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Active Management of Third Stage of Labor A model to an Evidence Based Obstetric Practice.

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Presentation on theme: "Active Management of Third Stage of Labor A model to an Evidence Based Obstetric Practice."— Presentation transcript:

1 Active Management of Third Stage of Labor A model to an Evidence Based Obstetric Practice

2 2Active Management of Third Stage of Labor Session Objectives To review: Why do we need the introduction of EBM and Information mastery in our day to day practice Definition of third stage of labor Physiologic vs. active management Risks and benefits of each method of management Drugs used in active management Where lies the EVIDENCE

3 3Active Management of Third Stage of Labor “ My students are dismayed when I say to them that half of what they are taught as medical students will in 10 years be shown to be wrong. And, the trouble is,none of their teachers knows which half” Prof. Sydney Burwell Dean of Harvard Medical school Half a century ago…

4 4Active Management of Third Stage of Labor

5 5 Would you care finding your way through the information maze…?!

6 6Active Management of Third Stage of Labor Anecdotes Intermediate Outcomes “ The Winds of Change ”

7 7Active Management of Third Stage of Labor The Pyramid of Evidence

8 8Active Management of Third Stage of Labor Definitions… Clinical guidelines are: ‘Systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ Developed using a standardized methodology

9 9Active Management of Third Stage of Labor -Ila Evidence obtained from at least one well- designed controlled study without randomization. -Ilb Evidence obtained from at least one other type of well-designed quasi- experimental Evidence obtained from well-designed non- experimental descriptive studies, such as comparative studies, correlation studies. Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities 1 - Ia Evidence obtained from meta-analysis of randomized controlled trials. - Ib Evidence obtained from at least one randomized controlled trial Classification of Evidence Levels

10 10Active Management of Third Stage of Labor Forms of Care… Beneficial Forms of care. Forms of care likely to be beneficial. Forms of care with a trade off. Forms of care with unknown effectiveness. Forms of care likely to be ineffective. Forms of care likely to be harmful.

11 11Active Management of Third Stage of Labor Grades of Recommendation AAt least one controlled trialLevel Ia, Ib BRequires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. Level IIa, IIb, III CRequires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality Level IV

12 12Active Management of Third Stage of Labor To put it short… We need to learn not only to read the medical literature, BUT what to read? And how ? We need to be introduced to the concept of “Information Mastery”.

13 13Active Management of Third Stage of Labor The 5 EBM Skills 1. Forming answerable clinical questions 2. Searching for the best evidence answer 3. Appraising evidence for relevance, impact, validity 4. Integrating the evidence into practice 5. Evaluating & improving

14 14Active Management of Third Stage of Labor A three-part Clinical Question Does active management of the third stage of labor decrease the rate of primary postpartum hemorrhage? The Prevention of Postpartum hemorrhage is by the proper conduction of the third stage of labor This is also a POEM.

15 15Active Management of Third Stage of Labor Where Are You Going To Search For The Evidence…? Textbooks…? Original publications…? Predigested Material

16 16Active Management of Third Stage of Labor Two Methods of Third Stage Management Physiologic (“expectant”) management Oxytocics are not used Placenta is delivered by gravity and maternal effort Cord is clamped after delivery of the placenta Active Management Oxytocic is given Cord is clamped Placenta delivered by controlled cord traction (CCT) with counter-traction on the fundus Fundal massage

17 17Active Management of Third Stage of Labor Critical Issues Pertaining to the Third Stage of Labor Active vs. physiologic management Theoretical potential risks of each Entrapment of placenta Avulsion of cord Uterine inversion Choice of oxytocic agent Stability, safety and side effects of oxytocics Unproven benefit of nipple stimulation CCT and fundal massage if no oxytocic available

18 18Active Management of Third Stage of Labor 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)

19 19Active Management of Third Stage of Labor Active Management: Advantages and Disadvantages Advantages Decreases length of third stage Decreases risk of PPH Disadvantages Requires oxytocics and items needed for injection Requires a birth attendant with skills in: Observation Giving an injection CCT

20 20Active Management of Third Stage of Labor Procedure for Active Management Oxytocin Within 1 minute of birth, palpate abdomen to rule out presence of another baby Give oxytocin CCT Await strong uterine contraction (2–3 minutes) Apply controlled cord traction while applying countertraction above pubic bone If placenta does not descend, stop traction and await next contraction

21 21Active Management of Third Stage of Labor 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.

22 22Active Management of Third Stage of Labor 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.

23 23Active Management of Third Stage of Labor The Bristol Trial: Details of Active Management Try to give one ampule of oxytocic (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.

24 24Active Management of Third Stage of Labor The Bristol Trial: Details of Physiologic Management Try not to give oxytocic 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.

25 25Active Management of Third Stage of Labor Active vs. Physiologic Management: Postpartum Hemorrhage Active Management Physiologic Management OR and 95% CI Bristol Trial50/846 (5.9%)152/849 (17.9%)3.13 ( ) Hinchingbrooke Trial 51/748 (6.8%)126/764 (16.5%)2.42 ( ) Prendiville et al 1988; Rogers et al 1998.

26 26Active Management of Third Stage of Labor Active vs. Physiologic Management: Results Active Management Physiologic Management OR and 95% CI Duration 3 rd stage (median) Bristol5 minutes15 minutesNot done Hinchingbrooke8 minutes15 minutesNot done Third stage > 30 minutes Bristol25 (2.9%)221 (26%)6.42 ( ) Hinchingbrooke25 (3.3%)125 (16.4%)4.9 ( ) Blood transfusion Bristol18 (2.1%)48 (5.6%)2.56 ( ) Hinchingbrooke4 (0.5%)20 (2.6%)4.9 ( ) Therapeutic oxytocics Bristol54 (6.4%)252 (29.7%)4.83 ( ) Hinchingbrooke24 (3.2%)161 (21.1%)6.25 ( )

27 27Active Management of Third Stage of Labor Active vs. Physiologic Management: The Bristol & Hinchingbrooke Trials Conclusion: Active management of the third stage reduces the risk of PPH: Increased risk of PPH associated with physiologic management Increased need of blood transfusion associated with physiologic management Oxytocin was drug of choice for active management No increase in entrapment of placenta with active management

28 28Active Management of Third Stage of Labor Oxytocic Drugs Oxytocin- posterior pituitary extract Ergometrine- preparation of ergot Syntometrine- combination of oxytocin and ergometrine Misoprostol- prostaglandin E1 analogue

29 29Active Management of Third Stage of Labor Oxytocic Drugs: Oxytocin Advantages Causes uterus to contract Acts within 2.5 minutes when given IM Generally does not cause side effects Disadvantages More expensive than ergometrine IM or IV preparations only Not heat stable

30 30Active Management of Third Stage of Labor Oxytocic Drugs: Ergometrine Advantages Low price Effect lasts 2–4 hours Disadvantages Takes 6–7 minutes to become effective when given IM; oral form insufficiently effective Causes tonic uterine contraction Increased risk of hypertension, vomiting, headache Contraindicated in women with hypertension or heart disease Not heat stable

31 31Active Management of Third Stage of Labor Oxytocic Drugs: Syntometrine Advantages Combined effect of rapid action of oxytocin and sustained action of ergometrine Disadvantages Increased risk of hypertension, nausea and vomiting Not heat stable

32 32Active Management of Third Stage of Labor Oxytocin vs. Syntometrine: Objective and Design Objective: To compare effects of syntometrine with oxytocin in reducing the risk of PPH and other maternal and neonatal outcomes Design: Randomized controlled trials McDonald, Prendiville and Elbourne 2000.

33 33Active Management of Third Stage of Labor Oxytocin vs. Syntometrine: Results Syntometrine was associated with a small reduction in risk of PPH < 1000 mL (OR 0.74, 95% CI ) Adverse effects of vomiting and hypertension were associated with the use of syntometrine There were no differences in other maternal or neonatal outcomes McDonald, Prendiville and Elbourne 2000.

