How effective are the components of active management of the third stage of labor?

Abstract

BackgroundActive management of the third stage of labor is recommended for the prevention of post-partum hemorrhage and commonly entails prophylactic administration of a uterotonic agent, controlled cord traction, and uterine massage. While oxytocin is the first-choice uterotonic, it is not known whether its effectiveness varies by route of administration. There is also insufficient evidence regarding the value of controlled cord traction or uterine massage. This analysis assessed the independent and combined effectiveness of all three interventions, and the effect of route of oxytocin administration on post-partum blood loss.MethodsSecondary data were analyzed from 39202 hospital-based births in four countries and two clinical regimens: one in which oxytocin was administered following delivery of the baby; the other in which it was not. We used logistic regression to examine associations between clinical and demographic variables and post-partum blood loss ≥ 700 mL.ResultsAmong those with no oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by nearly 50% as compared with expectant management (P < 0.001). Among those with oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by 66% when oxytocin was intramuscular (P < 0.001), but conferred no benefit when oxytocin was intravenous. Route of administration was important when oxytocin was the only intervention provided: intravenous administration reduced hemorrhage risk by 76% as compared with intramuscular administration (P < 0.001); when combined with other interventions, route of administration had no effect. In both clinical regimens, uterine massage was associated with increased hemorrhage risk.ConclusionsRecommendations for active management of the third stage of labor should account for setting-related differences such as the availability of oxytocin and its route of administration. The optimal combination of interventions will vary accordingly.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage

“…Earlier researchers found no consistent difference between oxytocin administered with delivery of the anterior shoulder or with delivery of the placenta (Soltani, Hutchon, & Poulose, ). Every facility should have a departmental protocol for oxytocin use in the immediate postpartum period (Sheldon, Durocher, Winikoff, Blum, & Trussel, ). The World Health Organization (), American Academy of Pediatrics and The College (), American Academy of Family Physicians (Evanson & Anderson, ), and AWHONN () recommend oxytocin administration after all births.…”

Third stage of labour: expectant versus active management-a comparative study in local low risk population

“…Sheldon et al, in their systematic assessment have documented that the significance of CCT is only if the uterotonic agents are not available or if oxytocin is given intramuscularly. 26 Similarly, Gulmezoglu et al, compared active management performed with and without controlled cord traction in a large WHO multi-center trial and only showed a slight increased risk of severe postpartum hemorrhage in cases without controlled cord traction and concluded that the main component of active management was the use of uterotonic. 27 A Cochrane database meta-analysis by Begley et al, showed that although active management reduced mean blood loss and postpartum hemorrhage (>500 cc), there was no statistically significant reduction in severe postpartum hemorrhage (>1000 cc) for women at low risk for bleeding as well as in mean duration of third stage of labour, which was in contrast to present study.…”

Ventilation before Umbilical Cord Clamping Improves the Physiological Transition at Birth

“…Debate on appropriate timing of UCC following birth has been ongoing for several decades (even centuries), yet the ideal time still remains unknown. As a result, although the potential benefits of delayed umbilical cord clamping (DCC) have been documented, ‘early’ or ‘immediate’ umbilical cord clamping (ICC) is the most widely used procedure and is part of the active management of third stage of labor; i.e., the period extending from complete delivery of the infant to complete delivery of the placenta ( 1 , 2 ). Although the reasons for this are unclear, a lack of understanding and awareness of the issues associated with UCC are thought to be a major underlying factor ( 3 , 4 ).…”