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Abstract:
Background and purpose: The third stage of labour
is the period of time following the birth of the baby
when the placenta separates and is expelled from the
uterus. There are two options or care pathways that
can be provided. The first is a physiological pathway
for the third stage (also called expectant management).
The second is an acti...
Context in source publication
Context 1
... the women who gave birth in a tertiary hospital 5.2% (n=372) had a blood loss of between 500 and 1000 mls and 1.5% (n= 105) had a blood loss of more than 1000mls. Birth place settings with the highest level of blood loss of more than 1000 mls were the tertiary facilities (1.5%, n=105) followed by secondary facilities (1.2%, n=158), then primary facilities (0.9%, n=62) and then home births (0.6%, n=25) ( Figure 2). A separate, weighted chi-squared test was performed within each blood loss category to investigate whether the proportions of women within each birthing facility differed significantly from expected. ...
Citations
... Midwives in Aotearoa New Zealand (Aotearoa NZ) continue to facilitate physiological placental birth, without a routine uterotonic and with the cord left intact, when the chance of a PPH is low. Even in tertiary hospitals in Aotearoa NZ, where intervention is prevalent, 34.1% of normal births are followed by a physiological placental birth (Dixon et al., 2009). ...
Background: When the umbilical cord is left unclamped after birth, a significant proportion of the blood from the placenta flows into the newborn, increasing the baby's blood volume by approximately 30%. Routine intervention of immediate cord clamping is harmful as it deprives the newborn access to their own blood, resulting in impaired physiological transition at birth and lower iron stores in early infancy. Iron deficiency in early life, even without anaemia, is linked with impaired neurodevelopment. Aim: The aim of this study was to accurately record birth to cord clamping interval at term vaginal births in a tertiary hospital in Aotearoa New Zealand and concurrently to examine some of the circumstances that may influence the timing of when the cord is cut. Method: This observational study was undertaken from August 2017 to April 2018. Participants were pregnant women having a vaginal birth at ≥37 weeks gestation. Data collected included birth to cord clamping interval, mode of birth (spontaneous or instrumental), maternal position for birth and practitioners involved in the birth. Descriptive statistics were used to summarise the data. Results: Participants were 55 women with term vaginal births. The median interval between birth and cord clamping was 3.5 minutes (IQR 2.18 - 5.68 mins). There was a longer median cord clamping time in the group who had a spontaneous birth (median 3.71; IQR 2.67 - 6.23) vs instrumental birth (2.08; IQR 0.55 - 2.30); with maternal side-lying position (6.37; IQR 4.15 - 9.48) vs lithotomy position (2.24; IQR 1.87 - 3.50); with midwife-facilitated birth (4.06; IQR 2.68 - 6.65) vs obstetric-facilitated birth (2.13; IQR 1.48 - 3.28); and when the neonatal team was not called to attend (4.73; IQR3.32 - 8.26) vs when they were called to attend (2.13; IQR 1.28 - 3.27). Discussion: The median cord clamping time of 3.5 minutes aligns with current local, national and international guidelines, although clamping times as short as 0.23 minutes were observed. The study provides a snapshot of practice at one tertiary hospital, examining data on a range of vaginal births, from uncomplicated midwifery-led births to complicated obstetric-led births requiring neonatal team attendance. By identifying some of the circumstances where cords are clamped early, we may be able to modify the associated factors for these births, thereby improving newborn health outcomes in the future.
... This review included a retrospective study from New Zealand of a cohort of low risk women who had had no interventions during labour and birth and had received physiological third stage care. Their findings indicated an increased risk of blood loss of more than 500ml with active management (Dixon et al., 2009). ...
... The results of our study differ from those reported by the studies reviewed by Dixon et al. (2011). In this review Thilaganathan et al. (1993), Dixon et al. (2009) and Bais, Eskes, Pel, Bonsel and Bleker (2004) reported mean blood losses of 200ml, 213.6ml and 361ml, respectively. The wide variation may be due to timing of blood loss measurement in each study. ...
... In our study and in the Swedish study, blood loss was measured for up to two hours following the birth. Whereas, both the Thilaganathan et al. (1993) and the Dixon et al. (2009) studies used estimated loss immediately following the birth. The timing of blood loss measurement was unclear in the study by Bais et al. (2004). ...
... In New Zealand, under the midwifery model of care, physiological management is suggested in the absence of risk factors. [41][42][43] While 60% of mothers in this study had a normal vaginal birth, only 9% (n = 140) had physiological management of the third stage i.e. no postpartum prophylaxis. Some mothers received three or more uterotonic administrations and this is likely to have been because they had bleeding which was considered heavier than normal (> 500 mLs) requiring treatment. ...
