Evidenc Based Perspectives On Third Stage

Institution:

There are two major approaches to third stage labour management. The first approach is called expectant management of third stage delivery where the mother delivers the placenta upon undergoing a contraction of the womb causing the placenta and the uterine wall to separate. The second approach, active management, involves using uterotonic drugs to induce a contraction of the uterus wall and clamping of the cord (usually immediately, after or alongside the birth of the baby), together with the traction of the cord on the uterus with pressure to cause a faster delivery of the placenta (Rogers et al 1998). Scientists have been keen to evaluate which of the two approaches is more effective or whether one approach is more effective than the other in certain conditions. The main aim of this paper is to conduct a critical analysis of the evidence-based studies on third stage labour management, with a specific focus on active versus expectant/physiological management of third stage labour.

A Critical Analysis of the Cochrane Review

Begley et al (2011) conducted a systematic literature review to compare the effectiveness of both active and expectant management of third stage labour based on the fact that the former management approach was introduced to reduce haemorrhage. Begley and colleagues expeditiously uses a total of seven quasi-randomised and randomised controlled trials research studies from both high-income and low/middle income involving a total of 8247 women to conclude that active management of third stage labour is more effective because, in the case of high-income countries, it benefits women of various levels of bleeding risks by reducing incidences of blood transfusion and severe haemorrhage despite the fact that it can cause pain and postnatal hypertension. However, a major issue with these findings is that they were based on a relatively very low number of data sources (only seven sources) and the quality of sources are very low because they are characterized by bias. For instance, only one trial was free of selective reporting while there was no clear whether they were biased or not. Begley and colleagues also included studies with incomplete data on outcome and selectively reported outcomes (i.e. Thilaganathan 1993). According to the Cochrane Collaboration Handbook (2005), such limitations affect the generalizability of the study findings. Besides, the use of only a small number of randomized control trials speaks to the need for further research with more data for purposes of yielding confident findings on the effectiveness of active vs. physiological management of third stage labour.

Currently Existing Evidence

An evaluation of existing literature reveals several pieces of evidence from different scholars regarding a comparison of the two approaches to third stage labour management (Tan et al, 2008), recommendations for practice (Farrar et al, 2010) and the effectiveness of the two approaches in lowering haemorrhage (Rogers et al 1998). The cross-sectional survey study by Tan et al (2008) aimed to explore the approaches preferred by practitioners (physicians and midwives) in the British Columbia to manage third stage labour, their level of knowledge of those approaches, why they prefer those approaches, and the appropriateness of the approaches to third stage labour. 97.8% of the respondents were aware of the guidelines for management of third stage labour, 51.2% of which agreed with the guidelines. 71.1% of the respondents preferred active management. In short, the study found that a majority of the British Columbia practitioners practice the active management approach, although the study found a major difference in preference between midwives and physicians. Particularly, the study found that midwives in British Columbia are more likely to use the passive approach while the physicians are more likely to use the active approach. According to Tan et al (2008), a major reason for this difference is that most midwives in the British Columbia were of the opinion that the active management approach does not consider the women’s preferences for the management of the third stage labour.

Similar to the findings of Tan et al (2008), Farrar et al (2010) also found that as compared to the physiological approach, the active management approach is used by a majority of the midwives and obstetricians who participated in the postal survey study (2230 being members and fellows of the Royal College of Obstetricians and Gynaecologists while 2400 were members of the Royal College of Midwives). Besides, Farrar et al (2010) found that only 2% of obstetricians and 9% of midwives who participated in the study always used physiological approach, while a majority of the midwives and obstetricians (89% and 815 respectively) were of the opinion that more evidence was required to inform the practice of physiological management of third stage labour. The findings by Tan et al (2008) and Farrar et al 2010 imply that availability of research-based evidence plays a major role in the selection between active and physiological management of third stage labour, where the availability of more evidence on active management contributes to it being the most frequently used approach to third stage labour.

However, Rogers et al (1998) has a different objective and evaluates the effectiveness of both active and physiological management of third stage labour in reducing primary postpartum haemorrhage (PPH). The randomized controlled trial study found a significantly low rate of PPH in the use of active approach compared to the use of physiological approach thus recommending that existing guidelines should advocate for the active management approach over the physiological approach.

Current Recommended Practice

NICE (2017) guidelines on the management of third stage labour are short and clear. First, the guidelines provide for both active and physiological approaches depending on the practitioner’s assessment of the mother’s condition. Similarly, according to NICE (2017), it is the responsibility of the midwife to explain to the pregnant woman the two approaches, what is entailed in each, and the circumstances under which each approach may be deemed appropriate. All in all, the guidelines indicate that in active management, the practitioner should inject oxytocin into the thigh as the woman is giving birth, clamp and cut the cord between 1 & 5 minutes after birth, and pull out the placenta upon its separation from the uterus wall (NICE 2017). In regards to the physiological approach, the guidelines show that the practitioner should not give injections and the clamping and cutting of the cord is done after its pulsing has stopped. The placenta is then pushed out with contractions in a procedure which can take up to one hour (NICE 2017).

Evidence-Based Recommendations

Based on the evidence gathered from the four studies, it is recommended that whereas not frequently used, the physiological approach requires more research in order to establish the best instances and the patient situation where it should be used. This recommendation is based on the findings of two studies evaluated in this paper, one of which (Tan et al 2008) show that midwives were not satisfied with how it considers the situation of the women while the other (Farrar et al, 2010) indicated that practitioners need more evidence-based research to inform their use of the physiological approach. Nonetheless, active approach emerges to be the best approach and is recommended for most deliveries due to its proven effectiveness of reducing PPH as compared to the physiological approach.

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References

• Begley M., Gyte L., Devane D., McGuire W., & Weeks A. (2015) Active Versus expectatnt management for women in the third stage of labour. Cochrane Database of Systematic Reviews, 3, 1-153.
• Cochrane Collaboration Handbook (2005) Systematic reviews of health promotion and public health intervention-Unit One: Background to systematic reviews. Available from:
• Farrar D., Tuffnell D., Rebecca A., & Lelia D. (2010) Care during the third stage of labour: A postal survey of UK midwives and obstetricians. BMC Pregnancy and Childbir 10, 23, 2-9.
• NICE (2017) Intrapartum care for healthy women and babies. Retrieved from [accessed on 10th Sep, 2018].
• Rogers J., Wood J., McCandlish R., Ayers S., Truesdale A., & Elbourne, D. (1998) Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial', Lancet, 351, 9104, p. 693.
• Tan M., Klein C., Saxell L., Shirkoohy E., & Asrat G. (2008) How Do Physicians and Midwives Manage the Third Stage of Labor? BIRTH 35:3 220-228.