The Effect of Active Management of the Third Stage of Labour on Maternal Morbidity and Mortality - Coursework Example

The Effect of Active Management of the Third Stage of Labour on Maternal Morbidity and Mortality Name: Date: Affiliation: The Effect of Active Management of the Third Stage of Labour on Maternal Morbidity and Mortality Introduction The third stage of labour consists of the period following the delivery of the neonate, up until the subsequent expulsion of the placenta and its attached membranes (Macdonald and Magill-Cuerden, 2011).Complications can accompany this stage and if not managed safely, this can lead to maternal morbidity and mortality ( Gulmezoglu et al.,2012). Therefore, effective management during this stage remains a critical component of the delivery process (Abalos, 2012). There are two ways of managing third stage of labour that is active and physiological (pregnant) management (Matar et al., 2010). According to Darrent valley Hospital (DVH) Trust policy (2012) active management should involve the use of uterotonic drugs prior to the delivery of the placenta and membranes, clamping and cutting the cord within three minutes following the birth of the neonate and also delivery the placenta by control cord traction. The active management is recommended by National Institute for Clinical Excellence (2011) because it reduces the risk of post-partum haemorrhage and shortens the third stage of labour. This is supported by systematic study, which reveals that, there is a significant reduction of primary blood loss greater than 700mls in a population of women at risk of post-partum haemorrhage (Begley et al, 2011).Nevertheless postpartum haemorrhage is one of the leading causes of maternal mortality, it occurs in about 10.5% of birth and account for over 13 000 maternal mortality annually (WHO, 2007).As a result, the routine use of active management is widely recommended.This care approach is in contrast to expectant management, which involves waiting for signs of placenta separation that enable the placenta to be delivered spontaneously by maternal effort and through the use of gravity (Prendiville et al., 2009). Moreover, the cord should not be clamped until pulsation has ceased (RCOG, 2011). The proposed advantages of active management include a reduced risk of significant postpartum haemorrhage, as well as its assumed benefits in hospitals with lower resources, where delivery-related deaths are far more common (Alfaifel, 2012). However, some debate exists as to the efficacy of this approach versus expectant management, and some of the benefits of active management have been called into question by leading researchers in the field (Breathnach& Geary, 2009). Furthermore, the potential dangers involved with uterine-relaxing agents, risks associated with cord-clamping and risks associated with controlled cord traction. Stanton et al,2009), demonstrated the lack of knowledge of effective active management strategies in low-resource countries such as Nicaragua and India has limited the effectiveness of this approach; while subsequently increasing the risk of mortality to the mother. Therefore, continued research is paramount in attempt to explore the possible use of this approach in both low- and high-resource areas alike (Stanton et al., 2009). Consequently, the aim of writing this topic is to systematically study how active third stage impact on women morbidity and mortality; and also to assess the effectiveness of active versus expectant management. Drawing on contemporary empirical studies, this dissertation seeks to explore the renowned practical and theoretical implications of active management, as well as advantage and disadvantage of this approach in applied settings. Policies and guideline regarding the procedures will be discussed and both local and international active management research will be considered. Gaps in literature will be highlighted throughout, and recommendations will be provided. Literature review on Active Management of the Third Stage of Labour on Maternal Morbidity and Mortality In an attempt to describe third stage of labour, morbidity and mortality, it is important to understand the underlying meaning of these terms since its only better comprehension, we will be in a position to grasp the whole and come up with strategies that will alleviate the process if not entirely solving the challenge. First, the third stage of labour refers to the time that follows the full delivery of the newly born child and also the delivery of the placenta. It is discovered that little commitment has been exerted on this stage compared on the first and second stages, yet it is one of the most important stages of delivery (Brown 2003, Pg 27). It is not possible work hard and when you are about to get the wages you vanish away. Therefore, most doctors have been doing the same thing hence ending up in cases of morbidity and prenatal mortality. Leading North American obstetrics text has only