Microsoft word - no 9 - prevention and management of pph
A O M C L I N I C A L P R A C T I C E G U I D E L I N E This guideline has been reviewed and approved by the AOM Board of Directors on March 30, 2006. Principal Authors AOM Clinical Practice Guideline Working Group
Lynne-Marie Culliton, R.M., Owen Sound, ON
Kathelijne Keeren, R.M., Mississauga, ON
BACKGROUND
countries. The midwife plays a central role in prevention and treatment of postpartum hemorrhage. This
This guideline is based on a review of the evidence on
guideline provides midwives with an accessible review
the prevention and management of postpartum
of the current evidence on postpartum hemorrhage that
hemorrhage. MEDLINE was used to identify relevant
can be used to guide clinical practice and informed
research from 1990 onwards. The Cochrane and
choice discussions. The physiology of third stage of
CINAHL databases were also accessed. Randomized
labour is reviewed, and management of the third stage
controlled studies and other relevant studies were
and of established postpartum hemorrhage are outlined.
obtained and a search for published obstetric and
midwifery clinical practice guidelines was undertaken.
PHYSIOLOGY OF THIRD STAGE
The level and quality of evidence following each
recommendation is based on the grading system
The third stage of labour consists of two phases:
developed by the Canadian Task Force on the Periodic
placental separation and placental expulsion. Separation
Health Exam (Appendix 1).1 This guideline has been
occurs as a result of the sudden decrease in the size of
developed and reviewed by the Association of Ontario
the uterine cavity after the birth. As the uterus contracts,
Midwives (AOM), and approved by the AOM Board of
the site of placental attachment decreases in size, while
the size of the placenta remains unchanged. The stress
thereby created causes the placenta to buckle and it is
INTRODUCTION
sheared from the uterine wall.2,3 Separation most often
begins in the central portion of the placenta, resulting in
Postpartum hemorrhage is one of the top five causes of
the formation of a haematoma between the placenta and
maternal mortality in both developed and developing
remaining decidua. The retroplacental clot is thought to facilitate the completion of separation, as the additional
This guideline review reflects information consistent with the best practice as of the date issued and is subject to change. The information is not intended to dictate a course of action. Local standards may cause additions to or modifications of this guideline. Such changes should be well documented by practice groups. The Association of Ontario Midwives respectfully acknowledges the financial support of the Ministry of Health and Long-Term Care in the development of this guideline. The views expressed in this guideline are strictly those of the Association of Ontario Midwives. No official endorsement by the Ministry of Health and Long-Term Care is intended or should be inferred.
weight in the mid-point of the placenta helps to strip the
Incidence
adherent lateral borders, and to peel the membranes from the uterine wall.
PPH occurs in five to fifteen percent of all deliveries and
contributes to twenty-five to thirty percent of maternal
Once it has separated, the placenta descends into the
mortality worldwide.10 PPH with blood loss of >1000 ml
lower uterine segment or into the upper vaginal vault.
affects one to five percent of births in the developed
This is evidenced by: a sudden trickle or small gush of
blood, lengthening of the amount of umbilical cord visible at the introitus, change in the size of the uterus
from discoid to globular, or change in the position of the
Uterine atony. The uterus fails to contract
effectively to control bleeding. Uterine atony accounts for 80-85% of all cases of primary PPH.13
The expulsion of the placenta from the uterus occurs by one of two mechanisms. The more common Schultz
Partial separation of the placenta. With the
mechanism results in the fetal side of the placenta
placental in utero, the uterus is unable to contract
presenting at the introitus, with the membranes
effectively and there is copious blood loss from the
inverted, trailing behind the placenta, and containing the
retroplacental clot. The less common Duncan
Retained placental fragments. Placental fragments
mechanism causes the placenta to escape sideways, with
the maternal side presenting first. The membranes in this presentation are not peeled off as effectively, and
Placental pathology. This includes variations of
may more often be delayed or retained.5 It is thought
placenta previa, placenta accreta, percreta, increta or
that the two mechanisms occur as a result of the original
site of attachment in the uterus, with higher
Trauma. Trauma most commonly includes
implantations resulting in a Schultz presentation and
episiotomy, perineal, vaginal or cervical tears
placentas attached in the lower segment being expelled
(particularly tears involving an artery). Trauma is
often associated with operative delivery or caesarean section.
Once expulsion of the placenta has occurred, bleeding from the placental site is controlled by the contraction of
Coagulation disorders. Such disorders are rarely
the “living ligature” of the oblique uterine muscle fibres
seen. They may be inherited or acquired.
in the upper uterine segment about the uterine blood
The SOGC Alarm course suggests that one can easily
vessels. As well, coagulation and fibrinolytic systems
remember these causes when categorized as the “4 T’s”:
are activated, securing hemostasis by the formation of a
fibrin “mesh” over the placental site.4
Risk Factors POSTPARTUM HEMORRHAGE
The likelihood that a woman will experience a
postpartum hemorrhage is dependent upon a variety of
Definition
factors. Table 1 outlines risk factors which may be
The World Health Organization defines postpartum
identified antenatally as well as those that may be
hemorrhage (PPH) during vaginal delivery as blood loss
identified during the intrapartum or postpartum
of greater than 500 cc.7 Alternative definitions of PPH as
periods. It is important to note that although
blood loss greater than 600 cc or greater than 1000 ccs
previously regarded as a risk factor, grand multiparity
have also been suggested.6,8 For clinical purposes any
has not been found to be associated with an increased
blood loss that has the potential to produce hemo-
dynamic compromise is considered a PPH. Estimating blood loss is fraught with inconsistencies – it has been
Risk factor assessment is an ongoing process that begins
suggested that clinicians’ subjective assessments may
with initial history taking and continues throughout the
underestimate blood loss by as much as 50%.4,9
course of care. Assessment of risk factors is not
prescriptive and needs to encompass the entire clinical
PPH can be divided into primary PPH, which occurs
picture including planned place of birth.
within 24 hours of birth, and secondary PPH, which occurs between 24 hours and 6 weeks postpartum.4
While risk factor identification is an ongoing aspect of management, two-thirds of PPHs occur without any
2 March 2006
predisposing factors.18 As many as twenty-eight percent
as is sometimes assumed. Rather, it describes a regimen
of women who require postpartum blood transfusion
which includes no routine use of oxytocics, delaying the
have no risk factors.19 Current evidence about risk
clamping of the umbilical cord until pulsations cease, no
factors is primarily based on practitioners’ clinical
uterine manipulation or controlled cord traction, and
experience and opinions. A higher quality of evidence
delivery of the placenta by maternal effort within one
would clarify the implications of risk factors on
hour of birth. Full physiologic management, as defined
management of third stage. In the meantime, risk
here, is not commonly used by practitioners in North
factors can be used to develop plans for care which
America. However, care providers who do not routinely
prevent or minimize the risks associated with PPH.
administer oxytocin, but who do employ controlled cord traction (sometimes called the Brandt-Andrews
manoeuvre), may consider their management style to be physiologic rather than active. According to the
Antenatal Risk Intrapartum/Postpartum Risk Factors
definitions used in relevant clinical trials, this approach falls into neither category. The same discrepancy occurs
for active management where, in practice, the oxytocic
drug of choice, the timing of drug administration and
route of delivery, the timing of cord clamping and the
use of controlled cord traction may all vary.
Active Management
A systematic review comparing active versus expectant
management of third stage21 identified five relevant
randomized controlled trials,22,23,24,25,2 four of which the
reviewers assessed to be of good quality. In these trials,
active management was defined as administering a
prophylactic uterotonic with the anterior shoulder or
immediately after birth, early cord clamping and
cutting, and controlled cord traction, while expectant
management was defined as awaiting spontaneous
delivery of the placenta with the aid of gravity or nipple
stimulation. Active management resulted in statistically
significant reductions in the risk of maternal blood loss
(Source: ESW, Scottish Obstetric Guideline, Reyel, SOGC, Aikins)
(weighted mean difference -79.33 ml, 95% CI -94.29 to -64.37), postpartum hemorrhage (relative risk 0.38, 95%
Recommendation #1: Identification of risk factors for
CI 0.32-0.46), and prolonged third stage of labour
PPH should occur in an ongoing manner throughout
(weighted mean difference -9.77minutes, 95% CI -10.00
the course of care. (III)
to -9.53). On the other hand, increases in the risk of
maternal nausea (relative risk 1.83, 95% CI 1.51 to2.23),
MANAGEMENT OF THIRD STAGE
vomiting and raised blood pressure were associated
with active management. These adverse effects were
Two common options for the management of third stage
attributed primarily to the use of ergometrine. The
are expectant (or physiological) management and active
Cochrane reviewers advocate for active management of
management. Expectant management can be defined as
third stage as the routine management of choice for
watchful waiting for signs of separation, and
women planning a vaginal delivery in hospital, and
spontaneous delivery of the placenta.20 Active
suggest that additional research is needed to clarify the
management involves prophylactic measures to facilitate
implications in other settings, including homebirths.21
expulsion of the placenta, including administration of a
prophylactic oxytocic, early clamping of the cord, and
In 2003, the International Confederation of Midwives
(ICM) and International Federation of Gynecologists and Obstetrics (FIGO) published a joint statement on the
Comparison of these two approaches is confounded by
prevention of PPH.27 In addition to recommending that
variations in the clinical practice of these two techniques.
birth attendants have the knowledge, skills and
The term “physiologic management” in research trials
judgment to carry out active management of the third
does not refer just to avoiding the use of oxytocic drugs,
stage of labour and access to needed supplies and
3 March 2006
equipment, the statement recommends that active
Recommendation #2: Active management should be
management should be offered to all women in labour.
offered to all pregnant women.(I-A)
The ICM/FIGO definition of active management includes delivery of oxytocin (10 IU IM) within one
Recommendation #3: Active management is
minute of the birth of the baby, clamping of the cord
strongly recommended for women with an identified
once it stops pulsing, controlled cord traction, and
increased risk of postpartum hemorrhage.(I-A)
massage of the fundus until it is contracted.
A) Delivery of Uterotonic
One debated aspect of active management is the ideal
shoulder, delivery on infant, or delivery of the
choice of prophylactic uterotonic. While some argue
that currently there is little evidence that any route, dose
Give oxytocin 10 IU IM – other routes of delivery include 5 IU IV push, or 20-50 IU in
or timing of oxytocin administration is superior,14,32
there has, in fact, been a fair amount of research done
Oxytocin should be stored between 15-30 C,
which compares the effects of oxytocin, ergonovine or a
combination of these drugs, administered intravenously
Clamp the cord close to the perineum after
A systematic review comparing ergometrine-oxytocin
Keep tension on the uterus and wait for a
(Syntometrine) versus oxytocin (Syntocinon) for third
stage management,33 identified six relevant trials
Encourage mother to push with contraction
(involving 9332 women). The combination of
ergonovine and oxytocin was associated with a small
If the placenta does not descend during 30-40 sec of CCT do not continue with traction.
reduction in the risk of blood loss >500ml compared to
As placenta delivers hold the placenta in two
oxytocin alone (odds ratio 0.82, 95% CI 0.71 to 0.95).
There was no statistically significant difference between
twisted. Slowly pull to complete delivery.
groups for blood loss of >1000 ml. Ergometrine-
oxytocin was associated with statistically significant
Massage the fundus to ensure contraction.
increases in the risks of nausea, vomiting and elevated
Palpate uterus every 15 minutes in the first 2
Another systematic review examined the effects of
There is a gap in current research regarding what impact
prophylactic oxytocin in the third stage of labour on
each of the individual components of active
maternal and neonatal outcomes.34 A total of fourteen
management has on preventing blood loss. It appears
randomized or quasi-randomized trials were included.
that the key element of active management is the
Seven trials in which prophylactic oxytocin was
administration of an oxytocic drug, but evaluation of the
compared to no uterotonics demonstrated the following
other components of active management is
benefits to be associated with oxytocin: reduced blood
incomplete.28,29 Subsequent sections of this guideline
loss (RR for blood loss >500 ml 0.50; 95% CI 0.43 to 0.59)
review the evidence regarding each of the components
and reduced need for therapeutic oxytocics (RR 0.50,
of active management. While future research may
95% CI 0.39 to 0.64). Six trials35,36,37,38,39,40 in which
define the components of active management that are
oxytocin was compared to ergot alkaloids demonstrated
most effective in preventing PPH and which, if any, hold
little difference in effect other than a lower risk of
risk if used incorrectly or alone,30,31 current evidence
manual removal of the placenta with oxytocin (RR 0.57,
suggests that active management of the third stage is the
95% CI 0.41 to 0.79), and a non-significant trend
most effective tool in preventing PPH and adverse
suggesting less raised blood pressure with oxytocin (RR
sequelae. Informed choice discussions with women
0.53, 95% CI 0.19 to 1.52). A comparison of ergometrine
regarding active management of third stage must be
alone to ergometrine with oxytocin was examined in five
trials, which demonstrated little difference in effect. The reviewers note that while oxytocin appears to be beneficial for the prevention of postpartum hemorrhage, overall there is insufficient information about other outcomes and adverse effects.34
4 March 2006
The results of these reviews suggest that oxytocin
use of oxytocics at the time of birth confers a decreased
appears to be the agent of choice of third stage
chance of hemorrhage when compared to giving
management in low risk women.30 Prophylactic
oxytocics after the placenta has been contradicted. A
oxytocin may be given as 10 IU IM, 20-50 IU per litre IV
recent RCT that compared giving oxytocin before versus
drip run at 100-150 cc/hr or 5 IU IV push.10,14 Some
after placental delivery found no difference in the
authorities caution against the use of a bolus of
incidence of PPH or the length of third stage.48 Given
intravenous oxytocin, citing small studies which suggest
the lack of clarity in the research and limited evidence
that such practices could compromise women’s
on which to base recommendations, prophylactic
hemodynamic state3. However, a recent randomized
oxytocin can be given after the birth of the anterior
controlled trial41 has demonstrated no significant
shoulder, or after the delivery of the baby up to and
difference in hemodynamic status between women
including within one minute of delivery of the baby.14,27
given prophylactic intravenous oxytocin by infusion or by bolus; this study does not address giving intravenous
Recommendation #4: When active management is
boluses of oxytocin to women who are already
employed, prophylactic oxytocin (given as 10 IU IM
hemodynamically unstable. When caring for women
or 5 IU IV slow push) should be given after delivery
who give birth without pain medication, care providers
of the anterior shoulder within up to one minute after
should remember that intramuscular oxytocin is
birth of the infant. (I-B)
experienced by most women as being relatively painful.
B) Clamping of the Cord
Recent research focussing on third stage management
The second component of active management is early
has examined alternatives to oxytocin and syntometrine.
cord clamping. In trials investigating active
The majority of randomized controlled trials on the topic
management, early cord clamping, occurring within
published in the last 8 years have investigated use of
30-60 seconds of delivery, is undertaken regardless of
misoprostol, a prostaglandin E1 analogue.42,43
whether of not cord pulsation has ceased. The benefits
Misoprostol is inexpensive, stable, easily stored, and can
of immediate cord clamping, and its impact on blood
be given non-parenterally, and therefore has potential to
be particularly useful in developing countries.13 Three systematic reviews have been completed on misoprostol
When clamping is delayed until after pulsations have
use since 2002.44,44,46 This work concludes that
ceased, complete transfusion of blood from the placenta
misoprostol results in higher blood loss than
to the neonate occurs which leads to higher hemoglobin
conventional prophylactic uterotonics and is associated
and additional iron stores in infants.49 These effects in
with significant increases in rates of shivering and fever.
newborns are undetectable by 6 months after birth.29 On
The efficacy, dose, and route of administration of
the other hand, it is argued that early clamping is
misoprostol for prophylactic use in third stage continue
beneficial because reduced placental blood transfer
to be investigated and it is not recommended for use in
decreases the incidence of neonatal jaundice.29,50
the prevention of PPH at this time.13,29,44,45,46
Seven trials have compared the timing of cord clamping.
Injectable prostaglandins are another alternative to
Statistically non-significant findings from clinical trials
conventional uterotonics. Mean blood loss does appear
have suggested that there may be risks inherent in the
to be reduced with injectable prostaglandins compared
intervention of early cord clamping, including retained
to conventional injectable uterotonics (weighted mean
placenta, and increased bleeding,29 but there is not
difference -70 ml, 95% CI -73 to -67), but these agents
sufficient evidence to establish whether or not such risks
have more side effects.45 Injectable prostaglandins
exist. Methodological weakness, small sample size and
appear to be more appropriate for use in the treatment
variation in outcomes measured make interpretation
difficult. Evidence published to date has not clearly established the impact of the timing of cord clamping on
An additional issue of debate related to the
postpartum blood loss,29,51 and further investigation is
administration of prophylactic uterotonics is the ideal
needed. Until such time as studies reveal the effect of
timing of this intervention. It has been variously
this component of active management on blood loss and
suggested that oxytocin be given after the anterior
its ideal timing, clamping of the cord may be done
shoulder, after the birth of the baby or after delivery of
the placenta. Other midwifery and obstetrical guidelines argue for delivery after the anterior shoulder,
Recommendation #5: When active management is
and within one minute of delivery of the baby
employed, clamping of the cord may be done
respectively.14,27 Earlier work47 which proclaimed that
5 March 2006
immediately after delivery of the infant or when
During controlled cord traction, the mother may be
pulsation ceases. (I-C)
asked to push to assist expulsion. This may be of particular use in situations where the cord is beginning
C) Controlled Cord Traction
to separate, and the practitioner wishes to use minimal
Controlled cord traction is a component of active
traction in facilitating expulsion. As the placenta begins
management that is somewhat overlooked in the
to appear at the introitus, the non-dominant hand
research on third stage management. Two older trials
continues to guard the uterus by applying suprapubic
suggest that controlled cord traction is associated with
pressure slightly toward the umbilicus until the placenta
lower mean blood loss and shorter third stages
compared to less active approaches.29 These findings are supported by a recent RCT which found a reduction of
Recommendation #6: Controlled cord traction may
postpartum hemorrhage in the controlled cord traction
be used to decrease blood loss, and should be used
group (5.8% vs. 11%; OR 0.50, 95% CI 0.15-0.63).52 The
in combination with uterine guarding above the
results of this trial may be confounded by differences in
pubic bone on a contracted uterus. (I)
the timing and route of administration of oxytocin between the study groups.
Expectant Management Expectant management is a low intervention approach
Another small RCT (n=239) adds the element of cord
wherein the placenta is expelled spontaneously while
drainage to the issue of cord traction. This study
being aided by maternal effort, positioning or nipple
investigated the use of controlled cord traction in
stimulation. The umbilical cord is clamped and cut after
combination with cord drainage and found that
the placenta is delivered.28,29 Typically, the cord ceases to
compared to expectant management, the length of third
pulsate between 1-3 minutes after the birth, which may
stage and amount of blood loss was significantly
be considered “physiologic clamping”.56 Skin to skin
reduced in the cord traction/drainage group.53 A
contact between the mother and infant may support
systematic review of trials involving placental cord
physiological processes that contribute to separation and
drainage as an investigated variable identified two
relevant studies. The reviewers concluded that there appears to be potential benefit from the use of cord
Worldwide, expectant management is frequently
drainage in terms of reducing the third stage of labour,
practiced. The Global Network for Perinatal and
but more research is needed to fully investigate its
Reproductive Health conducted an observational, cross
impact.54 This practice is not typically included as a
sectional survey in 10 countries and concluded that the
rate of active management was 24.6%.58 This low rate may be accounted for by women’s desire for a more
Overall the evidence shows that controlled cord traction
“natural” childbirth, a philosophy that active
results in a statistically significant decrease in the
management is unnecessary, and a preference to avoid
incidence of PPH. Further investigation into the role of
the potentially unpleasant effects of uterotonic agents.59
controlled cord traction from larger trials with
The lack of availability of uterotonics also limits the use
comparable study groups would be useful.
When performing controlled cord traction, it is
A variation of expectant management that is used by
important to observe some key principles in order to
many practitioners who may consider their management
avoid the potential danger of uterine inversion.
style to be physiologic rather than active is the Brandt-
Controlled cord traction should not be attempted prior
Andrews manoeuvre. This manoeuvre involves no
to separation of the placenta, and should only be done in
administration of oxytocin, and controlled cord traction
the presence of a well-contracted uterus. While
with or without early clamping. There currently is no
performing cord traction, the non-dominant hand of the
research that compares the Brandt-Andrews manoeuvre
practitioner should rest on the abdomen with the heel of
to physiologic management of third stage. Both
the hand at the symphysis pubis, and the fingertips
approaches seem to be reasonable variations to offer
resting on the fundus. In addition to allowing the
when a woman has chosen physiological management,
practitioner to confirm that the uterus is contracted and
given the evidence discussed earlier in this guideline
to guard the uterus, this hand position allows detection
that suggests that controlled cord traction decreases the
of any “dipping” in the fundus, which would indicate
that the placenta is still attached and that traction should be discontinued until separation occurs.55
6 March 2006
Another component of third stage requiring
The three main principles of management of PPH are:
consideration with respect to physiologic management is
the duration. There is some debate regarding the maximum duration of a normal third stage. Third stage
usually lasts from 5-15 min, but may last up to an hour.4
After 30 minutes duration, there is an increase in the rates of postpartum hemorrhage.
Table 4 shows a clinical pathway for management of
out the association between prolonged third stage and
PPH. When PPH is identified, the likely cause must be
complications. It has been suggested that the most
determined so that appropriate action may be taken.
important aspect of third stage management is
Subsequent actions should take place as simultaneously
minimizing its duration, and that how this is
and as quickly as possible. While the uterus and genital
accomplished is secondary. For example, in two trials
tract are explored to identify cause of bleeding,
demonstrating active management to be the superior
measures such as monitoring vital signs, catheterization,
approach, 26% and 16.4% of women in the physiologic
administering oxygen and placing an IV, may be
groups had third stages exceeding 30 minutes
commenced.9 The order in which steps are taken may
(compared to 2.9% and 3.3% of women in the active
vary depending on the specific circumstances and the
demonstrated no benefit to active management, third
Table 3: Clinical findings with various degrees of shock
stage duration was less than 20 minutes in 93% of the physiologically managed and 95% of the actively
Systolic Signs and Symptoms Blood Pressure Change Recommendation #7: Either expectant management or the Brandt-Andrews manoeuvre is an acceptable Compensation option for women who decline active management. MANAGEMENT OF PPH Moderate
The majority of the existing research on PPH focuses on
the prevention of PPH, while evidence regarding the
safety and efficacy of treatments for primary PPH is
(Source: In SOGC Alarm manual from ACOG Bulletin #235)
more varied and controversial.61 The subsequent
discussion of the management of PPH is based primarily
Recommendation #8: When PPH occurs, the cause
on established protocols that have been developed based
of bleeding should be identified and directed
on the experience of clinicians. While in some cases the
treatment undertaken promptly. (III)
clinical benefits of interventions are clearly apparent, there is room for further research on the efficacy of
Prompt decision making and communication are the
various components of the emergency measures
cornerstones of management of PPH.62 Informing the
woman, her partner and other health care providers assisting the midwife of the situation initially and in an
Following careful identification of risk factors, and the
ongoing manner is an important aspect of management.
use of active management of the third stage, the third key aspect in preventing PPH is early recognition of
Recommendation #9: In addition to controlling
blood loss. Careful assessment in the immediate
bleeding, the initial steps in treatment of PPH
postpartum and prompt intervention when indicated
include treating shock and communicating with the
can help to reduce blood loss. Post delivery, the fundus
client and other health care providers assisting the
should be assessed at regular intervals. Signs and
midwife. (III)
symptoms that are associated with PPH include visible bleeding, pallor, rising pulse rate, falling blood pressure,
Options for treatment of PPH include drugs to increase
altered level of consciousness, restlessness, or enlarged
uterine contraction and surgical techniques.61 Treatment
uterus. Table 3 outlines the clinical findings associated
is directed based on the identification of the cause of
hemorrhage. The most common cause of PPH is uterine atony which can be treated by uterine massage and/or
7 March 2006
compression and administration of uterotonics.9 It is
within the midwife’s pharmacopeia to give oxytocin, ergonovine and carboprost for the treatment of PPH. See Table 5 for a summary of these medications. Current research shows promising developments in the potential use of rectal misoprostol as a first line drug for the treatment of primary PPH; however, more research is needed.42,61
8 March 2006 9 March 2006
Hemorrhage unresponsive to these actions requires the
between 2-8 degrees Celsius.62 Oxytocin is ideally stored
immediate assistance of a physician with obstetric
between 15-30C and should be protected from freezing.27
surgical skills. As with any emergency, careful attention
Midwives should not store these drugs in their cars
to communication and documentation is required.
where large temperature fluctuations can adversely
Uterine packing, artery ligation, x-ray guided
embolization, hysterectomy and the use of blood replacement products are all further interventions in the
It is important to acknowledge that there is variation in
management of PPH that may be performed by an
the preferences of both midwives and women regarding
third stage management. Woman and midwives who participated in the Bristol trial on active management of
Table 5: Properties of uterotonic medications
third stage both regarded the longer length of third stage with physiologic management as a negative feature,63
Mechanism Side Effects
and research suggests there is a tendency to favour
of Action
active management.29 Others favour physiologic
management because it is “less interventive,” though it
has been suggested that the label of interventive
medicine should be removed from the evidence based
practice of active management.64 Midwives are in a
position to preserve choice by respecting that some
women neither want or need active management while
presenting evidence based information to all clients.20,65
It is the role of midwives simultaneously to support
birth as a natural physiological practice and to
acknowledge the research that supports interventions
such as active management in decreasing postpartum
When a primary PPH occurs, early recognition,
communication, and attention to resuscitative measures
and cause of bleeding66 will assist the midwife in managing this rare but potentially life threatening
ADDITIONAL MI DW IF E R Y IM PLIC AT IO NS
situation. With careful management, third stage can remain an anti-climatic and uneventful part of one of the
The topic of third stage management should be
most important days of a woman’s life.
discussed with each client during the course of her prenatal care. Women need to be informed of the
RECOMMENDATIONS
benefits and risks of management options and made aware of any factors particular to their situation worthy
1. Identification of risk factors for PPH should occur in
of consideration. Access to previous obstetrical records
an ongoing manner throughout the course of care.
and continuing evaluation of risk factors will help
midwives to identify women to whom active
management should be recommended. Midwives
2. Active management should be offered to all
should endeavour to minimize any existing barriers to
the implementation of active management.
3. Active management is strongly recommended for
women with an identified increased risk of
One concern for midwives is the storage of ergonovine,
carboprost and oxytocin for women planning
homebirths. Storage and refrigeration is essential to the
4. When active management is employed, prophylactic
efficacy of ergometrine. Ergometrine loses 21-27% of
oxytocin (given as 10 IU IM or 5 IU IV slow push)
active ingredients after 1 month and 90% after 1 year of
should be given after delivery of the anterior
storage exposed to light and at 21-25 degrees Celsius.
shoulder within up to one minute after delivery of
For most effective long-term storage, ergonovine must
be kept between 2-8 degrees Celsius and protected from
light.43 Similarly, carboprost must also be stored at
10 March 2006
5. When active management is employed, clamping of
without the intervention; dramatic results in uncontrolled
the cord can occur immediately after delivery of the
Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert
6. Controlledcord traction may be used to decrease
blood loss, and should be used in combination with
Levels of Evidence - Quality (Internal Validity) Rating
counter traction above the pubic bone on a contracted uterus.(I-B)
Good A study (including meta-analyses or systematic reviews) that
meets all design-specific criteria* well. Fair A study (including meta-analyses or systematic reviews) that
7. Either expectant management or the Brandt-
does not meet (or it is not clear that it meets) at least one
Andrews manoeuvre is an acceptable option for
design-specific criterion* but has no known “fatal flaw.”
women who decline active management. (III)
Poor A study (including meta-analyses or systematic reviews) that
has at least one design-specific* "fatal flaw,” or an accumulation of lesser flaws to the extent that the results of
8. When PPH occurs, the cause of bleeding should be
the study are not deemed able to inform recommendations.
identified and directed treatment undertaken
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52. Symposion der Deutschen Gesellschaft für Endokrinologie Poster Kunsthalle Kongresshalle KunSthallE Kongresshalle 15.00-16.00 Male and Female Reproduction Identification of two active cholinesterases in human ovary: Elevated cholinesterase activity in follicle serum of women suffering from polycystic ovary syndrome Schmidt T.1, Kunz L.1, Berg U.1, Berg F.D.1, Mayerhofer A.1