Problem:
Supplementation of breastfed babies is common during the hospital stay.
Background:
The Baby Friendly Hospital Initiative (BFHI) optimises practices to support exclusive breastfeeding, yet supplementation is still prevalent.
Objective:
To determine predictors for supplementation in a cohort of breastfed babies in a Baby-Friendly hospital.
Methods:
Electronic hospital records of 1530 healthy term or near term singleton infants and their mothers were examined retrospectively and analysed to identify factors associated with in-hospital supplementation using Poisson regression (unadjusted and adjusted).
Findings:
Fifteen percent of breastfed infants were supplemented during their hospital stay. Analysis by multivariable Poisson regression found that supplementation was independently associated with overweight (reference normal weight) (aRR [adjusted relative risk]=1.46; 95% CI: 1.11-1.93); primiparity (aRR=1.40; 95% CI: 1.09-1.80); early term gestation (37-37(6) weeks, aRR=2.79; 95% CI: 1.88-4.15; 38-38(6) weeks, aRR=2.03, 95%CI: 1.46-2.82); birthweight less than 2500 grams (reference 3000-3499 grams) (aRR=3.60; 95% CI: 2.32-5.60) and use of postpartum uterotonic (aRR=2.47; 95% CI: 1.09-5.55). Greater than 65 minutes of skin-to-skin contact at birth reduced the risk of supplementation (aRR=0.66; 95% CI; 0.48-0.92).
Conclusion:
These identified predictors for supplementation, can inform the development of interventions for mother-infant pairs antenatally or in the early postpartum period around increased breastfeeding education and support to reduce supplementation. It may also be possible to reduce supplementation through judicious use of postpartum uterotonics and facilitation of mother-infant skin-to-skin contact at birth for greater than one hour duration.
... Adrenaline interferes with the uptake of oxytocin at the myometrial receptor site (Gimpl and Farenholtz, 2001;Odent, 2001;Tortora and Grabowski, 2003;Stables and Rankin, 2005;Coad and Dunstall, 2011;Saxton et al., 2014) causing uterine atony. Midwifery models of care where midwives practice pronurturance demonstrate low rates of PPH (Dixon et al., 2009;Fahy et al., 2010;Catling-Paull et al., 2013). Maybe the hypermedicalization of birth (Simpson and Thorman, 2005;Zwelling, 2008;Rossen et al., 2010;Belghiti et al., 2011) is interfering with innate pronurturance behaviours at birth. ...
... The active management of the third stage of labour supposedly prevents PPH but active management has been implicated as a possible causative factor for PPH in three empirical studies (Dixon et al., 2009;Fahy et al., 2010;Driessen et al., 2011). The psychophysiological explanation of why the active management of the third stage of labour can actually cause what it is trying to prevent, has been discussed by midwives and physiologists (Gimpl and Farenholtz, 2001;Hastie and Fahy, 2009;Uvnas-Moberg, 2012a, 2013Saxton et al., 2014). ...
... We believe, based on physiology and research evidence, from this and other studies (Dixon et al., 2009;Fahy et al., 2010;Catling-Paull et al., 2013;Saxton et al., 2014) that pronurturance is effective in reducing PPH rates. The purported effectiveness of pronurturance on PPH rates is further supported by the effect that even partial pronurturance had on PPH rates. ...
Objective: to examine the effect of skin-to-skin contact and breast feeding within 30 minutes of birth, on the rate of primary postpartum haemorrhage (PPH) in a sample of women who were at mixed-risk of PPH. Design: retrospective cohort study. Setting: two obstetric units plus a freestanding birth centre in New South Wales (NSW) Australia. Participants: after excluding women (n ¼3671) who did not have opportunity for skin to skin and breast feeding, I analysed birth records (n ¼ 7548) for the calendar years 2009 and 2010. Records were accessed via the electronic data base ObstetriX. Intervention: skin to skin contact and breast feeding within 30 minutes of birth. Measures: outcome measure was PPH i.e. blood loss of 500 ml or more estimated at birth. Data was analysed using descriptive statistics and logistic regression (unadjusted and adjusted). Findings: after adjustment for covariates, women who did not have skin to skin and breast feeding were almost twice as likely to have a PPH compared to women who had both skin to skin contact and breast feeding (aOR 0.55, 95% CI 0.41–0.72, p o0.001). This apparently protective effect of skin to skin and breast feeding on PPH held true in sub-analyses for both women at 'lower' (OR 0.22, 95% CI 0.17–0.30, po 0.001) and 'higher' risk (OR 0.37 95% CI 0.24–0.57), p o0.001. Key conclusions and implication for practice: this study suggests that skin to skin contact and breastfeeding immediately after birth may be effective in reducing PPH rates for women at any level of risk of PPH. The greatest effect was for women at lower risk of PPH. The explanation is that pronurturance promotes endogenous oxytocin release. Childbearing women should be educated and supported to have pronurturance during third and fourth stages of labour.
