Management of
Third Stage of Labour
Compiled by Jackie
Mawson.
The third stage of labour
is the period which occurs after the birth of the child, it
is the time during which the placenta and membranes are
delivered. This 3rd stage may be managed in one of three
ways; actively, physiologically or delayed active
management.
Oxytocic Drug
types:
- Originally Ergot,
which is a fungus which is found on rotting rye, was used
for it's ability to produce contractions of the smooth
muscle (eg, the uterus) following birth. This was used by
midwives as early as the 17th and 18th centuries. In 1935
a new water-soluble ergot principle had been produced,
which became known as Ergometrine. Ergometrine, given
into a vein, works within 45 seconds and is extremely
effective in producing uterine contractions, but it is
not without side effects.
- Syntocinon, a
synthetic oxytocic drug, was produced in 1954. It was
thought this new oxytocic drug would solve the problem of
some of the side effects of Ergometrine. It also produces
contractions of the uterus, but was not considered as
effective as Ergometrine, and subsequently Syntometrine
was developed. A combination of these two earlier
drugs.
- Syntometrine was
developed in the 1960's. It combines Syntocinon and
Ergometrine. This is often the oxytocic drug of choice,
for it's effectiveness and it's slightly reduced side
effects.
Definitions of
each type of management are:
'Active'
Management
- Use of oxytocic drug,
usually Syntometrine, although Syntocinon may be used
alternatively.
- Time
limit
- Cord clamped and cut
immediately
- Controlled cord
traction (or maternal effort)
- Observation by the
midwife
'Physiological'
Management
- No interventions in
labour
- Time not
crucial
- No routine oxytocic
drug
- Cord intact and
unclamped (until after placental delivery)
- No cord
traction
- Observation by the
midwife
'Delayed Active'
Management
One of two procedures:
1). Delay giving
Syntometrine until the cord has stopped pulsating and has
been clamped and cut. This method may provide the baby with
the proposed advantages of the 'physiological' approach (the
natural quantity of blood for the baby and a prolonged
oxygen supply via the cord if required).
Or
alternatively,
2). Agree to wait,
say 15 &endash; 30 minutes, to see if the mother can deliver
the placenta by herself, or if any problems arise.
- It must be remembered
that if no oxytocic drug has been administered, then the
'physiological' approach should be used. ie, no cord
clamping, no cord traction, no pressure on the uterus and
allowing the baby to suckle at the breast if
desired.
- If an oxytocic drug
is administered for any reason, then the guidelines for
'active' management become necessary. ie, immediate cord
clamping and usually controlled cord traction to deliver
the placenta.
The 3rd stage of labour
usually lasts about 5 to 10 minutes with 'active'
management, and about 20 minutes to an hour with a
'physiological' approach. 'Active' management of 3rd stage
was introduced, in most maternity units, to try to reduce
the amount of blood loss at delivery and to speed up the
process of the 3rd stage.
Some Advantages of
'Active' Management:
- Less blood loss and
less postpartum haemorrhage (PPH)
- Higher haemoglobin
levels for the mother in the first few days after
delivery
- Shorter 3rd
stage
- Less need for
oxytocic drugs to treat PPH
Some Disadvantages
of 'Active' Management:
- Some effects of the
oxytocic drugs used - In some women the ergometrine
component of Syntometrine produces a sharp rise in blood
pressure. If there is raised blood pressure at any time
during pregnancy/labour, then Syntocinon (instead of
Syntometrine) should be used in the 'active' management
of the 3rd stage. Other common side effects may include
nausea and vomiting, headaches, tingling of the limbs,
dizziness, ringing in the ears, cardiovascular
disturbances and pains in the backs of the legs in some
mothers. Very rare complications include heart
failure/attack, intracerebral haemorrhage (bleeding in
the brain), postpartum eclampsia (high blood pressure and
possible fits after birth), pulmonary oedema (fluid on
the lungs) and, in some rare cases, these have led to the
woman's death (see Inch 1989).
- Syntometrine affects
smooth muscle, and when it is given as the baby is being
born, while the cord is still intact, it may reach the
baby. It is thought that this may be implicated in
causing the well-known 'three month colic'.
- Early cord clamping
has been shown to make the placenta heavier than normal
as it prevents the passage of some of the baby's blood
from the placenta to the baby immediately after delivery.
This may make the placenta less easy to
deliver.
- Syntometrine causes
very strong contractions of the whole uterus. Therefore,
the reasoning behind some the interventions involved in
the active management of the 3rd stage of labour (ie,
cord traction, uterine pressure). Because the placenta
may need to be delivered without delay to avoid it
becoming trapped inside as the uterus contracts down
under the influence of Syntometrine. About 1.9% of women
require a manual removal of the placenta when 'active'
management of the 3rd stage is used.
