Tuesday, December 8, 2009

New thinking about the third stage of labour

For years it has been accepted by many that active management of the third stage of labour is the preferred way of birthing the placenta and membranes. But in New Zealand, midwives have been questioning this, saying that physiological birth is far safer for women who have had normal labour and no risk factors.

The latest audit of New Zealand midwives that has come from the New Zealand College of Midwives (NZCOM) suggests that women who have physiological third stage of labour, overseen by midwives who know what they are doing, are less likely to bleed heavily compared to women who have active management. This result is contrary to the commonly held belief that active management of the third stage reduces blood loss following birth.

Follow-up to this audit is going to be carried out by Professor Cecily Begley (Dublin) - she is reviewer for the Cochrane Database. Professor Begley is coming to New Zealand in January 2010 to talk to midwives who regularly carry out physiological management of the third stage. If you are interested in knowing more, please contact NZCOM.

Dixon et al. (2009). Midwives care during the third stage of labour: an analysis of the New Zealand College of Midwives Midwifery database 2004-2008. New Zealand College of Midwives Journal, number 41, October, p. 20

Image: 'placenta and amniotic sac - _MG_3995' sean dreilinger


Cafe Culture said...

it was particularly put into context for me by Karen Guilliland at the Joan Donley conference.
I have always mostly used active management of 3rd stage, it was the way I was trained, it was what I was comfortable with, it was what was expected of me wherever I worked.
However as karen highlighted many women in the developing world are suffering PPH not because they are having expectant management of 3rd stage but because midwives and doctors don't know how to do expectant management of 3rd stage. There is a lack of oxytoics in the developing world and lack of ability to store them correctly and so we need to practice more expectant management of 3rd stage, teach how it is done correctly and STOP doing hybrid versions of birthing 3rd stage!

Sarah Stewart said...

I have always said it is that mix and much approach that causes trouble, and not being patient enough when you are waiting for a placenta to arrive.

Thinkbirth said...

Fantastic Sarah! Great to see these stats out there. Same as we found with our cohort study (under review for Women and Birth). Kathleen Fahy published a critique of the Cochrane Review
Fahy KM, ’Third stage of labour care for women at low risk of postpartum haemorrhage’, Journal of Midwifery & Womens Health, 54 380-386 (2009)

and we had a paper published in Women and Birth

Hastie CR, Fahy KM, ’Optimising psychophysiology in third stage of labour: Theory applied to practice’, Women and Birth, 22 89-96 (2009)


Really good to see the evidence accumulating. I agree Pam, women in the developing countries could really be helped by a better understanding by everyone about third stage. Seems like much of the ancient wisdom has been lost.

Sarah Stewart said...

I meant to say "mix and match"!

Thinkbirth: Thanks for those references. It's very exciting to see good data come out on New Zealand midwifery at long last. I am also looking forward to seeing the results of the work that Deborah Davis et al is doing

InfoMidwife said...

this is great news Sarah, nice to see some research that can be quoted.... I always offer women physiological third stage, however any signs of bleeding it is active management... but it would be great to see midwives offering and doing more physiological third stage....

Linda Mitchell said...

I am a midwife in England and for some years I was a community midwife but unclear exactly what a physiological third stage entailed, because, like you, I was not trained in this until I researched this for myself.
I now work in maternity risk and I believe that third stage management is left wanting at times. As a result of this, I am undertaking my dissertation asking if active management of labour has marginalised midwives ability to undertake the physiological third stage. I thought the Dixon 2009research was great and makes a difference when it is midwifery led rather than obstetrically led! I would appreciate if anyone can lead me to further studies in NZ which seems to be more focussed on physiological management of labour. Thank you.

Sarah Stewart said...

Hi Linda

I am afraid I am not 100% up on all the research that is being out in NZ. The ones I know about at the moment is the place of birth study by Deborah Davis and fetal heart monitoring by Robyn Maude. Anfd, of course, there is the work by Caroyn Hastie in Oz: http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2010

For more info about NZ research, I'd get in touch with the NZ College of Midwives: www.midwife.org.nz