Integration of the Practice of Active Management of the Third Stage of Labor Within Training and Service Implementation Programming in Zambia

Introduction: Postpartum hemorrhage (PPH) is the leading cause of pregnancy‐related mortality (cited at 591 per 100,000 Zambian women), and is responsible for up to 60% of maternal deaths in developing countries. Active management of the third stage of labor (AMTSL) has been endorsed as a means of reducing the risk of PPH. The Ministry of Health/Zambia has incorporated the use of AMTSL into its reproductive health guidelines. Methods: Midwives employed in five public hospitals and eight health centers were interviewed (N = 62), and 82 observations were conducted during the second through fourth stages of labor. Results: Data from facilities in which oxytocin was available (62 births in 11 settings) indicated that a uterotonic was used in 53 of the births (85.5%); however, AMTSL was conducted in strict accord with the currently recommended protocol (a time‐specific use of the uterotonic, controlled cord traction, and fundal massage) in only 25 (40.4%) of births. Discussion: Midwives have concerns about risks of maternal to newborn HIV blood transfusion; it is doubtful that they will adopt the currently recommended practice of delayed cord clamping and cutting. Infrastructure issues and supply shortages challenged the ability to correctly and safely implement the AMTSL protocol; nevertheless, facilities were generally ready to support it.     

How Do Physicians and Midwives Manage the Third Stage of Labor?

ABSTRACT: Background: Current practice guidelines recommend active management of the third stage of labor. We compared practices of three maternity care provider disciplines in management of third‐stage labor and the justifications for their approach. Methods: This study is a cross‐sectional survey of maternity practitioners in usual practice settings in British Columbia. All 199 obstetricians, all 82 midwives, and a random sample of family physicians practicing intrapartum maternity care (one‐third, or 346) were surveyed The three main outcome measures by discipline were the method preferred in managing third‐stage labor, the reasons given for the chosen method, and views on the appropriateness of the current third‐stage labor guideline. Results: The overall response rate was 57.8 percent. Response rates indicating that the participants were “aware of guideline” were the following: obstetricians, 85.3 percent; family physicians, 53.7 percent; and midwives, 97.8 percent. Response rates indicating that the participants “agreed with guideline” were the following: obstetricians, 95.2 percent; family physicians, 97.6 percent; and midwives, 51.2 percent. Response rates indicating that “oxytocin should be given with anterior shoulder” were the following: obstetricians, 71.1 percent; family physicians, 68.3 percent; and midwives, 26.7 percent. Response rates indicating that “routine active management of third stage of labor should be the norm” were the following: obstetricians, 79.2 percent; family physicians, 60.2 percent; and midwives, 17 percent. All results were statistically significant (p < 0.01). Conclusions: A major difference was found between physicians and midwives in the management of third‐stage labor. Physicians routinely implemented active management of the third stage of labor; midwives preferred expectant approaches, principally based on women’s preference. Provincial data did not show differences in postpartum hemorrhage or transfusion rates by practitioner type. (BIRTH 35:3 September 2008)     

第三产程产后出血防治措施的分析

目的 :探讨第三产程产后出血的防治措施。方法 :前瞻性观察我院住院分娩的产妇 45 0例 ,其中阴道分娩30 0例 ,随机分为 5组。A组 :缩宫素组 (6 0例 ) ,于胎儿娩出后静脉推注生理盐水 2 0ml加缩宫素 2 0U ;B组 :卡前列甲酯组 (6 0例 ) ,于胎儿娩出后将卡前列甲酯 1mg塞肛 ;C组 :手法按摩组 (6 0例 ) ,胎儿娩出后手法持续宫底按摩≥ 5分钟 ,适度牵拉脐带 ;D组 :缩宫素加手法按摩组 (6 0例 ) ;对照组 (6 0例 ) :于胎儿娩出后静脉滴注生理盐水 5 0 0ml。另 15 0例剖宫产分娩者 ,随机分为 3组 ,A组 :缩宫素组 (5 0例 ) ;B组 :手法组 (5 0例 ) ;C组 :缩宫素加手法组 (5 0例 )。准确测量产后 2小时及 2 4小时出血量 ,记录第三产程时间。结果 :阴道分娩各组中 ,D组的第三产程时间最短 ,产后 2小时内出血量最少 ,C组、B组、A组依次减少 ;剖宫产各组中 ,C组的产后出血量及产后出血发生率与A组、B组相比 ,差异有显著性 ;剖宫产组产后出血量与阴道分娩组比较 ,其差异也有统计学意义。结论 :胎儿娩出后及时使用缩宫素或卡前列甲酯等促宫缩药 ,并采取主动手法辅助娩出胎盘 ,可减少产后出血 ,其预防产后出血的效果显著优于上述其他处理方法。     

