1. Active Management of Third Stage of Labor
4/15/2017
Active Management of Third Stage of Labor
A model to an Evidence Based Obstetric Practice
This presentation will:
- Briefly review the two methods of third stage management, and present the advantages/disadvantages for each method.
- Briefly review the procedure of active management
- Present the evidence comparing Active vs. Physiologic Management.
- Present available evidence comparing Controlled Cord Traction vs Minimal Intervention.
- Present available evidence regarding specific Oxytocic Drugs.
- Discuss the available evidence evaluating Nipple Stimulation and effect on PPH.
- The latest evidence on new oxytocics.

2. Active Management of Third Stage of Labor
4/15/2017
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. Active Management of Third Stage of Labor
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
4/15/2017
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. Intermediate Outcomes
4/15/2017
“The Winds of Change”
Anecdotes
Intermediate Outcomes
Negative social and cultural attitudes about family planning and reproductive health, or misunderstandings about them, can also impede access to quality services. Examples of such attitudes include:
Females should remain virgins until married, but males should experiment and “test” their sexuality/virility and have multiple partners.
Married females should have children before they use contraception in order to prove their fertility.
Gender-based violence (including female genital cutting) should be accepted.
Family members (e.g., in-laws) should be involved in decision making.
Use of contraception or provision of sexuality education will promote promiscuity.
Men and boys do not need to have FP/RH services.
Youth do not need special FP/RH services (e.g., clinic location, hours, cost, etc. do not need to accommodate youth).
Positive social norms, replacing outdated norms, can be created through behavior change and communication and through promotion of a positive image of family planning and contraception.
Active Management of Third Stage of Labor

7. The Pyramid of Evidence
4/15/2017
The Pyramid of Evidence
Active Management of Third Stage of Labor

8. Active Management of Third Stage of Labor
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. Active Management of Third Stage of Labor
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. Active Management of Third Stage of Labor
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
At least one controlled trial
Level
Ia, Ib B
Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations.
IIa, IIb, III C
Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality IV
Active Management of Third Stage of Labor

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

13. Active Management of Third Stage of Labor
4/15/2017
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
4/15/2017
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
4/15/2017
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
4/15/2017
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
4/15/2017
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 reduces the duration of the third stage and reduces postpartum hemorrhage.
Active Management of Third Stage of Labor

20. Procedure for Active Management
4/15/2017
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
WHO recommends giving oxytocin within 2 minutes to give provider time to give injection
Continuous gentle traction
Uterine massage every 15 minutes for 2 hours
Active Management of Third Stage of Labor

21. Active Management of Third Stage of Labor
4/15/2017
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
4/15/2017
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
4/15/2017
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
4/15/2017
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
4/15/2017
Active vs. Physiologic Management: Postpartum Hemorrhage
Active Management
Physiologic Management
OR and 95% CI
Bristol Trial
50/846 (5.9%)
152/849 (17.9%)
3.13 ( )
Hinchingbrooke Trial
51/748 (6.8%)
126/764 (16.5%)
2.42 ( )
The rate of postpartum hemorrhage was significantly lower with active management than with physiologic management in both trials (5.9% vs. 17.9% [Bristol] and 6.8% vs. 16.5% [Hinchingbrooke]).
Prendiville et al 1988; Rogers et al 1998.
Active Management of Third Stage of Labor

26. Active vs. Physiologic Management: Results
4/15/2017
Active vs. Physiologic Management: Results
Active Management
Physiologic Management
OR and 95% CI
Duration 3rd stage (median)
Bristol
5 minutes
15 minutes
Not done
Hinchingbrooke
8 minutes
Third stage > 30 minutes
25 (2.9%)
221 (26%)
6.42 ( )
25 (3.3%)
125 (16.4%)
4.9 ( )
Blood transfusion
18 (2.1%)
48 (5.6%)
2.56 ( )
4 (0.5%)
20 (2.6%)
4.9 ( )
Therapeutic oxytocics
54 (6.4%)
252 (29.7%)
4.83 ( )
24 (3.2%)
161 (21.1%)
6.25 ( )
The duration of third stage was reduced, as well as the need for blood transfusion and therapeutic oxytocics in the active management groups compared to the physiologic management group.
Active Management of Third Stage of Labor

27. Active vs. Physiologic Management: The Bristol & Hinchingbrooke Trials
4/15/2017
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. Active Management of Third Stage of Labor
4/15/2017
Oxytocic Drugs
Oxytocin- posterior pituitary extract
Ergometrine- preparation of ergot
Syntometrine- combination of oxytocin and ergometrine
Misoprostol- prostaglandin E1 analogue
Misoprostol holds promise for use as an oxytocic. It is effective, practical and inexpensive. In contrast to the other three oxytocics, misoprostol is stable (heat, light) and does not have to be given by injection. It can be given orally or rectally.
Active Management of Third Stage of Labor

29. Oxytocic Drugs: Oxytocin
4/15/2017
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
4/15/2017
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
4/15/2017
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
4/15/2017
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
4/15/2017
Oxytocin vs. Syntometrine: Results
Syntometrine was associated with a small reduction in risk of PPH < 1000 mL (OR 0.74, 95% CI )
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
4/15/2017
Oxytocin vs. Syntometrine: Conclusion
Need to weigh benefit of reduction in risk of PPH with risk of other adverse effects associated with syntometrine
Because syntometrine has more side effects: nausea, vomiting and increased blood pressure, it is less safe. Therefore, since oxytocin is equally effective and safer, it should be the first choice.
McDonald, Prendiville and Elbourne 2000.
Active Management of Third Stage of Labor

35. Stability of Oxytocics in Tropical Climates: Objective and Design
4/15/2017
Stability of Oxytocics in Tropical Climates: Objective and Design
Objective:
To determine pattern of stability in long term dark storage, short term exposure to high temperature and light
To develop guidelines
Methods: Tested field samples of ergometrine and methylergometrine and also simulated field storage conditions at different temperature/light exposure
WHO 1993.
Active Management of Third Stage of Labor

36. Stability of Oxytocics in Tropical Climates: Results
4/15/2017
Stability of Oxytocics in Tropical Climates: Results
Field:
Ergometrine: only 31% of samples had compliant level of active ingredient
Oxytocin: one expired, 5 samples had 104–142% of stated amount of active ingredient
WHO 1993.
Active Management of Third Stage of Labor

37. Stability of Oxytocics in Tropical Climates: Results (continued)
4/15/2017
Stability of Oxytocics in Tropical Climates: Results (continued)
Simulation condition
Ergometrine/
methylergometrine
Oxytocin
Refrigeration for 12 months
Lost 4-5% active ingredient
No loss
30oC, dark
Lost 25%
Lost 14%
21–25oC, light
Lost 21–27% in one month
>90% in 12 months
Lost 5%
40oC dark
Lost > 50%
Lost 80%
WHO 1993.
Active Management of Third Stage of Labor

38. Stability of Oxytocics in Tropical Climates: Conclusions
4/15/2017
Stability of Oxytocics in Tropical Climates: Conclusions
Stability of oxytocin is better than ergometrine/ methylergometrine, especially regarding light
Store refrigerated, in dark, labeled
Remove from box only for immediate use
Short periods unrefrigerated are fine (1 month at 30°C, 2 weeks at 40°C)
Oxytocics are not heat stable, but oxytocin is better than ergometrine/methyl-ergometrine.
WHO 1993.
Active Management of Third Stage of Labor

39. Active Management of Third Stage of Labor
4/15/2017
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
Need oxytocics; efforts should be made to make it available at all levels of care.
Getting the uterus to contract probably requires some “surge” of oxytocin, such as that delivered by an injection of oxytocin. When oxytocics are not available, CCT and fundal massage should be performed.
Natural oxytocin produced by suckling of baby at breast may be useful for helping to maintain the tone of an already contracted uterus.
Bullough, Msuku and Karonde 1989.
Active Management of Third Stage of Labor

40. Recommendations Concerning Selection of Oxytocic
4/15/2017
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

41. Active Management of Third Stage of Labor
4/15/2017
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

42. Active Management of Third Stage of Labor
4/15/2017
References
Bamigboye A et al 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 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 A simple alternative to parenteral oxytocics for the third stage of labor. Int J Obstet Gynecol 46:15–18.
Khan GQ et al 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

43. References (continued)
4/15/2017
References (continued)
McDonald S, W Prendiville and D Elbourne Prophylactic syntometrine versus oxytocin for delivery of the placenta (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford.
McDonald et al 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 The Bristol third stage trial: active versus physiological management of the third stage of labor. BMJ 297:1295–1300.
Rogers J et al Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351(9104): 693–699.
World Health Organization (WHO) 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