Community interventions;Physiological management of the third stage of labour.Karen GuillilandCEO New Zealand College of MidwivesICM Board Member

ObjectivesExamine the evidence for the components of physiological /expectant management of the third stage of labour

Define the components of physiological /expectant management of the third stage of labour when uterotonic drugs are not available.

BackgroundPPH is the cause of significant maternal morbidity and mortalityActive Management of third stage of labour (AMTSL) is recommended as the primary prevention method

What alternative methods are there if uterotonic drugs are not available?

Issues affecting access to and utilisation of uterotonic drugsAccess to uterotonic drugs is a problem in some areas due to:CostErratic supplyNeed for cold chain (injectable uterotonic drugs)Policy limiting the type of health worker authorized to administer uterotonic drugsMidwives also report in some areas issues ofauthenticity of drugs improper use (induce abortion or induce / augment labour)

ICM/FIGO Joint Statement on PPH prevention and treatment - 2006Refers to the lack of evidence for making a clear recommendation on how to manage the third stage of labour when uterotonic drugs are not availableAdded a clause on physiological management to the 2003 version recommending use of physiologic (expectant) management when no uterotonic drugs are available to either the skilled or non-skilled birth attendant Gives some definition and advice on physiological management

Research needsAMTSL country surveys (2007-2009) showed the following practices when uterotonic drugs were not used for third stage management:Controlled cord traction without a uterotonic drugControlled cord traction without countertraction to the uterusUterine massage before delivery of the placentaNo uterine massage after delivery of the placentaLiterature search initiated to establish what we know about physiological management

Results

There is little conclusive research to define the components of physiological management of third stage.

There is considerable variation between countries and disciplines about the components of normal birth and what is considered intervention.

Results

The text book definitions & the expert opinion on third stage management displays marked differences globally.

Midwives, as the main practitioners of physiological management of third stage, also differ but have the most similarities.

Assisting the physiology of third stagecurrent practiceIn 2010 ICM/FIGO formed a Multidisciplinary expert taskforce to define the components of physiological management. ICM conducted a survey of current best practice and 39 ICM Member Association Countries responded.There was consensus on;1) Signs of separation2) How to support women to expel the placenta3) The first two hours after the birth

Practice consensus

1) Signs of separationChange in the size, shape and position of the uterusA small gush of bloodThe cord lengthensThe woman becomes uncomfortable, get contractions or feel that she wants to change position or bear down

Most placentas will be delivered in one hour.

Practice consensus2) Supporting women to expel the placenta, after signs of separationEncourage woman into upright positionThe placenta may be expelled spontaneously orEncourage maternal effort to expel placentaThe birth attendant catches the placenta in cupped hands or a bowlIf the membranes are slow then assist by holding the placenta in two hands and gently turning it until the membranes are twisted then exert gentle tension

Practice consensus

Controlled cord traction is not recommended in the absence of uterotonic drugs

There is no need to clamp or cut the cord until after placenta is delivered

Practice consensus

3) The first two hours following the birthObserve and estimate the blood lossPalpate for a contracted uterus on a regular basisTeach the woman how to check her blood loss and the firmness of her own uterusEncourage breastfeeding

Recommendations

Physiology of 3rd stage needs to be a common knowledge competency & more research neededMore research on physiological management of 3rd stageEvery person attending a birth is taught how to assist at a physiological third stageEvery programme teaching AMTSL includes how to assist at a physiological third stageEducate women in self care