I just finished a MASSIVE (29 page whopper!) of a research paper on the management of the third stage of labour, so of course it’s only right and proper that my new, shiny and very-up-to-date knowledge of the subject should be shared here. I’ve found this topic incredibly interesting because…guess what? The management of the third stage of labour is handled very differently here in the UK than it is across the pond! (Shocker–NOT! After all, this is why I’m back at university–for this sort of thing exactly, right? Right??) Basically, there are two different strategies for managing the third stage of labour: active management, and expectant management (don’t worry–I’m going to get into the nitty-gritty of exactly what all of this means below). Here in the UK, active management is the norm, whereas in the US (at least in the hospitals where I was working), expectant management was the more common practice. I’m still not entirely sure why this is the case–the research on this has been around for awhile, but clearly the two countries have taken very different approaches to it. (Obviously, the follow-up to all of this should be looking into the history of why this occurred, but for now, I’ll just stick to the research and leave that for a different post). Also, interestingly, because of the prevalence and preference for active management here in the UK, many women at low risk of postpartum haemorrhage aren’t being offered true informed choice about the different management strategies available to them–in fact, researchers have found that many women at low risk of haemorrhage don’t even know they have a choice in the matter (again, see below for more on this)! Which all just goes to show that there is a desperate need for women, midwives and doctors to be better educated on this topic, and to understand and be able to support physiologic (i.e. expectant) third stage management. Which brings me to my research paper.
So, without further adieu…
The third stage of labour is the time from the birth of the baby up through the delivery of the placenta, followed by control of bleeding. The placenta is a miraculous and highly evolved organ which is created during the pregnancy and then expelled afterwards. (Just let that sink in for a moment: during pregnancy your body creates and grows a whole new organ solely for nourishing and sustaining a baby, and then, after pregnancy, this brand new organ is disposed of, just like that; talk about amazing!) It acts as a life-support system for the baby, providing an interface for maternal and fetal blood which allows for gas exchange, as well as letting hormones and nutrients pass to the baby. The placenta also provides a barrier for the baby, helping to keep out toxic chemicals, substances and pathogens. It even acts like a gland, producing hormones such as oestrogen and progesterone that sustain the pregnancy, and helps to metabolize various substances that the baby’s tiny, immature liver isn’t ready for yet. The placenta is so good at its job that it keeps maternal and fetal circulation completely separate (this is how babies are able to have different blood types from their mothers, or how a mother can be HIV positive while a her baby remains HIV negative)! And then, after the birth of the baby, this miraculous life-support system peels away from the uterine wall and slips out through the vagina, while meanwhile the uterine muscle fibers clamp down on the open blood vessels and prevent the woman from bleeding to death.
More specifically (in clinical speak), after the birth of the baby, a rush of oxytocin encourages the myometrium (the muscle layer of the uterus–another miraculous and highly specialized part of the body) to contract and reduce in size. As the uterus shrinks around the placenta, the placental bed separates from the uterine wall, and the woman will usually experience a cramp or feel an urge to push, combined with other clinical signs that placental separation has occurred, such as a small gush of blood, a lengthening of the cord, or the uterus rising in the abdomen and becoming globular and round rather than discoid. In physiological management, the placenta is birthed by maternal effort alone. Afterwards, the myometrium continues to retract around the placental site, creating ‘living ligatures’ around the torn blood vessels and ensuring haemostasis (Baker, 2014, pp. 191). An intricate cascade of hormones assists this process, led mostly by oxytocin, beta-endorphins and prolactin (Buckley, 2004). These hormones provide a blueprint for placental separation, maternal and infant bonding, control of bleeding and the initiation of breastfeeding (Buckley, 2004).