34 34Active Management of Third Stage of Labor Oxytocin vs. Syntometrine: Conclusion Need to weigh benefit of reduction in risk of PPH with risk of other adverse effects associated with syntometrine McDonald, Prendiville and Elbourne 2000.

35 35Active Management of Third Stage of Labor Stability of Oxytocics in Tropical Climates: Objective and Design Objective: To determine pattern of stability in long term dark storage, short term exposure to high temperature and light To develop guidelines Methods: Tested field samples of ergometrine and methylergometrine and also simulated field storage conditions at different temperature/light exposure WHO 1993.

36 36Active Management of Third Stage of Labor Stability of Oxytocics in Tropical Climates: Results Field: Ergometrine: only 31% of samples had compliant level of active ingredient Oxytocin: one expired, 5 samples had 104– 142% of stated amount of active ingredient WHO 1993.

37 37Active Management of Third Stage of Labor Stability of Oxytocics in Tropical Climates: Results (continued) Simulation conditionErgometrine/ methylergometrine Oxytocin Refrigeration for 12 months Lost 4-5% active ingredientNo loss 30 o C, darkLost 25%Lost 14% 21–25 o C, lightLost 21–27% in one month >90% in 12 months Lost 5% 40 o C darkLost > 50%Lost 80% WHO 1993.

38 38Active Management of Third Stage of Labor Stability of Oxytocics in Tropical Climates: Conclusions Stability of oxytocin is better than ergometrine/ methylergometrine, especially regarding light Store refrigerated, in dark, labeled Remove from box only for immediate use Short periods unrefrigerated are fine (1 month at 30°C, 2 weeks at 40°C) WHO 1993.

39 39Active Management of Third Stage of Labor Nipple Stimulation Nipple stimulation has not been shown to reduce risk of PPH Randomized controlled trial of suckling immediately after birth with over 4,000 subjects in Malawi showed no significant difference in frequency of PPH, mean blood loss or retained placenta When oxytocics are not available, CCT and fundal massage should be performed Advantages of early breastfeeding and nipple stimulation: Stimulates natural production of oxytocin May maintain tone of contracted uterus Benefits baby Bullough, Msuku and Karonde 1989.

40 40Active Management of Third Stage of Labor Recommendations Concerning Selection of Oxytocic Use oxytocin, when available: If oxytocin is not available, use syntometrine or ergometrine If oxytocic drugs are not available, use nipple stimulation Remember: Do not use ergometrine in women with hypertension or heart disease Store oxytocics in refrigerator (2–8ºC) and away from light Misoprostol rectally has advantages; awaiting confirmatory studies.

41 41Active Management of Third Stage of Labor Summary Active management of third stage includes: Oxytocin Controlled cord traction Fundal massage Ensuring supply of oxytocin is a priority Active Management Reduces risk of PPH Retained placenta Need for therapeutic oxytocics Need for blood transfusion

42 42Active Management of Third Stage of Labor References Bamigboye A et al Randomized comparison of rectal misoprostol with syntometrine for management of third stage of labor. Acta Obstet Gynecol Scand 77: 178 – 181. Bullough CH, RS Msuku and I Karonde Early suckling and postpartum haemorrhage: Controlled trial in deliveries by traditional birth attendants. Lancet 2(8662): 522 – 525. Irons DW, P Sriskandabalan and CHW Bullough A simple alternative to parenteral oxytocics for the third stage of labor. Int J Obstet Gynecol 46:15 – 18. Khan GQ et al Controlled cord traction versus minimal intervention technique in delivery of the placenta: A randomized controlled trial. Am J Obstet Gynecol 177(4): 770 – 774.

43 43Active Management of Third Stage of Labor References (continued) McDonald S, W Prendiville and D Elbourne Prophylactic syntometrine versus oxytocin for delivery of the placenta (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford. McDonald et al 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 The Bristol third stage trial: active versus physiological management of the third stage of labor. BMJ 297:1295–1300. Rogers J et al Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351(9104): 693–699. World Health Organization (WHO) Stability of injectable oxytocics in tropical climates: Results of field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin. WHO: Geneva.


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