Active Management of Third Stage of Labor

1. Active Management of Third Stage of Labor A model to an Evidence Based Obstetric Practice

2. Session Objectives To review: • Why do we need the introduction of EBM and Information mastery in our day to day practice • Definition of third stage of labor • Physiologic vs. active management • Risks and benefits of each method of management • Drugs used in active management • Where lies the EVIDENCE Active Management of Third Stage of Labor

3. Half a century ago… “ My students are dismayed when I say to them that half of what they are taught as medical students will in 10 years be shown to be wrong. And, the trouble is,none of their teachers knows which half” Prof. Sydney Burwell Dean of Harvard Medical school Active Management of Third Stage of Labor

4. Active Management of Third Stage of Labor

5. Would you care finding your way through the information maze…?! Active Management of Third Stage of Labor

6. Anecdotes • Intermediate Outcomes “The Winds of Change” Active Management of Third Stage of Labor

7. The Pyramid of Evidence Active Management of Third Stage of Labor

8. Definitions… • Clinical guidelines are: • ‘Systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ • Developed using a standardized methodology Active Management of Third Stage of Labor

9. Classification of Evidence Levels - Ia Evidence obtained from meta-analysis of randomized controlled trials. - Ib Evidence obtained from at least one randomized controlled trial. 1 -Ila Evidence obtained from at least one well- designed controlled study without randomization. -Ilb Evidence obtained from at least one other type of well-designed quasi- experimental 2 Evidence obtained from well-designed non- experimental descriptive studies, such as comparative studies, correlation studies . 3 Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities 4 Active Management of Third Stage of Labor

10. Forms of Care… • Beneficial Forms of care. • Forms of care likely to be beneficial. • Forms of care with a trade off. • Forms of care with unknown effectiveness. • Forms of care likely to be ineffective. • Forms of care likely to be harmful. Active Management of Third Stage of Labor

11. Grades of Recommendation Active Management of Third Stage of Labor

12. To put it short… • We need to learn not only to read the medical literature, • BUT whatto read? And how ? • We need to be introduced to the conceptof “Information Mastery”. Active Management of Third Stage of Labor

13. The 5 EBM Skills 1. Forming answerable clinical questions 2. Searching for the best evidence answer 3. Appraising evidence for relevance, impact, validity 4. Integrating the evidence into practice 5. Evaluating & improving Active Management of Third Stage of Labor

14. A three-part Clinical Question • Does active management of the third stage of labor decrease the rate of primary postpartum hemorrhage? • The Prevention of Postpartum hemorrhage is by the proper conduction of the third stage of labor • This is also a POEM. Active Management of Third Stage of Labor

15. Where Are You Going To Search For The Evidence…? • Textbooks…? • Original publications…? • Predigested Material Active Management of Third Stage of Labor

16. Two Methods of Third Stage Management • Physiologic (“expectant”) management • Oxytocics are not used • Placenta is delivered by gravity and maternal effort • Cord is clamped after delivery of the placenta • Active Management • Oxytocic is given • Cord is clamped • Placenta delivered by controlled cord traction (CCT) with counter-traction on the fundus • Fundal massage Active Management of Third Stage of Labor

17. Critical Issues Pertaining to the Third Stage of Labor • Active vs. physiologic management • Theoretical potential risks of each • Entrapment of placenta • Avulsion of cord • Uterine inversion • Choice of oxytocic agent • Stability, safety and side effects of oxytocics • Unproven benefit of nipple stimulation • CCT and fundal massage if no oxytocic available Active Management of Third Stage of Labor

18. Physiologic Management: Advantages and Disadvantages • Advantages • Does not interfere with normal labor process • Does not require special drugs/supplies • Disadvantages • Increases length of third stage • Increases risk of postpartum hemorrhage (PPH) Active Management of Third Stage of Labor

19. Active Management: Advantages and Disadvantages • Advantages • Decreases length of third stage • Decreases risk of PPH • Disadvantages • Requires oxytocics and items needed for injection • Requires a birth attendant with skills in: • Observation • Giving an injection • CCT Active Management of Third Stage of Labor

20. Procedure for Active Management • Oxytocin • Within 1 minute of birth, palpate abdomen to rule out presence of another baby • Give oxytocin • CCT • Await strong uterine contraction (2–3 minutes) • Apply controlled cord traction while applying countertraction above pubic bone • If placenta does not descend, stop traction and await next contraction Active Management of Third Stage of Labor

21. Active vs. Physiologic Management: The Bristol and Hinchingbrooke Trials • Bristol trial: 1695 women, Hinchingbrooke trial: 1512 women randomly assigned to: • Active management • Physiologic management Prendiville et al 1988; Rogers et al 1998. Active Management of Third Stage of Labor

22. Active vs. Physiologic Management: The Bristol Trial Objective Compare effects of fetal and maternal morbidity of: • Routine active management • Physiologic management Prendiville et al 1988. Active Management of Third Stage of Labor

23. The Bristol Trial: Details of Active Management • Try to give one ampule of oxytocic (5 units oxytocin and 0.5 mg ergometrine routinely or 10 units synthetic oxytocin if mother has high BP) immediately after delivery of anterior shoulder • Try to clamp cord 30 seconds after delivery of baby • When uterus has contracted, try to deliver placenta by CCT with protective hand on abdomen helping to shear off placenta and preventing uterine inversion • Try not to give any special instructions about posture Prendiville et al 1988. Active Management of Third Stage of Labor

24. The Bristol Trial: Details of Physiologic Management • Try not to give oxytocic • Try to leave cord attached to baby until placenta is delivered • Try not to use CCT or any manual interference with uterus at fundus • Try to encourage mother to concentrate on feeling for next contraction or urge to push • When mother feels contraction or urge or there are signs of separation, encourage mother and help her change posture • If placenta does not deliver spontaneously, wait, try putting baby to breast and encourage maternal effort Prendiville et al 1988. Active Management of Third Stage of Labor

25. Active vs. Physiologic Management: Postpartum Hemorrhage Prendiville et al 1988; Rogers et al 1998. Active Management of Third Stage of Labor

26. Active vs. Physiologic Management: Results Active Management of Third Stage of Labor

27. Active vs. Physiologic Management: The Bristol & Hinchingbrooke Trials • Conclusion: Active management of the third stage reduces the risk of PPH: • Increased risk of PPH associated with physiologic management • Increased need of blood transfusion associated with physiologic management • Oxytocin was drug of choice for active management • No increase in entrapment of placenta with active management Active Management of Third Stage of Labor

28. Oxytocic Drugs • Oxytocin- posterior pituitary extract • Ergometrine- preparation of ergot • Syntometrine- combination of oxytocin and ergometrine • Misoprostol- prostaglandin E1 analogue Active Management of Third Stage of Labor

29. Oxytocic Drugs: Oxytocin • Advantages • Causes uterus to contract • Acts within 2.5 minutes when given IM • Generally does not cause side effects • Disadvantages • More expensive than ergometrine • IM or IV preparations only • Not heat stable Active Management of Third Stage of Labor

30. Oxytocic Drugs: Ergometrine • Advantages • Low price • Effect lasts 2–4 hours • Disadvantages • Takes 6–7 minutes to become effective when given IM; oral form insufficiently effective • Causes tonic uterine contraction • Increased risk of hypertension, vomiting, headache • Contraindicated in women with hypertension or heart disease • Not heat stable Active Management of Third Stage of Labor

31. Oxytocic Drugs: Syntometrine • Advantages • Combined effect of rapid action of oxytocin and sustained action of ergometrine • Disadvantages • Increased risk of hypertension, nausea and vomiting • Not heat stable Active Management of Third Stage of Labor

32. Oxytocin vs. Syntometrine: Objective and Design • Objective: To compare effects of syntometrine with oxytocin in reducing the risk of PPH and other maternal and neonatal outcomes • Design: Randomized controlled trials McDonald, Prendiville and Elbourne 2000. Active Management of Third Stage of Labor

33. Oxytocin vs. Syntometrine: Results • Syntometrine was associated with a small reduction in risk of PPH < 1000 mL (OR 0.74, 95% CI 0.65-0.85) • Adverse effects of vomiting and hypertension were associated with the use of syntometrine • There were no differences in other maternal or neonatal outcomes McDonald, Prendiville and Elbourne 2000. Active Management of Third Stage of Labor

34. Oxytocin vs. Syntometrine: Conclusion Need to weigh benefit of reduction in risk of PPH with risk of other adverse effects associated with syntometrine McDonald, Prendiville and Elbourne 2000. Active Management of Third Stage of Labor

35. Nipple Stimulation • Nipple stimulation has not been shown to reduce risk of PPH • Randomized controlled trial of suckling immediately after birth with over 4,000 subjects in Malawi showed no significant difference in frequency of PPH, mean blood loss or retained placenta • When oxytocics are not available, CCT and fundal massage should be performed • Advantages of early breastfeeding and nipple stimulation: • Stimulates natural production of oxytocin • May maintain tone of contracted uterus • Benefits baby Bullough, Msuku and Karonde 1989. Active Management of Third Stage of Labor

36. Recommendations Concerning Selection of Oxytocic • Use oxytocin, when available: • If oxytocin is not available, use syntometrine or ergometrine • If oxytocic drugs are not available, use nipple stimulation • Remember: Do not use ergometrine in women with hypertension or heart disease • Store oxytocics in refrigerator (2–8ºC) and away from light • Misoprostol rectally has advantages; awaiting confirmatory studies. Active Management of Third Stage of Labor

37. Summary • Active management of third stage includes: • Oxytocin • Controlled cord traction • Fundal massage • Ensuring supply of oxytocin is a priority • Active Management Reduces risk of • PPH • Retained placenta • Need for therapeutic oxytocics • Need for blood transfusion Active Management of Third Stage of Labor

38. References • Bamigboye A et al. 1998. Randomized comparison of rectal misoprostol with syntometrine for management of third stage of labor. Acta Obstet Gynecol Scand 77: 178–181. • Bullough CH, RS Msuku and I Karonde. 1989. Early suckling and postpartum haemorrhage: Controlled trial in deliveries by traditional birth attendants. Lancet 2(8662): 522–525. • Irons DW, P Sriskandabalan and CHW Bullough. 1994. A simple alternative to parenteral oxytocics for the third stage of labor. Int J Obstet Gynecol 46:15–18. • Khan GQ et al. 1997. Controlled cord traction versus minimal intervention technique in delivery of the placenta: A randomized controlled trial. Am J Obstet Gynecol 177(4): 770–774. Active Management of Third Stage of Labor

39. References (continued) • McDonald S, W Prendiville and D Elbourne. 2000. Prophylactic syntometrine versus oxytocin for delivery of the placenta (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford. • McDonald et al. 1993. Randomized controlled trial of oxytocin alone versus oxytocin and ergometrine in active management of third stage of labor. BMJ 307(6913):1167–1171. • Prendiville et al. 1988. The Bristol third stage trial: active versus physiological management of the third stage of labor. BMJ 297:1295–1300. • Rogers J et al. 1998. Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351(9104): 693–699. • World Health Organization (WHO). 1993. Stability of injectable oxytocics in tropical climates: Results of field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin. WHO: Geneva. Active Management of Third Stage of Labor