Integrated Maternal and Newborn Care Basic Skills Course ...
Integrated Maternal and Newborn Care Basic Skills Course ...
Integrated Maternal and Newborn Care Basic Skills Course ...
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Uterotonic<br />
Signs of placental<br />
separation<br />
Delivery of the<br />
placenta<br />
Uterine massage<br />
Advantages<br />
Disadvantages<br />
Table 6. Comparison of Physiologic <strong>and</strong> Active Management<br />
of the Third Stage of Labor (AMTSL)4<br />
Physiologic (expectant)<br />
management<br />
Uterotonic is not given before<br />
the placenta is delivered.<br />
Wait for signs of separation:<br />
• gush of blood<br />
• lengthening of cord<br />
• uterus becomes rounder <strong>and</strong><br />
smaller as the placenta<br />
descends<br />
Placenta delivered by gravity<br />
assisted by maternal effort.<br />
Massage the uterus before the<br />
placenta is delivered.<br />
• Does not interfere with normal<br />
labor process.<br />
• Does not require special<br />
drugs/supplies.<br />
• May be appropriate when<br />
immediate care is needed for<br />
the baby (such as<br />
resuscitation) <strong>and</strong> no trained<br />
assistant is available.<br />
• May not require a birth<br />
attendant with injection skills.<br />
• The length of the third stage is<br />
longer compared to AMTSL.<br />
o Blood loss is greater<br />
compared to AMTSL.<br />
o Increased risk of PPH.<br />
Active management<br />
Uterotonic is given within one<br />
minute of the baby’s birth (after<br />
ruling out the presence of a<br />
second baby).<br />
Do not wait for signs of<br />
placental separation. Instead:<br />
• Palpate the uterus for a<br />
contraction.<br />
• Wait for the uterus to contract.<br />
• Apply CCT with<br />
countertraction.<br />
Placenta delivered by controlled<br />
cord traction (CCT) while<br />
supporting <strong>and</strong> stabilizing the<br />
uterus by applying countertraction.<br />
Massage the uterus after the<br />
placenta is delivered.<br />
• Decreases the length of the<br />
third stage.<br />
• Decreases the likelihood of<br />
prolonged third stage.<br />
• Decreases average blood loss.<br />
• Decreases the number of PPH<br />
cases.<br />
• Decreases the need for blood<br />
transfusion.<br />
• Requires uterotonic drugs <strong>and</strong><br />
items needed for<br />
injection/injection safety.<br />
• Requires a birth attendant with<br />
experience <strong>and</strong> skills giving<br />
injections <strong>and</strong> using CCT.<br />
(The definition of active management as described in this table differs from the original research protocol<br />
in the Bristol <strong>and</strong> Hinchingbrooke trials because the original protocols included immediate cord clamping<br />
<strong>and</strong> did not include massage of the uterus. In the Hinchingbrooke trial, midwives used either CCT or<br />
maternal effort to deliver the placenta.)<br />
4 Rogers J, et al. 1998. Active versus expectant management of the third stage of labour: the<br />
Hinchingbrooke r<strong>and</strong>omized controlled trial. Lancet 351:693–699.<br />
64<br />
<strong>Integrated</strong> maternal <strong>and</strong> newborn care<br />
<strong>Basic</strong> skills course