Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. The Bristol third stage trial: active versus physiological management of third stage of labour. A study of prophylactic use of 15-methyl prostalglandin F2alpha in the active management of third stage of labour. A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial. A study of the relationship between the delivery to cord clamping interval and the time of cord separation. Oxford Midwives Research Group. A behavioral intervention to improve obstetrical care. Intraumbilical veinous injection oxytocin in the active management of third stage of labour. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. The effect of intraumbilical oxytocin on the third stage of labour.
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.
                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.
                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.
                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. To compare the effects on fetal and maternal morbidity of routine active management of third stage of labour and expectant (physiological) management, in particular to determine whether active management reduced incidence of postpartum haemorrhage.
                Randomised trial of active versus physiological management. Women entered trial on admission to labour ward with allocation revealed just before vaginal delivery. Five months into trial high rate of postpartum haemorrhage in physiological group (16.5% v 3.8%) prompted modification of protocol to exclude more women and allow those allocated to physiological group who needed some active management to be switched to fully active management. Sample size of 3900 was planned, but even after protocol modification a planned interim analysis after first 1500 deliveries showed continuing high postpartum haemorrhage rate in physiological group and study was stopped.
                Maternity hospital.
                Of 4709 women delivered from 1 January 1986 to 31 January 1987, 1695 were admitted to trial and allocated randomly to physiological (849) or active (846) management. Reasons for exclusion were: refusal, antepartum haemorrhage, cardiac disease, breech presentation, multiple pregnancy, intrauterine death, and, after May 1986, ritodrine given two hours before delivery, anticoagulant treatment, and any condition needing a particular management of third stage.
                All but six women allocated to active management actually received it, having prophylactic oxytocic, cord clamping before placental delivery, and cord traction; whereas just under half those allocated to physiological management achieved it. A fifth of physiological group received prophylactic oxytocic, two fifths underwent cord traction and just over half clamping of the cord before placental delivery.
                Reduction in incidence of postpartum haemorrhage from 7.5% under physiological management to 5.0% under active management.
                Incidence of postpartum haemorrhage was 5.9% in active management group and 17.9% in physiological group (odds ratio 3.13; 95% confidence interval 2.3 to 4.2), a contrast reflected in other indices of blood loss. In physiological group third stage was longer (median 15 min v 5 min) and more women needed therapeutic oxytocics (29.7% v 6.4%). Apgar scores at one and five minutes and incidence of neonatal respiratory problems were not significantly different between groups. Babies in physiological group weighed mean of 85 g more than those in active group. When women allocated to and receiving active management (840) were compared with those who actually received physiological management (403) active management still produced lower rate of postpartum haemorrhage (odds ratio 2.4;95% CI1.6 to 3.7).
                Policy of active management practised in this trial reduces incidence of postpartum haemorrhage, shortens third stage, and results in reduced neonatal packed cell volume. To compare active management of third stage of labour with 15-methyl prostaglandin F2alpha (PGF2alpha) and conventional management with methylergometrine as prophylaxis for postpartum hemorrhage, a randomised comparative study was carried out at Calcutta National Medical College and Hospital, Kolkata on 100 women. They were randomly allotted to one of the two groups. Group A included 50 women who received 15-methyl PGF2alpha (125 microg) intramusculary at the time of delivery of the anterior shoulder and group B included 50 women who underwent conventional management of the third stage of labour where methylergometrine 0.2 mg was given after delivery of placenta. Main outcome measured were duration of third stage, amount of bleeding and side-effects. The present study showed that there were significent reduction of the duration of third stage as well as reduction of amount of bleeding particularly when 125 microg of 15-methyl PGF2alpha was given intramuscularly at the time of delivery of the anterior shoulder in comparison to coventional method of management of third stage of labour with methylergometrine. Placental expulsion occurred within 4 minutes in group A and 16.5 minutes in group B. The amount of bleeding following delivery was 95.6 ml in average in group A and 249.6 ml in average in group B. 15-methyl PGF2alpha (125 microg) is certainly effective in prevention of postpartum haemorrhage particularly in developing country like India where this complication contributes a major factor for maternal mortality. to compare blood loss in women actively and expectantly managed in the third stage of labour.
                randomised controlled trial (RCT).
                two delivery units at a Swedish university hospital.
                healthy women with normal pregnancies, at gestational age 34-43 weeks, with singleton cephalic presentation and expected vaginal delivery.
                the women were randomly allocated to either active (n = 903) or expectant (n = 899) management of the third stage of labour.
                the primary outcome was blood loss > 1000 ml, and secondary outcomes were mean blood loss, duration of third stage, retained placenta, haemoglobin level and blood transfusion.
                blood loss > 1000 ml occurred in 10% of the actively managed group and 16.8% of the expectantly managed group (P < 0.001). Mean blood loss was 535 ml in the actively managed group and 680 ml in the expectantly managed group (P < 0.001). A prolonged duration of the third stage was associated with increased blood loss. Increased placenta weight was associated with increased blood loss. The haemoglobin level was 118 g/dl in actively managed women and 115/dl in expectantly managed women (P < 0.001) the day after childbirth. The occurrence of retained placenta and the number of blood transfusions did not differ between the groups.