devoted only four pages out of the 1500 to the third stage of labour but significantly he has touched the complications that arise instantly after delivery. An anonymous author asserted that the third stage of labour is the most unforgiving and care and concern should be given an upper hand always (Clark 2006, pg.23). He continued and said that here; all treachery lies combined with those of the previous stages and, therefore, it is the most sensitive case. In this stage, a normal delivery can turn out to be disastrous in the next minute. Another most interesting aspect of the third stage is the discrepancy that is mostly marked as the appropriate optimal conduct. There is always a clear division which exists between the authorities who advocate for the psychological approach and also those who advocate for the active approach to the management. Management strategies might be controversial for disagreement to continue especially when compelling evidence is supporting one of the two approaches. Basically, third stage of labour starts when delivery of the foetus is full and the uterus and uterus and its attached membranes are removed (Fraser et al 2009, pg 44). From a practical perspective, a clinician is able to see complications some time after delivery of the latter mentioned above and the risk of complication to the mother and the child is at hand after few moments after infection. As a result, many authorities are advocating for the fourth stage of delivery that begins and lasts arbitrary few hours the delivery of the placenta. The most commonly accepted is duration for many mothers is one hour though some may go to as long as four hours. The real of the third stage is usually 5-15 minutes while the absolute time for the delivery of placenta remains unclear though, at normal cases-without, breeding-thirty to sixty minutes are advocated(Fraser et al 2009, pg 44). The third and fourth stages of labour are basically uneventful, though, at times, significant complications may occur at this particular time. The most common example is the postpartum haemorrhage (PPH) and it has continued to be a great cause of the maternal mortality rate. However, it should be noted that maternal mortality rate in developed countries has reduced though it has predominantly continued to be the leading cause of many deaths. The pregnancies that are related to direct maternal mortality rate are approximately 7-10 women out 100,000 live births. The national statistics affirm that approximately 8% of the deaths are caused by the PPH and that is in developed countries like US and Britain. In African countries and some developing countries, maternal mortality rates are very high whereby 1000 women out of 100,000 live births die. This is according to World Health organisation (WHO).Furthermore, (WHO) asserts that 25% of the maternal deaths are attributed to PPH and cumulatively, it accounts for more than 100,000 maternal deaths annually. The deaths of these particular mothers usually stick serious implication on the newborn and any other child who could be surviving (Geller et al 2003, pg 33). Various complications are usually encountered during the third stage of labour and this may lead to maternal morbidity-the second term that should be understood critically.PPH may lead to anaemia or lead to poor reserves of iron that is fatal. Little levels of iron in the blood stream lead to anaemia and if not distinguished early enough it is fatal. Anaemia causes weakness and fatigue and, therefore, prolonging hospitalisation (Gulmezoglu 2009, pg 37). At the same time breastfeeding the child becomes difficult and, therefore, contributing to morbidity and eventually mortality. Blood transfusion may reduce the span of living in the hospital but the same time it may make somebody prone to infections and transfusion reaction such as the Rhesus factor. Accessing a safe blood is not guaranteed and at the same time PPH can strain the blood bank resources. In the cases of severe PPH, uterine inversion usually requires emergency anaesthetic services. When the uterus and is instrumented, it increases the risk of sepsis that is dangerous to the life of the mother (Gulmezoglu 2009, pg 39). Physiology and the third stage of birth during the time of pregnancy, maternal blood usually increases by high volumes of about 50% i.e. from four litres to around six litres. More also, the plasma volume increases more than the actual total of the RBC volume and this leads to the fall in haemoglobin concentration according to the hematocrit values. The decrease is usually smaller to those women who take supplemental iron while the decrease is usually high especially to those women who do not take supplemental iron. Those who have limited iron stores usually become anaemic upon becoming pregnant. The increase in blood levels leads to effective perfusion demands of the low-resistance utero placental units which provide reserve for the blood during delivery. The increased volume of blood