September 15, 2004

Management of the third stage of labour

One issue that arose in the Israeli workshops was the management of third stage, especially the timing of the oxytocic injection. Group members reported two different hospital regimes - the injection was either given with the birth of the baby’s shoulders (or very soon after) or else after the placenta had been born.

This variation is a good example of the “habits” that can develop in maternity care. In the US, the oxytocic drug is always administered after the placenta has arrived. In the UK (and Europe, as far as I know) the oxytocic is given as the baby is being born and very definitely before the placenta arrives. Each camp are surprised at the routines of the other, and are doubtful of the wisdom of that approach. The research in the Cochrane Library, for example, appears to assume that the oxytocic will be given before the placenta is born and the reported studies centre mainly around the advisability of then applying controlled cord traction and the other elements of a “managed third stage” versus a more relaxed approach. Retained placenta is a possible outcome of early oxytocic administration, as is the entrapment of an undiagnosed twin (a very unlikely event these days due to the ubiquitous ultrasound) .

The active management of third stage is an example of the “through- put approach” to obstetrics. Left alone, and when the mother can cuddle and perhaps suckle her baby, the placenta usually arrives about 20 minutes after the baby. For some, this is too long, and no doubt that is why the practise of giving oxytocic drugs to speed up uterine contractions, coupled with cord traction, was developed, to enable the women to be tidied up and moved out of the labour room in a timely fashion.

I find it fascinating that some elements of the American way of birth have been adopted in other western countries, but not all. It seems that any practises that will speed up birth have gained favour (drips, drugs, rupturing membranes etc), while their habit of leaving the third stage to proceed at a more leisurely pace have been overlooked. It seems that research will also be based on local routines to some extent, with perhaps the basic premise of some studies being acceptance of a local habit and then investigating from there. This raises the question of the assumptions underpinning some research studies and the applicability and validity of their findings.

Meanwhile, do we wait for the placenta to arrive in its own good time and give the oxytocic drug after it comes, or do we administer it as soon as the baby puts in an appearance? Alternatively, do we not give the drug routinely at all and wait for the evidence that it is needed to stop heavy bleeding or a haemorrhage, before injecting? I favour the latter approach, to ensure that the woman receives appropriate care, rather than blind adherence to a routine or protocol that may have no relevance to her specific birth circumstances. It is an issue that always encourages heated discussion.

Posted by andrea at September 15, 2004 05:50 PM