Active versus Expectant Management of the Third Stage of Labor

1. Active versus Expectant Management of the Third Stage of Labor Frances C. Kelly, MSN, RNC-OB, NEA-BC, CPHQ, PhD(c) fckelly@texaschildrens.org April 4, 2014

2. Objectives • Describe trends in maternal mortality in the United States since late 1980s. • Differentiate between active and expectant management of the third stage of labor. • Identify risks and benefits of active and expectant management of the third stage of labor. • Summarize recommendations for managing the third stage of labor.

3. Conflict of Interest • The speaker has no known conflicts of interest.

4. MATERNAL MORTALITY: USA Hoyert DL. Maternal mortality and related concepts. Vital Health Stat3. 2007 Feb;(33):1-13.

5. MATERNAL MORTALITY: USA Hoyert DL. Maternal mortality and related concepts. Vital Health Stat3. 2007 Feb;(33):1-13.

6. Trends in Pregnancy–Related Mortality in the United States, 1987–2009 Trends in Pregnancy-Related Mortality in the United States, 1987–2008 Trends in Maternal Mortality in the United States from 1987 - 2009 http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

7. Causes of Pregnancy-Related Death in the United States, 2006–2009 Causes of Maternal Mortality in the United States from 2006 - 2009 http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

8. Causes of Pregnancy-Related Death in the United States, 2006–2009 Causes of Maternal Mortality in the United States from 2006 - 2009 http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

9. Postpartum Hemorrhage (PPH) Not only is PPH one of the leading causes of maternal mortality in the United States (and we are a high resource country) (CDC), it remains an underestimated obstetric emergency (Rath, 2011).

10. PPH Challenges • No consensus about what estimated blood blood (EBL) constitutes PPH (500mL vs 1000mL) • Variation in how EBL determined • Diagnosis of PPH based on fall in hematocrit (e.g. 10%) • Diagnosis of PPH based on whether patient requires transfusion?

11. PPH Challenges • Basing the diagnosis of PPH on whether or not the patient exhibits signs or symptoms is also problematic, because by the time a postpartum patient exhibits signs or symptoms suggesting that she may be experiencing PPH, the patient is much closer to decompensation than a non-pregnant adult female

12. Rajan & Wing, 2010, as adapted from Obstetrics: Normal and Problem Pregnancies. 5th ed. 2007: 456-485.

13. What is the most frequently identified etiology of PPH?

14. Uterine Atony and PPH • Population database study in U.S. • All inpatient discharges from 1994-2006 with ICD-9 code for PPH. • Uterine atony identified as most frequent etiology of primary PPH, P < 0.001 (Callaghan, Kuklina, & Berg, 2010).

15. Uterine Atony and PPH • Population database study in U.S. • All inpatient discharges from 1995-2004 with ICD-9 code for PPH. • Uterine atony identified as most frequent etiology (79%) of primary PPH cases in 2004 (Bateman, Berman, Riley & Leffert (2010).

16. Uterine Atony and PPH • Prospective observational descriptive study over one year in India • Identified uterine atony to be most common etiology of primary PPH cases (57%) (Shirazee, Saha, Das, Mondal, Samanta, & Sarkar, (2010).

17. Uterine Atony and PPH • Observational study in Abbottabad • Identified uterine atony to be most common etiology of primary PPH cases (58%) (Naz, Sarwar, Fawad, & Nisa (2008).

18. Uterine Atony and PPH • Retrospective observational study in Abbottabad • Identified uterine atony to be most common etiology of primary PPH cases (70.5%) (Bibi, Danish, Fawad, & Jamil (2007).

19. Factors Associated with Increased Risk of PPH and Uterine Atony • Augmented labor • Prolonged labor • Retained placental tissues • Retained placenta • Couvelliar uterus • Placental implantation abnormalities (previa, increta) • Chorioamnionitis • Multiple gestation • Grand multiparity • Antepartum hemorrhage • Instruments used during delivery • Previous PPH • Induced labor • Lower socioeconomic status • No risk factor Bibi, et al. (2007)

20. Factors Associated with Increased Risk of PPH Related to Atony • Maternal age < 20 • Maternal age ≥ 40 • Cesarean delivery • Hypertensive diseases of pregnancy • Polyhydramnios • Chorioamnionitis • Multiple gestation • Retained placenta • Antepartum hemorrhage Bateman, et al (2010)

21. Factors Associated with Increased Risk of PPH Related to Atony • Prolonged 2nd stage • Operative vaginal delivery • Over-distended uterus • Macrosomia • Polyhydramnios • Multifetal gestation • Medications • Magnesium sulfate • Nifedipine • Halogenated anesthetic agents • Chorioamnionitis • Abnormal placental implantation • Retained products Rajan & Wing (2010)

22. Rath, 2011. PPH caused by uterine atony which results in the need for transfusion has occurred in the absence of recognized risk factors!