                active management of the third stage of labour was associated with less blood loss compared with expectant management. It is reasonable to advocate this regime, especially in primiparous women. A randomised controlled trial of 554 women was carried out to compare the effects of late and early umbilical cord clamping on the time of cord separation. In addition data were collected on maternal and neonatal outcomes. There were no significant differences between the two groups in the duration of cord adherence and neonatal and maternal outcomes. There appeared to be a higher rate of jaundice in the late clamped group which did not reach statistical significance. There was an unexpectedly higher rate of breast feeding at home in the late clamped group which did reach statistical significance. Overall the trial provides no clear evidence for the benefit of early cord clamping (the current policy as part of the active management of the third stage in the UK) on the outcomes considered. Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed.
                We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention.
                The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention.
                A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy. (ClinicalTrials.gov number, NCT00070720 [ClinicalTrials.gov]; Current Controlled Trials number, ISRCTN82417627 [controlled-trials.com].).
                Copyright 2008 Massachusetts Medical Society. To determine the role of intraumbilical vein oxytocin reducing blood loss during and after one hour of delivery of placenta and its efficacy in reducing the frequency of retained placenta.
                Randomized controlled trial.
                Combined Military Hospital, Multan, from June 2002 to October 2002.
                Five hundred parturient women with low risk singleton term pregnancy were enrolled in the study. Two hundred and fifty women each were included in the study and control group after randomization. The patients and health care providers both were blinded to the intervention. Primary outcome measures were kept as duration and amount of blood loss in third stage of labour. Secondary outcome measures included incidence of retained placenta, abdominal need for additional utero-tonics, frequency of postpartum pain, nausea and vomiting, fever, need for blood transfusion, establishment of breast feeding and total duration of hospital stay.
                Women in study group who received intraumbilical vein syntocinon lost 234.03 ml of blood while the control group lost 276.51 ml (p=0.001). Mean duration of third stage was 2.59 minutes in the study group and 7.67 minutes in the control group (p<0.001). The frequency of retained placenta was 1.2%, which involved only the control group. Abdominal pain was experienced by study group but the difference was not found statistically significant. Nausea and vomiting was more in study group (p=0.001). No discernible difference was found in length of hospital stay, the need for blood transfusion, fever and establishment of breast-feeding in both groups.
                The addition of intraumbilical vein syntocinon 10 units resulted in marked reduction in amount of blood loss, duration of third stage and incidence of retained placenta in comparison to intravenous 5 IU oxytocin+0.5 mg ergometrine alone. This study compared the effects of immediate (ICC) and delayed (DCC) cord clamping on very low birth weight (VLBW) infants on 2 primary variables: bronchopulmonary dysplasia (BPD) and suspected necrotizing enterocolitis (SNEC). Other outcome variables were late-onset sepsis (LOS) and intraventricular hemorrhage (IVH).
                This was a randomized, controlled unmasked trial in which women in labor with singleton fetuses <32 weeks' gestation were randomly assigned to ICC (cord clamped at 5-10 seconds) or DCC (30-45 seconds) groups. Women were excluded for the following reasons: their obstetrician refused to participate, major congenital anomalies, multiple gestations, intent to withhold care, severe maternal illnesses, placenta abruption or previa, or rapid delivery after admission.
                Seventy-two mother/infant pairs were randomized. Infants in the ICC and DCC groups weighed 1151 and 1175 g, and mean gestational ages were 28.2 and 28.3 weeks, respectively. Analyses revealed no difference in maternal and infant demographic, clinical, and safety variables. There were no differences in the incidence of our primary outcomes (BPD and suspected NEC). However, significant differences were found between the ICC and DCC groups in the rates of IVH and LOS. Two of the 23 male infants in the DCC group had IVH versus 8 of the 19 in the ICC group. No cases of sepsis occurred in the 23 boys in the DCC group, whereas 6 of the 19 boys in the ICC group had confirmed sepsis. There was a trend toward higher initial hematocrit in the infants in the DCC group.
                Delayed cord clamping seems to protect VLBW infants from IVH and LOS, especially for male infants. The umbilical vein administration of oxytocin in saline was compared with umbilical vein saline alone and the traditional management of the third stage of labour. Seventy-two women were randomized to 3 groups. Group 1 received intraumbilical 20 IU of oxytocin diluted to 40 mL with saline. Group 2 received intraumbilical vein 40 mL of saline while subjects in group 3 were managed according to the standard protocol without any intraumbilical injection. No significant differences were found in terms of the length of the third stage, the blood loss in the third stage and postpartum haematocrit differences among the 3 groups. The administration of diluted oxytocin or saline do not seem to have any superiority to the traditional management of the third stage of labour.
Although there is a lack of high quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.