References

Anderson O, Hellstrom-Westas L, Andersson D, Domellöf M. Effects of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months. British Medical Journal. 2011; 343

Begley C. A comparison of active and physiologica’ management of the third stage of labour. Midwifery. 1990; 6:(1)3-17

Begley C, Devane D, Clarke M. An evaluation of midwifery-led care in the health service executive north eastern area: the report of the MidU study.Dublin: Health Service Executive; 2009

Begley C, Devane D, Clarke M Comparison of midwife-led and consultant-led care of healthy women at low risk of childbirth complications in the Republic of Ireland: a randomised trial. BMC Pregnancy and Childbirth. 2011a; 11:85-94

Begley C, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews. 2011b;

Begley C, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews. 2015;

Begley C, Gyte GML, Devane D, McGuire W, Weeks A, Biesty LM. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews. 2019;

Blackburn S. Physiological third stage of labour and birth at home. In: Edwins J (Ed). Oxford: Blackwell; 2008

Buckley S. Undisturbed birth – nature's hormone blueprint for safety, ease and ecstasy. MIDIRS Midwifery Digest. 2004; 14:(2)203-209

Buckley S. Gentle birth, gentle mothering: a doctors guide to natural childbirth and gentle parenting choices.CA, USA: Celestial Arts; 2009

Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. 2015. https://www.nationalpartnership.org/our-work/resources/health-care/maternity/hormonal-physiology-of-childbearing.pdf (accessed 8 September 2021)

Chararro CM, Neufeld LM, Tena Alavez G, Eguia-Líz Cedillo R, Dewey KG. Effects of timing of the umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet. 2006; 367:(9527)1997-2004

Cunningham FG, Williams JW. Williams Obstetrics, 21st ed. New York, USA: McGraw-Hill; 2001

Davis D, Baddock S, Pairman S Risk of severe postpartum hemorrhage in low-risk childbearing women in New Zealand: exploring the effect of place of birth and comparing third stage management of labor. Birth. 2012; 39:(2)98-105

Dixon L, Fletcher L, Tracy S, Guilliland K, Pairman S, Hendry C. Midwives care during the third stage of labour: An analysis of the New Zealand College of Midwives Midwives Database 2004-2008. New Zealand College of Midwives Journal. 2009; 41:20-25

Dixon L, Tracy S, Guilliland K, Fletcher L, Hendry C, Pairman S. Outcomes of physiological and active third stage labour care amongst women in New Zealand. Midwifery. 2013; 29:67-74

de Groot AN, van Roosmalen J, van Dongen PW, Borm GF. A placebo-controlled trial of oral ergometrine to reduce postpartum hemorrhage. Acta Obstetricia et Gynecologica Scandinavica. 1996; 75:464-468

Fahy K, Hastie C, Bisits A, Marsh C, Smith L, Saxton A. Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study. Women and Birth: Journal of the Australian College of Midwives. 2010; 23:(4)146-52

Farrar D, Airey R, Law GR, Tuffnel D, Cattle B, Duley L. Measuring placental transfusions for term babies: weighing babies with cord intact. British Journal of Obstetrics and Gynaecology. 2011; 118:70-75

Fry J. Physiological third stage of labour: support it or lose it. British Journal of Midwifery. 2007; 15:(11)693-5

Gottvall K, Waldenström U, Tingstig C, Grunewald C. In-hospital birth center with the same medical guidelines as standard care: A comparative study of obstetric intervention and outcomes. Birth: Issues in Perinatal Care. 2011; 38:(2)120-128

Grigg CP, Tracy SK, Tracy M, Daellenbach R, Kensington M, Monk A, Schmied V. Evaluating maternity units: a prospective cohort study of freestanding midwife-led primary maternity units in New Zealand clinical outcomes. BMJ Open. 2017; 7:(8)

Homer CS, Leap N, Edwards N, Sandall J. Midwifery continuity of carer in an area of high socio-economic disadvantage in London: A retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997-2009). Midwifery. 2017; 51

Inch S. Management of the third stage of labour-another cascade of intervention?. Midwifery. 1985; 1:(2)114-122

International Conference of Midwives and International Federation of Gynecology and Obstetrics. Management of the third stage of labour to prevent postpartum haemorrhage. 2003. https://sogc.org/wp-content/uploads/2013/02/136E-JPS-November2003.pdf (accessed 8 September 2021)

International Conference of Midwives and International Federation of Gynecology and Obstetrics. Prevention and treatment of postpartum haemorrhage: new advances for low-resource settings. 2006. http://www.who.int/pmnch/events/2006/figo2006statementeng.pdf (accessed 8 September 2021)

Kanikosamy F. Third stage: the why of physiological practice. Midwives. 2007; 10:(9)422-5

Khan L. Anemia in Childhood. Pediatric Ann. 2018; 47:(2)e42-e47

Kataoka Y, Masuzawa Y, Kato C, Eto H. Maternal and neonatal outcomes in birth centers versus hospitals among women with low-risk pregnancies in Japan: A retrospective cohort study. Japan Journal of Nursing Science. 2018; 15:(1)91-96

Laws PJ, Xu F, Welsh A, Tracy SK, Sullivan EA. Maternal morbidity of women receiving birth center care in New South Wales: a matched-pair analysis using linked health data. Birth. 2014; 41:(3)268-275

McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews. 2013; https://doi.org/10.1002/14651858.CD004074.pub3

