Active Management of Third Stage of
Labor
A model to an Evidence Based Obstetric Practice
Session Objectives
To review:
Why do we need the introduction of EBM and
Information mastery in our day to day practice
Definition of third stage of labor
Physiologic vs. active management
Risks and benefits of each method of
management
Drugs used in active management
Where lies the EVIDENCE
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Half a century ago…
“ My students are dismayed when I say to
them that half of what they are taught as
medical students will in 10 years be shown
to be wrong. And, the trouble is,none of
their teachers knows which half”
Prof. Sydney Burwell
Dean of Harvard Medical school
Active Management of Third Stage of Labor
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Active Management of Third Stage of Labor
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Would you care finding your way
through the information maze…?!
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“The Winds of Change”
•Anecdotes
•Intermediate
Outcomes
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The Pyramid of Evidence
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Definitions…
Clinical guidelines are:
‘Systematically developed statements which
assist clinicians and patients in making
decisions about appropriate treatment for
specific conditions’
Developed using a standardized methodology
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Classification of Evidence Levels
1
2
- Ia Evidence obtained from meta-analysis of
randomized controlled trials.
- Ib Evidence obtained from at least one
randomized controlled trial.
-Ila Evidence obtained from at least one welldesigned controlled study without randomization.
-Ilb Evidence obtained from at least one
other type of well-designed quasi- experimental
3
Evidence obtained from well-designed nonexperimental descriptive studies, such as
comparative studies, correlation studies .
4
Evidence obtained from expert committee reports or
opinions and/or clinical experience of respected
authorities
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Forms of Care…
Beneficial Forms of care.
Forms of care likely to be beneficial.
Forms of care with a trade off.
Forms of care with unknown effectiveness.
Forms of care likely to be ineffective.
Forms of care likely to be harmful.
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Grades of Recommendation
A
B
C
At least one controlled trial
Requires the availability of well controlled
clinical studies but no randomised clinical
trials on the topic of recommendations.
Level
Ia, Ib
Level
IIa, IIb, III
Requires evidence obtained from expert
Level
committee reports or opinions and/or clinical
IV
experiences of respected authorities.
Indicates an absence of directly applicable
clinical studies of good quality
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To put it short…
We need to learn not only to read the
medical literature,
BUT what to read? And how ?
We need to be introduced to the concept
of “Information Mastery”.
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The 5 EBM Skills
1. Forming answerable clinical questions
2. Searching for the best evidence answer
3. Appraising evidence for relevance, impact,
validity
4. Integrating the evidence into practice
5. Evaluating & improving
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A three-part Clinical Question
Does active management of the third stage of labor
decrease the rate of primary postpartum
hemorrhage?
The Prevention of Postpartum hemorrhage is by the
proper conduction of the third stage of labor
This is also a POEM.
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Where Are You Going To Search
For The Evidence…?
Textbooks…?
Original publications…?
Predigested Material
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Two Methods of Third Stage Management
Physiologic (“expectant”) management
Oxytocics are not used
Placenta is delivered by gravity and maternal effort
Cord is clamped after delivery of the placenta
Active Management
Oxytocic is given
Cord is clamped
Placenta delivered by controlled cord traction (CCT)
with counter-traction on the fundus
Fundal massage
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Critical Issues Pertaining to the
Third Stage of Labor
Active vs. physiologic management
Theoretical potential risks of each
Entrapment of placenta
Avulsion of cord
Uterine inversion
Choice of oxytocic agent
Stability, safety and side effects of oxytocics
Unproven benefit of nipple stimulation
CCT and fundal massage if no oxytocic available
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Physiologic Management:
Advantages and Disadvantages
Advantages
Does not interfere with normal labor process
Does not require special drugs/supplies
Disadvantages
Increases length of third stage
Increases risk of postpartum hemorrhage (PPH)
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Active Management:
Advantages and Disadvantages
Advantages
Decreases length of third stage
Decreases risk of PPH
Disadvantages
Requires oxytocics and items needed for injection
Requires a birth attendant with skills in:
Observation
Giving an injection
CCT
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Procedure for Active Management
Oxytocin
Within 1 minute of birth, palpate abdomen to rule
out presence of another baby
Give oxytocin
CCT
Await strong uterine contraction (2–3 minutes)
Apply controlled cord traction while applying
countertraction above pubic bone
If placenta does not descend, stop traction and
await next contraction
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Active vs. Physiologic Management:
The Bristol and Hinchingbrooke Trials
Bristol trial: 1695 women, Hinchingbrooke
trial: 1512 women randomly assigned to:
Active management
Physiologic management
Prendiville et al 1988; Rogers et al 1998.