The two main management strategies available in the third stage of labour are Expectant Management of the Third Stage of Labour (EMTSL) and Active Management of the Third Stage of Labour (AMTSL) (and no, I’m not making these acronyms up–this is actually how it’s referred to in the literature!). Interestingly, there are NO universally recognised protocols available for either strategy (and arguing over exactly which protocol is superior is the raison d’etre for most of the research on this topic). However, in general, EMTSL tends to utilise a ‘hands-off’ approach that allows the placenta to deliver spontaneously, by maternal pushing effort alone. The aid of skin-to-skin contact, gravity or nipple stimulation can encourage delivery, and early cord clamping, controlled cord traction (CCT) or administration of prophylactic uterotonic agents (i.e. drugs which cause the uterus to contract) are not employed. In contrast, AMTSL involves the routine administration of uterotonic agents after the birth of the baby, and then early cord clamping and CCT to deliver the placenta. These strategies pertain to routine management and not emergency situations where uterotonic agents are administered as a treatment for postpartum haemorrhage (PPH). And in fact, once you get into it, the evidence on this subject is pretty murky. Reams and reams of papers have been written on various types of active management. Studies comparing the timing of uterotonic administration (should it happen with the birth of the baby, after the birth of the baby, or even after the delivery of the anterior shoulder of the baby but before the entire baby is out), the types of uterotonic agent used (carbetocin versus syntocinon versus syntometrine versus misoprostyl) and other parts of active management (early cord clamping v. delayed cord clamping–and if delayed, for how long?–controlled cord traction v. no CCT, uterine massage v. no uterine massage etc. etc.) is what fills most of the literature on this topic.
The reason so much research has been devoted to various management options on this is because postpartum haemorrhage (PPH) is a real and very serious risk. On a global level, PPH is the number one killer of pregnant women, responsible for 25% of all maternal deaths worldwide, particularly in developing countries where access to medical care and decent nutrition is hard to come by (which leaves women aenemic and much more vulnerable should a heamorrhage occur). Similar to AMTSL and EMTSL, there is no universal definition of PPH, but many guidelines define it as blood loss greater than 500 mls from the genital tract. The most common cause is uterine atony (ineffective uterine contraction), followed by trauma to the vaginal tract (such as lacerations), retained tissue in the uterus (such as retained membranes or placental lobes) or coagulation disorders (WHO, 2012; RCOG, 2016). However, it’s also worth noting that these definitions are not always helpful. For example, 500 mls is equivalent to a blood donation, and is often an amount of blood loss that women can tolerate well, especially women who live in developed countries, have good nutritional status and who aren’t aenemic (Goer and Romano, 2013). Many of these studies would be BETTER studies if they looked at clinically important outcomes, such as symptoms like dizziness, weakness or tachycardia (fast heart rate), or the clinical need for a blood transfusion, rather than surrogate outcomes such as blood loss. Also, a lot of the studies use Estimated Blood Loss (EBL) as their clinical indicator, which is a visual estimate of how much blood has come out; not surprisingly, EBL varies significantly from provider to provider and is a notoriously inaccurate way of measuring blood loss, particularly as blood is often mixed with amniotic fluid after a delivery, and the amount often looks like more than it really is (Yoong et. al., 2010; Lilley et. al., 2015).
Global guidelines universally recommend AMTSL as the preferred management strategy in the developing world (WHO, 2012; ICM/ FIGO, 2014), which makes a lot of sense given that postpartum haemorrhage is such a risk. In the UK, guidelines also recommend AMTSL in all situations, but acknowledge that if a woman at low-risk for PPH requests EMTSL, she should be supported in that choice (NICE, 2014; RCOG, 2016; RCM, 2012). The National Institute for Health and Care Excellence (NICE) guidelines encourage counseling low-risk women on both management strategies, but recommend AMTSL over EMTSL to help prevent PPH. These guidelines are based on a recent Cochrane Review (Begley et. al., 2015) and the earlier Cochrane Review which preceded it (Prendiville et. al., 2000). However, there is some research which suggests that for women at low-risk of PPH, expectant management may actually produce lower rates of postpartum haemorrhage than active management (Fahy et. al., 2010; Dixon et. al., 2013). These studies are observational studies rather than the randomised control trials (RCTs) used in the Cochrane reviews, but they are well done and hold up under scrutiny. Nevertheless, over half of all maternity units in the UK still advise AMTSL for all women regardless of risk status (Rogers et. al., 2012) and most practitioners in the UK are more familiar and comfortable with AMTSL than EMTSL (Farrar et. al., 2009; Downey and Bewley, 2010). This has led some authors to question whether women at low-risk of PPH are being offered a true informed choice regarding management options (Selfe and Walsh, 2015), and this is something that my clinical experience in the UK so far would confirm.
