Rhythms in Labour 3rd Stage

1
Rhythms in Labour (3rd Stage)

• Starting premise that physiological processes are
  sub-optimal due to blood loss associated with it
• Therefore most clinicians have pessimistic
  attitude to natural 3rd stage, think of
  haemorrhage rather than bleeding (Walsh, 2003)
• Uncommon to read positive perspective on
  physiological 3rd stage but there are some
• Edwards (1999)
• Harris (2001)
• Odent (2002)
• Long (2003)

2
History of Oxytocics (den Hertog et al, 2001)

• Ergot known about since 1582 but use discontinued
  in 1828 because of uterine rupture and fetal
  death
• Oxytocin described first in 1954 and use has
  increased since that time
• PPH major cause of maternal death in developing
  world and WHO recommends routine oxytocic use
• Research reviews indicated
• prophylactic oxytocics reduced PPH by 40
• syntometrine maybe drug of choice v ergot,
  syntocinon, prostin

3
Contextualising Issues for 3rd Stage

• Historical concerns with impact of 500ml blood
  loss needs updating (public health and affluence
  of population moved on since 1960s)
• 500 ml threshold not clinically significant for
  most women in the developed world
• Assembly line birth requires rapid completion of
  labour stages
• Routine use of oxytocin part of medicalisation of
  childbirth since hospitalisation of birth
• Do the results of RCTs inform
• care in midwife-led birthing suites?
• home birth?

4
Active Management

• Prophylactic oxytocics
• Early cord clamping cutting - within 2 minutes
  of birth
• /- Wait for signs of separation
• Delivery by controlled cord traction

5
Physiological 3rd Stage

• Watchful waiting (up to at least 1 hour midwife
  retires to background)
• Delivered by maternal effort gravity
• Cutting of cord after delivery of placenta
• Breast feeding, skin to skin, prioritise
  mother/parent baby connection
• Therefore
• not managed
• mother births placenta herself
• no oxytocic prophylaxis

6
Bristol Trial (Elbourne, 1996)

• Active v physiological management
• Hypothesis
• active reduce PPH rate from 7.5 to 5 sample
  size 3900
• Stopped because of level of PPH in physiological
  group

7
Bristol Trial Criticisms

• Definition of physiological approach flawed
• Some did not have physiological 1st 2nd stages
• Some of known risk for PPH were still included in
  trial
• Midwife practice non-compliant with physiological
  approach
• Definition of PPH accuracy of measurement

8
Hinchinbrook Trial (Rogers et al, 1998)

• Midwives skilled at physiological management
• Results confirm higher PPH rate
• 14 v 5 (500-999 ml) significant
• 3 v 2 (1000 ml) non significant
• numbers needed to treat (NND)
• 48 i.e. prevent 1 blood transfusion in every 48
  cases

9
Hinchinbrook Trial

• Best position
• active - semi recumbent
• physiological - upright
• Other issues (Rogers Wood, 1999)
• definition of PPH
• syntocinon is oxytocic of choice

10
Active v Physiological (Prendiville et al, 2005)

• 4 RCTs
• Active management better
• blood loss
• PPH rate
• length of 3rd stage
• p/n anaemia
• Worse with ergotmetrine
• nausea/vomiting
• hypertension

11
Syntometrine v Oxytocin (McDonald et al, 2005)

• 6 RCTs
• syntometrine assoc. with significant reduction of
  PPH compared with oxytocin 5 units
• less so with oxytocin 10 units
• no difference with blood loss gt 1000ml
• worse nausea/vomiting/raised BP
• higher retained placenta rates (Elbourne et al,
  2004)
• may reduce duration of breast feeding (Begley,
  1990)

12
Lente Trial in Holland (Herschderfer, 1999)

• Ongoing trial, but preliminary results available
• Community setting of independent midwifery
  practices
• Defined PPH as 1000 mls
• Used as marker of clinical significance transfer
  for acute care
• No difference between 2 groups

13
Rationale for Physiology Maternal Effects

• Reverse haemodilution of pregnancy (Harris, 2001)
• Flush out placenta
• Cleanse uterine cavity
• Umbilical attachment facilitates
• skin-to-skin, breast feeding, less crying
  (Anderson et al, 2005)
• emotional connection
• (Finigan Davies, 2005)
• Blood loss over 24-36 hours evens out between
  both methods? (Wickham, 1999)

14
Rationale for Physiology Fetal Effects (Long,
2003)

• Delayed cord cutting means fetus slowly and
  gently adapts to extra-uterine life
• breathing may be delayed beyond 1 minute
• Less transfusion intraventricular bleeding in
  pre-term (Rabe et al, 2005)
• Conversely, early cutting starves baby of oxygen,
  forcing early breathing/crying efforts
• Leaving cord intact allows for physiological
  transfer of blood, appropriate for babys blood
  volume, neither under-transfusing or
  over-transfusing (Mercer Skovgaard, 2002)
• Conversely, early cord cutting combined with
  oxytocic can result in under or over transfusing

15
Psycho-Social Factors

• Physiological
• woman partner can be left with their baby
  uninterrupted after birth
• should be completed in up to 1-2 hours
• Active
• immediate intervention after birth
• completed much earlier
• Implications for bonding (Odent, 2002)
• Implications for breastfeeding

16
Haemorrhage or Normal Bleeding?

• Why stipulate an amount at all?
• Treat on basis of clinical signs symptoms
• Individualise assessment i.e. any predisposing
  risks for 3rd stage, challenge spurious ones like
  grand multiparity (Page, 2000)
• Set local benchmark for amount?
• Time pressure driving early completion of 3rd
  stage

17
Issues for Midwifery Practice

• Dealing with midwives concern about potential
  bleeding and time taken
• Fish cant see water syndrome (Wagner, 2001)
• Need for exposure to physiological 3rd stage
• Need to remove time pressure (left alone for 1st
  hour if possible)
• Cease checking for nuchal cord (cordclamping.com,
  2004)
• Skill drills on physiological 3rd stage

18
Practice Recommendations

• Women should be encouraged to consider
  physiological approach antenatally
• Research evidence needs contextualising
• all studies in hospitals
• historical legacy re haemorrhage and time
  pressure
• medicalisation of childbirth

19
Practice Recommendations

• Midwives need reskilling in physiological care
• Physiological approach is the appropriate care
  when labour is normal
• Piecemeal approach not recommended
• If active chosen, risk/benefit of syntocinon 10
  units v syntometrine need weighing

20
Questions

• How could you change the perception of the
  physiology of 3rd stage where you work so that it
  is viewed as normal for normal labour?
• How would you ensure midwives are competent in
  physiological third stage care?
• What should be done about the current definition
  of PPH?
• Is there a need to review early clamping cutting
  of the cord where you work?