also acts against hypotension that is caused by the decreased venous return and reduced vascular escalated levels of progesterone (Gupta 2012, pg 14). There are changes that also occur in the coagulation system which marks an increase in the clotting factors and general decrease in the fibrinolytic activities. The count of the platelets may fall slightly during pregnancy as a result of dilution that is related to the increased volume of plasma and consequential low –grade consumption. However, different platelet volume is added and the activities are maintained (Htay 2007, pg 14). Although, at times, uterine contraction is first responsible for controlling the blood loss at the placental site, formation of clots and deposition of fibrin occurs rapidly and they are essential in the maintenance of homeostasis and the ultimate maintenance of involution in the following days of delivery. Early pregnancy is when the uterus grows dramatically from its original small weight of around 70g and a cavity that is barely 10Ml for a weight totalling to1.1kg and a capacity of around five litres. As the haematological and coagulation continues to increase, high levels of oestrogen promotes allows and enhance changes in the uterus. The preliminary growth of the uterus and final growth of the placenta require quite impressive high inflow of blood during the pregnancy. During pregnancy, the estimated flow of flood to the uterus is actually 500-800 ml per minute that turns out to be at least 10-15% of the cardiac output. However, it should be noted that most of this blood usually transverses in the low resistance placental bed (Htay 2007, pg 14). Upon the delivery of the foetus, the uterine contractions persist and this is meant to shear the placenta from the endometrial. The separation ideally occurs through reduction of the surface area of the placenta site as the uterus continues to shrink. The decrease is attributed to the myometrial contraction which is one of the unique features of the uterus. Through this, the placenta is usually undermined and propelled into the lower section of the uterine segment. The second mechanism which is behind separation is through hematoma formation which is made as a result of venous occlusion and the rupture of placental bed which is usually caused by the uterine contractions (Huda 2012, pg 13). As the placenta continues to detach itself, the spiral arteries are exposed in the placental bed and uncontrolled haemorrhage might occur it caution is not taken. The blood vessels which supply placental bed transverse a complicated lattice work of crisscrossing muscle bundles which occlude and ultimately kink-off the blood vessels they retract and contract after expulsion of the placenta. This complicated arrangement of the muscle bundles has been commonly known as the living ligatures or the physiologic sutures of the uterus. The several causes that can be attributed to uterine contraction and one of them are the sensitivity of the myometrium to the oxytocin hormone. Nonapeptide is usually produced in the posterior end of the pituitary gland and these increases greatly in the cases of late pregnancy and more also during the labour. Exogenous and prostaglandins which are locally produced more also the F series also prompt myometrial contraction after birth (Huda 2012, pg 13). The synthetic ergot alkaloids usually cause very strong titanic contractions of the entire uterus. The agents who are responsible for uterine relaxation are toxic since they can lead to bleeding immediately after delivery. Some Beta-sympathomimetics such as the ritodrine, salbutamol, terbutaline, usually help relax the uterus through beta-2-stimulation.Nonsteroidal anti-inflammatory agents usually have a dual action which has both antiplatelet and antiprostaglandin activities. The primary effects usually make them useful in treating after pains and dysmenorrhea which occurs due to uterine cramping. However, in the postpartum season, especially following the PPH, massive and strong uterine contraction is desired. The antagonists of calcium such as nifedipine and magnesium sulphate also inhibit uterine contractions (Huda 2012, pg 13). Most of the women who deliver at the risk of developing third stage labour. The complications include PPH, retention of placenta and the inversion of the uterus. Some other conditions that are usually manifested include the placenta accrete and the variants. Risk factor which numerable may be found in articles which in dwelling many on different complications. It should be noted that third stage labour morbidity and mortality is exhibited in low-risk mothers and it is paramount for caregivers and institutions to formulate strategies that will deal with these problems upon eruption. Third stage of labour is a critical phase and, therefore, considering the following characteristics is pivotal in attempt to notice placental separation (Hunt 2013, pg 24). First and most reliable sign of placental separation is