The Cochrane systematic review by Begley et. al. (2015) provides some of the strongest evidence on this subject, based on the fact that it’s a meta-analysis which pools together the results of several RCTs and then does further statistical tests in order to provide a larger sample size and greater statistical power. This particular meta-analysis uses seven RCTs examining AMTSL versus EMTSL in hospital settings, for a combined sample size of 8,247 women. The maternal outcomes of interest were severe and very severe PPH (blood loss greater than 1000mls and 2500mls respectively), blood transfusion requirement, maternal mortality, and maternal haemoglobin (Hb) levels less than 9g/dl at ≥ 24 hours postpartum. The authors found that overall AMTSL significantly reduced the rates of PPH, the need for blood transfusions and low maternal Hb. However, for women at low risk of PPH, AMTSL offered no statistically significant reduction in PPH (although there was still a reduction in the need for blood transfusions). Additionally, AMTSL has several disadvantages, including maternal hypertension, nausea and vomiting, increased postpartum pain (afterpains), an increased chance of returning to the hospital after discharge due to postnatal bleeding, and a decrease in newborn birth weight due to early cord clamping. The authors concluded that for women at low risk of PPH, the benefits of AMTSL may not outweigh the disadvantages of it, and advised that low risk women should be counseled on both options and allowed to make their own choice.
There were several strengths to this meta-analysis. Because of the large sample size, the study was able to provide statistically significant results with 95% confidence intervals and low p-values, which indicates that the findings were likely due to the experimental treatment (in this case AMTSL) and not due to chance. However, there was a large degree of heterogeneity between the RCTs analysed, meaning that the populations and experimental treatments being compared were quite different, and therefore may have prevented a true comparison between the outcomes. Only three of the RCTs limited their sample to women at low risk of PPH; the four remaining studies included women regardless of their PPH risk status, which may have introduced a selection bias that weighted the results in favour of AMTSL. Additionally, the studies varied significantly in terms of uterotonic agent used, route of administration (intravenous versus intramuscular), timing of cord clamping, use of uterine massage, and EMTSL protocol observed. Finally, among the seven trials analysed, four of them reported that many women in the EMTSL group received prophylactic uterotonic agents (rates varied from 2.5% to 38% among the studies), which again weakens the findings as many of the women in the EMTSL group were treated with the AMTSL protocol.
In contrast, two retrospective cohort studies examined EMTSL in more detail and found that PPH rates were lower than AMTSL when used in a holistic midwifery model (Fahy et. al., 2010; Dixon et. al., 2013). Fry (2007) and Hastie and Fahy (2009) have both proposed that EMTSL is more than merely a “hands-off” approach during the third stage, but also involves guarding and facilitating normal physiology in all aspects of care. Hastie and Fahy (2009) named this ‘holistic psychophysiological care’ as it considers all aspects of a woman’s experience, including her environment, and is a more sophisticated approach to EMTSL than the limited definition employed by Begley et. al. (2015). This approach requires a physiological labour and birth, a private and warm environment, uninterrupted skin-to-skin and suckling after delivery, plus waiting until the cord stops pulsing before cutting it. Furthermore, a trusting and respectful relationship between woman and midwife is necessary. In their qualitative descriptive study interviewing midwives who were expert at EMTSL, Begley et. al. (2012) found that midwives skilled in this management approach intuitively provided this type of care, with themes of watchful waiting, guardianship and trust in the woman and the process emerging from their study.