- The cord needs to
clamped immediately to avoid the baby receiving too much
blood, as the uterine muscles contract and force blood
out of the placenta. If clamping is delayed then this may
contribute to neonatal jaundice because of the
overtransfusion of blood to the baby. The necessary
immediate clamping may compromise the oxygen supply to
the baby, especially in premature babies or those in
respiratory distress, and it may also reduce the baby's
haemoglobin levels after birth.
- Possible foetal death
may occur in the case of undiagnosed extra babies (ie,
twins). This is quite rare these days, but any extra
babies can be affected if 'active' management is
administered after the delivery of the first
baby.
- The immediate cord
clamping required increases the incidence of
feto-maternal transfusion of blood, as the pressure from
the uterine contractions may force some of the baby's
blood (within the placenta) into the mother's circulatory
system. This may be critical if the mother is Rhesus
negative and her baby is Rhesus positive.
Undoubtedly, oxytocic
drugs have saved many lives and will continue to do so. But
note that it has been stated by the Cochrane Pregnancy and
Childbirth database (Elbourne 1994), "It cannot be said that
the case for routine 'active' management of third stage of
labour for all women has been made."
Some Advantages of
the 'Physiological' Approach:
- Avoiding the possible
risk of suffering from the side effects of Syntometrine,
unless you require the oxytocic drugs for the treatment
of complications.
- Less likely that the
placenta will become trapped within the uterus by the
strong contractions of the uterus induced by
Syntometrine.
- A 'physiological' 3rd
stage allows your baby to receive the natural quantity of
blood from the placenta, following delivery. This may
allow the baby to continue to receive oxygen via the
cord, and this may possibly be helpful if your baby has
respiratory problems.
- The mother may find
satisfaction in completing labour using her own
resources.
Some Disadvantages
of the 'Physiological' Approach:
- In the trials
conducted to date, the 'physiological' approach was found
to be associated with a larger blood loss and more cases
of PPH compared with active management.
- The 'physiological'
approach normally takes longer than 'active'
management.
If a woman has a normal
birth, she will usually sit, or kneel, as she picks up her
baby. This type of upright position may possibly aid
delivery of the placenta. As the baby's head is delivered it
has been suggested that a surge of natural oxytocin may be
released. Seeing, smelling, holding and hearing the baby may
encourage the body to release more oxytocin, and other
hormones, which cause the uterus to contract and the
placenta to separate. In the 'physiological' approach,
after about 5 to 10 minutes the cord stops pulsating,
indicating that the baby no longer has any need for the
placenta.
With 'active' management
the oxytocic drug is administered, into the mother's thigh,
usually, with the delivery of the baby's first shoulder.
This is either Syntocinon or Sytometrine. As soon as the
baby is born the cord is clamped immediately. Once the
placenta has separated from the wall of the uterus (usually
identified by a little gush of blood, and more of the cord
appearing) the midwife may encourage the mother to push the
placenta out as she pulls gently on the cord and at the same
time applies pressure onto your lower abdomen (this is
called controlled cord traction). The membranes and placenta
are expelled, and the process is normally completed within ~
7 minutes from the time of the injection.
'Delayed Active'
Management.
'Active' and
'Physiological' methods should not be mixed! A better name
for this type 'delayed active' management may be
'therapeutic' management. When there is a need to interrupt
the process of 'physiological' management, then
'therapeutic' management should be used (ie, an oxytocic
drug administered, immediate cord clamping and controlled
cord traction).
If an oxytocic drug is
given , then cord clamping becomes necessary to prevent too
much blood being squeezed along the cord into the baby by
the unnaturally strong contractions of the uterus produced
by the drug. Controlled cord traction often needs to be used
to remove the placenta from the uterus within the time taken
for the ergometrine component of Syntometrine to close the
cervix (though sometimes maternal effort can accomplish
this).
'Therapeutic' management
would involve the possible administration of a oxytocic drug
later in the third stage, not prophylactically but for a
specific reason, with the remaining components of 'active'
management then being implemented.
'Active' management of
the 3rd stage may be most appropriate following a managed
labour (ie, inductions, epidurals, etc) as it is thought
these factors may influence the normal functioning of the
uterus. This should not be the case in a Birth Centre
setting where intervention is kept to a minimum and Mothers
are well supported to experience a 'normal' labour and the
natural delivery of their baby. This support should
continue, in this particular setting especially, with the
natural delivery of the placenta, making use of the
'therapeutic' approach discussed earlier, if it's found to
be necessary.
The 'physiological'
approach to 3rd stage is most appropriate following an
uncomplicated, normal labour and delivery, as would be
expected in a Birth Centre.