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Active vs. Physiologic Management:
The Bristol Trial Objective
Compare effects of fetal and maternal morbidity
of:
Routine active management
Physiologic management
Prendiville et al 1988.
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The Bristol Trial:
Details of Active Management
Try to give one ampule of oxytocic (5 units oxytocin
and 0.5 mg ergometrine routinely or 10 units synthetic
oxytocin if mother has high BP) immediately after
delivery of anterior shoulder
Try to clamp cord 30 seconds after delivery of baby
When uterus has contracted, try to deliver placenta by
CCT with protective hand on abdomen helping to
shear off placenta and preventing uterine inversion
Try not to give any special instructions about posture
Prendiville et al 1988.
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The Bristol Trial:
Details of Physiologic Management
Try not to give oxytocic
Try to leave cord attached to baby until placenta is delivered
Try not to use CCT or any manual interference with uterus at fundus
Try to encourage mother to concentrate on feeling for next
contraction or urge to push
When mother feels contraction or urge or there are signs of
separation, encourage mother and help her change posture
If placenta does not deliver spontaneously, wait, try putting baby to
breast and encourage maternal effort
Prendiville et al 1988.
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Active vs. Physiologic Management:
Postpartum Hemorrhage
Active
Management
Physiologic
Management
OR and 95% CI
Bristol Trial
50/846 (5.9%)
152/849 (17.9%)
3.13 (2.3-4.2)
Hinchingbrooke
Trial
51/748 (6.8%)
126/764 (16.5%)
2.42 (1.78-3.3)
Prendiville et al 1988; Rogers et al 1998.
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Active vs. Physiologic Management:
Results
Active
Management
Physiologic
Management
OR and 95% CI
Duration 3rd
stage
(median)
Bristol
5 minutes
15 minutes
Not done
Hinchingbrooke
8 minutes
15 minutes
Not done
Third stage
> 30
minutes
Bristol
25 (2.9%)
221 (26%)
6.42 (4.9-8.41)
Hinchingbrooke
25 (3.3%)
125 (16.4%)
4.9 (3.22-7.43)
Blood
transfusion
Bristol
18 (2.1%)
48 (5.6%)
2.56 (1.57-4.19)
Hinchingbrooke
4 (0.5%)
20 (2.6%)
4.9 (1.68-14.25)
Therapeutic
oxytocics
Bristol
54 (6.4%)
252 (29.7%)
4.83 (3.77-6.18)
Hinchingbrooke
24 (3.2%)
161 (21.1%)
6.25 (4.33-9.96)
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Active vs. Physiologic Management:
The Bristol & Hinchingbrooke Trials
Conclusion: Active management of the third stage
reduces the risk of PPH:
Increased risk of PPH associated with physiologic
management
Increased need of blood transfusion associated
with physiologic management
Oxytocin was drug of choice for active management
No increase in entrapment of placenta with active
management
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Oxytocic Drugs
Oxytocin- posterior pituitary extract
Ergometrine- preparation of ergot
Syntometrine- combination of oxytocin and
ergometrine
Misoprostol- prostaglandin E1 analogue
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Oxytocic Drugs: Oxytocin
Advantages
Causes uterus to contract
Acts within 2.5 minutes when given IM
Generally does not cause side effects
Disadvantages
More expensive than ergometrine
IM or IV preparations only
Not heat stable
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Oxytocic Drugs: Ergometrine
Advantages
Low price
Effect lasts 2–4 hours
Disadvantages
Takes 6–7 minutes to become effective when given
IM; oral form insufficiently effective
Causes tonic uterine contraction
Increased risk of hypertension, vomiting, headache
Contraindicated in women with hypertension or
heart disease
Not heat stable
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Oxytocic Drugs: Syntometrine
Advantages
Combined effect of rapid action of oxytocin
and sustained action of ergometrine
Disadvantages
Increased risk of hypertension, nausea and
vomiting
Not heat stable
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Oxytocin vs. Syntometrine:
Objective and Design
Objective: To compare effects of syntometrine
with oxytocin in reducing the risk of PPH and
other maternal and neonatal outcomes
Design: Randomized controlled trials
McDonald, Prendiville and Elbourne 2000.
