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Active Versus Physiological Management Of The Third Stage Of Labour. ...


Active versus physiological management of the third stage of labour.

Undergraduate Degree Level Dissertation

10,000 words


Introduction

This essay is primarily concerned with the arguments that are currently active in relation to the benefits and disadvantages of having either an active or passive third stage of labour. We shall examine this issue from several angles including the currently accepted medical opinions as expressed in the peer reviewed press, the perspective of various opinions expressed by women in labour and the evidence base to support these opinions.

It is a generally accepted truism that if there is controversy surrounding a subject, then this implies that there is not a sufficiently strong evidence base to settle the argument one way or the other. (De Martino B et al. 2006). In the case of this particular subject, this is possibly not true, as the evidence base is quite robust (and we shall examine this in due course).

Midwifery deals with situations that are steeped in layers of strongly felt emotion, and this has a great tendency to colour rational argument. Blind belief in one area often appears to stem from total disbelief in another (Baines D. 2001) and in consideration of some of the literature in this area this would certainly appear to be true.

Let us try to examine the basic facts of the arguments together with the evidence base that supports them.

In the civilised world it is estimated that approximately 515,000 currently die annually from problems directly related to pregnancy. (extrapolated from Hill K et al. 2001). The largest single category of such deaths occur within 4 hrs. of delivery, most commonly from post partum haemorrhage and its complications (AbouZahr C 1998), the most common factor in such cases being uterine atony. (Ripley D L 1999). Depending on the area of the world (as this tends to determine the standard of care and resources available), post partum haemorrhage deaths constitutes between 10-60% of all maternal deaths (AbouZahr C 1998). Statistically, the majority of such maternal deaths occur in the developing countries where women may receive inappropriate, unskilled or inadequate care during labour or the post partum period. (PATH 2001). In developed countries the vast majority of these deaths could be (and largely are) avoided with effective obstetric intervention. (WHO 1994). One of the central arguments that we shall deploy in favour of the active management of the third stage of labour is the fact that relying on the identification of risk factors for women at risk of haemorrhage does not appear to decrease the overall figures for post partum haemorrhage morbidity or mortality as more than 70% of such cases of post partum haemorrhage occur in women with no identifiable risk factors. (Atkins S 1994).
Prendiville, in his recently published Cochrane review (Prendiville W J et al.

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