Active versus expectant management for women in the third stage of labour
Compared with expectant management, active management of the third stage of labour is associated with less blood loss and lower incidence rates of severe postpartum haemorrhage and blood transfusion.
RHL Commentary by Abalos E
Some 358 000 women die each year in childbirth, mostly in developing countries (1). Severe bleeding in the postpartum period is the single most important cause of maternal deaths worldwide (2). More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive blood loss. In the mother, postpartum haemorrhage (PPH) also causes serious morbidity in many women. Sequelae of PPH include respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis. In many developing countries, only a small proportion of women, living in mostly urban areas, have access to health-care facilities for delivering their babies. Most of the deliveries in rural areas take place at home and a relatively low percentage of them are assisted by skilled birth attendants. However, institutional deliveries can also be risky owing either to the lack of emergency drugs, blood, and appropriate equipment, or to insufficiently trained or under-skilled staff. Consequently, PPH contributes to maternal mortality in part due to poor maternal health status and also to the lack of adequately equipped delivery facilities and inappropriate management of the third stage of labour.
Different interventions have been proposed for the management of the third stage of labour: prophylactic uterotonic at or after delivery of the baby, early cord clamping and cutting, controlled cord traction to deliver the placenta and uterine massage following delivery of the placenta have been packaged together in different combinations as part of active management of the third stage of labour (3, 4). On the other hand, expectant management implies a hands-off approach – i.e. waiting for the signs of separation of the placenta and its spontaneous delivery and late cord clamping (clamping the umbilical cord when pulsation in the cord has ceased) and cutting. This Cochrane review (5) sought to assess the effects on blood loss, PPH and other maternal and perinatal complications of active versus expectant management of the third stage of labour.
This is an update of a previously published Cochrane Review. Although no new trials were included, there were variations in the analysis plan (a new category for comparison, a more careful evaluation of the risk of bias, and the use of random-effects model for heterogeneity). All adequately controlled trials identified have been included in this review and were evaluated for methodological quality and appropriateness of inclusion. The methods of the review are generally sound. The reviewers conducted a subgroup analysis to assess whether the risk profile of women might have affected the results as well as study quality.
Five randomized controlled trials, involving nearly 6500 women delivering in maternity hospitals in high-income countries, are included in this review. The included trials varied in terms of: (i) definition and timing of early cord clamping and cutting; (ii) types, dosages and routes of administration of the uterotonics used; and non-standardized use of cord traction. In the trials included in this Cochrane review there was no mention of uterine massage and controlled cord traction involved traction on the cord while maintaining an upwards counter pressure on the lower segment of the uterus by placing a hand on the lower abdomen of the mother. Hence, the relative benefits of the individual components of active or expectant management could not be assessed. Active management reduced the average risk of severe maternal primary haemorrhage (more than 1000 ml of blood loss) [risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14–0.87, three studies, 4636 women], primary blood loss > 500 ml (RR 0.34, 95% CI 0.27–0.44, three studies, 4636 women), and of maternal haemoglobin less than 9 g/dl following birth (RR 0.50, 95% CI 0.30–0.83, two studies, 1572 women) for women irrespective of their risk of bleeding. Women also experienced less blood loss [average mean difference (MD) −78.80 ml, 95% CI −95.96 to −61.64, two studies, 2941women], and a reduced risk of maternal blood transfusion (RR 0.35, 95% CI 0.22–0.55, four studies, 4829 women), iron therapy in the puerperium (RR 0.59, 95% CI 0.48–0.72, one study, 1494 women), therapeutic uterotonics postpartum (average RR 0.19, 95% CI 0.15–0.23, four studies, 4829 women). However, active management was also associated with an increased risk of postnatal diastolic blood pressure >90 mmHg up to discharge from labour ward (average RR 4.10, 95% CI 1.63–10.30, three studies, 4636 women). It is worth pointing out that these three studies included in the meta analysis had used syntometrine as the uterotonic of choice for the active management arm. One study also reported a statistically significant increase in the use of postnatal analgesia. The trials in this review did not report any maternal deaths. There were no apparent adverse effects on the baby, except for lower average birth weight in the active management arm (MD −76.90 g, 95% CI −45.30 to −108.51, two studies, 3207 infants), which could indirectly suggest a lower blood volume in these babies as a result of the interference with normal placental blood transfusion after birth.
Compared with expectant management, active management of the third stage of labour is associated with less blood loss and lower incidence rates of severe postpartum haemorrhage and blood transfusion. However, there is concern that active management may be associated with an increased rate of hypertension in the mother. Active management has also been linked with lower birth weight of babies, which may be due to decrease in the average blood volume of the infants, possibly related to timing of cord clamping.
4.1. APPLICABILITY OF THE RESULTS
The trials included in this review were conducted in Ireland, United Arab Emirates, and the United Kingdom. All were hospital-based and the interventions were administered by trained staff. Hence, the findings of this review would be applicable to all settings where deliveries are attended by staff trained in active management of the third stage of labour. Three trials involved women at low risk of bleeding and two included women irrespective of their risk of bleeding.
4.2. IMPLEMENTATION OF THE INTERVENTION
Health-care facilities planning to introduce active management of the third stage of labour into their services would need to ensure that their staff have the training and skills needed to administer uterotonics (at or after delivery of the baby), clamp and cut the cord at the appropriate time (usually between 1–3 minutes after delivery of the baby) and identify the babies that need earlier cord clamping and cutting, and perform controlled cord traction to deliver the placenta. It is important to note that the competencies required to administer injectable uterotonics are also essential for managing emergencies related to PPH.
In the five trials included in the review, oxytocin and ergometrine, alone or in combination, were given either intramuscularly or intravenously. The choice of uterotonics for active management of the third stage of labour and prevention of PPH is the subject of other Cochrane reviews (6, 7, 8). The timing of administration of uterotonics, which can potentially influence maternal blood loss, neonatal haemoglobin, and the resources (such as additional uterotonics) needed at the time of birth, was evaluated in a separate systematic review (9), as well as the timing of cord clamping and cutting (10). Finally, a systematic review that sought to determine the efficacy of fundal pressure versus controlled cord traction as part of active management of the third stage of labour found no eligible trials for inclusion (11).
In the guidelines issued by the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) (3), and in those issued by WHO (4), the word "early" has been left out in relation to the timing of cord clamping and cutting because of evidence suggesting benefits for the baby of delayed cord clamping and cutting. In its guidelines for the prevention of postpartum haemorrahge (12), WHO recommends delayed cord clamping and cutting as part of the active management of the third stage of labour. The guidelines recommend that the timing of cord clamping and cutting should be determined by observing uterine contractions following the administration of a uterotonic; in practice, it is thought to be around 1–3 minutes after delivery of the baby.
4.3. IMPLICATIONS FOR RESEARCH
It has been suggested that traction on the cord before separation of the placenta from the uterus may increase the risk of maternal complications. Hence, the different components of active management of the third stage of labour need to be studied further to evaluate their individual contributions to the effectiveness of this approach, including the safety of each of them.
There is a need to conduct randomized controlled trials of active versus expectant management of the third stage of labour in women delivering at home, irrespective of the development status of the country. Results of recent trials of misoprostol in rural (13, 14) and primary-care (14, 15) settings need to be reconfirmed in relation to dose adjustments and safety assessment. Future research should also aim to determine the economic benefits of active management and women's views related to the choice of uterotonic drugs.
Sources of support: Centro Rosarino de Estudios Perinatales. Rosario. Argentina.
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This document should be cited as: Abalos E. Active versus expectant management of the third stage of labour: RHL commentary (last revised: 1 January 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.