23. What is the best approach in reducing maternal morbidity and mortality associated with PPH?

24. Preventing PPH is the First and Best Line of Defense

25. Preventing PPH • Avoid unnecessary induction and augmentation of labor • Assess for risk factors • Actively manage 3rd stage of labor

26. 3rd Stage of Labor: Active vs. Expectant Management Active Management Expectant Management Delayed umbilical cord clamping and cutting (e.g. after pulsations cease) Delivery of placenta once signs of placental separation occur and delivers spontaneously • Prophylactic uterotonic medication • Early umbilical cord clamping • Delivery of the placenta by gentle, controlled traction • Uterine massage

27. Prendiville, et al (1988) • Early trial (N = 1695) • Compared active management (admin oxytocin after delivery of anterior shoulder, early cord clamping, controlled cord traction) with expectant management • 3 times the likelihood of PPH among patients who were expectantly managed during 3rd stage (OR 3.1 [95% CI 2.3 – 4.2])

28. Rogers, et al (1998) • Early trial (N = 1512) • Randomized patients to either active (prophylactic admin of oxytocin + ergotamine within 2 min of delivery, immediate cord clamping, and placenta delivery with controlled traction or maternal expulsive effort) or expectant management of 3rd stage of labor • Patients whose 3rd stage of labor was actively managed had lower incidence of PPH (51 of 748 (6.8%) vs 126 of 764 (16.5%), reporting RR 2.42 (95% CI 1.78 – 3.30)

29. Prendiville, et al (2000) • Systematic review confirmed benefits of active management of 3rd stage of labor • 4 trials enrolling total of 6284 subjects • Less blood loss • Lower risk of PPH due to atony (RR 0.38 [95% CI 0.32 – 0.46]) • Less likely to require therapeutic oxytocics (RR 0.34 [95% CI 0.22 – 0.53])

30. Begley, et al (2010) • Cochrane database of systematic reviews (N = 5 studies, 6486 women) • Compare active versus expectant management of third stage of labor • Included randomised and quasi-randomised controlled trials from high-income countries • Active management reduced mean risk of primary PPH of > 1000 mL (RR 0.34 [95% CI 0.14 – 0.98]) • Active management also risk of maternal hemoglobin < 9 g/dl after birth (RR 0.50 [95% CI 0.30 – 0.83])

31. Soltani, et al. (2010) • Cochrane database (intervention reviews; 3 trials, 1671 women) • Included only Oxytocin • Determine effect of timing of administration of prophylactic uterotonics on 3rd labor stage outcomes • No significant differences in incidence of PPH (>500 or 1000mL), retained placenta, length of 3rd stage, PP blood loss, maternal hypotension, blood transfusion, or change in hemoglobin

32. Active Management of 3rd Stage of Labor (AMTSL) Benefits Risks Increased maternal diastolic blood pressure Increased after pains Increased use of analgesia Increased number of women returned to hospital with c/o bleeding Decrease in newborn birth weight • Decreased PPH of more than 1000 mL • Decreased maternal hemoglobin of less than 9 g/dl after birth • No difference in Apgar scores of less than 7 at 5 minutes

33. 3rd Stage of Labor: Expectant (Physiological) Management Benefits Risks Interferes with physiological processes during 3rd stage of labor in women of low risk of PPH and uterine atony Decreased maternal hemoglobin • Patient centered • More relaxed atmosphere • Increased newborn birth weight

34. Recent Studies • Prospective observational study reported consistent use of AMTSL low, and recommend consistent definitions (Int J. Gynaecol Obstet, 2013)

35. Recent Studies • Secondary analysis of 39,202 hospital births from 4 countries and 2 clinical regimens (with and without oxytocin) (Sheldon, et al, 2013) • No oxytocin and umbilical cord traction reduced risk of PPH by 50% (P < 0.001) • With oxytocin and umbilical cord traction reduced risk of PPH by 66%, but only if oxytocin admin IM (P < 0.001) • IV route of oxytocin reduced risk of PPH by 76%, but only if only intervention

36. Cochrane Library Review: (Westhoff, Cotter, & Tolosa, 2013) • Prophylactic admin Oxytocin↓ risk PPH > 500 mL (rr 0.53, 95%CI 0.38-0.74; 6 trials, 4203 women) • Decreased need for therapeutic uterotonics (rr 0.56, 95%CI 0.36-0.87; 4 trials, 3174 women) • Benefit prophylactic admin Oxytocin seen in all groups • IV bolus route (if possible) at dose of 10IU • Oxytocin “superior” to ergot alkaloids to prevent PPH >500mL and no benefit seen in combining • Fewer side effects (nausea, vomiting) with Oxytocin • No difference in rate of manual placenta removal or length of 3rd labor stage

