Download Slide 1

Evidence to Support Active
Management
of Third Stage of Labor (AMTSL)
Name of presenter
Prevention of Postpartum Hemorrhage Initiative
(POPPHI) Project
Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in Maternal and Neonatal
Health. Available at: http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.htm. Accessed
March 12, 2008.
Session Objectives
By end of the session, participants will have
reviewed:
• Definition of third stage of labor
• Physiologic vs. active management of the third
stage of labor
• Evidence to support promotion of active
management of the third stage of labor (AMTSL)
Third Stage of Labor
• Definition:
The third stage of labor begins with birth of the
newborn and ends with the delivery of the placenta
and its attached membranes.
Two Methods of Third Stage
Management
•
Physiologic (“expectant”) management
• Uterotonic drugs are not used before delivery of the placenta
• Placenta is delivered by gravity and maternal effort
• Cord is clamped after pulsation has ceased
• Fundal massage may be provided after delivery of the placenta
•
Active Management
• Uterotonic drug is given within one minute after birth of the
baby
• Cord is cut when it ceases to pulsate or 2–3 minutes after the
baby’s birth, whichever comes first.
• Placenta is delivered by controlled cord traction (CCT) with
counter-traction to the uterus
• Uterine fundal massage provided after delivery of the placenta
Physiologic Management:
Advantages and Disadvantages
• Advantages
• Does not interfere with normal labor process
• Does not require special drugs/supplies
• Disadvantages
• Increases length of third stage
• Increases risk of postpartum hemorrhage (PPH)
Active Management: Advantages and
Disadvantages
• Advantages
• Decreases length of third stage
• Decreases risk of PPH
• Disadvantages
• Requires uterotonic drug and items needed for
injection
• Requires a birth attendant with skills in:
- Observation
- Giving an injection
- CCT
Active vs. Physiologic Management:
The Bristol and Hinchingbrooke Trials
• Bristol trial: 1695 women, Hinchingbrooke trial: 1512
women randomly assigned to:
• Active management
• Physiologic management
Prendiville et al 1988; Rogers et al 1998.
Active vs. Physiologic Management:
The Bristol Trial Objective
Compare effects of fetal and maternal morbidity of:
• Routine active management
• Physiologic management
Prendiville et al 1988.
The Bristol Trial:
Details of Active Management
• Try to give one ampule of uterotonic (5 units oxytocin
and 0.5 mg ergometrine routinely or 10 units
synthetic oxytocin if mother has high BP) immediately
after delivery of anterior shoulder
• Try to clamp cord 30 seconds after delivery of baby
• When uterus has contracted, try to deliver placenta
by CCT with protective hand on abdomen helping to
shear off placenta and preventing uterine inversion
• Try not to give any special instructions about posture
Prendiville et al 1988.
The Bristol Trial:
Details of Physiologic Management
• Try not to give uterotonic
• Try to leave cord attached to baby until placenta is
delivered
• Try not to use CCT or any manual interference with
uterus at fundus
• Try to encourage mother to concentrate on feeling for
next contraction or urge to push
• When mother feels contraction or urge or there are
signs of separation, encourage mother and help her
change posture
• If placenta does not deliver spontaneously, wait, try
putting baby to breast and encourage maternal effort
Prendiville et al 1988.
Active vs. Physiologic Management:
Postpartum Hemorrhage
Active
Management
Physiologic
Management
OR and 95%
CI
Bristol Trial
50/846 (5.9%)
152/849 (17.9%)
3.13 (2.3-4.2)
Hinchingbrooke
Trial
51/748 (6.8%)
126/764 (16.5%)
2.42 (1.78-3.3)
Prendiville et al 1988; Rogers et al 1998.
Active vs. Physiologic Management:
Results
Active
Management
Physiologic
Management
OR and 95% CI
Duration 3rd
stage
(median)
Bristol
5 minutes
15 minutes
Not done
Hinchingbrooke
8 minutes
15 minutes
Not done
Third stage
> 30
minutes
Bristol
25 (2.9%)
221 (26%)
6.42 (4.9-8.41)
Hinchingbrooke
25 (3.3%)
125 (16.4%)
4.9 (3.22-7.43)
Blood
transfusion
Bristol
18 (2.1%)
48 (5.6%)
2.56 (1.57-4.19)
Hinchingbrooke
4 (0.5%)
20 (2.6%)
4.9 (1.68-14.25)
Therapeutic
uterotonics
Bristol
54 (6.4%)
252 (29.7%)
4.83 (3.77-6.18)
Hinchingbrooke
24 (3.2%)
161 (21.1%)
6.25 (4.33-9.96)
Active vs. Physiologic Management:
The Bristol and Hinchingbrooke Trials
• Conclusion:
– Active management of the third stage reduces the
risk of PPH
– There is an increased risk of PPH associated with
physiologic management
– There is an increased need of blood transfusion
associated with physiologic management
– Oxytocin is the drug of choice for active
management
– There was no increase in entrapment of the
placenta with active management
Seeking solutions for births that occur without skilled
care
Why do we need to seek solutions
for births that occur without skilled
care?
•We cannot predict PPH on the
basis of risk factors.
•In many countries very few
deliveries are attended by a
skilled attendant.
•Once severe PPH occurs, death
follows very rapidly
•Timely referral and transport to
facilities is not available or
affordable
•Availability of emergency obstetric
care services is grossly limited.
Summary of WHO RecommendationsOctober 2006 Technical Consultation
• Active management of the third stage of labor
should be offered by skilled attendants to all
women.
• In the absence of AMTSL, a uterotonic drug
(oxytocin or misoprostol) should be offered by a
health worker trained in its use for prevention of
PPH.