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Oxytocin vs. Syntometrine:
Results
Syntometrine was associated with a small
reduction in risk of PPH < 1000 mL (OR 0.74,
95% CI 0.65-0.85)
Adverse effects of vomiting and hypertension
were associated with the use of syntometrine
There were no differences in other maternal or
neonatal outcomes
McDonald, Prendiville and Elbourne 2000.
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Oxytocin vs. Syntometrine:
Conclusion
Need to weigh benefit of reduction in
risk of PPH with risk of other adverse
effects associated with syntometrine
McDonald, Prendiville and Elbourne 2000.
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Nipple Stimulation
Nipple stimulation has not been shown to reduce risk of PPH
Randomized controlled trial of suckling immediately after birth with
over 4,000 subjects in Malawi showed no significant difference in
frequency of PPH, mean blood loss or retained placenta
When oxytocics are not available, CCT and fundal massage should be
performed
Advantages of early breastfeeding and nipple stimulation:
Stimulates natural production of oxytocin
May maintain tone of contracted uterus
Benefits baby
Bullough, Msuku and Karonde 1989.
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Recommendations Concerning
Selection of Oxytocic
Use oxytocin, when available:
If oxytocin is not available, use syntometrine or ergometrine
If oxytocic drugs are not available, use nipple stimulation
Remember: Do not use ergometrine in women with
hypertension or heart disease
Store oxytocics in refrigerator (2–8ºC) and away from light
Misoprostol rectally has advantages; awaiting confirmatory
studies.
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Summary
Active management of third stage includes:
Oxytocin
Controlled cord traction
Fundal massage
Ensuring supply of oxytocin is a priority
Active Management Reduces risk of
PPH
Retained placenta
Need for therapeutic oxytocics
Need for blood transfusion
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References
Bamigboye A et al. 1998. Randomized comparison of rectal
misoprostol with syntometrine for management of third stage of
labor. Acta Obstet Gynecol Scand 77: 178–181.
Bullough CH, RS Msuku and I Karonde. 1989. Early suckling
and postpartum haemorrhage: Controlled trial in deliveries by
traditional birth attendants. Lancet 2(8662): 522–525.
Irons DW, P Sriskandabalan and CHW Bullough. 1994. A simple
alternative to parenteral oxytocics for the third stage of labor. Int
J Obstet Gynecol 46:15–18.
Khan GQ et al. 1997. Controlled cord traction versus minimal
intervention technique in delivery of the placenta: A randomized
controlled trial. Am J Obstet Gynecol 177(4): 770–774.
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References (continued)
McDonald S, W Prendiville and D Elbourne. 2000. Prophylactic
syntometrine versus oxytocin for delivery of the placenta
(Cochrane Review), in The Cochrane Library. Issue 4. Update
Software: Oxford.
McDonald et al. 1993. Randomized controlled trial of oxytocin
alone versus oxytocin and ergometrine in active management of
third stage of labor. BMJ 307(6913):1167–1171.
Prendiville et al. 1988. The Bristol third stage trial: active
versus physiological management of the third stage of labor.
BMJ 297:1295–1300.
Rogers J et al. 1998. Active versus expectant management of
third stage of labour: The Hinchingbrooke randomised
controlled trial. Lancet 351(9104): 693–699.
World Health Organization (WHO). 1993. Stability of injectable
oxytocics in tropical climates: Results of field surveys and
simulation studies on ergometrine, methylergometrine, and
oxytocin. WHO: Geneva.
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