Wishful thinking is not enough . . .

Recently I had a patient request for a “physiological” management of the third stage of pregnancy.  The third stage is an important aspect of care because it can be complicated by postpartum hemorrhage, which is one of the leading causes of maternal morbidity and mortality.  The process occurs by contraction of the uterus which helps to separate the placenta from the uterine wall.  The placenta is then expelled and the uterus contracts down even further.

For some reason, there is a push to allow this to happen more “naturally” or “physiologically”.  I am not exactly sure what they are hoping to get from this.  I am also frustrated because the same group of birth activists advocating for this management of the third stage are often the some group complaining that modern obstetrics is not evidence based.  Here, one of the few aspects of labour and delivery that is well studied, the evidence is not good enough for them.

Physiological Management of the Third Stage

What are the benefits that women are hoping to gain?  Surely they are not looking to bleed more, because that would be unreasonable.  Are they looking to have less “medical” intervention?  How invasive would a single intramuscular injection of oxytocin be?  Or there is the option of rectal misoprostol – if you want to mimic third world conditions, at least use third world medications.  Each of these options has been shown to be effective in decrease the risk for postpartum hemorrhage, even without the other aspects of active third management.  The extra medication is to help the uterus contract and separate the placenta and help keep the uterus contracted after delivery to reduce the blood loss.

I have seen some women argue that active management removes the benefit for the baby.  I would ask what benefit do they think the baby is getting while the placenta remains attached to mom.  There is some small benefit to delayed cord clamping, but this can safely be achieved with active management as well.  I am no advocating for all placentas to be removed by my hand inside the uterus within seconds of the baby being delivered after all. I would argue that babies are not being oxygenated just because the cord is still attached and the placenta undelivered.  That is a bit of wishful thinking.  It is well proven in animal studies that regular uterine contractions, like those associated with labour, temporarily decrease blood supply to the placenta, and can overtime, decrease the amount of oxygen to the baby.  The contraction of the uterus after delivery of the infant is even more dramatic that the contractions of labour.  The uterus may decrease by more than 50% in size, from being up by the ribcage being below the umbilicus.  This is a result of muscle contraction, squeezing not only blood vessels in the uterus but also starting to shear the placenta off the uterine what.  When there is a planned delivery of a baby with potential airway problems, such that we actually want to maintain placenta oxygenation, there needs to be medication on board to prevent uterine contractions.  This means that these babies, being delivered by C-section, are born to mothers receiving deep general anaesethia so that the uterine muscle don’t contract.  Only than change the placental oxygen exchange be somewhat reliable for the newborn to be sufficiently  well oxygenated.

Active Management of the Third Stage

All I am going to say about this is that it is actually one of the best studied aspects of maternity care.  It saves live.  For those always quoting WHO, I have linked to their recommendations.  This is really a no brainer to me.  I really don’t understand how after a discussion about informed consent and active management of the third stage of labour, anyone who decline.

Its all about magically thinking and the not me phenomenon of statistics.  The rates are low, therefore it is not going to happen to me.  However, it will happen to someone, why not reduce your risk.

Drugs are more effective than wishful thinking.


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