Active Management of Third Stage of Labor

Definitions and Related Facts

Postpartum hemorrhage and complications of third stage of labor

  • Blood loss in excess of 500 ml, with severe postpartum hemorrhage being loss of 1,000 ml or more, and very severe being a loss of 2,500 ml or more.
  • Anemia in the mother can pre-exist or be the result of hemorrhage; severe cases may necessitate a blood transfusion.
  • Postpartum hemorrhage is the main cause of maternal death in a number of countries, the vast majority of which occur in the developing world.

Active management of third stage

  • 10 units IM pitocin administered to all mothers within one minute of delivery
  • Early clamping and cutting of the umbilical cord, often before the cord ceases to pulse
  • Wait one minute, after clamping the cord, and initiate controlled cord traction for delivery of the placenta

Expectant management of third stage

  • Signs of placental separation are awaited and the placenta is delivered spontaneously
  • May involve nipple stimulation by putting the baby to breast immediately after delivery
  • Interventions that interfere with the body’s natural oxytocin release may reduce the effectiveness of the physiological process (e.g., oxytocin release can be inhibited by anxiety and excess adrenaline, oxytocin augmentation in labor, and administration of epidural or narcotic analgesia)
  • Does not involve early clamping and cutting of the umbilical cord
  • Uterotonic drugs are used only in case of excess bleeding

What does the evidence say?

Current medical recommendations in favor of active management are based on five studies (involving 6,477 women) that found active management of third stage reduces severe postpartum blood loss, blood transfusions, and postnatal anemia for all women, irrespective of risk.

The following negative effects of active management were noted:

  • Increase in mother’s blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief; these effects are apparently due to administration of a specific uterotonic (choice of drug used, specifically ergometrine).
  • Increase in the number of women returning to the hospital ER after discharge for excessive bleeding due to controlled cord traction leading to retained shreds of membrane or placenta.
  • Decrease in newborn birth weight due to early cord clamping leading to a 20% reduction in the baby’s overall blood volume. (The World Health Organization now recommends active management with delayed cord clamping—allowing baby’s blood that is in the placenta to return to the baby’s circulation—to reduce the likelihood of anemia in the newborn. However, in many healthcare settings, this recommendation is not followed.)

In summary, while active management of the third stage of labor reduces blood loss at the time of birth (and concomitant treatments required), it puts mothers and babies at risk of a number of other negative outcomes.

Source: Cochrane Review, Active versus expectant management for women in the third stage of labor, http://www.ncbi.nlm.nih.gov/pubmed/20614458

Consumer Recommendations

From the review: “Women should be given information prenatally to help them make informed choices.”

Question for Parents to Consider:

For low-risk women, especially those experiencing drug-free labors, do the benefits of active management of third stage of labor outweigh the risks?

Comments/Other Considerations

In my experience, in healthcare settings where active management (including the non-evidence-based practice of early cord clamping and cutting) is routine, informed consent for this practice is rare. Two specific pieces of active management, the early cord clamping and administration of a uterotonic drug, are usually completed within 30 seconds after the birth of the baby, therefore many parents don’t even notice until after the fact. Parents who prefer an expectant management approach will need to discuss their preferences with their care provider, express their wishes in a birth plan, and then be prepared to advocate for their birth plan at the birth.

Further study is needed on the possibility of a “mixed management option” but should be considered based on the mother’s risk factors. A mixed management system might be most beneficial for someone with a high risk birth. For example, for someone with low iron, one option might look like this: “IM Pitocin immediately following the birth to decrease the chance of hemorrhage (active management), delayed cord clamping to allow the baby to receive his/her full blood volume from the placenta (expectant management), and careful cord traction once the cord is done pulsing to ensure there isn’t excessive bleeding behind the placenta (mild active management).”

If active management of third stage is being promoted as a benefit to anemic mothers (those with low blood levels of iron who might suffer more from even a normal blood loss at their birth), then let’s become as proactive as possible about preventing and treating the anemia prior to the birth through proper nutrition and supplementation!

Finally, active management of third stage of labor is inconsistent with the Midwifery Model of Care. Specifically, it violates the basic tenet of respect for the birth process as it unfolds uniquely, as well as the belief that birth is a normal life process for which women’s bodies are well designed. This is to be distinguished from the medical model approach wherein birth is viewed as an emergency waiting to happen and interference with the birth process is the norm. Parents are encouraged to discuss the benefits and the risks of active management with their midwife or doctor as it applies uniquely to their situation.

Related Story

In a recent post on Lamaze International’s Science and Sensibility blog, pediatrician Dr. Mark Sloan examines common objections to delayed cord clamping and what the evidence says about its benefits. Dr. Sloan writes, “The evidence of benefit from delayed cord clamping is so compelling that the burden of proof must now lie with those who wish to continue the practice of immediate clamping, rather than with those who prefer-as nature intended-to wait.” Read the blog post.

Excerpted from our Childbirth Preparation Online program, Navigating the Medical Setting, by Patty Brennan.

Posted by Patty Brennan on January 18, 2013 • Filed under
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