the lengthening of the umbilical cord because the placenta is separating and it is being pushed into lower region of the uterine segment as a result of the uterine retraction. Placing clamp on near perineum makes it swifter to determine the lengthening. However, it should be noted that you should never place the traction on the cord before counter traction of the uterus which is above the symphysis which otherwise may mistake the lengthening of the cord as a result of the impeding inversion of the uncomplicated separation of the placenta. The second sign is whereby the uterus takes more globular shape and it continues to become firm. This happens when the placenta descends in the final lower segment of the body and the uterus continues to retract and the change is difficult to clinically determine. The third characteristic is whereby the uterus rises in the abdomen and finally it descends into the lower sections and finally it moves out through the vagina. Gush of blood usually occurs and the retro placental clot is able to move out as the placenta is descending into the lower uterine segment. The retro placental clot is usually made at the centre and it escapes through complete separation. However, if the blood finds a way to move out, it might move out and this is not a good indicator of complete separation. This occurrence is at times associated with increased haemorrhage and prolonged third stage (Hunt 2013, pg 24). Management of the Third Stage of Labour on Maternal Morbidity and Mortality it is paramount to commence the preparation of the third stage of labour long before the child has been delivered. During the ante partum period, it is good to discuss with the patient and the partner regarding the delivery of the child in case of complications might occur and affect the woman. The discussion should be through and variations or concerns should be brought to book. It is essential for the patient to grasp the underlying risks if the management options tend to be limited (Kehoe 2010, pg 33). Active management versus the psychological aspect There is a controversy that surrounds third stage management between the authorities who advocate for the physiological approach and those who advocate for the active approach. It should be noted that the proponents of the psychological management posit that natural processes promote the healthy disintegration and delivery of the placenta hence culminating to fewer complications. Developments of PPH lead to effective management of available drugs and techniques. These proponents assert that active management usually increase the PPH and uterine rates of inversion due to cord traction and this increases the chances where the placenta may be retained as a result of the entrapment that is attributed to uterotonic agents. The delivery of the placenta usually occurs through uterine contractions and the maternal expulsive efforts and at this moment traction is usually prohibited (Kehoe 2010, pg 30). The concern also exists regarding the cases of undiagnosed second twin if by chance uterotonics are used routinely at the moment of delivery. The advocates of the active management posit that administering prophylactic uterotonic agents leads to strong uterine contractions therefore leading to hasty retraction and delivery of the placenta. This will increase the amount of blood that is lost and also the rate of PPH is decreased. More also active management leads to effective uterine activities therefore leading to the reduction in the cases of retention of the placenta (Kehoe 2010, pg 32). The gentle cord traction is only applicable when the uterus has contracted well enough and it is manually manipulated above the level of the symphysis with a particular counteraction (Brandt-Andrews maneuver).The maneuver is commonly referred to as the controlled cord traction (CCT).It should be noted that Cord traction should not be used in the absence of the counteraction and it is usually applied in the axis of the woman’s birth canal. Researchers affirm that undiagnosed second twin is dangerously rare problem that a clinical assessment in the labour should take into account before use of the uterotonic administration (Kehoe 2010, pg 33). Several large and randomized trials have addressed the big question of whether physiological management or active management is the best to administer during the third stage of labour. The trials have affirmed that active management is more advantageous when compared to physiological management. The named trials have used ergonovine, oxytocin or the renowned Syntomterine which is a combination of ergometrine and oxytocin. Researchers and gynaecologists have affirmed that there is significant reduction in blood loss that is greater than 500ml when active control is used in the third stage of labour. More also decreased maternal blood loss at birth is noted hence pin pointing the need to use active management. More also, significant increase in the maternal diastolic blood