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Further Analysis Of The Practices Reported That Where Uterotonic Drugs Were ...



Further analysis of the practices reported that where uterotonic drugs were given, cord traction was not done in 49%, and early cord clamping not done in 7% of the deliveries observed where the optimum active management of the third stage of labour protocols were not followed.

>From an analytical point of view, we should cite the evidence base to suggest the degree to which these two practices are associated with morbidity.

Walter P et al. 1999 state that their analysis of their data shows that early cord clamping and controlled cord traction are shown to be associated with a shorter third stage and lower mean blood loss, whereas Mitchelle (G G et al. 2005) found them to be associated with a lower incidence of retained placenta.

Other considerations relating to the practice of early cord clamping are that it reduces the degree of mother to baby blood transfusion. It is clear that giving uterotonic drugs without early clamping will cause the myometrium to contract and physically squeeze the placenta, thereby accelerating the both the speed and the total quantity of the transfusion. This has the effect of upsetting the physiological balance of the blood volume between baby and placenta, and can cause a number of undesirable effects in the baby including an increased tendency to jaundice. (Rogers J et al. 1998)

The major features that are commonly accepted as being characteristic of active management and passive management of the third stage of labour are set out below.

Physiological Versus Active Management
. . .
Physiological Management
Active Management

Uterotonic
None or after placenta delivered
With delivery of anterior shoulder or baby

Uterus
Assessment of size and tone
Assessment of size and tone

Cord traction
None
Application of controlled cord traction* when uterus contracted

Cord clamping
Variable
Early


(After Smith J R et al. 1999)
physiology of third stage

The physiology of the third stage can only be realistically considered in relation to some of the elements which occur in the preceding months of pregnancy. The first significant consideration are the changes in haemodynamics as the pregnancy progresses. The maternal blood volume increases by a factor of about 50% (from about 4 litres to about 6litres). (Abouzahr C 1998)

This is due to a disproportionate increase in the plasma volume over the RBC volume which is seen clinically with a physiological fall in both Hb and Heamatocrit values. Supplemental iron can reduce this fall particularly if the woman concerned has poor iron reserves or was anaemic before the pregnancy began.

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