Fahy et. al. (2010) designed a retrospective cohort study to evaluate the effectiveness of ‘holistic psychophysiological care’. Using data from the computer-based Midwives Data Set in Australia, the study compared women at low risk of PPH in a tertiary-care hospital receiving AMTSL to women at a midwife-led unit (MLU) receiving EMTSL. At the hospital, women received 10 IU syntocinon intramuscularly within one minute of birth, followed by CCT and then uterine massage, whereas at the MLU, midwives were taught how to facilitate ‘holistic psychophysiological care’ as described by Hastie and Fahy (2009) above. The study found that 11.2% of low-risk women in the hospital setting experienced PPH (defined as ≥ 500 mls blood loss) versus 2.8% at the MLU (95% Confidence Intervals).
These findings were quite rigorous and trustworthy, as they excluded all women in both settings who were at higher risk of PPH. They also used a stronger definition of EMTSL and eliminated women who received mixed management from the EMTSL cohort. The results from this study also provided data from an MLU setting, whereas Begley at. al. (2015) only looked at hospital settings; this provides greater generalisability and transferability to other settings (Rees, 2011). However, the retrospective design prevented complete control over all of the interventions. The data set also used EBL rather than measured blood loss, which could contribute to inaccurate measurements (Yoong et. al., 2010). Additionally, the authors noted that ‘holistic psychophysiological care’ is hard to achieve in all settings due to the extent of its definition, and may be difficult to apply outside of an MLU or home.
The findings in Dixon et. al. (2013) confirmed the findings of Fahy et. al. (2010). Dixon et. al. (2013) designed a population based retrospective cohort study using data from the New Zealand Maternity and Midwifery Provider Organisation (Dixon et. al., 2009; Davis et. al., 2012). It compared 17,514 low-risk women who received AMTSL (51.9%) to 16,238 low-risk women who received EMTSL (48.1%) over a five-year period. Midwives provided continuity of care to all women from booking to six-weeks postpartum, and women could choose to deliver either at home, an MLU or a hospital. Therefore, the midwives in this database practiced in all settings depending on the woman’s history and preference, and were familiar and comfortable with both AMTSL and EMTSL strategies. Similar to Fahy et. al. (2010), the authors found that AMTSL resulted in higher rates of blood loss than EMTSL, regardless of setting (6.9% v. 3.7%, Confidence Intervals 95% and 94% respectively). Women who received AMTSL were also three times more likely to have a retained placenta (0.7% AMTSL v. 0.2% EMTSL, p<0.0001). Women in hospitals were more likely to receive AMTSL, and also experienced the highest levels of blood loss, while women at home were more likely to receive EMTSL, and had the lowest levels of blood loss.
Dixon et. al. (2013) was also quite rigorous and trustworthy. They defined the populations carefully and excluded all women at high risk of PPH. They also had a very large sample size (32,752 in total) and provided data from a wide range of settings, collected by midwives who worked in a variety of settings and were comfortable facilitating both management strategies. Limitations to this study included its retrospective observational design and the use of EBL rather than measured blood loss. There may have also been other confounding factors not accounted for, as women who choose to give birth at home or in a MLU may differ in health, lifestyle or philosophy from women who choose a hospital setting.
So what does all of this mean?? It means that for women at low risk of PPH, who have good nutritional status and (more importantly) a NORMAL, PHYSIOLOGIC birth, expectant management is probably safer than active management, and has a lower rate of PPH, especially when provided in a holistic midwifery model and occurring in a calm, private and undisturbed setting, such as a home or birth centre. However, let’s be honest here….how many women experience normal, physiologic birth in a hospital, without an epidural, or syntocinon to augment contractions? Labours that started spontaneously, without induction? Waters that broke spontaneously, rather than artificially? The sad, grim statistic is that only about 25% of all births occur in this manner…the remaining 75% have been fiddled with in some way. Which means that for the majority of women, AMTSL probably IS the superior choice. Midwife Thinking sums this up far more eloquently than I ever could in her excellent blog post (which I just linked to, and which I highly encourage you to read). She also concludes that for most women, AMTSL is most likely the better option, given how rare true physiologic, undisturbed birth is.
