Active Management of the Third Stage of Labour

The Third Stage of Labour is the period during which the woman's body pushes out the baby's placenta. Active Management is a routine intervention during this stage. It is offered to women in most hospital labour wards to reduce the risk of serious bleeding after the birth. Active Management involves an injection of artificial oxytocin into the mother's thigh as the baby is born; early cord clamping and cutting; and pulling the placenta out once it has detached from the wall of the uterus, via the cord.

Recent research indicates that for low-risk women who have experienced a normal birth, Active Management of the Third Stage has no benefits for the woman or the baby.

Active Management Procedure

An injection of oxytocin is given into the thigh, as the baby's second shoulder is being born. If the woman already has an intravenous drip in place then the medication is given using this. Once the injection has been given, it is important to clamp and cut the baby's cord as soon as possible.The artificial oxytocin will stimulate the woman's uterus to contract more vigorously and this can force extra blood through the cord to the baby. Once the cord begins to lengthen, the midwife or doctor gently pulls on it in order to speed up the birth of the placenta and membranes.

Advantages for the woman

• Reduces the risk severe postnatal bleeding for all risk types of women by 50% (Enkin et al. 2000 and Begley at al.2011)

Disadvantages for the woman

• When only low risk women were studied there were no differences between women who had the injection and those who did not (Begley at al.2011 and RCOG 2009).
• One large New Zealand study of over 30,000 low risk women (Dixon et al.2009) and a smaller study in New South Wales (Fahy et al.’s 2010), found that it increased the risk of blood loss.
• Associated with lower breastfeeding rates 48 hours after the birth (Jordan 2009).

Other unwanted effects included an increase in:

• blood pressure;
• after pains;
• nausea and vomiting;
• the use of medication for pain relief in the postnatal period;
• the number of women readmitted to hospital with vaginal bleeding (Begley at al. 2011).

Advantages for the baby

• The research does not highlight any statistically significant benefits for the baby.

Disadvantages for the baby

• Babies have a reduced birth weight, attributed to the loss of up to 80 mls of infant blood which is retained in the placenta due to early cord clamping (Farrar et al. 2009).
• Associated with lower breastfeeding rates 48 hours after the birth (Jordan 2009).

References

• Australian Breastfeeding Association (2008). Breastfeeding naturally. Second Edition. Ed. Day, J. Australian Breastfeeding Association: Melbourne.
• Begley CM, Gyte GML, Murphy DJ, et al. (2011) Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews, Issue 11. Chichester: John Wiley and Sons
• Dixon, L., Fletcher, L., Tracey, S., Guilliland, K., Pairman, S. and Hendry, C. (2009) Midwives’ care during the third stage of labour. New Zealand College of Midwives, 41: 20-5.
• Enkin, M., Kierse, M., Neilson, J., Crowther, C., Duley, L., Hodnett, E., and Hofmeyr, J. (2000) A Guide to Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press.
• Fahy, K., Hastie, C., Bisits, A., Marsh, C., Smith, L. and Saxton, A. (2010) Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study. Women and Birth, 23: 145-52.
• Farrar D, Airey R, Tuffnell D, Law G, Cattle B, Duley L. (2009). Measuring Placental Transfusion For Term Births: Weighing Babies With The Cord Intact. Arch Dis Child Fetal Neonatal Ed 2009, 94:Fa7. OpenURL.
• Jordan, S., Emery, S. Watkins. A., Evans, J.D., Storey, M., Morgan, G. (2009). Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey. BJOG An International Journal of Obstetrics and Gynaecology. Available online at http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02256.x/pdf
• Royal Collegeof Obstetricians and Gynaecologists (2009) Prevention and Management of Postpartum Haemorrhage. Available online at http://www.rcog.org.uk/files/rcog-corp/GT52PostpartumHaemorrhage0411.pdf. [Accessed on 12 September 2013].