Third Stage of Labour Care for Women at Low Risk of Postpartum Haemorrhage

In normal birth there should be a valid reason to interfere with normal processes. Yet, active management of third stage labor is being imposed on women who have no known risks of postpartum hemorrhage. This article examines the evidence from existing randomised trials comparing active and physiological third stage care for its relevance and validity to the effectiveness of physiological third stage care for women who are at low risk of postpartum hemorrhage. Consideration is given to midwifery and medical perspectives of the following definitions: ‘postpartum hemorrhage’; ‘low‐risk status’; ‘active’; ‘expectant’ and ‘physiological’ third stage care. A systematic search of the research literature regarding the third stage of labour is described. Four randomised trials and a meta‐analysis by Cochrane were considered. These studies are examined in terms of their potential generalisability to women who are at low risk of postpartum hemorrhage. All trials included women who were at high risk of postpartum hemorrhage. The existing research does not provide relevant and valid evidence about the effectiveness of physiological third stage care, as defined by midwives, for women who are at low risk of postpartum hemorrhage.     

Effects of LI4 Acupressure on Labor Pain in the First Stage of Labor

Introduction: Complementary and alternative medicines have been used to decrease labor pain for many years. Despite reports that some of these methods reduce pain, increase maternal satisfaction, and improve other obstetric outcomes, they have received limited attention in the US medical literature. The purpose of this study was to evaluate the effects of LI4 acupressure on labor pain in the first stage of labor, on labor duration, and on patient satisfaction. Methods: A single, blind, randomized clinical trial was performed with eligible women (N = 100) who were at the beginning of the active phase of labor (3–4 cm dilatation of cervix with regular uterine contractions). The women in the acupressure group (n = 50) received LI4 acupressure at the onset of the active phase for the duration of each uterine contraction over a period of 20 minutes, and the women in the control group (n = 50) received a touch on this point without massage. Labor pain was measured using a structured questionnaire of a subjective labor pain scale (visual analogue scale) before the intervention, immediately after the intervention, 20 and 60 minutes after the intervention, and then every hour. Results: There were significant differences between the groups in subjective labor pain scores immediately and 20, 60, and 120 minutes after intervention (P≤ .001). Active phase duration (3–4 cm dilatation to full dilatation) and second stage duration (full dilatation to birth) were shorter in the acupressure group. The women in the acupressure group reported greater satisfaction. Discussion: LI4 acupressure was effective at decreasing pain and duration of labor. The participants were satisfied, and no adverse effects were noted.     

A Comparative Study of Oxytocin/Misoprostol/Methylergometrine for Active Management of the Third Stage of Labor

Objectives

To study oxytocin, misoprostol, and methylergometrine in active management of the third stage of labor and determine duration of the third stage of labor, blood loss, adverse effects, and need for additional uterotonics in each group.

Methods

Clinical trial of 300 women with healthy singleton pregnancy allocated into three groups to receive either: 10 IU intravenous oxytocin infusion, 600 μg sublingual misoprostol, or 200 μg intravenous methylergometrine. Primary outcome measure was blood loss in the third stage of labor; secondary measures were duration of the third stage, side effects, and complications.

