Evidence to Support Active Management of Third Stage of Labor (AMTSL) Name of presenter Prevention of Postpartum Hemorr

1. Evidence to Support Active Management of Third Stage of Labor (AMTSL)Name of presenterPrevention of Postpartum Hemorrhage Initiative (POPPHI) Project Adapted from JHPIEGO. Active Management of the Third Stage of Labor: Advances in Maternal and Neonatal Health. Available at: http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/3rdstagepg.htm. Accessed March 12, 2008.

2. Session Objectives By end of the session, participants will have reviewed: • Definition of third stage of labor • Physiologic vs. active management of the third stage of labor • Evidence to support promotion of active management of the third stage of labor (AMTSL)

3. Third Stage of Labor • Definition: The third stage of labor begins with birth of the newborn and ends with the delivery of the placenta and its attached membranes.

4. Two Methods of Third Stage Management • Physiologic (“expectant”) management • Uterotonic drugs are not used before delivery of the placenta • Placenta is delivered by gravity and maternal effort • Cord is clamped after pulsation has ceased • Fundal massage may be provided after delivery of the placenta • Active Management • Uterotonic drug is given within one minute after birth of the baby • Cord is cut when it ceases to pulsate or 2–3 minutes after the baby’s birth, whichever comes first. • Placenta is delivered by controlled cord traction (CCT) with counter-traction to the uterus • Uterine fundal massage provided after delivery of the placenta

5. Physiologic Management: Advantages and Disadvantages • Advantages • Does not interfere with normal labor process • Does not require special drugs/supplies • Disadvantages • Increases length of third stage • Increases risk of postpartum hemorrhage (PPH)

6. Active Management: Advantages and Disadvantages • Advantages • Decreases length of third stage • Decreases risk of PPH • Disadvantages • Requires uterotonic drug and items needed for injection • Requires a birth attendant with skills in: • Observation • Giving an injection • CCT

7. Active vs. Physiologic Management: The Bristol and Hinchingbrooke Trials • Bristol trial: 1695 women, Hinchingbrooke trial: 1512 women randomly assigned to: • Active management • Physiologic management Prendiville et al 1988; Rogers et al 1998.

8. Active vs. Physiologic Management: The Bristol Trial Objective Compare effects of fetal and maternal morbidity of: • Routine active management • Physiologic management Prendiville et al 1988.

9. The Bristol Trial: Details of Active Management • Try to give one ampule of uterotonic (5 units oxytocin and 0.5 mg ergometrine routinely or 10 units synthetic oxytocin if mother has high BP) immediately after delivery of anterior shoulder • Try to clamp cord 30 seconds after delivery of baby • When uterus has contracted, try to deliver placenta by CCT with protective hand on abdomen helping to shear off placenta and preventing uterine inversion • Try not to give any special instructions about posture Prendiville et al 1988.

10. The Bristol Trial: Details of Physiologic Management • Try not to give uterotonic • Try to leave cord attached to baby until placenta is delivered • Try not to use CCT or any manual interference with uterus at fundus • Try to encourage mother to concentrate on feeling for next contraction or urge to push • When mother feels contraction or urge or there are signs of separation, encourage mother and help her change posture • If placenta does not deliver spontaneously, wait, try putting baby to breast and encourage maternal effort Prendiville et al 1988.

11. Active vs. Physiologic Management: Postpartum Hemorrhage Prendiville et al 1988; Rogers et al 1998.

12. Active vs. Physiologic Management: Results

13. Active vs. Physiologic Management: The Bristol and Hinchingbrooke Trials • Conclusion: • Active management of the third stage reduces the risk of PPH • There is an increased risk of PPH associated with physiologic management • There is an increased need of blood transfusion associated with physiologic management • Oxytocin is the drug of choice for active management • There was no increase in entrapment of the placenta with active management

14. Seeking solutions for births that occur without skilled care Why do we need to seek solutions for births that occur without skilled care? • We cannot predict PPH on the basis of risk factors. • In many countries very few deliveries are attended by a skilled attendant. • Once severe PPH occurs, death follows very rapidly • Timely referral and transport to facilities is not available or affordable • Availability of emergency obstetric care services is grossly limited.

15. Summary of WHO Recommendations- October 2006 Technical Consultation • Active management of the third stage of labor should be offered by skilled attendants to all women. • In the absence of AMTSL, a uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH.