For some women it is
important to allow the third stage to unfold in it's own
time and to have a sense of completion, before moving their
focus of attention to the baby. Carers should seek to
minimise interference at this time. This particularly
delicate, and awesome, time is when the mother sees her baby
for the first time and, if all is well, she is able to
slowly come to terms with all that has just occurred.
Quietness and privacy are essential.
One of the main reasons
for 'active' management of 3rd stage is PPH. Blood loss is
defined as PPH when it reaches a specific quantity.
According to the World Health Organisation (1996), "1000 mls
is not thought to be necessarily excessive in a well
nourished healthy population, providing the woman appears
well." During pregnancy there is an increase in blood
volume, with the plasma volume thought to be increased by
about 40-50%, and the red cell mass by about 18%. After the
birth of her baby, the mother is no longer pregnant and so
there will be adjustments in her haematological status,
either immediate or gradual, to bring her blood parameters
back to their non-pregnant levels. That is, this extra blood
which is made during pregnancy needs to be lost.
The main mechanisms of
blood loss are; at delivery (this is immediate), through
diuresis (over 24-48 hours after delivery) and in the lochia
(vaginally after delivery, over a week or so). Warning signs
of excessive blood loss, such as PPH, are facial pallor,
minor changes in pulse rate, coldness of fingers, ears and
nose. In this situation a clinical evaluation, by the carer,
must decide if PPH has occurred, and whether the blood loss
is too much, or physiologically acceptable. If it is too
much then 'therapeutic' management of 3rd stage would be
initiated.
Please note, that it is
important to identify the cause of the bleeding, before
'therapeutic active' management is initiated. The bleeding
may be due to a tear in the cervix, or vaginal wall, an
episiotomy/tear or blood clotting abnormalities. These need
to be treated appropriately, as oxytocic drugs will not stop
the haemorrhage in these cases. This is where midwifery
skills, and expertise, are invaluable.
When looking at these
three methods of managing 3rd stage labour, and trying to
decide which is the best form of care for the Family Birth
Centre, or indeed any maternity facility, policy-makers and
care-givers should realise that the answer lies in providing
individual assessments and care to individual women, taking
into account their preferences and individual
circumstances.
There are factors which
can contribute to problems in the 3rd stage of labour and
although these factors need to be identified, and taken into
consideration, they still should not necessarily preclude a
mother from a 'physiological' 3rd stage if that is her
choice (depending, of course, on the seriousness of the
factor involved). Rather, the presence of a predisposing
factor should encourage informed unbiased discussion with
the Mother, respect for her decisions and more vigilance in
a carer, with a more 'therapeutic' approach to the 3rd stage
of labour in this incidence.
Continuity of carer,
especially in a Birth Centre, and the development of a
mutual trust, and understanding, will allow a midwife and
the Mother to work together during labour and birth, to
optimise the likelihood of all going well. In the unlikely
event of bleeding occurring unexpectedly, this trust enables
them to work together efficiently and deal with the
emergency as safely and quickly as possible. Midwives
practising in such a way can use scientific evidence to
guide their practice and also incorporate their own
experience, and that of others, which has been gained over
many years.
Whilst the midwife may
expect birth to unfold safely, they are alert at all times
to the possibility of unexpected changes, which may require
rapid and efficient responses. They also heed their
intuition, and because the relationship with the women is
central to their practice, they are attuned to the women in
their care.
Many women have informed
themselves of the pros and cons of oxytocic usage and, if
they choose a physiological birth, choose not to involve it
in the delivery of their placentas' unless necessary. They
often realise they can verbally refuse 'active' management
of 3rd stage.
The whole transaction of
policy dictating 'active management' for all labours sets up
a wall of deception between the Mother and midwife,
preventing a trusting/respectful relationship from
developing. It is essential that when a woman intends to
avoid the use of oxytocic drugs she is able to discuss this
fully with a midwife who is knowledgeable and confident
about this preference. That way the Mother can receive full
and balanced information during her pregnancy, and develope
the trusting relationship necessary if an emergency
situation should arise.
References:
1. AIMS (Association for
Improvements in the Maternity Services) 'Delivering your
Placenta. The Third Stage' 1999.
2. Gillian M.L. Gyte
BSc., Mphil. 'Evaluation of the Meta-Analyses on the
Effects, on Both Mother and Baby, of the Various Components
of 'Active' Management of the Third Stage of Labour'
3. NCT (National
Childbirth Trust) 'Third Stage Care'
4. Gillian M.L. Gyte
BSc. 'The Significance of Blood Loss at Delivery' MIDIRS,
1992.
5. Gillian M.L. Gyte
BSc. 'Informed Choice and the Third Stage of Labour' BMJ
and NCT, Research Matters, 1998, No 7.
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