Results

Subjects who received 600 μg of misoprostol had the least blood loss, followed by oxytocin, and methylergometrine. The shortest mean duration of the third stage was with misoprostol. Shivering and pyrexia were observed in misoprostol group, and raised blood pressure in methylergometrine group.

Conclusions

Misoprostol is as effective as oxytocin and both are more effective than methylergometrine in active management of the third stage of labor.     

Perineal Outcomes and Maternal Comfort Related to the Application of Perineal Warm Packs in the Second Stage of Labor: A Randomized Controlled Trial

ABSTRACT: Background: Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor. Methods: A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second‐stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention‐to‐treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort. Results: The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third‐ and fourth‐degree tears and they had significantly lower perineal pain scores when giving birth and on “day 1” and “day 2” after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group. Conclusions: The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third‐ and fourth‐degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care. (BIRTH 34:4 December 2007)     

Randomized Controlled Trial of Rectal Misoprostol Versus Oxytocin in Third Stage Management

Objective: To compare rectal misoprostol with oxytocin for routine management of the third stage of labour.Study design: A total of 240 parturient women were randomized, at three University of Toronto teaching hospitals, to receive either rectal misoprostol (400 µg) after delivery of the infant or parenteral oxytocin (5 units IV or 10 units IM) with the delivery of the anterior shoulder, when possible, or 5 units IV or IM after the delivery of the placenta.The primary outcome measure was change in hemoglobin (Δ[Hgb]) from admission in early labour to day one postpartum.Setting: The labour ward of three University of Toronto teaching hospitals: St. Michaels, Toronto General, and Mount Sinai.Population: Labouring women either nulliparous or muciparous with no known risk for excessive third stage blood loss; vertex presentation; no previous Caesarean delivery; induced, spontaneous, or augmented labour.Results: No difference in Δ[Hgb] was observed between the two groups; the Δ[Hgb] in the oxytocin and misoprostol groups were 1.43 g/L (95% confidence interval [Cl], 1.2–1.6 g/L) and 1.59 g/L (95% Cl, 1.4–1.8 g/L) respectively (p = 0.35). Secondary outcome measures (excessive third stage bleeding, duration of third stage of labour, need for manual removal of the placenta or the need for additional oxytocics) did not differ between the two groups.Conclusion: Rectal misoprostol is of equivalent efficacy to parenteral oxytocin for the prevention of primary postpartum hemorrhage. Rectal misoprostol is an appropriate uterotonic agent for routine management of the third stage of labour.     

Labor Dystocia: A Common Approach to Diagnosis

Contemporary labor and birth population norms should be the basis for evaluating labor progression and determining slow progress that may benefit from intervention. The aim of this article is to present guidelines for a common, evidence‐based approach for determination of active labor onset and diagnosis of labor dystocia based on a synthesis of existing professional guidelines and relevant contemporary publications. A 3‐point approach for diagnosing active labor onset and classifying labor dystocia‐related labor aberrations into well‐defined, mutually exclusive categories that can be used clinically and validated by researchers is proposed. The approach comprises identification of 1) an objective point that strictly defines active labor onset (point of active labor determination); 2) an objective point that identifies when labor progress becomes atypical, beyond which interventions aimed at correcting labor dystocia may be justified (point of protraction diagnosis); and 3) an objective point that identifies when interventions aimed at correcting labor dystocia, if used, can first be determined to be unsuccessful, beyond which assisted vaginal or cesarean birth may be justified (earliest point of arrest diagnosis). Widespread adoption of a common approach for diagnosing labor dystocia will facilitate consistent evaluation of labor progress, improve communications between clinicians and laboring women, indicate when intervention aimed at speeding labor progress or facilitating birth may be appropriate, and allow for more efficient translation of safe and effective management strategies into clinical practice. Correct application of the diagnosis of labor dystocia may lead to a decrease in the rate of cesarean birth, decreased health care costs, and improved health of childbearing women and neonates.