Third Stage Practices and the Neonate

Abstract

The third stage of labour is defined as the period following the completed delivery of the newborn until the completed delivery of the placenta and its attached membranes. Whilst to the exhausted labouring woman this stage may be an afterthought, it is a crucial time for fetal-to-neonatal transition. Major changes in anatomy and physiology occur in both mother and baby. It has also been described as ‘potentially the most hazardous part of childbirth, largely due to the risk of postpartum haemorrhage (PPH) on placental separation. Despite this, the current management guidelines are based on an ‘eclectic combination of historical, anecdotal, philosophical and research-based factors.

Historical perspectives on umbilical cord clamping and neonatal transition

“…Saigal found significant increases in both neonatal hyperbilirubinaemia and polycythaemia in infants randomized to delayed vs early cord clamping. 4 A subsequent systematic review and meta-analysis found a non-statistically significant increase in polycythaemia among infants in whom cord clamping was delayed, although the condition appeared benign. 4 A recent Cochrane review 5 concluded that although later cord clamping increases the risk of jaundice requiring phototherapy, it advantages the term infant by improving iron stores.…”

“…Expectant management excludes prophylactic drugs, the cord is neither clamped nor cut early, and the placenta is expelled by maternal effort. 4 Active management traditionally involves routine prophylactic administration of a uterotonic agent, early cord clamping and cutting, and controlled cord traction. The administration of uterotonics reduces the risk of postpartum haemorrhage, a complication of childbirth which accounts for almost one quarter of all maternal deaths worldwide.…”

“…The administration of uterotonics reduces the risk of postpartum haemorrhage, a complication of childbirth which accounts for almost one quarter of all maternal deaths worldwide. 4 For this reason, active management has become the convention in both developed and developing countries although within it, the early cord clamping facet has little evidence-based rationale. A recent Cochrane review has revealed that the timing of cord clamping is not associated with postpartum haemorrhage.…”

“…3 Yet, early umbilical cord clamping can be detrimental to the newborn, leading to an increased risk of anaemia and, in the premature infant, an increased risk of intraventricular haemorrhage and respiratory complications. 4,5 Delaying clamping in preterm infants decreases the need for blood transfusion 4 which has been associated with neonatal necrotizing enterocolitis and death. 6 In the term infant, delayed clamping improves neonatal oxygen transport and red blood cell flow and in premature infants it is associated with fewer days on oxygen and ventilation.…”

The Broader Implications of Early Cord Clamping at Birth.

“…Initially introduced as part of active management of the third stage of labour to reduce the risk of post-partum hemorrhage [1], the safety of early cord clamping was soon questioned [2] and investigated [3]. The finding that depriving the neonate of a volume of blood [4] resulted in anaemia and iron deficiency six weeks later [5] was not surprising but only recently this anaemia and iron deficiency has been shown to have more significant long term adverse consequences [6].…”