A Guest post by Lucy Juedes LCCE

Third Stage Components for Discussing with Caregivers

It will be important for the caregiver to share his/her perspectives and usual care of the third stage with expectant parents, as well as what the parent might expect from colleagues and the policies of the birth site. This helps the mothers/parents to better understand the suggested practices. Perhaps the caregiver might be strongly leaning towards an active approach to placenta delivery even if the mom wants a more expectant approach. The mom does not have to agree with the caregiver's reasoning, but she will understand more as she advocates for what she feels is best for herself and her baby.

So, in an effort to help parents understand the third stage, here are the possible components of third stage management. Moms and birth partners can use these components to ask about specifics, particularly if the caregiver uses the general terms of 'active' or 'expectant management' of the third stage of labor. Here are some specifics to assist in asking your questions.

Oxytocin: In hospitals in theUS, oxytocin (via IV drip or intramuscular shot) is generally administered after the placenta is expelled. Ergotamines and prostaglandins are often second- and third-tier uterotonic choices, based on the need and characteristics of the situation. If a mom is planning a homebirth, ask if the midwife has these medications for emergencies or as back-up. A uterotonic could also be used proactively to decrease the amount of bleeding, as described earlier in current research. If the mom does not use a uterotonic, the caregiver and mother will have to be more vigilant so that her uterus does not get soft and she bleeds.

Breastfeeding & skin to-skin contact: Immediate, baby-led breastfeeding has already been shown to be the best care practice in terms of infant feeding. The physiological approach allows the mom more undivided attention to get to know her baby and begin observing for feeding cues. It is also very helpful in terms of placental expulsion and uterine contraction. If the baby is not breastfeeding, manual or oral nipple stimulation can help bring about oxytocin and contractions, helping to get the uterus back down to size from a more physiological perspective.

Cord clamping: There is evidence, and the WHO recommends, to wait until the umbilical cord stops pulsing before it is clamped and cut. This usually means waiting 3 - 5 minutes (WHO recommends 2 - 3 minutes), after which time the partner can tell that the cord has stopped pulsing and slackens. In these first few minutes, the baby receives the last 20% or more of his or her blood volume, which helps with iron levels. There might be an increased chance for jaundice later, which can be treated by taking the baby outside in the sun, without sunscreen on, or taking the baby to the hospital for exposure to phototherapy.

Controlled cord traction and counter traction: When this is done, it must be done carefully, and the caregiver should never pull on the cord without pushing the uterus up with the other hand. The mom could also bear down during this process, or might practice her focusing and relaxation strategies for these last few contractions. The caregiver will examine the placenta to make sure all of it and its membrane has been expelled. This is a more active approach.

Uterine massage: This is done after the placenta is out. The caregiver or the mom rubs or kneads the mother's abdomen until the uterus hardens, then the massage is ended. This massage is done regardless of approach and is a part of good postpartum care. The uterus must become and remain smaller and hard so that the blood vessels close to the appropriate degree. Afterpains are associated with placenta expulsion and uterine shrinking, particularly with experienced mothers. The mom might prefer to do this massage herself and can ask the caregiver to show her how.

The above information has been combined from a variety of sources: ACOG, Armbruster, Burke, Gaskin, Goer, ICM/FIGO, Lothan & DeVries, Simkin et al., Walsh, and WHO.

Additional Thoughts - Risk Factors? Too Much Bleeding?

Risk Factors

One of the most important things for parents to know is that there are risk factors for a postpartum hemorrhage. Some of these risk factors are associated with the interventions used and the outcomes of stages one and two of labor. In class, when we discuss third stage management, we can refer back to interventions that increase the likelihood of postpartum bleeding: inducing or augmenting contractions with oxytocin, prolonged induction, episiotomy, forceps/vacuum, and cesarean surgery. (Goer)

Other pregnancy, labor, maternal, or fetal characteristics are associated with increased bleeding as well: rapid labor, use of magnesium sulfate, previous postpartum hemorrhage, preeclampsia, intra-amniotic infection, overdistended uterus (twins, macrosomia, hydramnios), Asian or Hispanic ethnicity, and chorioamniotis. (ACOG; Burke) Many of these risk factors the mother can do nothing to change. Others, she might have some ability to influence - this knowledge might help her focus even more on strategies to keep labor physiological from the start.

