National Women's Annual Clinical Report 2010

7.2 Third stage management
Methods:
In 2008, the collection of third stage data was refined to better determine initial management
of third stage compared to subsequent treatment in response to postpartum bleeding. Active
management of third stage includes routine ecbolic given with birth of the anterior shoulder,
early clamping of the cord, followed by gentle traction until the placenta is delivered.
Physiologic third stage entails expectant management and delivery of the placenta by
maternal effort.
Findings:
Table 60: Third stage management among vaginal births
Physiologi
cal
n=447
Active
syntocinon
n=2688
Active
syntometrine
n=1969
Other
n=46
Unknown
n=171
n % n % n % n % n %
Primary PPH (>500mls) 38 8.5 514 19.1 396 20.1 9.0 19.6 28 16.4
Primary PPH (>1000mls) 12 2.7 142 5.3 112 5.7 2.0 4.3 9 5.3
Postpartum blood transfusion 5 1.1 62 2.3 49 2.5 2.0 4.3 7 4.1
In 2010, active management of third stage was used in at least 88% of vaginal births. This is
supported by randomised controlled trials that have shown that active management of the
third stage reduces the risk of postpartum haemorrhage by a half. In addition, the WHO
advises that all women in childbirth attended by a trained accoucheur receive active
management of the third stage.
The primary postpartum haemorrhage (PPH) and blood transfusion rates were higher among
the actively managed than among physiologically managed mothers. Randomised controlled
trials have shown a halving of the postpartum haemorrhage rate with active management.
The higher rates of primary PPH and transfusion among actively managed women are most
likely due to the paradox in observational studies of interventions where caregivers choose
the appropriate management according to patient and clinician identified risk.
At NW, physiological management of third stage is supported in low risk women, and with
informed consent. Women with BMI>35, a history of Caesarean section, hypertension or
multiple pregnancy almost always received active management at NW in 2010. (see
appendix 6)
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