Active Management of Third Stage of Labor Cheyanne D. Franklin, BSN Senior Nursing Student School of Nursing, Usha Kundu MD College of Health, University of West Florida SYNTHESIS OF THE EVIDENCE BACKGROUND/SIGNIFICANCE FINDINGS • Healthy People 2020 Goal: Improve the health • Uterine massage did not significantly decrease and well-being of women, infants, children and Article Author Evidence Sample Study Findings Limitations Rating postpartum blood loss, but is still recommended. # & Date Type Size families. • Oxytocin is the first line drug of choice. Level/Quality • Postpartum hemorrhage (PPH) is the leading 1 Saccone et Systematic 3842 Uterine massage was not associated with a significant reduction in Limited | A • Controlled cord traction had no significant effect on cause of maternal morbidity and mortality al, 2017 review and singleton the incidence of postpartum hemorrhage. Administration of evidence postpartum hemorrhage. meta-analysis gestation prophylactic oxytocin at any dose decreases PPH and the need for • Preventable of RCTs therapeutic uterotonics compared with placebo alone. Controlled • Placental blood drainage reduced the duration, • Most cases of morbidity and mortality due to PPH cord traction has the advantage of reducing the risk of manual blood loss, and incidence of postpartum removal of the placenta and of blood loss. Delayed cord clamping occur in the first 24 hours after delivery has been associated with neonatal benefits with no effects on hemorrhage. blood loss. Due to lack of evidence, three standard interventions should be followed: prophylactic oxytocin, DCC, and CCT. 2 WHO, 2012 Systematic Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the | A review prevention of PPH. In settings where skilled birth attendants are available, CCT is recommended for vaginal births if the care CLINICAL QUESTION provider and the parturient woman regard a small reduction in • In postpartum patients (P), is active management blood loss and a small reduction in the duration of the third stage of labor as important. Late cord clamping is recommended for all of the third stage of labor (I) effective in reducing births while initiating simultaneous essential newborn care. postpartum hemorrhage occurrences (O)? Sustained uterine massage is not recommended as an intervention SUMMARY to prevent PPH in women who have received prophylactic I. Recommendation for a more concise definition of oxytocin. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. AMTSL Uterine massage is recommended for the treatment of PPH. II. Possible research using single interventions to measure if one intervention alone decreases 3 Deneux- Multicentre, CCT: Controlled cord traction for the management of placental expulsion The study || A SEARCH STRATEGY Tharaux et RCT had no significant effect on the incidence of postpartum was not postpartum hemorrhage versus multiple 2175 al, 2013 hemorrhage and other markers of postpartum hemorrhage. blinded • An online literature review was conducted. Standard interventions used in combination. • Search Terms: Active management of the placental III. Further research needed on all intervention to assess expulsion effectiveness due to differing results and lack of third stage of labor, interventions, postpartum : 2180 hemorrhage, AMTSL literature. 4 Gülmezoglu RC, non- Simplified The omission of controlled cord traction results in very little || A • EBSCO et al, 2017 inferiority trial package increased risk of severe hemorrhage. Controlled cord traction is • Inclusion criteria: written in English, vaginal group: safe and its use can continue in settings that practice it. Effective 11861 prevention of postpartum hemorrhage can be accomplished with deliveries, peer reviewed, and published from Full an IM injection of oxytocin 10 IU after delivery of the baby. 2008 to 2018. package Teaching of controlled cord traction in medical and midwifery group: curricula should continue. There is a need to focus on strategies to 11820 scale up the use of oxytocin as the primary component of AMTSL. This study did not examine the role of uterine massage in reducing REFERENCES blood loss. Deneux-Tharaux, C., Sentilhes, L., Maillard, F., Closset, E., Vardon, D., Lepercq, J., & Goffinet, F. (2013). Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR). BMJ: British Medical Journal, 14. 5 Roy, 2016 Prospective Study Placental blood drainage as part of active management of the third || A Gülmezoglu, A. M., Lumbiganon, P., Landoulsi, S., Widmer, M., Abdel-Aleem, H., Festin, M., … Elbourne, D. (2012). Articles: RCT Group: stage of labor was effective in reducing he duration, the blood loss, Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, IMPLICATIONS FOR PRACTICE non-inferiority trial. The Lancet, 379, 1721–1727. https://doi.org/10.1016/S0140-6736(12)60206-2 100 and also the incidence of postpartum hemorrhage. Roy, P., Sujatha, M. S., Bhandiwad, A., Biswas, B., & Chatterjee, A. (2016). Placental Blood Drainage as a Part of Active Management of Third Stage of Labour After Spontaneous Vaginal Delivery. Journal of Obstetrics and Gynecology of • Assess physician adherence to guidelines Control India, (1), 242. Group: Saccone, G., Caissutti, C., Ciardulli, A., Abdel-Aleem, H., Hofmeyr, G., & Berghella, V. (2018). Uterine massage as part of • Healthcare facilities should adopt a formal protocol active management of the third stage of labour for preventing postpartum haemorrhage during vaginal delivery: a 100 systematic review and meta-analysis of randomised trials. BJOG: An International Journal of Obstetrics and for the management of PPH Gynaecology, (7), 778. 6 Tenaw, Cross Sectional 528 The knowledge and practice of obstetric care providers towards ||| A World Health Organization. (2012). WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. Retrieved from • Simulations of PPH and treatment may be included Zelalem et al, Study Obstetric active management of third stage of labor can be improved with https://login.ezproxy.lib.uwf.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=235 2017 care appropriate interventions like in-service trainings. The level of 86122&site=eds-live in pre-service and in-service training programs Zelalem Tenaw, Zemenu Yohannes, & Abdela Amano. (2017). Obstetric care providers’ knowledge, practice and associated providers knowledge and practice needs immediate attention of universities factors towards active management of third stage of labor in Sidama Zone, South Ethiopia. BMC Pregnancy and • Education of controlled cord traction should and health science colleges to revise obstetrics course content. Childbirth, Vol 17, Iss 1, Pp 1-7 (2017), (1), 1. https://doi.org/10.1186/s12884-017-1480-8 continue in medical and midwifery curricula.