1. RCM Evidence based Guidelines for Midwifery-led Care in Labour Mervi Jokinen Practice and Standards Development Advisor APPG 20 th November 2012

2. Management of Third Stage of Labour Active management involves giving a prophylactic uterotonic, cord clamping and controlled cord traction Physiological management involves no administration of a prophylactic uterotonic, no clamping and cutting of the cord until the placenta is delivered and promoting use of gravity to assist delivery of the placenta in a timely manner with maternal effort

3. Management of Third Stage of Labour Historically third stage was actively managed with Ergometrine in 1940s then changing into Syntometrine with fast acting oxytocin and longer lasting Ergometrine in 1960s. Most recently move into Syntocinon 10u i/m Effective care in pregnancy and childbirth looking at evidence-based obstetrics in and 1989 questioned the value of active management Side effects: hypertension headaches nausea vomiting, pulmonary oedema, cardiac arrest, myocardial infarction Ergometrine lowering effect on serum prolactin levels Free bleeding from the placental end of the cord is associated with reduced risk of feto-maternal transfusion linked to iso-immunization note Rh-neg women On conclusion the reduced risk of amount of bleeding overrode the harms

4. Management of Third Stage of Labour Evolvement of women’s choices and increased information sharing with informed decision- making Requests from women to allow cord stop pulsating prior clamping Professionals’ concerns re Syntocinon and polycytheamia Gradual increase in physiological births

5. Management of Third Stage of Labour Neonatal outcomes v. maternal outcomes Evidence shows that cord clamping timing significantly affects the haematological status of term neonates improving their iron status up to 6 months (important in areas of malaria/aneamia) There are benefits to neonatal resuscitation with the umbilical cord intact whenever possible Physiological labour; are we introducing an intervention that may have an adverse effect? Healthy mothers are well able to tolerate blood loss up-to 1000mls Does the administration of oxytocin delay bleeding?; impact on current early discharge policy Does Syntocinon as well as ergometrine affect prolactin levels or breastfeeding reduced natural oxyticins?

6. Practice Issues One person present at birth Skin-to skin contact, newborn thermoregulation, breastfeeding maternal position (waterbirth) Artificial oxytocin v. natural Timing of oxytocin

7. Practice issues Little evidence of increase in neonatal jaundice Rh –ve mothers; should we make specific recommendation?

8. Practice guideline updated Delayed cord clamping is currently the recommended practice known to benefit the neonate improving iron status up to 6 months but with a possible risk of jaundice that requires phototherapy. Timing is not prescribed as will always depend on clinical decision making and agreement with mother

9. Thank you http://www.rcm.org.uk/college/policy- practice/guidelines/practice-guidelines/