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Whilst Accepting That Both Of These Concepts Are Manifestly True, Such ...

Whilst accepting that both of these concepts are manifestly true, such arguments do not take account of the natural wastage that drives such evolutionary adaptations. In human terms such natural wastage is simply not ethically or morally acceptable in modern society. (Sugarman J et al. 2001)

There may be some validity in the arguments that natural processes will achieve normal separation and delivery of the placenta and may lead to fewer complications and if the patient should suffer from post partum haemorrhage then there are techniques, medications and equipment that can be utilised to contain and control the clinical situation. Additional arguments are invoked that controlled cord traction can increase the risk of uterine inversion and ecbolic drugs can increase the risks of other complications such as retained placenta and difficulties in delivering an undiagnosed twin. (El-Refaey H et al. 2003)

The proponents of active management counter these arguments by suggesting that the use of ecbolic agents reduces the risks of post partum haemorrhage, faster separation of the placenta, reduction of maternal blood loss. Inversion of the uterus can be avoided by using only gentle controlled cord traction when the uterus is well contracted together with the controlling of the uterus by the Brandt-Andrews manoeuvre.
The arguments relating to the undiagnosed second twin are loosing ground as this eventuality is becoming progressively more rare. The advent of ultrasound together with the advent of protocols which call for the mandatory examination of the uterus after the birth and before the administration of the ecbolic agent effectively minimise this possibility. (Prendiville, 2002).

If we consider the works of Prendiville (referred to above) we note the meta-analyses done of the various trials on the comparison of active management against the passive management of the third stage of labour and find that active management consistently leads to several benefits when compared to passive management. The most significant of which are set out below.


Benefits of Active Management Versus Physiological Management
Outcome
Control Rate, %
Relative Risk
95% CI*
NNT†
95% CI

PPH >500 mL
14
0.38
0.32-0.46
12
10-14

PPH >1000 mL
2.6
0.33
0.21-0.51
55
42-91

Hemoglobin <9 g/dL
6.1
0.4
0.29-0.55
27
20-40

Blood transfusion
2.3
0.44
0.22-0.53
67
48-111

Therapeutic uterotonics
17
0.2
0.17-0.25
7
6-8


*95% confidence interval
†Number needed to treat
(After Prendiville, 2002).

The statistics obtained make interesting consideration.

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