Mercer JS, Erickson-Owens DA, Deoni SCL The Effects of delayed cord clamping on 12-month brain myelin content and neurodevelopment: a randomized controlled trial. American Journal of Perinatology. 2020;

Monk A, Tracy M, Foureur M, Grigg C, Tracy S. Evaluating Midwifery Units (EMU): a prospective cohort study of freestanding midwifery units in New South Wales, Australia. British Medical Journal Open. 2014; 4:(10)

Narasimhan SR, Govindaswami B, Vallejo M Long-term neurodevelopment outcomes at 18 to 36 months of life in extremely low birth weight infants who received delayed cord clamping for a minimum of 30 and 60 seconds. Pediatrics. 2019; 144

National Collaborating Centre for Women and Children's Health. Intrapartum care, Care of Healthy women and their babies during childbirth. 2014. https://www.nice.org.uk/guidance/cg190/evidence/full-guideline-248734765 (accessed 8 September 2021)

National Institute for Health and Care Excellence. Intrapartum Care for healthy women and babies. 2017. https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#third-stage-of-labour (accessed 8 September 2021)

Oishi T, Tamura T, Yamamoto U. Outcomes of blood loss post physiological birth with physiological management in the third stage of labour at a maternity home in Japan. New Zealand College of Midwives Journal. 2017; 53:23-29

Prendiville WJP, Elbourne D, McDonald SJ. Active versus expectant managements in the third stage of labour. Cochrane Database of Systematic Reviews. 2000;

Prendiville WJP, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: Active versus physiological management of the third stage of labour. British Medical Journal. 1988; 29:295-300

Razvi K, Chua S, Arulkumaran S, Ratnam SS. A comparison between visual estimation and laboratory determination of blood loss during the third stage of labour. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2008; 36:(2)152-4

Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of the third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet. 1998; 351:(9104)693-699

Royal College of Midwives. Midwifery Blue Top Guidance, No 1. 2018. https://www.rcm.org.uk/media/2539/professionals-blue-top-guidance.pdf (accessed 8 September 2021)

Royal College of Obstetrics and Gynaecology. Prevention of postpartum haemorrhage. 2016. http://onlinelibrary.wiley.com/ (accessed 8 September 2021)

Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Databaseof Systematic Reviews. 2016;

Schorn MN. Measurement of blood loss: review of the literature. Journal of Midwifery & Women's Health. 2010; 55:(1)20-27

Shallows H. The birth centres project, 4th ed. In: Kirkham M (ed). Oxford: Oxford Books for Midwives; 2003

Thilaganathan B, Cutner A, Latimer J, Beard R. Management of the third stage of labour in women at low risk of postpartum haemorrhage. European Journal of Obstetrics and Gynecology and Reproductive Biology. 1993; 48:19-22

Uvnas Moberg K. The oxytocin factor: tapping the hormone of calm, love and healing.London: Pinter and Martin Ltd; 2011

Walsh D. Evidence and skills for normal labour and birth, A guide for midwives, 2nd ed. London: Routledge; 2012

Werner EJ. Disorders of the fetomaternal unit. In: de Alarcon PA, Werner EJ (Eds). Cambridge: Cambridge University Press; 2005

Winter C, Macfarlane A, Deneux-Tharaux C Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. British Journal of Obstetrics and Gynaecology. 2007; 114:(7)845-54

Care in normal birth: a practical guide. report of a technical working group.Geneva: World Health Organization; 1997

World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012. http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf?ua=1 (accessed 8 September 2021)

World Health Organization. Guideline: delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. 2014. https://apps.who.int/iris/bitstream/handle/10665/148793/9789241508209_eng.pdf (accessed 27 September 2021)

World Health Organization. WHO recommendations on intrapartum care for a positive childbirth experience. 2018. https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf (accessed 8 September 2021)

A review of third stage of labour care guidance

02 October 2021
Volume 29 · Issue 10

Abstract

Introduction

Concerns exist regarding the suitability of national and international guidance informing third stage of labour care for women at low risk of postpartum haemorrhage.

Methods

The robustness and appropriateness of the research evidence underpinning third stage of labour care guidance by institutions such as the National Institution for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives was assessed and areas for further research to address any gaps in knowledge were identified.

Results

National and international third stage of labour practice guidance recommend active management for all women. This may not be suitable for women at low risk of postpartum haemorrhage giving birth in a midwife-led unit or a home birth setting. This is because of the reduced reliability, validity and generalisability of the evidence informing this guidance to this group of women.

Conclusions

Expectant management may be more appropriate for women at low risk of postpartum haemorrhage who choose to birth in a midwife-led unit or home birth setting and want to experience a birth with minimal intervention. However, more research into third stage management practices in these settings is needed.

Labour is traditionally divided into three artificial stages. The first stage consists of the woman in labour experiencing regular, painful contractions, with progressive cervical dilation from 4 cm until fully dilated at 10 cm. The second stage continues from when the woman's cervix is fully dilated until the birth of the baby. The third stage is the period of time between the birth of the baby and the delivery of the placenta and membranes (National Institute for Health and Care Excellence (NICE), 2017). There is always some blood loss during this third stage, and healthcare professionals' care aims to reduce excessive blood loss. In clinical practice, care is managed by two distinct clinical approaches: active management and expectant management, often referred to as physiological management (Begley et al, 2019). This paper reviews evidence on the effectiveness of these approaches and the implications of this research for current practice guidelines for women at low risk of postpartum haemorrhage who choose to birth in a midwife-led unit or home birth setting and want to experience a birth with minimal intervention.

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • New content and clinical newsletter updates each month