16. Simple steps… a balanced approach to PPH prevention An evidence-based intervention for skilled birth attendants (SBAs), combined with a community-based strategy, can prevent 50-60 % of PPH • Active management of the third stage of labor for SBAs • Community-based distribution of misoprostol

17. A Randomized Placebo-Controlled Trial of Oral Misoprostol 600 mcg for Prevention of PPH Belgaum District, Karnataka India

18. Evidence from community based PPH prevention programs Country example: Indonesia Safety: No women took oral misoprostol at wrong time Acceptability: women who used oral misoprostol said they would recommend it and purchase the drug for future births Feasibility: Community volunteers successfully offered information about PPH and safely distributed oral misoprostol Effectiveness: the combination of skilled providers using oxytocin and community distribution of misoprostol allowed 94% coverage with PPH prevention method In partnership with Depkes, POGI, IBI & supported by USAID through the MNH program Sanghvi et al 2004

19. Critical issues pertaining to choice for managing the third stage of labor (1) • Choice of active vs. physiologic management • Different theoretical advantages and disadvantages for each • Theoretical potential risks of each • Entrapment of placenta • Avulsion of cord • Uterine inversion • Issues surrounding use of a uterotonic agent • Choice of the uterotonic drug to use will depend upon cost, stability, safety and side effects • Choice and/or use of an uterotonic drug will depend upon cadres of birth attendants authorized to administer specific uterotonic drugs and facilities authorized to carry them

20. Critical issues pertaining to choice for managing the third stage of labor (2) • Issues if a skilled birth attendant is not available • Controlled cord traction should only be performed by a skilled birth attendant • Giving a uterotonic drug (oxytocin or misoprostol) without controlled cord traction can still reduce blood loss • Women and/or community health workers can be trained in the correct use of misoprostol after birth of the baby • Issues if no uterotonic drug is available • Limited/unproven benefit of nipple stimulation for reduction of maternal blood loss but clear benefits for baby • CCT not recommended if no uterotonic available • Fundal massage after delivery of the placenta is recommended even if no uterotonic available

21. Summary Physiologic management • Advantages • Does not interfere with normal labor process • Does not require special drugs/supplies • Delay in cord clamping may increase newborn hemoglobin • May be appropriate if baby not breathing immediately after delivery • Disadvantages • Increases length of third stage • Increases risk of postpartum hemorrhage (PPH) Active management • Advantages • Decreased length 3rd stage • Decreased average blood loss & fewer cases of PPH • Decreased need for blood transfusion • No apparent disadvantages for baby • Disadvantages • Requires uterotonic drug • If injectable uterotonic, requires items needed for injection • Requires a birth attendant with skills in: • observation • giving an injection • controlled cord traction

22. Conclusions • Active management of third stage reduces risk of PPH by: • Reducing length of third stage • Reducing average blood loss • Reducing the risk for retained placenta • Reducing the need for therapeutic uterotonics • Active management of the third stage of labor should be offered by skilled attendants to all women • In the absence of AMTSL, a uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH.

23. References Gouder et al. 2007. Experiences from Oral Misoprostol for PPH Prevention Study at Belgaum, India. Lancet Khan GQ et al. 1997. Controlled cord traction versus minimal intervention technique in delivery of the placenta: A randomized controlled trial. Am J Obstet Gynecol 177(4): 770–774. McDonald S, W Prendiville and D Elbourne. 2000. Prophylactic syntometrine versus oxytocin for delivery of the placenta (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford. McDonald et al. 1993. Randomized controlled trial of oxytocin alone versus oxytocin and ergometrine in active management of third stage of labor. BMJ 307(6913):1167–1171. Prendiville et al. 1988. The Bristol third stage trial: active versus physiological management of the third stage of labor. BMJ 297:1295–1300. Rogers J et al. 1998. Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351(9104): 693–699.

24. References (continued) Sanghvi H, Wiknjosastro G, Chanpoing G, Fishel J, Ahmed S. Prevention of postpartum hemorrhage study: West Java, Indonesia. Baltimore, MD: JHPIEGO; 2004. World Health Organization (WHO). 1993. Stability of injectable uterotonics in tropical climates: Results of field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin. WHO: Geneva. International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO; 2006. Available at: www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed April 2, 2007.