RCM Evidence based Guidelines for

Midwifery-led Care in Labour

Mervi Jokinen

Practice and Standards Development Advisor

APPG

20th November 2012

Management of Third Stage of Labour

• Active management involves giving a prophylactic uterotonic, cord clamping and controlled cord traction

• Physiological management involves no administration of a prophylactic uterotonic, no clamping and cutting of the cord until the placenta is delivered and promoting use of gravity to assist delivery of the placenta in a timely manner with maternal effort

Management of Third Stage of Labour

• Historically third stage was actively managed with Ergometrine in 1940s then changing into Syntometrine with fast acting oxytocin and longer lasting Ergometrine in 1960s . Most recently move into Syntocinon 10u i/m

• Effective care in pregnancy and childbirth looking at evidence-based obstetrics in and 1989 questioned the value of active management

• Side effects: hypertension headaches nausea vomiting, pulmonary oedema, cardiac arrest, myocardial infarction

• Ergometrine lowering effect on serum prolactin levels• Free bleeding from the placental end of the cord is associated with reduced

risk of feto-maternal transfusion linked to iso-immunization note Rh-neg women

• On conclusion the reduced risk of amount of bleeding overrode the harms

Management of Third Stage of Labour

• Evolvement of women’s choices and increased information sharing with informed decision-making

• Requests from women to allow cord stop pulsating prior clamping

• Professionals’ concerns re Syntocinon and polycytheamia

• Gradual increase in physiological births

Management of Third Stage of Labour

• Neonatal outcomes v. maternal outcomes• Evidence shows that cord clamping timing significantly affects the

haematological status of term neonates improving their iron status up to 6 months (important in areas of malaria/aneamia)

• There are benefits to neonatal resuscitation with the umbilical cord intact whenever possible

• Physiological labour; are we introducing an intervention that may have an adverse effect?

• Healthy mothers are well able to tolerate blood loss up-to 1000mls• Does the administration of oxytocin delay bleeding?; impact on

current early discharge policy• Does Syntocinon as well as ergometrine affect prolactin levels or

breastfeeding reduced natural oxyticins?

Practice Issues

• One person present at birth

• Skin-to skin contact, newborn thermoregulation, breastfeeding maternal position (waterbirth)

• Artificial oxytocin v. natural

• Timing of oxytocin

Practice issues

• Little evidence of increase in neonatal jaundice

• Rh –ve mothers; should we make specific recommendation?

Practice guideline updated

• Delayed cord clamping is currently the recommended practice known to benefit the neonate improving iron status up to 6 months but with a possible risk of jaundice that requires phototherapy.

• Timing is not prescribed as will always depend on clinical decision making and agreement with mother

Thank you

http://www.rcm.org.uk/college/policy-practice/guidelines/practice-guidelines/