Chataut, D

Sharma, G

Upadhyay, M

LSHTM Research Online

Upadhyay, M; Sharma, G; Chataut, D (2006) Active management ofthird stage of labor: Assessment of standard of care in one of thetraining institute. Nepal Journal of Obstetrics and Gynaecology, 1(2). pp. 28-30. ISSN 1999-8546Downloaded from: http://researchonline.lshtm.ac.uk/2535074/DOI:Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Copyright the publishers25Introduction:Delivery of the placenta and membranes (The thirdstage of labour) is potentially the most hazardous stageof childbirth for the mother, mainly because of the riskof post-partum haemorrhage and it’s subsequentmorbidity. This stage of labour can be managed activelyor expectantly. Active management involvesprophylactic administration of an uterotonic agent, earlycord-clamping and cutting, and controlled cordtraction.1,2,3 and uterine massage. In expectantmanagement (sometimes called conservative orphysiological management) uterotonic drugs are notgiven prophylactically, the cord is neither clamped norcut early and the placenta is expelled by maternaleffort.1,2,3 From 1988 through 1998, four good qualitylarge-scale randomized controlled studies conductedin well resourced maternity hospitals (two in the UnitedKingdom, one in the United Arab Emirates and one inIreland) have compared the effects of active andexpectant management of 3rd stage of labour. AlthoughActive management of third stage of laborMeena Thapa, Rachana Saha, Sumita Pradhan, Sushil Thakur, Archan Shamsher RanaKathmandu Medical College Teaching Hospital,Sinamangal, Kathmandu, NepalAbstract:Objective: Overall objective of the study was to see effects of active management of third stage of labour(AMSTL) with oxytocin. Specific objective of the study was to look for incidence of Post-Partum Haemorrhage(PPH), length of 3rd stage, incidence of retained placenta and average blood loss.Methodology: A hospital based prospective, descriptive, observational study was carried out from 1st July2005 to 30th June 2006 at department of Obstetrics and Gynaecology, Kathmandu Medical College TeachingHospital (KMCTH). All patients undergoing vaginal delivery excluding twins, polyhydraminios and instrumentaldeliveries were included in the study. The active management of 3rd stage included administration of 10 unitsIU of oxytocin, early cord clamping, controlled cord traction and uterine massage. Blood loss was estimatedby visual inspection and measured by jar pressed against perineum.Result: Total number of deliveries during the study period was 530. There were 13 cases of PPH. Incidenceof PPH was 2.4%. There were six cases each of uterine atony and genital tract trauma. One case was ofretained placenta requiring Manual Removal (MRP). Average third stage duration was less than 5 minutes.Average blood loss was 90 ml. In 2 cases the third stage lasted more than 30 mins.Conclusion: Active management of 3rd stage of labour reduces the incidence of PPH from uterine atony,reduces the duration as well as average blood loss during third stage.condition.Key words: Labor analgesia; epidural, combined spinal epidural; complications, dural puncture, post-dural puncture headache (PDPH); prevention.CorrespondenceDr. Meena Thapa, Department of Obstetrics & GynaecologyKathmandu Medical College Teaching Hospital, 184, Baburam Acharya Sadak,Sinamangal – 9, Kathmandu, Nepal, Ph. No. 4481903the studies used different uterotonic drugs (oxytocin/ergometrine either or both drugs) with different dosagesand routes of administration and varied in thecomponents of active management, their results wereinformative.1, 2,3 In all four studies, active managementwas associated with a decrease in PPH and a decreasein the length of 3rd stage of labour. A Cochrane Librarysystematic review and meta-analysis concluded thatactive management of the third stage of labour in thesetting of maternity hospital was superior to expectantmanagement in reducing blood loss, post-partumhaemorrhage and duration of 3rd stage. Activemanagement with ergometrine (compared to oxytocin),however was associated with an increase in nausea,vomiting and hypertension. Other studies havesuggested that there are no advantages ordisadvantages for the newborn and the uterotonicdrugs are more effective in preventing PPH if they areadministered before, rather than after, the placenta isdelivered. 