Community interventions;Physiological management of the

third stage of labour.

Karen GuillilandCEO 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