Community interventions;
Physiological management of the
third stage of labour.
Karen Guilliland
CEO New Zealand College of Midwives
ICM Board Member
Objectives
• Examine the evidence for the components of
physiological /expectant management of the
third stage of labour
• Define the components of physiological
/expectant management of the third stage of
labour when uterotonic drugs are not
available.
Background
• PPH is the cause of significant maternal
morbidity and mortality
• Active Management of third stage of labour
(AMTSL) is recommended as the primary
prevention method
What alternative methods are there if
uterotonic drugs are not available?
Issues affecting access to and
utilisation of uterotonic drugs
Access to uterotonic drugs is a problem in some areas
due to:
– Cost
– Erratic supply
– Need for cold chain (injectable uterotonic drugs)
– Policy limiting the type of health worker
authorized to administer uterotonic drugs
Midwives also report in some areas issues of
– authenticity of drugs
– improper use (induce abortion or induce /
augment labour)
ICM/FIGO Joint Statement on PPH
prevention and treatment - 2006
• Refers to the lack of evidence for making a
clear recommendation on how to manage the
third stage of labour when uterotonic drugs
are not available
• Added a clause on physiological management
to the 2003 version recommending use of
physiologic (expectant) management when no
uterotonic drugs are available to either the
skilled or non-skilled birth attendant
• Gives some definition and advice on
physiological management
Research needs
• AMTSL country surveys (2007-2009) showed the
following practices when uterotonic drugs were not
used for third stage management:
– Controlled cord traction without a uterotonic drug
– Controlled cord traction without countertraction
to the uterus
– Uterine massage before delivery of the placenta
– No uterine massage after delivery of the placenta
• Literature search initiated to establish what we know
about physiological management
Results…
•There is little conclusive research to
define the components of physiological
management of third stage.
•There is considerable variation between
countries and disciplines about the
components of “normal” birth and what is
considered intervention.
Results…
The text book definitions & the expert
opinion on third stage management
displays marked differences globally.
Midwives, as the main practitioners of
physiological management of third stage,
also differ but have the most similarities.
Assisting the physiology
of third stage…current practice
In 2010 ICM/FIGO formed a Multidisciplinary expert
taskforce to define the components of physiological
management. ICM conducted a survey of current best
practice and 39 ICM Member Association Countries
responded.
There was consensus on;
1) Signs of separation
2) How to support women to expel
the placenta
3) The first two hours after the birth
Practice consensus…
1) Signs of separation
– Change in the size, shape and position of the
uterus
– A small gush of blood
– The cord lengthens
– The woman becomes uncomfortable, get
contractions or feel that she wants to change
position or bear down
Most placentas will be delivered in one hour.
Practice consensus…
2) Supporting women to expel the placenta,
after signs of separation
–
–
–
–
Encourage woman into upright position
The placenta may be expelled spontaneously or
Encourage maternal effort to expel placenta
The birth attendant catches the placenta in
cupped hands or a bowl
– If the membranes are slow then assist by holding
the placenta in two hands and gently turning it
until the membranes are twisted then exert gentle
tension
Practice consensus…
Controlled cord traction is not recommended in the
absence of uterotonic drugs
There is no need to clamp or cut the cord until after
placenta is delivered
Practice consensus…
3) The first two hours following the birth
– Observe and estimate the blood loss
– Palpate for a contracted uterus on a regular
basis
– Teach the woman how to check her
blood loss and
the firmness of her own uterus
– Encourage breastfeeding
Recommendations
• Physiology of 3rd stage needs to be a
common knowledge competency &
more research needed
• More research on physiological
management of 3rd stage
• Every person attending a birth is
taught how to assist at a physiological
third stage
• Every programme teaching
AMTSL includes how to assist
at a physiological third stage
• Educate women in self care