1. Active Management of Third Stage of Labor
4/20/2017
Active Management of Third Stage of Labor
Advances in Maternal and Neonatal Health BY
MOHAMMED OMOWUNMI O.
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
4/20/2017
Session Objectives
To review:
Definition of third stage of labor
Physiologic vs. active management
Risks and benefits of each method of management
Drugs used in active management
Active Management of Third Stage of Labor

3. Two Methods of Third Stage Management
4/20/2017
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

4. Physiologic Management: Advantages and Disadvantages
4/20/2017
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

5. Active Management: Advantages and Disadvantages
4/20/2017
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

6. Procedure for Active Management
4/20/2017
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

7. Details of Physiologic Management
4/20/2017
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

8. Active vs. Physiologic Management:
4/20/2017
Active vs. Physiologic Management:
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

9. Active Management of Third Stage of Labor
4/20/2017
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

10. Oxytocic Drugs: Oxytocin
4/20/2017
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

11. Oxytocic Drugs: Ergometrine
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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

12. Oxytocic Drugs: Syntometrine
4/20/2017
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

13. Oxytocin vs. Syntometrine: Objective and Design
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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

14. Oxytocin vs. Syntometrine: Results
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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

15. Oxytocin vs. Syntometrine: Conclusion
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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

16. Active Management of Third Stage of Labor
4/20/2017
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

17. Recommendations Concerning Selection of Oxytocic
4/20/2017
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

18. Active Management of Third Stage of Labor
4/20/2017
Summary
Active management of third stage includes:
Oxytocin
Controlled cord traction
Fundal massage
Ensuring supply of oxytocin is a priority
Reduces risk of PPH
Retained placenta
Need for therapeutic oxytocics
Active Management of Third Stage of Labor

19. Active Management of Third Stage of Labor
4/20/2017
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

20. References (continued)
4/20/2017
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