... Elle a été critiquée 38 pour avoir retenu des recherches qui n'ont pas tenu compte des facteurs de risques d'HPP ainsi que pour son approche morcelée et elle a finalement été retirée des revues de Cochrane en 2009. Pour Begley et al, 33 le taux d'HPP de plus de 1000 ml avec la gestion active ou avec la gestion physiologique est similaire pour des femmes à bas risque alors que Dixon et al, 34 qui ont étudié la pratique sage-femme, constatent qu'il y a moins de pertes de sang (500-1000ml et >1000 ml) avec la gestion physiologique lorsque comparé à la gestion active. A la suite d'une revue systématique sur l'efficacité de la gestion physiologique après un accouchement physiologique Dixon et al 35 concluent que la gestion physiologique peut être encouragée pour une femme en santé, qui se sent bien et qui a eu un accouchement normal/ physiologique. ...
... 35 Une recherche sur l'utilisation de la gestion active chez les sages-femmes de Nouvelle-Zélande auprès de femmes ayant eu un accouchement normal/physiologique (n=33,752) a abouti à un taux d'HPP bien plus important lorsque comparé à l'utilisation de la gestion physiologique (6,9 % vs 3,7 %). 34 De leur côté Davis et al 45 montrent que la gestion active est associée à une augmentation des pertes de plus de 1000 ml chez des femmes à bas risque, et qu'il n'y a aucun lien entre le lieu de naissance (hôpital ou domicile) et le taux d'hémorragie. ...
... Elle a été critiquée 38 pour avoir retenu des recherches qui n'ont pas tenu compte des facteurs de risques d'HPP ainsi que pour son approche morcelée et elle a finalement été retirée des revues de Cochrane en 2009. Pour Begley et al, 33 le taux d'HPP de plus de 1000 ml avec la gestion active ou avec la gestion physiologique est similaire pour des femmes à bas risque alors que Dixon et al, 34 qui ont étudié la pratique sage-femme, constatent qu'il y a moins de pertes de sang (500-1000ml et >1000 ml) avec la gestion physiologique lorsque comparé à la gestion active. A la suite d'une revue systématique sur l'efficacité de la gestion physiologique après un accouchement physiologique Dixon et al 35 concluent que la gestion physiologique peut être encouragée pour une femme en santé, qui se sent bien et qui a eu un accouchement normal/ physiologique. ...
... 35 Une recherche sur l'utilisation de la gestion active chez les sages-femmes de Nouvelle-Zélande auprès de femmes ayant eu un accouchement normal/physiologique (n=33,752) a abouti à un taux d'HPP bien plus important lorsque comparé à l'utilisation de la gestion physiologique (6,9 % vs 3,7 %). 34 De leur côté Davis et al 45 montrent que la gestion active est associée à une augmentation des pertes de plus de 1000 ml chez des femmes à bas risque, et qu'il n'y a aucun lien entre le lieu de naissance (hôpital ou domicile) et le taux d'hémorragie. ...
... Elle a été critiquée 38 pour avoir retenu des recherches qui n'ont pas tenu compte des facteurs de risques d'HPP ainsi que pour son approche morcelée et elle a finalement été retirée des revues de Cochrane en 2009. Pour Begley et al, 33 le taux d'HPP de plus de 1000 ml avec la gestion active ou avec la gestion physiologique est similaire pour des femmes à bas risque alors que Dixon et al, 34 qui ont étudié la pratique sage-femme, constatent qu'il y a moins de pertes de sang (500-1000ml et >1000 ml) avec la gestion physiologique lorsque comparé à la gestion active. A la suite d'une revue systématique sur l'efficacité de la gestion physiologique après un accouchement physiologique Dixon et al 35 concluent que la gestion physiologique peut être encouragée pour une femme en santé, qui se sent bien et qui a eu un accouchement normal/ physiologique. ...
... 35 Une recherche sur l'utilisation de la gestion active chez les sages-femmes de Nouvelle-Zélande auprès de femmes ayant eu un accouchement normal/physiologique (n=33,752) a abouti à un taux d'HPP bien plus important lorsque comparé à l'utilisation de la gestion physiologique (6,9 % vs 3,7 %). 34 De leur côté Davis et al 45 montrent que la gestion active est associée à une augmentation des pertes de plus de 1000 ml chez des femmes à bas risque, et qu'il n'y a aucun lien entre le lieu de naissance (hôpital ou domicile) et le taux d'hémorragie. ...
