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Third stage of labour management approaches and postpartum haemorrhage in midwife-led units

02 May 2022
13 min read
Volume 30 · Issue 5

Abstract

Background

National and international guidelines advise active management of the third stage of labour. Studies conducted in obstetric-led units reveal evidence for reductions in primary postpartum haemorrhage with active management compared to expectant management. The association in midwife-led units for low-risk women is relatively untested in the UK.

Aims

To examine the relationship between third stage of labour management approaches, and incidence of postpartum haemorrhage and severe postpartum haemorrhage in women birthing in midwife-led units.

Methods

Anonymised data were collected in 2015–2016 from women birthing in England. Adjusted logistic regression was used to assess the effect of management approach on the outcomes of postpartum haemorrhage and severe postpartum haemorrhage, controlling for variables additionally identified as risk factors for postpartum haemorrhage.

Results

Of the 765 women intending to receive active management and the 508 intending to receive expectant management, 9.54% and 14.0% experienced postpartum haemorrhage respectively (P=0.015). Severe postpartum haemorrhage was experienced by 14 (1.83%) women intending to receive active management and 16 (3.66%) intending to receive expectant management (P=0.134).

Conclusions

Postpartum haemorrhage, but not severe postpartum haemorrhage, was statistically significantly higher in women birthing in midwife-led units intending to receive expectant management.

Active management of the third stage of labour is advised by national and international third stage of labour practice guidelines and recommendations (World Health Organization (WHO), 2012; 2018; Royal College of Obstetrics and Gynaecology (RCOG), 2016; National Institute for Health and Care Excellence (NICE), 2017; Royal College of Midwives (RCM), 2018). This is a result of evidence provided by research studies conducted in obstetric-led units, which found evidence for a reduction in blood loss (primary postpartum haemorrhage) and treatment of this excessive blood loss after the birth of the baby with active management compared to expectant management (Prendiville et al, 1988; Thilaganathan et al, 1993; de Groot et al, 1996; Rogers et al, 1998; Prendiville et al, 2000; Begley et al, 2010; 2011a; 2015). However, research studies have reported many beneficial outcomes for healthy women at low risk of obstetric complications, who plan to give birth away from hospital obstetric-led units, particularly for women who choose to birth in midwife-led units (Brocklehurst et al, 2011; Hollowell et al, 2011; Hodnett et al, 2012; Christensen and Overgaard, 2017). Consequently, it has been suggested that the generalisability of these research studies and the guidelines for which they provide evidence may not be generalisable to women who have a normal physiological birth and choose to birth away from a hospital obstetric-led unit (Baker and Stephenson, 2022).

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