Begley et al. shared something to be noted. 'Anecdotally, midwives experienced in expectant management say that only women who have had a normal, physiological labor should have expectant management of the third stage.' (25) The natural oxytocin levels of these women will be high throughout, and these high levels would help with uterine contraction in the third stage. The moms can weigh the risks of any blood loss, possible transfusions, and additional uterotonics.

Conversely, it could be that the most appropriate candidates for active management of the third stage are those who have already experienced active management of the earlier stages of labor. The Prendiville study was the only study that included both women who seemed to receive a more expectant care in the first two stages of labor and those who received a more active approach. Some of these actively managed first/second stage mothers were induced with pitocin, had epidurals, had a previous postpartum hemorrhage, etc. All of these mothers were randomly assigned to active versus expectant care groups for the third stage of labor. However, after five months the protocol was modified due to higher than expected blood loss by the expectantly managed group. Some of these women needed at least some active management and were switched to fully active management. Then, the trial was halted early because of potential harm due to too much blood loss in the expectant arm: the sample size was meant to be 3,900 and the researchers stopped after 1,695 participants. In the hospital where women with a variety of risk were served, there was a significant difference of more third stage blood loss in expectantly managed mothers as compared to those actively managed.

Lastly, regarding risk, the above factors are ones that we are aware of. However, most of the time a postpartum hemorrhage cannot be predicted - some analysts suggest up to 90% of the time. Hence, public health experts prefer a focus on prevention among a wide range of women. (POPPHI/USAID)

And for all moms, how much blood is too much blood to lose?

Our body has built up a large store of blood during pregnancy, called by some a vascular reserve. It is physiologically necessary for us to expel some of it during the time period from right birth into the next few weeks. If the mother loses around 500 mL, she is likely to feel similarly to how she might feel when giving blood, and will need to sit or lie down, eat, and rest. If a mother has one or more of the risk factors shared above, though, she might lose closer to between 1,000 - 2,499 mL of blood at birth. Many experts use a threshold of 1,000 mL for healthy women in affluent societies, noting that they can tolerate blood loss of around 1,000 mL without decompensating. (Walsh) Goer shares that, 'According to William's Obstetrics, the obstetric bible, healthy postpartum women don't begin to show actual symptoms of excessive blood loss until they have lost around 1500mL.'

Another factor is that a mother might have other responsibilities in addition to caring for her newborn. Is this her first child or does she have others at home? Is she caring for an older adult? Is she married, engaged, dating, or single? Will she be going back or seeking paid work and if so, is that sooner or later? Breastfeeding also requires a lot of physiological resources from the mother. It is important to help expectant mothers and their birth partners situate their ideal birth into their daily lives. All of these considerations can help mothers be more prepared both for birth and for life with their newborn.

Active Management and Lamaze's 6 Healthy Birth Practices

Lamaze's Healthy Birth Practice 4 is 'Avoid interventions that are not medically necessary'. It will be important to know both non-labor risk factors and take into account how the labor and delivery of the baby was managed. If there was moderate to high intervention in the birth of the baby or if there are other risk factors present, she is more likely to bleed more. If this is a concern for her, active management techniques are likely to help lessen any bleeding. If there was no to low intervention in the birth of the baby and there are no other risk factors present, the mom and baby may benefit more from an expectant approach to expelling the placenta. In all of this the mother is the person to consent to or refuse any interventions.

Lamaze's Healthy Birth Practice 6 is 'Keep mother and baby together - It's best for mother, baby and breastfeeding'. Here, according to the research, the benefits of the active approach is a decrease in bleeding; with some mothers severe bleeding is prevented. Less bleeding means more energy that the mom can devote to recuperating and breastfeeding. And according to one study there was no difference between the two approaches in breastfeeding rates upon leaving the hospital. The benefits of the expectant approach is less disturbance and distraction of the mother from her baby in that key time right after birth, as well as increased natural oxytocin that helps with bonding.

Three Bigger Picture Thoughts

For mothers planning birth center births or homebirths in the US, in accord with the ICM/FIGO joint statement, they, too, should be offered active management of the third stage of labor. The key word here is offered. This is not regimented, but it is also not to be overlooked. It also means that the homebirth or birth center caregiver should be able to purchase, store, carry, and administer uterotonics as part of their standards of practice.

I began this topic with the stated goal of preventing postpartum hemorrhage. It seems clear that, from a public health/greater good perspective, data supports the standard offering of active management to prevent excessive bleeding in situations when the mom's labor has already been managed using an active approach or where there are other known risk factors. It also is somewhat supportive of the offering of active management of the third stage of labor even when there are no risk factors present.

However, if the overall goal is preventing postpartum hemorrhage, then the leaders who set hospital policies could also reconsider the use of several other practices that are known risk factors of increasing postpartum hemorrhage. One such practice is induction rather than waiting the 42 weeks. Recent efforts to limit births to at least the 39 week mark has probably helped. Another practice is a focus on providing pain medication and continuous monitoring/IVs rather than encouraging doulas or providing continuous staffing who could provide natural comfort help. Other routine practices at hospitals probably have an effect, such as routine use of continuous electronic monitoring, IV, and withholding of food.

Lastly, I am positive that evidence-based Lamaze Certified Childbirth Educators can be pretty helpful for many expectant moms and birth partners. We have the time to answer questions, and to answer the questions behind the questions. We understand the background behind specific practices. We know the alternatives, and there is always an alternative. We can help the moms and birth partners figure out what they want and how to make it most likely. Though Lamaze childbirth classes, they are already getting used to parenthood, and the baby hasn't even made it topside yet.

References

• AmericanCollegeof Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetricians-Gynecologists Number 76 October 2006: 'Postpartum hemorrhage'
• Armbruster, D. personal conversation, February 2012
• Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. 'Active versus expectant management for women in the third stage of labor (Review)'. The Cochrane Collaboration. 2011, Issue 11. John Wiley & Sons, Ltd.
• Burke, Carol. 'Active Versus Expectant Management of the Third Stage of Labor and Implementation of a Protocol'. Journal of Perinatal and Neonatal Nursing. July/September 2010. Volume 24 Number 3. Pages 215-228
• Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, Syverson CJ. MMWR Surveillance Summaries. 'Pregnancy-Related Mortality Surveillance - United States, 1991-1999'. February 21, 2003/52 (SS02); 1-8
• Enkin M, Keirse M J N C, Neilson J, Crowther C, Duley L, Hodnett E, Hofmeyer J. A guide to effective care in pregnancy and childbirth. OxfordUniversity Press: New York, 2000
• Gaskin I M. Ina May's Guide to Childbirth. Bantam Books: New York, 2003 www.inamay.com
• Goer, H. Ask Henci Forum. 'Third Stage Management'. July 29, 2007. Lamaze International
• Hull, K. Science & Sensibility. 'Maternal Morbidity and Mortality in the United States'. January 2 - 6, 2012
• International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians. 'Joint Statement Management of the Third Stage of Labour to Prevent Postpartum Haemorrhage'. 2004
• Lothian J and DeVries C. The Official Lamaze Guide. Simon & Shuster, Meadowbrook Press: New York, 2010
• Prevention of Postpartum Hemorrhage Initiative (POPPHI) & USAID. 'Saving Women's Lives: Prevention of Postpartum Hemorrhage'
• Simkin P, Bolding A, DurhamJ, Whalley J, and Keppler A. Pregnancy, Childbirth and the Newborn. Simon & Schuster:New York, 2010
• Walsh D. Evidence-based Care for Normal Labour and Birth. Routledge:London &New York, 2001
• World Health Organization. MPS Technical Update 'Prevention of Postpartum Haemorrhage by Active Management of Third Stage of Labour'.

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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