Simple steps… a balanced approach to PPH
prevention
An evidence-based intervention for skilled birth
attendants (SBAs), combined with a communitybased strategy, can prevent 50-60 % of PPH
• Active management of the third stage of labor
for SBAs
• Community-based distribution of misoprostol
A Randomized Placebo-Controlled Trial
of Oral Misoprostol 600 mcg for Prevention of PPH
Belgaum District, Karnataka India
Primary Outcome
Postpartum
Misoprostol
Placebo
Relative
(N= 812*)
(N=808)
Risk
N (%)
N (%)
(95% CI)
53
97
0.53
(6.5)
(12.0)
(0.39, 0.74)
2
10
0.20
(0.2)
(1.2)
(0.04, 0.91)
NNT
18
Hemorrhage
(blood loss  500 ml)
Severe Postpartum
Hemorrhage
(blood loss  1,000
ml)
Gouder et al 2007
100
Evidence from community based PPH prevention
programs
Country example: Indonesia
In partnership with Depkes, POGI,
IBI &
supported by USAID through the
MNH program
Sanghvi et al 2004
•
Safety: No women took oral misoprostol at
wrong time
•
Acceptability: women who used oral
misoprostol said they would recommend it and
purchase the drug for future births
•
Feasibility: Community volunteers successfully
offered information about PPH and safely
distributed oral misoprostol
•
Effectiveness: the combination of skilled
providers using oxytocin and community
distribution of misoprostol allowed 94%
coverage with PPH prevention method
Critical issues pertaining to choice for
managing the third stage of labor (1)
•
Choice of active vs. physiologic management
• Different theoretical advantages and disadvantages for each
• Theoretical potential risks of each
- Entrapment of placenta
- Avulsion of cord
- Uterine inversion
•
Issues surrounding use of a uterotonic agent
• Choice of the uterotonic drug to use will depend upon cost,
stability, safety and side effects
• Choice and/or use of an uterotonic drug will depend upon
cadres of birth attendants authorized to administer specific
uterotonic drugs and facilities authorized to carry them
Critical issues pertaining to choice for
managing the third stage of labor (2)
•
Issues if a skilled birth attendant is not available
• Controlled cord traction should only be performed by a
skilled birth attendant
• Giving a uterotonic drug (oxytocin or misoprostol) without
controlled cord traction can still reduce blood loss
• Women and/or community health workers can be trained in
the correct use of misoprostol after birth of the baby
•
Issues if no uterotonic drug is available
• Limited/unproven benefit of nipple stimulation for reduction
of maternal blood loss but clear benefits for baby
• CCT not recommended if no uterotonic available
• Fundal massage after delivery of the placenta is
recommended even if no uterotonic available
Summary
Physiologic management
•
•
Advantages
•
Does not interfere with normal
labor process
•
Does not require special
drugs/supplies
•
Delay in cord clamping may
increase newborn hemoglobin
•
May be appropriate if baby not
breathing immediately after
delivery
Active management
•
Advantages
•
•
•
Decreased length 3rd stage
Decreased average blood loss &
fewer cases of PPH
• Decreased need for blood
transfusion
• No apparent disadvantages for
baby
Disadvantages
•
•
Disadvantages
•
Increases length of third stage
•
Increases risk of postpartum
hemorrhage (PPH)
•
Requires uterotonic drug
If injectable uterotonic, requires
items needed for injection
Requires a birth attendant with
skills in:
- observation
- giving an injection
- controlled cord traction
Conclusions
• Active management of third stage reduces risk of
PPH by:
– Reducing length of third stage
– Reducing average blood loss
– Reducing the risk for retained placenta
– Reducing the need for therapeutic uterotonics
• Active management of the third stage of labor
should be offered by skilled attendants to all women
• In the absence of AMTSL, a uterotonic drug
(oxytocin or misoprostol) should be offered by a
health worker trained in its use for prevention of
PPH.
References
Gouder et al. 2007. Experiences from Oral Misoprostol for PPH
Prevention Study at Belgaum, India. Lancet
Khan GQ et al. 1997. Controlled cord traction versus minimal
intervention technique in delivery of the placenta: A randomized
controlled trial. Am J Obstet Gynecol 177(4): 770–774.
McDonald S, W Prendiville and D Elbourne. 2000. Prophylactic
syntometrine versus oxytocin for delivery of the placenta (Cochrane
Review), in The Cochrane Library. Issue 4. Update Software: Oxford.
McDonald et al. 1993. Randomized controlled trial of oxytocin alone
versus oxytocin and ergometrine in active management of third stage
of labor. BMJ 307(6913):1167–1171.
Prendiville et al. 1988. The Bristol third stage trial: active versus
physiological management of the third stage of labor. BMJ 297:1295–
1300.
Rogers J et al. 1998. Active versus expectant management of third
stage of labour: The Hinchingbrooke randomised controlled trial.
Lancet 351(9104): 693–699.
References (continued)
Sanghvi H, Wiknjosastro G, Chanpoing G, Fishel J, Ahmed S.
Prevention of postpartum hemorrhage study: West Java,
Indonesia. Baltimore, MD: JHPIEGO; 2004.
World Health Organization (WHO). 1993. Stability of injectable
uterotonics in tropical climates: Results of field surveys and
simulation studies on ergometrine, methylergometrine, and
oxytocin. WHO: Geneva.
International Confederation of Midwives (ICM), International
Federation of Gynaecology and Obstetrics (FIGO). Prevention
and Treatment of Post-partum Haemorrhage: New Advances
for Low Resource Settings Joint Statement. The Hague: ICM;
London: FIGO; 2006. Available at:
www.figo.org/docs/PPH%20Joint%20Statement%202%20Engli
sh.pdf. Accessed April 2, 2007.