pressure, occasional vomits after birth, pains and the normal analgesia which were used from birth to the discharge were reported. Additionally, the reduction the infants’ body weight was also noted (Maier 2008, pg 44). Choosing uterotonic agent Randomized experiments and trials have continued to examine the usage of oxytocin, misoprostol and synometrine in the practice of active management when compared with psychological management. The experiments have compared different uterotonics and their success in active management and the findings have been varying depending on the type that is being used. The trial findings affirm that Syntometrine have slight advantages in the reduction of PPH by approximately 500ml or more than that. However, oxytocin alone is very efficient and it does not have any adverse effects which are associated with preparations that contain ergot. Research affirms that increasing the intramuscular dose of the oxytocin hormone from at least 5IU to approximately 10IU enhances its effectiveness in active management (Maier 2008, pg 33). Moreover, additional randomized and controlled trial led to the discovery that infusing 80U to around 40U contrary to the usual 10U did not reduce the postpartum haemorrhage at all. However, it marked the need of increasing oxytocin for the sake of decreasing hematrocit at a considerable level of around 6%.Moreral;so, it has been suggested that the initial intravenous administration of the oxytocin hormone leads to increased effectiveness in active management of the third stage labour. It should be noted that no more than 5IU should be administered through bolus intravenous injection (Maier 2008.pg 34). When oxytocin was used alone, reduced rates of manual exit of the placenta was noted while the use of ergot proved to increase the rates at which the placenta was being ejected. The slight trend of the increased manual removal in the Cochrane Meta-analysis as shown above is attributed entirely to the single trials where intravenous ergot was applied. The increased nausea, blood pressure, and vomiting can all be attributed to the trials using ergot. The possible explanations for these differences are attributed to ergot act of preparation on smooth muscle while oxytocin is specifically for smooth muscles for the uterus. Oxytocin usually causes increased contraction of the uterus in strength and frequency and it does not go through titanic contractions as in the case of ergot. Research conducted by WHO (World Health Organisation) continues to favour oxytocin since it is more stable when it is exposed to light and heat compared to ergot. This effect makes oxytocin useful in areas where storage in an issue especially refrigeration cases. On the other hand, potential benefit of the ergot hormone is that stay for longer duration of action compared to oxytocin. After comparing all the uterotonic agents, oxytocin proves to be used in active management of the third stage labour (Maier, 2008, pg 32). Misoprostol has also depicted early optimism in the treatment of PPH and its form and low cost makes it suitable. More also, its ability to withstand heat has qualified it to be the possible agent of prophylaxis in the thirds stage of labour. However, its various trials have shown that it is inferior to injectable uterotonics and it is not effective as many other uterotonics. It has also some side effects such as shivering especially in the postpartum period may lead to the general confusion especially in the diagnosis of sepsis (Moffat& Lee 2011, pg 33). Administering uterotonic The active management practice involves administering uterotonic agents with the ultimate delivery of the anterior shoulder or with complete delivery of the newly born child. Practically, these events are usually separated by mere seconds and the distinction is not particularly important. Most importantly, the anterior shoulder should be delivered before the uterotonic administration. In case of shoulder, dystocia, very strong uterine contractions usually serve to impact the anterior shoulder and make curative maneuvers a bit more difficult and any particular reduction may lead to foetal deoxygenation. Such deoxygenating may not only lead to morbidity of the foetus but it can also lead to mortality eventually (Moffat& Lee 2011, pg 33). Immediately after birth, the size of the uterus is determined in an effort to determine the possibility of another child and also to establish the baseline of the uterus. “Fudus fiddling “or uterine massage should be avoided prior the delivery of the placenta. The uterotonic should be drawn prior they deliver in pursuit of rapid administration. Typically during vaginal delivery, the dose of 10IU of oxytocin is usually administered intramuscularly in effort to help the patient deliver appropriately. However, when Cesarean delivery is taking place 5IU is usually administered inform of intravenous bolus and also an infusion is injected. Some authorities advocate the same thing for vaginal deliveries (Moffat& Lee 2011, pg 33). Higher infusion of doses may at times the risk of subsequent atony and result in the retention of fluid. The negative effects of oxytocin should be kept in mind though they are usually problematic at times especially in that particular setting. Routine administration of the uterotonics following the delivery of the placenta uses physiological management though it has not been shown to provide similar benefits that are seen in the active management. Trends in the reduction of the PPH are usually present but it affects the size and it is less seen with the active management. Need for the therapeutic uterotonics is usually compared with no uterotonics following a successful delivery. Findings continue to posit that if CCT is actually used it does not alter the rate at which PPH at all (Moyo 2005, pg 34). Management of the cord the traction of the cord is usually applied during the active management especially when counteraction is applied. Counteraction is primarily performed through trapping the body of the uterus slightly above the pubis symphysis and later directing back. The traction that is applied through continuous and downward manner it is only when the uterus has contracted well enough. Delay occurs between administration of the uterotonic and the good contraction of the uterus. It should be noted that at these level several issues must be considered. Most f, the active management practices, involve early clamping of the cord but out of the three management components, the practice proves to be least in the conferring of the recognized benefits(Walker 2010,pg 44). The early cord clamping may be indicated to facilitate newborn resuscitation and assessment. However, barring this indication and rushing to clamp the cord is basically unnecessary since the traction cannot be applied until the contraction of the uterus to the maximum. Delayed clamping of the cord may lead to several complications to the newly born child and, therefore, it is paramount for it to be done timely to avoid any cases of morbidity (Taylor 2010, pg 37). Conclusion Research has postulated active management of the third stage of labour is effective in preventing postpartum haemorrhage that in turn deters morbidity and maternal mortality. Loss of blood through postpartum haemorrhage is dangerous since it predisposes the mother to disease that is commonly known as morbidity. Anaemia is a common disease that most mothers experience immediately after birth. This disease is dangerous since the mother cannot breastfeed the child exposing the child to disease due to reduced immunity. The reduced immunity can expose the child to infections lead to child mortality that should be discouraged under all costs. Research carried out by WHO affirms that 1000 women die to maternal mortality which is attributed to PPH, and therefore, it is paramount for all stakeholders to join hands and embrace active management in the third stage of labour. Active management has proved to be effective in controlling PPH compared to the physiological process. Institutions that are known to use active management have reduced the deaths significantly especially in the developing countries where only 10 women out of 100,000 dies due to maternal haemorrhage. This not only confirms any outstanding, but it shows that it good methods in pursuant of saving live. The practice involving injecting artificial hormone like oxytocin that acts helps in the delivery of the placenta efficiently therefore making the entire delivery a success. However, experienced midwife and clinicians are needed to be at the position to ensure the right dosage of the hormone is administered therefore making it easy and effective in the long run. Continuous use of active management will not only reduce morbidity but also maternal deaths will also be reduced therefore making delivery safe and sound. However, some complications related to active management include nausea and vomiting but they cannot inhibit proper third stage delivery. References Brown, J. (2003, January 1). Saving mothers' lives: what works: Judi Brown writes about the White Ribbon Alliance's International Conference on Safe Motherhood Best Practices, October 3-5, 2002, New Delhi, India.. International Midwifery , 2, 27. Clark, P. A. (2006, March 1). 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(2012, March 1). Systematic Review of Oxytocin Dosing at Caesarean Section. Anaesthesia and Intensive Care, 3, 12. Taylor, F. C. (2010). Is active management superior to physiological management in third stage of labour?: a detailed review of the literature.. London: Oxford. Tomkins, A. (2001). Nutrition and maternal morbidity and mortality. British Journal of Nutrition, 85(S2), S93. Walker, N. (2010). Development and use of the Lives Saved Tool (LiST) a model to estimate the impact of scaling up proven interventions on maternal, neonatal and child mortality. Oxford: Oxford University Press. Read More