Active versus expectant management for women in the third stage of labour

RHL Summary

12 February 2016
Woman in sitting position receiving oxytocin.
WHO / PAHO

Key findings

The review compared the effect of active versus expectant (four studies) or mixture of management (three studies) of the third stage of labour on severe primary PPH and other maternal and infant outcomes. The key findings were:

  • Statistically significant reduction in severe PPH more than 1000ml and hemoglobin less than 9g/dL (at 24 to 72 hours) with active management of third stage of labour as compared to expectant management.
  • Lower average birthweight for the baby (possibly related to timing of the cord clamping) and an increase in the incidence of maternal postpartum diastolic blood pressure >90mmHg.
  • No other significant differences in maternal and fetal outcomes, including neonatal admission to special care or intensive care.

Evidence included in this review

The review included seven hospital-based randomized and quasi-randomized studies involving 8247 women. All except one of the studies were conducted in high-income countries.

Quality assessment

The quality of the evidence was assessed using the GRADE approach. Overall, the quality of evidence for primary outcomes was low.

Clinical implications

The review suggests that health care providers should provide information to women in the antenatal period on the benefits and harms of the active management of the third stage of labour to facilitate informed choices of care.

Further research

The review indicates a need for further high quality research on this question in low- and middle-income countries. The different components of the active management of the third stage of labour would benefit from further research to evaluate their individual contributions to effectiveness.


Cochrane review

Citation: Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Review, 2015, Issue 3. Art. No. : CD007412. DOI: 10.1002/14651858.CD007412.pub4

Abstract

Background

Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cordtraction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is deliveredspontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in l ow-income countries.

Objectives

To compare the effectiveness of active versus expectant management of the third stage of labour.

Search methods

We searched the Cochrane Pregnancy and Chil dbirth Group Trials Register (30 September 2014) and reference lists of retrieved studies.

Selection criteria

Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour.

Data collection and analysis

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

Main results

We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women, GRADE:very low quality) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women, GRADE:low quality). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 infants, GRADE:low quality) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 infants, GRADE:very low quality). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.

Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both, and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.

In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).

Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here.

Authors' conclusions

Although there is a lack of high-quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.