Research Roundup

By Nadine Edwards

AIMS Journal, 2011, Vol 23 No 2

Third Stage Reviewed

Nadine Edwards summarises the Cochrane Review of active v expectant management

In 20102, Cecily Begley, Gill Gyte, Deirdre Murphy, Declan Devane, Susan McDonald and William McGuire updated the Cochrane Review on 'Active versus expectant management for women in the third stage of labour'. The full Review can be viewed at

In the UK, most women routinely receive active management of the third stage of labour. This usually means that as the baby is being born, the midwife gives the woman an injection of the drug syntometrine (a combination of ergometrine and syntocinon), or syntocinon on its own. These drugs are called oxytocics and cause the woman's womb to contract. The midwife then immediately clamps and cuts the umbilical cord, and pulls the woman's end of the cord with one hand and applies counter-pressure against her womb (controlled cord traction) to get her placenta out quickly. Most researchers, doctors and midwives have recommended this for many years because overall, it was, and still is, believed to speed up the birth of the placenta and reduce heavy bleeding after birth.

The potential for heavy blood loss is a concern, even in a relatively healthy population. Thankfully, very few women in the UK die during childbearing, but very heavy bleeding after birth is still a cause of death.1 Heavy blood loss can also affect a woman's health after birth when she has a new baby to care for, just when she needs to feel healthy and well. In low-income countries heavy bleeding after birth continues to be a major cause of death and illhealth among childbearing women for complex reasons that centre on pover ty and the unequal distribution of wealth and resources.

Over the last years there has been a growing body of research which has given us a more detailed understanding about the birth of the placenta and how a baby makes the transition from life inside its mother's womb, to the outside world.

Research has looked at managing the birth of the placenta with drugs, cord clamping and cutting, and controlled cord traction, compared with not giving oxytocic drugs, leaving the cord unclamped and uncut, and not pulling on it (expectant management of the third stage of labour).

The lastest Cochrane Review on third stage management by Cecily Begley and her colleagues2 sets out to examine the research on active compared with expectant management of the third stage of labour, and how this impacts on the woman and on the baby's transition to life in the outside world. The Review authors have also considered the uncertainties around this issue and what we do not know about the third stage of labour.

The Review is based on five randomised controlled trials carried out in the UK, Ireland and Abu Dhabi between 1988 and 1998. While randomised controlled trials are often thought to be the best way of finding out about the impacts of treatments, they can only tell us how most people in a population will respond to the treatment, they cannot tell us about individuals. There are those who are critical about using the results of randomised controlled trials on their own because they cannot take into account complexities that could change the meaning of the results, and can miss important factors. The research carried out by Helen Stapleton and her colleagues3,4 about the impact of the MIDIRS Informed Choices leaflets on women's decision making is a good example. The randomised controlled trial showed that giving the leaflets to women made little difference to the choices they made about maternity care. If this trial had not had a qualitative arm to it (where researchers talked to midwives and women, and watched how the leaflets were given out and used), it might have been assumed that it is a waste of resources to give women information! However, from the qualitative research, it became clear that the leaflets were often not always being given out, or that they were being given in a way that made it difficult for women to use the information in them, or that the women were discouraged from acting on the information they received in the leaflets if the information contradicted obstetricians' usual practices.

There were criticisms of the five randomised controlled trials on active and expectant management of the third stage of labour used in the Cochrane Review. Cecily Begley and her colleagues acknowledged and examined the potential flaws in these trials and the uncertainty of their findings in their Review. They also drew on other interesting research and suggested that even with all the research we have, we cannot be sure about many aspects of active or expectant third stage management.

The authors of the Review defined active management of labour as:

They defined expectant management of the third stage of labour as:

The main findings of their Review are as follows:

When active management of the third stage of labour is used routinely for all women whether or not they are likely to bleed heavily after birth:

For women who were at low risk of bleeding, the Review suggests that the results are the same, except that there is no difference in severe bleeding. This was of particular concern to the authors because it means that women at low risk of bleeding suffer the side effects of active management of the third stage of labour with no reduction in bleeding over 1000ml.

The Review concludes that while routinely applying active management for the birth of the placenta 'reduced the risk of haemorrhage greater than 1000ml in an unselected population', there are harmful effects. The authors state that women should be told about the benefits and harms so that they can make their own decisions. They also suggest that we need to know more about each component of active management of the third stage of labour because: