Elsevier

The Lancet

Volume 351, Issue 9104, 7 March 1998, Pages 693-699
The Lancet

Articles
Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial

https://doi.org/10.1016/S0140-6736(97)09409-9Get rights and content

Summary

Background

This study tested the hypotheses that active management of the third stage of labour lowers the rates of primary postpartum haemorrhage (PPH) and longer-term consequences compared with expectant management, in a setting where both managements are commonly practised, and that this effect is not mediated by maternal posture.

Background

1512 women judged to be at low risk of PPH (blood loss >500 mL) were randomly assigned active management of the third stage (prophylactic oxytocic within 2 min of baby's birth, immediate cutting and clamping of the cord, delivery of placenta by controlled cord traction or maternal effort) or expectant management (no prophylactic oxytocic, no cord clamping until pulsation ceased, delivery of placenta by maternal effort). Women were also randomly assigned upright or supine posture. Analyses were by intention to treat.

Findings

The rate of PPH was significantly lower with active than with expectant management (51 [6·8%] of 748 vs 126 [16·5%] of 764; relative risk 2·42 [95% CI 1·78–3·30], p<0·0001). Posture had no effect on this risk (upright 92 [12%] of 755 vs supine 85 [11%] of 757). Objective measures of blood loss confirmed the results. There was more vomiting in the active group but no other important differences were detected.

Interpretation

Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.

Introduction

Delivery of the placenta and membranes (the third stage of labour) is potentially the most hazardous part of childbirth for the mother, mainly because of the risk of primary postpartum haemorrhage (PPH, defined as estimated maternal blood loss of 500 mL or more within 24 h of delivery) and its subsequent morbidity. This stage of labour can be managed actively or expectantly. Active management generally involves routine prophylactic administration of a uterotonic agent, early cord clamping and cutting, and controlled cord traction. In expectant management (sometimes called conservative or physiological management) uterotonic drugs are not given prophylactically, the cord is neither clamped nor cut early, and the placenta is expelled by maternal effort. An upright posture and early suckling have also been recommended.1

A systematic review2 of three controlled trials3, 4, 5 suggested that, compared with expectant management, active management of the third stage reduces the risk of PPH and the need for therapeutic uterotonics, particularly oxytocics. However, it also increases the risk of unpleasant and occasionally dangerous side-effects, such as nausea, vomiting, and hypertension, mainly due to the action of ergometrine used alone or in combination with oxytocin.

Three criticisms have been raised and have led to disagreements over the application of these results in routine practice. First, since a survey by Garcia and Garforth6 indicated that a policy of active management (with intramuscular Syntometrine [oxytocin plus ergometrine], Sandoz Pharmaceuticals, Camberley, UK) was almost universal throughout England and Wales, and since active management was the norm in hospitals involved in the three controlled trials, women assigned expectant management might have been at a disadvantage because midwives were less experienced in this approach.

Second, many women who choose expectant management of the third stage are encouraged to expel the placenta by adopting an upright posture. Thus, the differences in blood loss between active and expectant management could be due to position rather than other factors. In a trial comparing upright with recumbent position for the second stage of labour, Spiby7 found that the adoption of a maternal posture aiding gravity predisposed women to greater blood loss.

Third, the significance of PPH per se in a healthy population delivered in a hospital setting has also been questioned.8 Inch9 proposed that the hazards of expectant management in the short term may be outweighed by physical and psychological advantages for the mother in the months after childbirth.

We report here a randomised controlled trial that compared the effects of active and expectant management of the third stage of labour on maternal and neonatal morbidity and attempted to address these three issues. The trial was carried out in a setting where the philosophy of care was to place emphasis on helping women to give birth with minimum intervention, including during the third stage of labour. In this context midwives were similarly confident with active and expectant management for women at low risk of PPH. To take account of maternal posture, participants were simultaneously randomised to upright or supine position for the third stage of labour. Women were followed up at 6 weeks post partum.

Section snippets

Methods

The trial was carried out in the Maternity Unit of Hinchingbrooke Healthcare NHS Trust, a district general hospital in Cambridgeshire, UK, with an annual birth rate of about 2500. Approval was obtained from the local research ethics committee.

Before the trial began, an advisory group was established with membership from lay and professional representatives of the local maternity service. The principal investigators (JR and JW) wrote to all local midwives inviting them to participate; none

Results

Recruitment and randomisation for the trial began in June, 1993. After the trial had been under way for 15 months, an independent data-monitoring committee looked at the data from an interim analysis based on the 700 women randomised by June, 1994. There was no significant difference between the two trial groups but the overall PPH rate was higher than expected. The power calculations were revised accordingly, suggesting that a sample size of about 1500 women would be sufficient.

The trial

Discussion

Our findings are consistent with those of previous studies. Compared with expectant management, active management of the third stage of labour reduced the risk of PPH. The relative risk associated with expectant management (2·4) can also be expressed in terms of the need to treat ten women with active management to prevent one PPH. This trial shows in addition that this effect occurs even when expectant management is carried out by midwives already accustomed to this technique. In addition, the

References (17)

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