1,2,3 In our hospital strict practice of AMSTLwas started from 1st July 2005.N. J. Obstet. Gynaecol  Vol. 1, No. 2, p. 25 - 27   Nov-Dec 200626Objective:General: to observe the effects of active managementof 3rd stage of labour with oxytocin.Specific objective: to determine the1. Incidence of PPH2. Length of 3rd stage3. Incidence of retained placenta4. Average blood loss during third stageMethodology:A hospital based prospective, descriptive,observational study for a period of 1 year from 1st July2005 to 30th June 2006 was carried out at the departmentof Obstetrics & Gynaecology, KMCTHInclusion criteria: All vaginal deliveryExclusion criteria: Twins, polyhydraminios,instrumental deliveriesAdministration of uterotonic drug:Within 1 minute of delivery of the baby, the abdomenis palpated to rule out the presence of an additionalbaby (s) and oxytocin 10 units I/M is given.Early cord clamping:The cord is clamped close to the perineumControlled cord traction:Controlled cord traction is performed after 2 – 3 minutesof administration of syntocinon when strong uterinecontraction occurs. If the placenta does not descendduring 30 – 40 seconds of controlled cord traction, thepull is discontinued and another contraction isawaited.Uterine massage:Uterus is massaged immediately through woman’sabdomen until it is contracted for 1st two hours doneby the patient herself.Estimation of blood loss:Blood loss was measured by a jar pressed againstperineum and visual inspection.In our study there were 13 cases of post-partumhaemorrhage out of 530 deliveries. Uterine atony andgenital tract trauma were responsible equally (six caseseach). There was one case of retained placenta requiringmanual removal. Two cases had 3rd stage of more than30 minutes. Average duration of 3rd stage was 5 minutes.Average blood loss was 90 ml. We used clinicalestimation of blood loss which was an imperfect measureof the actual amount of blood loss but the basis onwhich clinical decision are usually made. Concern thatactive management increases the likelihood of placentalentrapment are not supported by our data. When activeand passive management of 3rd stage are comparedwith Bristol and Hinching Brooke Trial there wasdefinite decrease in incidence of PPH.(5.9% Vs 17.9%)in Birstol Trial (6.8% Vs 16.5%) in Hinching BrookeTrial. Our findings are consistent with the results ofboth.Meena Thapa et alNormal 530LSCS 228Instrumental 32Twins 4Result:Cause of PPH NumberUterine atony 6Genital tract trauma 6Retained placenta 1Total 13Incidence 2.4%Table 2: causes of PPHTable 1: Type of delivery27Conclusion:Numerous studies of the active management of 3rd stageof labour and individual active management componentsupport the effectiveness and the need to expand theuse of active management of 3rd stage of labourespecially in developing country.Out study concludes that active management reducesthe incidence of PPH from uterine atony, reduces theduration and the average blood loss in 3rd stage of labourReferences:1. Prendville WJ, Harding JE, Elbourno DR,Active management of third stage of labourKMCTH Bristol Trial Hitching Brooke TrialIncidence of PPH 13/530 (2.4 %) 50/846 (5.91%) 51 /748 ( 6.81%)Average duration of 3rd stage 5 minutes 5 minutes 8 minutesDuration of Third stage >30 2/530 (0.37 %) 25/846 (2.9%) 25/748 (3.31%)Average blood loss 90 ml. 268.5 ml.Table 3: Comparison between KMCTH, Bristol Trial, Hitching Brooke TrialStirrat GM. The Bristol 3rd stage trial. Activevs physiologic management of 3rd stage oflabour. British Medical Journal 1998; 297:1295 –1300.2. Rogers J, Wood J, McCandeish R, Ayers S,Truesdale A, Elbourne D. Active versus expectantmanagement of 3rd stage of labour: The HinchingBrooke randomised control trial lancet 1998; 351:693-99.3. Prendville WJ, Elbourne D,McDonald S.Active versus expectant management in the 3rdstage of labour (Cochrane review). In theCochrane Library, issue 1, 2003 Oxford: updateSoftware.

Active management of third stage of labor: Assessment of standard of care in one of the training institute

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Active management of third stage of labor: Assessment of standard of care in one of the training institute

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