February 20, 2012

On Birth and Bleeding - Part 1

By: Deena H. Blumenfeld, ERYT, RPYT, LCCE, FACCE | 0 Comments

A guest posting by Lucy Juedes LCCE

Active, Expectant, and Mixed Management for Placenta Delivery, Hospital Births

Postpartum hemorrhage is a major cause of maternal death worldwide. International health experts are successfully using a specific combination of protocols, called active management of the third stage of labor, to lower the number of mothers dying in resource-poor countries.

Although not nearly on the scale of resource-poor countries, the US lags behind many other resource-rich countries in terms of maternal death. Postpartum hemorrhage is also a major cause of maternal death in the US. From 1991-1999, hemorrhage was at 17.2% of causes for maternal mortality, behind embolism (19.6%). (Chang et al.)

Recent Science & Sensibility blogs have discussed other specifics of reducing maternal mortality in the US. In this blog I will share information specifically about the use of the Active Management of the Third Stage of labor. Specifically:

Definition of terms
November, 2011 Cochrane Collaboration Review, third stage management, resource-rich countries, hospital-based
Key points from this research
Third stage components for discussing with caregivers
Additional thoughts: risk factors, too much bleeding?
Active management and Lamaze's 6 Healthy Birth Practices
Three bigger picture thoughts

Defining Terms: Third Stage of Labor, Expectant Management, Active Management, Postpartum Hemorrhage

There were key variations among my sources with regards to definitions of term. So for the purposes of this article, here is how I'm defining the terms.

The third stage of labor is from right after the baby's birth through when the placenta and membranes (sometimes called the 'afterbirth') are expelled. After the baby is born there is a brief lull, then contractions resume. While the mom's uterus is contracting and the placenta is shrinking and being expelled, the mom and baby are getting to know each other by sight, sound, smell, touch, and taste. (Simkin et al.)

There are generally two ways of approaching the management of the third stage of labor: expectant management and active management. These are the standard components but there can be marked variation among caregivers.

In expectant management, the baby is put on the mom's belly for sustained skin-to-skin contact. At the earliest, the cord is clamped only after pulsation has stopped. Sometimes it is clamped later, after placenta delivery. The caregiver observes the mom, checking for any excessive bleeding, and baby, checking for basic health. However generally the caregiver tries to provide privacy so the mom and baby can get to know each other. This focus on each other also increases the feelings of love and levels of oxytocin in the mom, which stimulate contractions. The baby's movements physically massage the mom's abdomen, helping with contractions and maintaining warmth. Breastfeeding or nipple stimulation also brings contractions. After about 20 minutes, the cord might get longer and there will often be a gush of blood, indicating that the placenta has separated from the uterine wall. The mom then sits up, kneels, or squats, using gravity and/or her own bearing down to bring out the placenta. This process usually takes 30 minutes. (Burke, Gaskin, Lothian & DeVries)

The active management of the third stage of labor is comprised of three parts. It begins with the caregiver giving a uterotonic, either as an intromuscular shot or via IV, within one minute of the baby's birth. Next, after the cord has stopped pulsing and is clamped, the caregiver delivers the placenta by controlled cord traction. This is generally within 5 - 30 minutes after the baby's birth. Lastly, the caregiver massages the uterus to ensure that it becomes firm. During this process the caregiver also provides comfort and assurance to the mom, who is probably getting to know her baby. As with expectant management, the baby has been put skin-to-skin on the mom's chest. Breastfeeding can also begin now, but the focus of the caregiver is expelling the placenta as soon as possible. (Burke, Gaskin, Lothian & DeVries, ICM & FIGO, WHO)

It is important to note that uterine massage is an integral part of both expectant and active care. After the placenta and membranes are out in-full, the caregiver feels the mother's uterus, which needs to be hard. If it is soft, the caregiver massages it until it is hard, and checks back every 15 minutes to make sure it remains hard.

It is helpful to remember here that we are talking about the routine use of one or the other type of third stage labor management. At any point if the caregiver notices too much bleeding, she or he would change procedures. We are not talking about the best ways to manage a hemorrhage, but the most effective practices to prevent a severe hemorrhage after the birth of the baby.

Postpartum hemorrhage refers to the bleeding that a mother experiences after giving birth. The time window I am referring to is primary postpartum hemorrhage, which is within 24 hours after the baby's birth. Here are the standard levels:

500 - 999 mL Postpartum hemorrhage, vaginal birth
1,000 - 2,499 mL Severe postpartum hemorrhage
2,500 + mL Very severe postpartum hemorrhage

If the mother had cesarean surgery, postpartum hemorrhage is defined as beginning at 1,000 mL. (Begley et al.)

