 percent; family physicians, 53.7 percent; and midwives, 97.8 percent. Response rates indicating that the participants "agreed with guideline" were the following: obstetricians, 95.2 percent; family physicians, 97.6 percent; and midwives, 51.2 percent. Response rates indicating that "oxytocin should be given with anterior shoulder" were the following: obstetricians, 71.1 percent; family physicians, 68.3 percent; and midwives, 26.7 percent. Response rates indicating that "routine active management of third stage of labor should be the norm" were the following: obstetricians, 79.2 percent; family physicians, 60.2 percent; and midwives, 17 percent. All results were statistically significant (p < 0.01). A major difference was found between physicians and midwives in the management of third-stage labor. Physicians routinely implemented active management of the third stage of labor; midwives preferred expectant approaches, principally based on women's preference. Provincial data did not show differences in postpartum hemorrhage or transfusion rates by practitioner type.

Active Management of Third Stage Labor Is Associated with a Lower Cord Blood Unit Volume.

Aim: It has been demonstrated that active management of third stage of labour (AMTSL) (prophylactic administration of a uterotonic agent, early cord blood clamping and controlled cord blood traction) reduces the risk of primary post partum haemorrhage compared with expectant (or physiological) management. However this strategy might decrease the cord blood unit (CBU) volume which is collected in order to be banked for therapeutic use. Knowing that efficacy of CBU transplantation correlates with CD34+ progenitor cells content (which is correlated with the collected volume of CBU), we conducted a retrospective study to analyse the impact of AMTSL on volume and CD34 progenitor's content of CBU.Material and Method: From Jan 1st 2001 to Oct 2nd, 2004 the maternity affiliated to the Besançon CBB performed 3838 CBU collections after normal deliveries. Different factors that might impact on CBU volume and CD34+ cell content were analysed: age, parity, and smoking habit of the mother, gestational age, type of initiation and duration of first labour stage, duration (from the beginning of labour to initiation of the pushing phase), time of the second stage of labour (from the initiation of pushing time to the birth of the baby), foetal cardiac rhythm (FCR) alterations during labour, type of delivery (assisted or not) and variables of the third stage of labour (AMTSL, uterine revision, primary post partum haemorrhage occurrence, placenta weight). Moreover, variables in relation with the baby were studied: sex, weight, Apgar score at 1 and 5 minutes. Each factor were submitted to a univariate analysis. Multivariate analysis was carried only onto factors significant after univariate analysis. Analysis concerning volume was performed on all 3838 CBU while analysis for CD34+ cells content was performed only on CBU with a volume > 80 ml (minimum volume required for banking in our CBB)Results: In univariate analysis, assisted initiation of first stage of labour (p=0.04), FCR modification during labour (p=0.01), uterine revision (p=0.01), primary post partum haemorrhage (p=0.01), gestational stage (p=0.0001), duration of second stage labour (P=0.0001), placenta and baby weight (both p=0.0001) instrumental expulsion (p= 0.0001) and male baby (p=0.01) were associated with higher CBU volume. Conversely, AMSTL (p= 0.01) and Apgar sore at 1 and 5 minutes (p=0.0007 and 0.004 respectively) were associated with lower CBU volume. In multivariate analysis, only assisted initiation of first stage of labour (p=0.02), primary post partum haemorrhage (p=0.0001), duration of second stage labour (P=0.003), placenta and baby weight (both p=0.0001) were associated with higher CBU volume. However, AMSTL (p= 0.03) and Apgar sore at 1 (p=0.003) were associated with lower CBU volume. Concerning CD34+ cells, in multivariate analysis, only maternal age (p=0.02), gestational stage (p=0.0001), FCR modification during labour (p=0.001), duration of second stage labour (p=0.0001), placenta and baby weight (respectively p= 0.001 and p=0.0001) were associated with higher CD34+ cells content in CBU. Conversely, only Apgar sore at 1 (p=0.0001) was associated with lower CD34+ cells content in CBU.Conclusion: AMSTL is associated with a low CBU volume but not with a low CD34+ cell count. In view of the know generalized use of AMSTL, such findings could have on impact on the determination of volume and CD34+ cell content threshold required for CBU banking.