... More community women had physiological management of the placenta delivery, a practice considered to predispose a woman to postpartum hemorrhage (35), yet the incidence of postpartum hemorrhage was similar across care settings. This study is the first to report on both postpartum hemorrhage and the method of third-stage management in women using a birthing pool, but recent studies on women not using a birthing pool have also shown that physiological management was not associated with an increase in the risk of postpartum hemorrhage in low-risk women (26,(36)(37)(38). ...
Birthing pools are integrated into maternity care in the United Kingdom and are a popular care option for women in midwifery-led units and at home. The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool.
A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland. Descriptive analysis was performed.
Overall, 7,915 (88.9%) women had a spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas. Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI: 9.6-13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3-25.2]), or obstetric unit (639, 26.3% [95% CI: 24.5-28.1]). Results were similar for epidural analgesia and episiotomy. More community nulliparas had spontaneous birth (1,172, 88.9% [95% CI: 87.1-90.6]), compared with birth in an alongside midwifery unit (942, 79% [95% CI: 76.6-81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5-80.8]); and fewer required hospital transfer (265, 20% [95% CI: 17-22.2]) compared with those in an alongside midwifery unit (370, 31% [95% CI: 28.3-33.7]). Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth.
Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas. Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas. No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns. During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface. (BIRTH 39:3 September 2012).
... This is curious when considering the Level 1 evidence available that supports active management of third stage as reducing PPH rates (Begley et al., 2010). However, other recent lower level evidence supports this finding in midwife led units in New Zealand (Dixon et al., 2009) and Australia (Fahy et al., 2010) and comparisons of midwife and physician led care in Canada (Tan et al., 2008). The higher incidence of babies born with lower Apgar scores of o7 at 5 mins under obstetric care was also surprising considering all these women had normal vaginal births. ...
Background:
the option of giving birth in water is available to most women in birth centres in Australia but there continues to be resistance in mainstream delivery wards due to safety concerns. Women in birth centres are more likely to give birth in upright positions and be attended by experienced midwives and obstetricians who are comfortable facilitating normal birth. The aim of this study was to determine rates of perineal trauma, postpartum haemorrhage and five-minute Apgar scores amongst low risk women in a birth centre who gave birth in water compared to six birth positions on land.
Methods:
this was a descriptive cross sectional study of births occurring in a large alongside Sydney birth centre from January 1996 to April 2008. Handwritten records were kept by midwives on each birth in the birth centre over twelve and a half years (n=6,144). Descriptive statistics and logistic regression were applied controlling for risk factors for perineal trauma, postpartum haemorrhage and the five-minute Apgar score.
Findings:
waterbirth (13%) and six main birth positions on land were identified: kneeling/all fours (48%), semi-recumbent (12%), lateral (5%), standing (8%), birth stool (10%) and squatting (3%). Compared to waterbirth, birth on a birth stool led to a higher rate of major perineal trauma (second, third, fourth degree tear and episiotomy) (OR 1.40 [1.12-1.75]) and postpartum haemorrhage (OR 2.04 [1.44-2.90]). Compared to waterbirth, babies born in a semi-recumbent position had a significantly greater incidence of five-minute Apgar scores <7 (OR 4.61 [1.29-16.52]).
Conclusions:
waterbirth does not lead to more infants born with Apgar score <7 at 5 mins when compared to other birth positions. Waterbirth provides advantages over the birth stool for maternal outcomes of major perineal trauma and postpartum haemorrhage.
... A retrospective cohort study (n = 33,752) in New Zealand (using the same database accessed for this study) (8), focusing on the third stage management of low-risk women, found that 48.1 percent of this group experienced a physiological third stage of labor. Higher proportions of women giving birth at home and in primary settings had a physiological third stage of labor compared with those giving birth in secondary and tertiary hospitals. ...
... In this study of low-risk women (during the period 2006-2007), 35.6 percent had a physiological third stage of labor. Using the same database (for the period 2004-2008), Dixon et al reported that 48.1 percent of their low-risk cohort experienced a physiological third stage (8). This disparity may arise because of the different study samples. ...
... Drawing on the same data set as our study, Dixon et al (8) found that compared with the active management group, significantly fewer women in the physiological group had a blood loss greater than 1,000 mL (0.5% vs 1.5%). In Australia a retrospective cohort study by Fahy et al (13) comparing physiological third stage (in a birth center, n = 361) and active management of the third stage of labor (in a tertiary hospital, n = 3075) in low-risk women found that active management of labor was associated with an increase in the risk of postpartum hemorrhage (OR: 4.4, 95% CI: 2.3-8.4). ...
Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage.
Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g.
In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically.
Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012).