Interestingly, though, my (completely anecdotal) experience in the US counters this somewhat. In the States, the third stage was most often handled in a physiologic manner, although with a few aspects of AMTSL thrown in for good measure. For example, in the hospitals in Brooklyn where I was practicing, pitocin (syntocinon, i.e. artificial oxytocin) was not given until after the placenta was delivered (usually intravenously). The practitioner awaited signs of placental separation, and then, once the signs were visible, gentle cord traction was used to facilitate the delivery (which isn’t quite right for true physiologic management, which should be entirely hands-off until the delivery has occurred). Pitocin given prior to the delivery of the placenta was only used in cases of PPH, and often accompanied by manual removal of the placenta in those situations. The received wisdom behind waiting to give pitocin until after delivery of the placenta was to prevent placental entrapment (i.e. the uterus contracting around the placenta and preventing it from being delivered), but the research on AMTSL doesn’t back this up, as active management regularly employs uterotonic agents before placental separation, and placental entrapment rarely occurs. We generally used physiologic third stage management on the majority of women regardless of whether their birth had been induced, or whether augmentation was used, or whether they had an epidural or not, and I don’t believe our rates of PPH were significantly higher because of this (although it’s worth noting that the US ranks 47th globally in terms of maternal mortality as of 2014, whereas the UK ranks 38th).
If you’re planning a birth in the UK, though, keep in mind that expectant management is a valid option for you, particularly if you’re at low risk of haemorrhage, and you’ve had a normal, physiologic birth. My experience so far has shown that this conversation rarely happens during the antenatal period, unfortunately, and options are most often mentioned after the birth of the baby. Sadly, I have seen “informed choice” offered like this: “Would you like the shot that will bring the placenta more quickly, or do you want to wait for the placenta to separate and push it out yourself?” That’s not at all what I would call informed choice! Midwives in the UK are more familiar with active management, and tend to prefer it (Rogers et. al., 20120; Farrar et. al., 2009), and as the research by Selfe and Walsh (2015) demonstrates, many women don’t even realise they have a choice in the matter. But you do! And it’s well within your rights to ask for expectant management, as per the latest NICE guideline. If you’re looking for more information on this, I’d highly recommend the Association for Improving Maternity Services (AIMs) publication on this, which you can purchase here (Birthing Your Placenta).
Baker, K.C. (2014) ‘Postpartum haemorrhage and the management approaches in the third stage of labour’. MIDIRS Midwifery Digest, 24(2), pp. 191-196.
Begley, C.M., Gyte, G.M., Devane, D., McGuire, W. and Weeks, A. (2015) Active versus expectant management for women in the third stage of labour. [Cochrane Systematic Review] Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007412.pub4/full (Accessed: 25 September, 2017)
Begley, C.M., Guilliland, K., Dixon, L., Reilly, M. and Keegan, C. (2012) ‘Irish and New Zealand midwives’ expertise in expectant management of the third stage of labour: The MEET study’, Midwifery, 28(6), pp. 733-739.
Buckley, S. (2004) ‘Undisturbed birth—nature’s hormonal blueprint for safety, ease and ecstasy’, Midirs Midwifery Digest, 14(2), pp. 203-209.
Davis, D., Baddock, S., Pairman, S., Hunger, M., Benn, C., Anderson, J., Dixon, L. and Herbison, P. (2012) ‘Risk of Severe Postpartum Hemorrhage in Low-Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor’, Birth: Issues in Perinatal Care, 39(2), pp. 98-105.
Dixon, L., Fletcher, L., Tracy, S., Guilland, K., Pairman, S. and Hendy, C. (2009) ‘Midwives Care During the Third Stage of Labour: An Analysis of the New Zealand College of Midwives Midwifery Database 2004-2008’, New Zealand College of Midwives Journal, 41(10), pp. 20-25.
Dixon, L., Tracy, S.K., Guilliland, K., Fletcher, L., Hendry, C. and Pairman, S. (2013) ‘Outcomes of physiological and active third stage labour care amongst women in New Zealand’, Midwifery, 29(1), pp. 67-74.
Downey, C. and Bewley, S. (2010) ‘Childbirth practitioners’ attitudes to third stage management’, British Journal of Midwifery’, 18(9), pp. 576-582.
Fahy, K., Hastie, C., Bisits, A. Marsh, C. Smith, L., and Saxton, A. (2010) ‘Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: A cohort study’, Women and Birth, 23(4), pp. 146-152.