Recent Review & Analysis from Resource-rich Countries, Hospital Based

There is no question that, in resource-poor countries, increased use of active management of the third stage of labor has prevented postpartum hemorrhaging and saved both mothers' - and consequently babies' - lives. In 2004, the International Confederation of Midwives (ICM) and the International Federation of Gynaecologists and Obstetricians (FIGO) signed a joint statement agreeing that, 'Active management of the third stage of labour should be offered to women since it reduces the incidence of postpartum haemorrhage due to uterine atony.' (ICM & FIGO) Training all birthworkers in active management has been a major focus of global Safe Motherhood efforts to reduce maternal death and disability in resource-poor countries. (Armbruster)

Research conducted in resource-rich countries has indicated similar results, although not on a similar scale to results seen in resource poor-countries. A recent Cochrane Pregnancy and Childbirth Group Intervention Review was completed in November, 2011 on 'Active versus expectant management for women in the third stage of labour'. This protocol was first completed in 2008, and this is the most recent review. (Begley et al.)

The analysts looked at seven trials, all in hospitals, in five countries (6 in high-income countries/UK, Ireland, Sweden, Abu-Dhabi; 1 in a low-income country/Tunisia), involving 8,247 women. Four of these trials looked at active compared to expectant management (4,829 women). Three trials looked at active versus a mix of active and expectant management components (3,418 women). There were no maternal or fetal deaths reported, and no very severe postpartum hemorrhage (>2,500 mL). Three trials included only women at low risk of bleeding; four included women irrespective of their risk of bleeding. All the mothers were healthy and expected to give birth vaginally.

The authors looked at a range of variables. They noted, however, that the following results are the more clinically important effects, so these are what will be examined here:

reduced average severe primary postpartum hemorrhage (1,000 - 2,499 mL within the first 24 hours of birth)
reduced average need for transfusions
reduced average need for uterotonic therapy during the third stage or within the first 24 hours

Active Compared to Expectant Management

Hospital studies that included expectant mothers who had a wide range of risk factors for bleeding.

The primary outcomes of this analysis were these: (1) in resource-rich countries, (2) in hospitals, and (3) in situations where expectant mothers at mixed levels of risk for postpartum hemorrhage are served, active management:

reduced average severe primary postpartum hemorrhage (4,636 women, three studies);
reduced average maternal blood transfusions (4,829 women, four studies); and
reduced average therapeutic uterotonics (4,829 women, four studies).

In terms of reducing severe postpartum hemorrhage, this result was found in three studies totaling 4,636 women. Two of these studies included only women with no risk factors whatsoever and are described below (Begley and Rogers). One study (Prendiville, 1988, United Kingdom, 1,695 women) included mothers who had one or more risk factor: who were of any age, had more than five children, had a prior postpartum hemorrhage, had an epidural, had a long labor, or who required an operative delivery. The study only excluded mothers who had a larger medical issue or any condition needing a particular management of the third stage.

Hospital studies that included only women who were at low risk of bleeding

Compared with expectant management, low risk women who received active management showed a statistically significant average reduction in:

maternal blood transfusions (3 studies, 3,134 women) and
therapeutic uterotonics (3 studies, 3,134 women).

There was no statistical difference between the low-risk mothers whose third stage was actively or expectantly managed in terms of severe primary postpartum hemorrhage.

This research was done on three studies, totaling 3,134 mothers, and contained only low risk women: one in Ireland (Begley, 1990, 1,429 births) and two in the United Kingdom (Rogers, 1998, 1,512 births and Thilaganathan, 1993, 193 births). Women were risked out if they had any predisposition to hemorrhaging: labor induced or augmented with oxytocin, had an epidural, had a first stage longer than 15 hours, had a previous postpartum hemorrhage, intended an instrumental birth, or had more than five children. If the investigator felt there was any predisposition to bleeding or any other possible participation contraindication, the mother's data was not included in the study. Midwives were the professional in charge of the third stage for the Irish study, and waterbirths were a component of birth with the other, large UK study.

Active Compared to Mixed Management

Begley et al. also looked at active compared to mixed management. Two studies, described below, show a significant reduction in one or two of the three characteristics of concern to clinicians.

Khan, 1997, looked at a final sample of 1,648 births in Abu-Dhabi, a resource-rich country. Comparing active to mixed management, Begley et al. found a statistically significant reduction in:

severe primary postpartum hemorrhage and
therapeutic uterotonics.

There was no significant difference regarding blood transfusions.

This study included women at all risk levels. Similar to the US, oxytocin was administered after the placenta was out. Begley et al. were concerned with the adequacy of the midwifery training and the overall quality of the study due to uncertain sequence generation.

