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Less bleeding with active management of third stage of labor: Swedish study

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Active management of the third stage of labor leads to less blood loss compared to expectant management, without altering the childbirth experience, a Swedish study suggests.

Based on their findings, Dr. Elisabeth Jangsten of Sahlgrenska University Hospital, Gothenburg and colleagues think it is “reasonable to advocate this regimen,” especially in healthy primiparous women with normal pregnancies.

Their study was published online December 7 in BJOG: An International Journal of Obstetrics and Gynecology.

In this study, active management included clamping the cord immediately after birth; IV administration of 10 IU (2 mL) oxytocin within 2 minutes; controlled cord contraction and encouraging the mother to push; and uterine massage after expulsion of the placenta.

Expectant management included cord clamping immediately after birth; IV administration of 2 mL saline within 2 minutes, waiting for signs of placenta detachment and encouraging the mother to push out the placenta without cord traction; and uterine massage after placenta delivery.

Analyses were based on 810 women who underwent active management and 821 who underwent expectant management at two delivery units at a Swedish university hospital. Each woman was pregnant with a single infant in cephalic presentation and vaginal delivery was expected.

Blood loss greater than 1000 mL, the primary outcome, occurred in 10% of the actively managed mothers versus 17% of the expectantly managed mothers (P < 0.001), the investigators report.

In primiparas, blood loss greater than 1000 mL occurred in 13% of those actively managed and 20% of those expectantly managed. In multiparas, the corresponding percentages were 6.5% and 12% (P < 0.001).

Regardless of management approach during the third stage of labor, more primiparous than multiparous women bled more than 1000 mL: 17% compared with 9.3% (P < 0.001). Thirty-five primiparous women required blood transfusion compared with only six multiparous women (P < 0.001).

The average blood loss before placenta expulsion was lower in the actively managed group compared to the expectantly managed group (301 mL vs 395 mL; P < 0.001). Average blood loss after placenta expulsion was also lower in the actively managed group (233 mL vs 282 mL; P < 0.001).

At baseline, hemoglobin levels were the same in both groups (129 g/dL), but the day after delivery, hemoglobin levels were higher in the actively managed than the expectantly managed mothers (118 vs 115 g/dL; P < 0.001).

A similar number of actively managed and expectantly managed mothers had retained placenta or placental tissue (31 vs 29).

The investigators note that while this study found active management to be “preferable in most cases,” only women with normal pregnancies were included in the study.


A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial