Should Active Management of the Third Stage of Labor Be Routine?

MELISSA NOTHNAGLE, M.D., and JULIE SCOTT TAYLOR, M.D., M.SC., Brown Medical School, Pawtucket, Rhode Island

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Melissa Nothnagle, M.D., and Julie Scott Taylor, M.D., M.Sc., present a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

A 24-year-old, gravida 2, para 1 woman vaginally delivers a healthy term infant at a community hospital. Her physician waits for the placenta to deliver.

Clinical Question

Should active management of the third stage of labor be routine in women who deliver vaginally in a hospital?

Evidence-Based Answer

Active management of the third stage of labor (i.e., administration of a uterotonic medication before the placenta is delivered, early clamping and cutting of the umbilical cord, and application of controlled traction to the cord) is associated with reduced maternal blood loss, fewer cases of postpartum hemorrhage, and a lower incidence of a prolonged third stage of labor. Disadvantages for mothers include an increased risk of nausea and vomiting and elevated blood pressure associated with the use of ergometrine. (Editor's note: In the United States, ergometrine is known as ergonovine. It might be presumed that the other preparations available in the United States, methylergonovine maleate and ergonovine maleate, produce the same effects and outcomes.)

Cochrane Abstract Background. Expectant management of the third stage of labor involves allowing the placenta to deliver spontaneously or aided by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta and, usually, early cord clamping and cutting, and controlled cord traction on the umbilical cord. Objectives. The objective of this review1 was to assess the effects of active versus expectant management on blood loss, postpartum hemorrhage, and other maternal and perinatal complications of the third stage of labor. Search Strategy. The authors searched the Cochrane Pregnancy and Childbirth Group trials register. Selection Criteria. Randomized trials comparing active and expectant management of the third stage of labor in women who were expecting a vaginal delivery were included. Data Collection and Analysis. Trial quality was assessed, and data were extracted independently by the reviewers. Primary Results. Five studies were included. Four of the trials were of good quality. Compared with expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference [WMD], -79.33 mL, 95 percent confidence interval [CI], -94.29 to -64.37); postpartum hemorrhage greater than 500 mL (relative risk [RR], 0.38, 95 percent CI, 0.32 to 0.46); and prolonged third stage of labor (WMD, -9.77 minutes, 95 percent CI, -10.00 to -9.53). Active management was associated with an increased risk of maternal nausea (RR, 1.83, 95 percent CI, 1.51 to 2.23), vomiting, and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the infant. Reviewers' Conclusions. Routine active management is superior to expectant management in terms of blood loss, postpartum hemorrhage, and other serious complications of the third stage of labor. Active management is, however, associated with an increased risk of unpleasant side effects (e.g., nausea and vomiting) and hypertension when ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear in other settings, including home birth in developing and industrialized countries. These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in The Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (www.cochrane.org).

Cochrane Critique

Did the author address a focused clinical question? Yes.

Were the criteria used to select articles for inclusion appropriate? Yes.

Is it likely that important relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes.

Were the assessments of studies reproducible? Yes.

Were the results similar from study to study? Yes.

Can the results be applied to patient care? Yes. These results apply to women with low-risk, singleton pregnancies at term who deliver spontaneously in the cephalic presentation.

Women with anemia, antepartum bleeding, history of postpartum hemorrhage, grand multiparity, hypertension, or previous cesarean section, and women who received epidural analgesia, oxytocin infusion, or anticoagulation were excluded from several of the studies, which limits generalizability to those patients. Nor were results generalizable to home births, because only births in hospital maternity wards were studied.

Do the conclusions make clinical and biologic sense? Yes.

Are the benefits of active management worth the harms and costs? Yes. Side effects were minor and mostly associated with ergometrine, which is not commonly used in third-stage management in the United States. Potential costs include the cost of uterotonic medications and the pain of intramuscular injections (although intravenous administration could be offered to patients with intravenous access). There would be no cost for early cord clamping and cutting and cord traction.

Practice Pointers

Management of the third stage of labor varies widely among individual practitioners and maternity units in the United States, in contrast to management in several European countries, in which active management is standard.¹ Postpartum hemorrhage remains a significant cause of maternal morbidity and mortality, especially in developing areas. Because of variability in clinical estimates of blood loss after delivery, there are few data regarding the prevalence of postpartum hemorrhage in the United States. Using a strict definition of postpartum hemorrhage (i.e., hematocrit decrease of 10 points or more or need for transfusion), one large U.S. study found a 3.9 percent incidence of postpartum hemorrhage after vaginal delivery.²

Based on the data from the reviewed studies, active management of the third stage of labor should be routine after uncomplicated vaginal deliveries in a hospital setting. Instituting the routine practice of active management of the third stage is simple and inexpensive, and it confers significant clinical benefit in reducing maternal complications with minimal risk. Uterotonic agents already are available on all maternity units for treatment of postpartum hemorrhage.

The studies reviewed used oxytocin, ergometrine, or a mixture of those drugs administered intravenously or intramuscularly immediately after delivery of the infant. A subsequent review found that the combination of oxytocin and ergometrine resulted in greater reductions in postpartum blood loss (but not in need for transfusion) compared with oxytocin alone.³ However, more adverse effects (e.g., nausea, vomiting, hypertension) were observed with use of the combined medications.

Based on these reviews, oxytocin appears to be the agent of choice for third-stage management in low-risk women, because of the incidence of side effects associated with ergometrine. Educating obstetric providers about early cord clamping and controlled cord traction will be necessary in maternity units where active management is not standard. Future research may define which components of active management are most effective in preventing maternal complications. Other agents, including prostaglandins such as misoprostol, are currently under investigation for use in the management of the third stage of labor.

Melissa Nothnagle, M.D., is clinical assistant professor of family medicine at Brown Medical School, Pawtucket, R.I.

Julie Scott Taylor, M.D., M.Sc., is assistant professor of family medicine and director of predoctoral education at Brown Medical School.

Address correspondence to Melissa Nothnagle, M.D., Memorial Hospital of Rhode Island, Department of Family Medicine, 111 Brewster St., Pawtucket, RI 02860 (e-mail: melissa_nothnagle@mhri.org). Reprints are not available from the authors.

REFERENCES

1. 1. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev 2003:CD000007.
2. 2. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77: 69-76.
3. 3. McDonald S, Prendiville WJ, Elbourne D. Prophylactic syntometrine versus oxytocin for delivery of the placenta. Cochrane Database Syst Rev 2003:CD000201.