The second study that Begley et al. reviewed was by Jangsten, 2011, which followed 1,631 births at a university hospital in Sweden.

There was a significant reduction in therapeutic uterotonics.

There was no significant difference regarding:

severe primary postpartum hemorrhage or
blood transfusions

Midwives were responsible for third stage management. Both high and low risk women were included. The analysts considered this study to be of good quality.

Other notes from the analysis:

The trials included in this analysis met high standards. Several other trials were not included in this review due to questions or issues with data quality. However, when analyzed together the evidence was not high-quality. The authors noted considerable differences in the specific protocols for active and expectant management used in the included trials. The authors suggested that more data are necessary to be more confident of the findings.

The authors also noted that there were adverse effects or harms of the active management (when not practiced according to WHO/ICM/FIGO guidelines): hypertension, afterpains, and return to the hospital due to bleeding. Active management also resulted in lower birth-weight infants who had lower iron levels. The authors suggested that these side effects might be reduced by modifications to the active care techniques, and that more research would help identify this. Specifically, the high blood pressure and afterpains seemed to be related to the use of ergometrine and IV oxytocin. Controlled cord traction might have led to retained pieces of membrane or placenta, requiring a return to the hospital due to bleeding. Early cord clamping is related to a 20% or greater reduction of infant blood volume, as compared to the physiological approach of waiting until the cord has stopped pulsing.

Regarding the health of the babies from both women who were low risk and women at varying levels of risk for postpartum bleeding, there was no statistical difference between active and expectant management in the number of admissions to NICUs or in neonatal jaundice requiring phototherapy or exchange transfusions.

The Prendiville, 1988 study was the only study that looked at the effect of active versus expectant management on breastfeeding at discharge, and it found no statistical difference. However, this study involved women at a range of bleeding risks. Even on the expectant side, 20% were considered to need a uterotonic prophylacticly and another 30% received it for actual treatment. Because half of the mothers in the expectant arm received a uterotonic, perhaps there was not such a big difference between the two groups in terms of experience of birth and its effect on establishing breastfeeding.

The authors suggested that it would be important to investigate if the reduced bleeding due to active management were due to the uterotonic component alone, and if so, what would be the ideal timing. An earlier analysis (Enkin, 2000) addressed this, which showed that routine use of an oxytoxic alone, without the other two components of active management, cuts the risk of postpartum hemorrhage by 50% and reduces the therapeutic use of oxytoxics by 70%. New research accepted for publication in The Lancet found that, of the three parts of active management, the uterotonic plays the most important role in preventing postpartum hemorrhage. (Armbruster)

Key Points from this Research

First, a note about choice of birth site. The previously described research, which meets the highest standard possible, was done on hospital births. When specifically asked about if they thought that the routine use on the active management of the third stage of labor should be applied to home births or midwifery-led birth centers, the lead author stated there were no trials at other sites that fit their criteria for inclusion so the authors could not provide evidence-based information for other settings. The authors noted that there is other research available with pertinent information to home and birth center births, such as these studies:

Bais, 2004, Holland, 3,464 women, descriptive study;
New Zealand College of Medicine, 2009, New Zealand, 33,752 women, population-based, retrospective cohort study; and
Begley, 2009, Ireland, 446 women, observational study.

One of the things that the Begley et al. research might encourage is that more hospitals use a more active approach to third stage management. For example, a large tertiary hospital in Illinois recently adopted an active management protocol similar to the WHO guidelines. This protocol resulted in a decrease in postpartum hemorrhage rates (from 4.52% in the 6 months prior to the protocols to 4.21% in the first 6 months after implementation, totaling 10,582 births) and a decreased use of additional uterotonics. (Burke)

In situations where a specific protocol for a preventative measure is adopted, consent could become an issue. Regarding the above hospital and of note to parents who prefer a less active approach to third stage management: 'Once the protocol was announced and clarified to all medical and nursing providers, it became the standard practice for management of the third stage of labor, and deviation from the protocol is not acceptable unless the woman is adamantly opposed to it and adequate counseling has occurred.' (Burke, 222) The question here is what does 'adamantly opposed' mean in the above context? Where does consent fit into this?

Parents who prefer an expectant approach to childbirth and who are planning to birth in a hospital that routinely uses a more active approach will need to understand even more about labor and delivery to more effectively advocate for themselves. This has always been the case, but it might be more so if hospitals adopt routine active management of the third stage of labor.

References

Lucy Juedes is an LCCE and created Birth Prep Basics, serving the needs of growing
families in Southeastern Ohio. She is also the mother of three young children.
Prior to this she worked in public relations and marketing.

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