1. Community interventions; Physiological management of the third stage of labour. Karen Guilliland CEO New Zealand College of Midwives ICM Board Member

2. Objectives Examine the evidence for the components of physiological /expectant management of the third stage of labour Define the components of physiological /expectant management of the third stage of labour when uterotonic drugs are not available.

3. Background PPH is the cause of significant maternal morbidity and mortality Active Management of third stage of labour (AMTSL) is recommended as the primary prevention method What alternative methods are there if uterotonic drugs are not available?

4. Issues affecting access to and utilisation of uterotonic drugs Access to uterotonic drugs is a problem in some areas due to: –Cost –Erratic supply –Need for cold chain (injectable uterotonic drugs) –Policy limiting the type of health worker authorized to administer uterotonic drugs Midwives also report in some areas issues of –authenticity of drugs –improper use (induce abortion or induce / augment labour)

5. ICM/FIGO Joint Statement on PPH prevention and treatment - 2006 Refers to the lack of evidence for making a clear recommendation on how to manage the third stage of labour when uterotonic drugs are not available Added a clause on physiological management to the 2003 version recommending use of physiologic (expectant) management when no uterotonic drugs are available to either the skilled or non-skilled birth attendant Gives some definition and advice on physiological management

6. Research needs AMTSL country surveys (2007-2009) showed the following practices when uterotonic drugs were not used for third stage management: –Controlled cord traction without a uterotonic drug –Controlled cord traction without countertraction to the uterus –Uterine massage before delivery of the placenta –No uterine massage after delivery of the placenta Literature search initiated to establish what we know about physiological management

7. Results… There is little conclusive research to define the components of physiological management of third stage. There is considerable variation between countries and disciplines about the components of “normal” birth and what is considered intervention.

8. Results… The text book definitions & the expert opinion on third stage management displays marked differences globally. Midwives, as the main practitioners of physiological management of third stage, also differ but have the most similarities.

9. Assisting the physiology of third stage…current practice In 2010 ICM/FIGO formed a Multidisciplinary expert taskforce to define the components of physiological management. ICM conducted a survey of current best practice and 39 ICM Member Association Countries responded. There was consensus on; 1) Signs of separation 2) How to support women to expel the placenta 3) The first two hours after the birth

10. Practice consensus… 1) Signs of separation –Change in the size, shape and position of the uterus –A small gush of blood –The cord lengthens –The woman becomes uncomfortable, get contractions or feel that she wants to change position or bear down Most placentas will be delivered in one hour.

11. Practice consensus… 2) Supporting women to expel the placenta, after signs of separation –Encourage woman into upright position –The placenta may be expelled spontaneously or –Encourage maternal effort to expel placenta –The birth attendant catches the placenta in cupped hands or a bowl –If the membranes are slow then assist by holding the placenta in two hands and gently turning it until the membranes are twisted then exert gentle tension

12. Practice consensus… Controlled cord traction is not recommended in the absence of uterotonic drugs There is no need to clamp or cut the cord until after placenta is delivered

13. Practice consensus… 3) The first two hours following the birth –Observe and estimate the blood loss –Palpate for a contracted uterus on a regular basis –Teach the woman how to check her blood loss and the firmness of her own uterus –Encourage breastfeeding

14. Recommendations Physiology of 3 rd stage needs to be a common knowledge competency & more research needed More research on physiological management of 3 rd stage Every person attending a birth is taught how to assist at a physiological third stage Every programme teaching AMTSL includes how to assist at a physiological third stage Educate women in self care