Farrar, D., Tuffnell, D., Airey, R. and Duley, L. (2009) ‘Care during the third stage of labour: a postal survey of obstetricians and midwives in the UK’, BMC Pregnancy and Childbirth, 10(23), pp. 1-9.
Fry, J. (2007) ‘Physiological third stage of labour: support it or lose it’, British Journal of Midwifery, 15(11), pp. 693-695.
Goer, H. and Romano, A. (2013) Optimal Care in Childbirth: The Case for a Physiologic Approach. London: Pinter and Martin.
Hastie, C. and Fahy, K. (2009) ‘Optimising psychophysiology in third stage of labour: Theory applied to practice’, Women and Birth, 22(3), pp. 89-96.
International Confederation of Midwives (ICM) and International Federation of Obstetricians and Gynaecologists (FIGO) Joint Statement (2014) Misoprostol for the treatment of postpartum haemorrhage in low resource settings. Available at: https://www.figo.org/sites/default/files/ICM-FIGO%20Joint%20Statement%20English.pdf (Accessed: 16 October 2017)
Jangsten, E., Mattsson, L-Å., Lyckestam, I., Hellstram, A-L. and Berg, M. (2011) ‘A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial’, BJOG: An International Journal of Obstetrics & Gynaecology, 118(3), pp. 362-369.
Knight, M., Nair, M., Tuffnell, D., Kenyon, S., Shakespeare, J., Brocklehurst, P. and Kurinczuk, J.J. (eds.) on behalf of MBRRACE-UK. (2016) Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland. (Confidential Enquiries into Maternal Deaths and Morbidity 2009-14). Available at: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202016%20-%20website.pdf (Accessed: 26 September 2017)
Lilley, G., Burkett-st-Laurent, D., Precious, E., Bruynseels, D., Kaye, A., Sanders, J., Alikhan, R., Collins, P.W., Hall, J.E. and Collis, R.E. (2015) ‘Measurement of blood loss during postpartum haemorrhage’, International Journal of Obstetric Anesthesia, 24, pp. 8-14.
National Institute for Health and Care Excellence (NICE) (2014) Intrapartum Care for Healthy Women and Babies. (Clinical Guideline CG190). Available at: https://www.nice.org.uk/guidance/cg190 (Accessed: 22 September 2017)
Prendiville, W., Elbourne, D., McDonald, S. (2000) Active versus expectant management of the third stage of labour. [Cochrane Systematic Review – withdrawn in 2009 due to publication of new Systematic Review] Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000007.pub2/full (Accessed: 21 October 2017)
Rogers, C., Harman, J. and Selo-Ojeme, D. (2012) ‘The management of the third stage of labour—A national survey of current practice’, British Journal of Midwifery, 20(12), pp. 850-857.
Rees, C. (2011) An Introduction to Research for Midwives. London: Churchill Livingstone.
Royal College of Midwives (RCM) (2012) Evidence Based Guidelines for Midwifery-Led Care in Labour: Third Stage of Labour. Available at: https://www.rcm.org.uk/sites/default/files/Third%20Stage%20of%20Labour.pdf (Accessed: 22 September 2017)
Royal College of Obstetricians and Gynaecologists (RCOG) (2016) Prevention and Management of Postpartum Haemorrhage. [Green-top Guideline No. 52] Available at: http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14178/epdf (Accessed: 11 October 2017)
Selfe, K. and Walsh, D.J. (2015) ‘The third stage of labour: are low-risk women really offered an informed choice?’, MIDIRS Midwifery Digest, 25(1), pp.66-72.
World Health Organization (WHO) (2012) WHO recommendations for the prevention and treatment of postpartum haemorrhage. Available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf (Accessed: 27 September 2017)
Yoong, W., Karavalos, S., Damodaram, M., Madgwick, K., Milestone, N., Al-Habib, A., Fakokunde, A., and Okolo, S. (2010) ‘Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health care professionals?’, Archives of Gynecology and Obstetrics, 281(2), pp. 207-213.