Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in Maternal and Neonatal Health. Available at: http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.htm. Accessed March 12, 2008. - PowerPoint PPT Presentation

Loading...

PPT – Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in Maternal and Neonatal Health. Available at: http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.htm. Accessed March 12, 2008. PowerPoint presentation | free to download - id: 1037c7-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in Maternal and Neonatal Health. Available at: http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.htm. Accessed March 12, 2008.

Description:

Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in ... Try not to use CCT or any manual interference with uterus at fundus ... – PowerPoint PPT presentation

Number of Views:169
Avg rating:3.0/5.0
Slides: 25
Provided by: sengel4
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in Maternal and Neonatal Health. Available at: http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.htm. Accessed March 12, 2008.


1
Evidence to Support Active Management of Third
Stage of Labor (AMTSL) Name of
presenter Prevention of Postpartum Hemorrhage
Initiative (POPPHI) Project
  • Adapted from JHPIEGO. Active Management of the
    Third Stage of Labor Advances in Maternal and
    Neonatal Health. Available at http//www.reprolin
    e.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.h
    tm. Accessed March 12, 2008.

2
Session Objectives
  • By end of the session, participants will have
    reviewed
  • Definition of third stage of labor
  • Physiologic vs. active management of the third
    stage of labor
  • Evidence to support promotion of active
    management of the third stage of labor (AMTSL)

3
Third Stage of Labor
  • Definition
  • The third stage of labor begins with birth of the
    newborn and ends with the delivery of the
    placenta and its attached membranes.

4
Two Methods of Third Stage Management
  • Physiologic (expectant) management
  • Uterotonic drugs are not used before delivery of
    the placenta
  • Placenta is delivered by gravity and maternal
    effort
  • Cord is clamped after pulsation has ceased
  • Fundal massage may be provided after delivery of
    the placenta
  • Active Management
  • Uterotonic drug is given within one minute after
    birth of the baby
  • Cord is cut when it ceases to pulsate or 23
    minutes after the babys birth, whichever comes
    first.
  • Placenta is delivered by controlled cord traction
    (CCT) with counter-traction to the uterus
  • Uterine fundal massage provided after delivery of
    the placenta

5
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)

6
Active Management Advantages and Disadvantages
  • Advantages
  • Decreases length of third stage
  • Decreases risk of PPH
  • Disadvantages
  • Requires uterotonic drug and items needed for
    injection
  • Requires a birth attendant with skills in
  • Observation
  • Giving an injection
  • CCT

7
Active vs. Physiologic Management The Bristol
and Hinchingbrooke Trials
  • Bristol trial 1695 women, Hinchingbrooke trial
    1512 women randomly assigned to
  • Active management
  • Physiologic management

Prendiville et al 1988 Rogers et al 1998.
8
Active vs. Physiologic Management The Bristol
Trial Objective
  • Compare effects of fetal and maternal morbidity
    of
  • Routine active management
  • Physiologic management

Prendiville et al 1988.
9
The Bristol Trial Details of Active Management
  • Try to give one ampule of uterotonic (5 units
    oxytocin and 0.5 mg ergometrine routinely or 10
    units synthetic oxytocin if mother has high BP)
    immediately after delivery of anterior shoulder
  • Try to clamp cord 30 seconds after delivery of
    baby
  • When uterus has contracted, try to deliver
    placenta by CCT with protective hand on abdomen
    helping to shear off placenta and preventing
    uterine inversion
  • Try not to give any special instructions about
    posture

Prendiville et al 1988.
10
The Bristol Trial Details of Physiologic
Management
  • Try not to give uterotonic
  • 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.
11
Active vs. Physiologic Management Postpartum
Hemorrhage
Active Management Physiologic Management OR and 95 CI
Bristol Trial 50/846 (5.9) 152/849 (17.9) 3.13 (2.3-4.2)
Hinchingbrooke Trial 51/748 (6.8) 126/764 (16.5) 2.42 (1.78-3.3)
Prendiville et al 1988 Rogers et al 1998.
12
Active vs. Physiologic Management Results
Active Management Physiologic Management OR and 95 CI
Duration 3rd stage (median) Bristol 5 minutes 15 minutes Not done
Duration 3rd stage (median) Hinchingbrooke 8 minutes 15 minutes Not done
Third stage gt 30 minutes Bristol 25 (2.9) 221 (26) 6.42 (4.9-8.41)
Third stage gt 30 minutes Hinchingbrooke 25 (3.3) 125 (16.4) 4.9 (3.22-7.43)
Blood transfusion Bristol 18 (2.1) 48 (5.6) 2.56 (1.57-4.19)
Blood transfusion Hinchingbrooke 4 (0.5) 20 (2.6) 4.9 (1.68-14.25)
Therapeutic uterotonics Bristol 54 (6.4) 252 (29.7) 4.83 (3.77-6.18)
Therapeutic uterotonics Hinchingbrooke 24 (3.2) 161 (21.1) 6.25 (4.33-9.96)
13
Active vs. Physiologic Management The Bristol
and Hinchingbrooke Trials
  • Conclusion
  • Active management of the third stage reduces the
    risk of PPH
  • There is an increased risk of PPH associated with
    physiologic management
  • There is an increased need of blood transfusion
    associated with physiologic management
  • Oxytocin is the drug of choice for active
    management
  • There was no increase in entrapment of the
    placenta with active management

14
Seeking solutions for births that occur without
skilled care
  • Why do we need to seek solutions for births that
    occur without skilled care?
  • We cannot predict PPH on the basis of risk
    factors.
  • In many countries very few deliveries are
    attended by a skilled attendant.
  • Once severe PPH occurs, death follows very
    rapidly
  • Timely referral and transport to facilities is
    not available or affordable
  • Availability of emergency obstetric care services
    is grossly limited.

15
Summary of WHO Recommendations- October 2006
Technical Consultation
  • Active management of the third stage of labor
    should be offered by skilled attendants to all
    women.
  • In the absence of AMTSL, a uterotonic drug
    (oxytocin or misoprostol) should be offered by a
    health worker trained in its use for prevention
    of PPH.

16
Simple steps a balanced approach to PPH
prevention
  • An evidence-based intervention for skilled birth
    attendants (SBAs), combined with a
    community-based strategy, can prevent 50-60 of
    PPH
  • Active management of the third stage of labor for
    SBAs
  • Community-based distribution of misoprostol

17
A Randomized Placebo-Controlled Trial of Oral
Misoprostol 600 mcg for Prevention of PPH
Belgaum District, Karnataka India
Primary Outcome Misoprostol (N 812) N () Placebo (N808) N () Relative Risk (95 CI) NNT
Postpartum Hemorrhage (blood loss ? 500 ml) 53 (6.5) 97 (12.0) 0.53 (0.39, 0.74) 18
Severe Postpartum Hemorrhage (blood loss ? 1,000 ml) 2 (0.2) 10 (1.2) 0.20 (0.04, 0.91) 100
Gouder et al 2007 Gouder et al 2007 Gouder et al 2007 Gouder et al 2007 Gouder et al 2007
18
Evidence from community based PPH prevention
programs
  • Country example Indonesia
  • Safety No women took oral misoprostol at wrong
    time
  • Acceptability women who used oral misoprostol
    said they would recommend it and purchase the
    drug for future births
  • Feasibility Community volunteers successfully
    offered information about PPH and safely
    distributed oral misoprostol
  • Effectiveness the combination of skilled
    providers using oxytocin and community
    distribution of misoprostol allowed 94 coverage
    with PPH prevention method

In partnership with Depkes, POGI, IBI
supported by USAID through the MNH program
Sanghvi et al 2004
19
Critical issues pertaining to choice for managing
the third stage of labor (1)
  • Choice of active vs. physiologic management
  • Different theoretical advantages and
    disadvantages for each
  • Theoretical potential risks of each
  • Entrapment of placenta
  • Avulsion of cord
  • Uterine inversion
  • Issues surrounding use of a uterotonic agent
  • Choice of the uterotonic drug to use will depend
    upon cost, stability, safety and side effects
  • Choice and/or use of an uterotonic drug will
    depend upon cadres of birth attendants authorized
    to administer specific uterotonic drugs and
    facilities authorized to carry them

20
Critical issues pertaining to choice for managing
the third stage of labor (2)
  • Issues if a skilled birth attendant is not
    available
  • Controlled cord traction should only be performed
    by a skilled birth attendant
  • Giving a uterotonic drug (oxytocin or
    misoprostol) without controlled cord traction can
    still reduce blood loss
  • Women and/or community health workers can be
    trained in the correct use of misoprostol after
    birth of the baby
  • Issues if no uterotonic drug is available
  • Limited/unproven benefit of nipple stimulation
    for reduction of maternal blood loss but clear
    benefits for baby
  • CCT not recommended if no uterotonic available
  • Fundal massage after delivery of the placenta is
    recommended even if no uterotonic available

21
Summary
  • Physiologic management
  • Advantages
  • Does not interfere with normal labor process
  • Does not require special drugs/supplies
  • Delay in cord clamping may increase newborn
    hemoglobin
  • May be appropriate if baby not breathing
    immediately after delivery
  • Disadvantages
  • Increases length of third stage
  • Increases risk of postpartum hemorrhage (PPH)
  • Active management
  • Advantages
  • Decreased length 3rd stage
  • Decreased average blood loss fewer cases of PPH
  • Decreased need for blood transfusion
  • No apparent disadvantages for baby
  • Disadvantages
  • Requires uterotonic drug
  • If injectable uterotonic, requires items needed
    for injection
  • Requires a birth attendant with skills in
  • observation
  • giving an injection
  • controlled cord traction

22
Conclusions
  • Active management of third stage reduces risk of
    PPH by
  • Reducing length of third stage
  • Reducing average blood loss
  • Reducing the risk for retained placenta
  • Reducing the need for therapeutic uterotonics
  • Active management of the third stage of labor
    should be offered by skilled attendants to all
    women
  • In the absence of AMTSL, a uterotonic drug
    (oxytocin or misoprostol) should be offered by a
    health worker trained in its use for prevention
    of PPH.

23
References
  • Gouder et al. 2007. Experiences from Oral
    Misoprostol for PPH Prevention Study at Belgaum,
    India. Lancet
  • Khan GQ et al. 1997. Controlled cord traction
    versus minimal intervention technique in delivery
    of the placenta A randomized controlled trial.
    Am J Obstet Gynecol 177(4) 770774.
  • McDonald S, W Prendiville and D Elbourne. 2000.
    Prophylactic syntometrine versus oxytocin for
    delivery of the placenta (Cochrane Review), in
    The Cochrane Library. Issue 4. Update Software
    Oxford.
  • McDonald et al. 1993. Randomized controlled trial
    of oxytocin alone versus oxytocin and ergometrine
    in active management of third stage of labor. BMJ
    307(6913)11671171.
  • Prendiville et al. 1988. The Bristol third stage
    trial active versus physiological management of
    the third stage of labor. BMJ 29712951300.
  • Rogers J et al. 1998. Active versus expectant
    management of third stage of labour The
    Hinchingbrooke randomised controlled trial.
    Lancet 351(9104) 693699.

24
References (continued)
  • Sanghvi H, Wiknjosastro G, Chanpoing G, Fishel J,
    Ahmed S. Prevention of postpartum hemorrhage
    study West Java, Indonesia. Baltimore, MD
    JHPIEGO 2004.
  • World Health Organization (WHO). 1993. Stability
    of injectable uterotonics in tropical climates
    Results of field surveys and simulation studies
    on ergometrine, methylergometrine, and oxytocin.
    WHO Geneva.
  • International Confederation of Midwives (ICM),
    International Federation of Gynaecology and
    Obstetrics (FIGO). Prevention and Treatment of
    Post-partum Haemorrhage New Advances for Low
    Resource Settings Joint Statement. The Hague
    ICM London FIGO 2006. Available at
    www.figo.org/docs/PPH20Joint20Statement20220En
    glish.pdf. Accessed April 2, 2007.
About PowerShow.com