Outcomes of physiological and active third stage labour care amongst women in New Zealand

Background

during the third stage of labour there are two approaches for care provision – active management or physiological (expectant) care. The aim of this research was to describe, analyse and compare the midwifery care pathway and outcomes provided to a selected cohort of New Zealand women during the third stage of labour between the years 2004 and 2008. These women received continuity of care from a midwife Lead Maternity Carer and gave birth in a variety of birth settings (home, primary, secondary and tertiary maternity units).

Methods

retrospective aggregated clinical information was extracted from the New Zealand College of Midwives research database. Factors such as type of third stage labour care provided; estimated blood loss; rate of treatment (separate to prophylaxis) with a uterotonic; and placental condition were compared amongst women who had a spontaneous onset of labour and no further assistance during the labour and birth. The results were adjusted for age, ethnicity, parity, place of birth, length of labour and weight of the baby.

Findings

the rates of physiological third stage care (expectant) and active management within the cohort were similar (48.1% vs. 51.9%). Women who had active management had a higher risk of a blood loss of more than 500 mL, the risk was 2.761 when a woman was actively managed (95% CI: 2.441–3.122) when compared to physiological management. Women giving birth at home and in a primary unit were more likely to have physiological management. A longer labour and higher parity increased the odds of having active management. Manual removal of the placenta was more likely with active management (0.7% active management – 0.2% physiological p<0.0001). For women who were given a uterotonic drug as a treatment rather than prophylaxis a postpartum haemorrhage of more than 500 mL was twice as likely in the actively managed group compared to the physiological managed group (6.9% vs. 3.7%, RR 0.54, CI: 0.5, 0.6).

Conclusions

the use of physiological care during the third stage of labour should be considered and supported for women who are healthy and have had a spontaneous labour and birth regardless of birth place setting. Further research should determine whether the use of a uterotonic as a treatment in the first instance may be more effective than as a treatment following initial exposure prophylactically.