37. 3rd Stage Labor Management:Conclusions • AMTSL reduces risk of PPH (though medication and timing of administration may vary) • Patients should be informed of risks and benefits of AMTSL and expectant management • Prophylactic administration of uterotonic (generally oxytocin) • Timing of cord clamping may be modified based on gestational age of newborn

38. 3rd Stage Labor Management:Conclusions • Anticipate: Review your patient’s history and the presence of risk factors • Anticipate: • Medication to be administered during 3rd stage of labor • Timing may vary • Assess: • Fundus • Amount of bleeding

39. 3rd Stage Labor Management:Conclusions • Outcomes are improved when efforts are based on evidence and carried out in an interdisciplinary manner. • Nurses are in a key position to positively impact patient outcomes by performing thorough assessments before, during, and after delivery; communicating abnormal assessment parameters; and anticipating patient needs (e.g. additional medications, equipment or procedures)

40. References • Bateman, B.T., Berman, M.F., Riley, L.E., & Leffert, L.R. (2010). The epidemiology of postpartu hemorrhage in a large, nationwide sample of deliveries. Anesthesia & Analgesia, 110(5), 1368-1373. • Begley, C.M., Gyte, G.M., Murphy, D.J., Devane, D., McDonald, S.J. & McGuire, W. (2010). Active versus expectant management for women in the third stage of labour. Cochrane database of systematic reviews (2010). (7). CD007412. • Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998–2005.Obstet Gynecol. 2010;116:1302–1309. • Bibi, S., Danish, N., Fawad, A., & Jamil, M. (2007). An audit of primary post partum hemorrhage. Journal of Ayub Medical College, Abbottabad,19(4), 102-106.

41. References • Bingham, D., Lyndon, A., Lagrew, D, & Main, E. (2011). A state-wide obstetric hemorrhage quality improvement initiative. Maternal Child Nursing, 36(5), pg 297-304. • Bischofberger, A., Savoldelli, G.L., & Irion, O. (2011). Multidisciplinary management of post-partum hemorrhage: new strategies. Rev Med Suisse, 7(281), pg 334-339. • Callaghan, W.M., Kuklina, E.V., & Berg, C.J. (2010). Trends in postpartum hemorrhage: United States, 1994-2006. American Journal of Obstetrics and Gynecology, 202(4), e1-e6. • Centers for Disease Control. http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html, retrieved 3-31-14.

42. References • Clark, et al. (2008). Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. American Journal of Obstetrics & Gynecology, 199(36), 36.e1-36.e5. • Donabedian, A. Retrieved from http://www.ahrq.gov/qual/medteam/medteamfig2.htm • Fahy, K.M. (2009). Third stage of labour care for women at low risk of postpartum hemorrhage. Journal of Midwifery & Women’s Health, 54(5), pg 380-386.

43. References • Geller, S.E. et al. (2004). The continuum of maternal morbidity and mortality: Factors associate with severity. American Journal of Obstetrics & Gynecology, 191(3), pg 939-944. • Healthgrades. (2006, April 5, 2006). Medical Errors Leading Cause of Death in Hospitals, Study Says. Retrieved October 14, 2009, from http://www.kaisernetwork.org/daily_report • Hoyert, D.L. (2007). Maternal mortality and related concepts. Vital Health Stat3. Feb;(33):1-13.

44. References • Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (1999). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press. • Leape, L. (2009). Errors in medicine. Clinica Chimca Acta, 404(1), 2-5.  • Leduc, Senikas, Ballerman, et al. (2009). Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. Journal of Obstetrics and Gynaecology of Canada 31(20). pg 980-983.

45. References • Naz, H., Sarwar, I., Fawad, A., & Nisa, A.U. (2008). Maternal morbidity and mortality due to primary PPH-experience at Ayub teaching hospital Abbottabad. Journal of Ayub Medical College, Abbottabad, 20(2), 59-65. • Prendiville, W., Harding, J. & Elbourne, D, et al. (1988). The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ, 297. pg 1295-1300. • Prendiville, W., Elbourne, D. & McDonald, S. (2000). Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews, 3. • Rajan, P.V. & Wing, D.A. (2010). Postpartum hemorrhage: evidence-based medical interventions for prevention and treatment. Clinical Obstetrics and Gynecology, 53(1), pg 165-181.

46. References • Rath, W.H. (2011). Postpartum hemorrhage-update on problems of definitions and diagnosis. ActaObstetGynecolScand, 90(5), pg 421-428. • Rogers, J., Wood, McCandlish, R. (1998). Active versus expectant management of third stage of labour: the Hinchingbrookerandomised controlled trial. Lancet, 351, pg 693-699. • Rouse, D.J., MacPherson, C., Landon, M, et al. (2006). Blood transfusion and cesarean delivery. Obstetrics and Gynecology, 108. Pg 891-897.

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50. Questions?