Active management of the third stage of labourBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4546 (Published 06 July 2012) Cite this as: BMJ 2012;345:e4546
- Nasreen Aflaifel, research fellow,
- Andrew D Weeks, professor of international maternal health
- 1Sanyu Research Unit, Department of Women’s and Children’s Health, University of Liverpool, Liverpool Women’s Hospital, Liverpool L8 7SS, UK
The original description of active management of the third stage of labour had three components—delivery of a prophylactic uterotonic drug, early cord clamping and cutting, and controlled cord traction.1 When randomised trials in the 1980s found that this package reduced the risk of severe postpartum haemorrhage by 70%,2 active management was adopted widely. It was thought to be especially important in low resource settings, where more than 20 000 deaths occur each year as a result of haemorrhage.3 In these settings, active management of the third stage has almost become a mantra for the safe motherhood movement.
But in the half century since active management was described, we have never known which component is the most important. Guidelines from around the world have varied widely in their selection of oxytocic agent, early cord clamping, cord traction, uterine massage, and cord drainage.4 Controlled cord traction became popular only when it was incorporated into the active management package in 1962, and, although there were no major randomised trials of cord traction, it was thought to decrease the incidence of postpartum haemorrhage and retained placenta.5
The required evidence on cord traction appeared in March this year.6 Gulmezoglu and colleagues from the World Health Organization’s maternal health research network conducted a large multicentre controlled trial to examine the effect of active management of the third stage of labour with and without cord traction in more than 24 000 women.6 All women received oxytocin (10 IU intramuscularly immediately after delivery) and had “delayed” cord clamping at one to three minutes. Participants then either underwent cord traction at the time of the first uterine contraction or the placenta was allowed to deliver with the aid of gravity and maternal effort only. The study had a non-inferiority design, and the team decided a priori that the two groups would be equivalent if the 95% confidence interval of the relative risk did not include a 30% or more increase in severe postpartum haemorrhage in the controlled traction group over the simplified regimen.
Compliance with the protocol was good, but in the simplified package group 6% of women still needed cord traction to deliver the placenta. The researchers found that omission of cord traction from the active management package had no significant effect on the rate of severe haemorrhage (risk ratio 1.09, 95% confidence interval 0.91 to 1.31), but the difference in the risk of haemorrhage of more than 500 mL was of borderline significance (1.07, 1.00 to 1.14). Furthermore, given that the upper 95% confidence interval limit just crossed the pre-stated non-inferiority margin of 1.30, the authors had not proved that the two were equivalent. The time to placental delivery was halved in those having cord traction from 12 to six minutes (difference 6.5, 6.2 to 6.8), and this reduced the need for manual removal (1.45, 1.14 to 1.86). Further analysis of the results, however, showed that the difference in manual removal occurred in one country only. That country had experienced difficulty with recruitment and one of the two sites had been giving a combination of oxytocin and ergometrine for prophylaxis (in contravention of the study protocol). When the data were analysed without the results from that country (81% of all recruits were still included) no effect on the need for manual removal was seen (0.97, 0.68 to 1.37).
This study therefore showed that during active management of the third stage of labour cord traction has little, if any, part to play in reducing severe postpartum haemorrhage. It also showed that in sites using oxytocin alone for prophylaxis, cord traction reduced the length of the third stage by six minutes but had no effect on manual removal rates. The same may not be true when the combined oxytocin-ergometrine preparation is used.
The study is good news for maternity care providers, especially in low resource settings. Although cord traction is straightforward, it is often poorly done. If traction is performed before a contraction occurs it can result in uterine inversion or haemorrhage, and if the cord is pulled too vigorously it cause the cord to snap. In settings where the training of birth attendants is brief and continuing support minimal, trainers are therefore likely to err on the side of caution and omit the cord traction step from the standard “oxytocin alone” active management package. The method will, however, still need to be taught because about one in 20 women who use maternal effort will require the procedure, and it may be important in settings that still use ergometrine based prophylaxis.
In settings where providers are confident that cord traction will be performed correctly, it will probably remain part of the package because it does no harm and could still have a small beneficial effect on blood loss.
Where does this leave the components of active management of the third stage of labour? Oxytocin is now widely accepted as the optimal choice for third stage prophylaxis because it is highly effective and has few side effects. Ergometrine (with or without oxytocin) may be slightly more effective but has side effects of vomiting and hypertension and is associated with retained placenta when given intravenously.7 The second choice after oxytocin may therefore be misoprostol, which, although slightly less effective than oxytocin, has the benefits of stability and the option of oral or sublingual administration.8
The third component of the traditional package, early cord clamping, was removed from many active management packages some years ago. It seems to have no maternal benefit and reduces neonatal blood volume and infant iron stores in term babies by about 30%.9 This effect is seen in resource rich and resource poor settings, and it persists to at least 4 months of age.10 The hazards of early cord clamping seem to be increased in fragile premature fetuses—those who undergo early cord clamping on delivery have increased rates of blood transfusions and low grade intraventricular haemorrhages.11
It has taken 50 years since active management of the third stage of labour was first described for it to become clear that the oxytocic agent has the greatest effect. In settings where cord traction is currently being used it should continue to be part of the package. However, those looking to reduce deaths from postpartum haemorrhage in low resource settings will be delighted by these results because they show that high quality management of the third stage of labour does not require midwifery skills. Public health experts can therefore concentrate their efforts on simplified oxytocin injections (Uniject) and misoprostol alone.
Cite this as: BMJ 2012;345:e4546
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years: ADW has an unpaid position as director of the WHO Collaborating Centre for Research and Research Synthesis in Reproductive Health at the University of Liverpool.
Provenance and peer review: Not commissioned; externally peer reviewed.