Friday, April 1, 2011

INFOSHEET: The Third Stage of Labour

This is the second in the current review of the INFOSHEET series. To download this, and other INFOSHEETs, click here.
The revised INFOSHEET - click to enlarge

This INFOSHEET deals primarily with natural physiological Third Stage, the time from the spontaneous, unmedicated birth of the baby to the spontaneous birth of the placenta. It may seem like stating the obvious, but remember that physiological Third Stage can only be considered when the rest of labour, the first and second stages have been physiological and uncomplicated, and mother and baby are well.

In today's maternity care world, relying heavily and often unnecessarily on medical interventions including pain medications, anaesthesia, continuous fetal monitoring, and surgical measures, the proportion of women who proceed through their births in harmony with normal physiological processes is small. Likewise, midwives and doctors in mainstream maternity care have become progressively deskilled in their care of women for whom physiological birth is a realistic option.

A midwifery student who will graduate as a midwife in a few months wrote:
"I have been at X[health network] as a mid student since Feb 2010, I have seen one attempted physiological third stage where the mum had enough after a while and we discontinued and went for active managment. I have not had any other women request physiological management. For those who are not aware it is also worth noting that women who chose to birth in X's homebirth program must sign a contract stating they agree to active 3rd stage managment at home, as physiological third stage is not offered in the [hospital's] homebirth program."

This is a common scenario in midwifery education, and in maninstream maternity care today. In reviewing the Third Stage INFOSHEET, the working group will need to address the issue of evidence relied upon in support of active management, and what the current guidelines around active management advise.

I believe it is important that we take an assertive position, now that the Cochrane review (2010) has concluded that, for women at low risk of bleeding,
“there was no significant difference identified for severe haemorrhage.”

The revised INFOSHEET will address debate internationally around the risk vs benefit of active management in resource-rich settings.

Also, as has been noted in the reviewed INFOSHEET on Baby's Transition, there is more debate now than a few years ago around time of clamping of the cord. The Women’s Clinical Practice Guidelines requires ‘early’ clamping of the cord 2-3 minutes after birth, rather than depriving the baby of the placental blood. Guidelines from another major Level 5 hospital requires injection of oxytocic as the anterior shoulder is delivered, or within one minute of the birth of the baby, followed by:
"Clamp and cut the umbilical cord.
In the preterm, If maternal /neonatal condition allows, in collaboration with the neonatal resuscitation team, consider delaying clamping the cord for up to 2 minutes. Delayed cord clamping has been shown to diminish the risks for the pre term baby of needing a transfusion, being hypotensive or having an interventricular haemorrhage." (Southern Health cp-ma42)

Readers will understand that there is an imperative that those midwives who seek to work in harmony with the natural physiological processes, and promote normal birth when ever possible, establish clear statements about physiological Third Stage.

For further reading, go to
The ICM page on post partum haemorrhage
The FIGO-ICM Joint statement (2006) 

Thankyou for comments and discussion on this important topic.


Joy Johnston said...

See for more discussion

Joy Johnston said...

This INFOSHEET has now been revised, and is available as a .pdf file upon request.

When midwives are advising women and other midwives or students on the third stage, we can now use Cochrane review in an assertive way, in that the risks of active management, including increase in “the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased.”

Change is in the air. However there are many midwives and doctors in the maternity workforce who are de-skilled in physiological third stage, and who are likely to ignore the woman’s need for privacy and warmth as she welcomes her baby, and fiddle with the fundus and ...

There needs to be a new national education campaign, to teach midwives particularly how to attend a physiological third stage.