Rona McCandlish

Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial.

BACKGROUND This study tested the hypotheses that active management of the third stage of labour lowers the rates of primary postpartum haemorrhage (PPH) and longer-term consequences compared with expectant management, in a setting where both managements are commonly practised, and that this effect is not mediated by maternal posture. BACKGROUND 1512 women judged to be at low risk of PPH (blood loss >500 mL) were randomly assigned active management of the third stage (prophylactic oxytocic within 2 min of babys birth, immediate cutting and clamping of the cord, delivery of placenta by controlled cord traction or maternal effort) or expectant management (no prophylactic oxytocic, no cord clamping until pulsation ceased, delivery of placenta by maternal effort). Women were also randomly assigned upright or supine posture. Analyses were by intention to treat. FINDINGS The rate of PPH was significantly lower with active than with expectant management (51 [6.8%] of 748 vs 126 [16.5%] of 764; relative risk 2.42 [95% CI 1.78-3.30], p<0.0001). Posture had no effect on this risk (upright 92 [12%] of 755 vs supine 85 [11%] of 757). Objective measures of blood loss confirmed the results. There was more vomiting in the active group but no other important differences were detected. INTERPRETATION Active management of the third stage reduces the risk of PPH, whatever the womans posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.

Place of birth.

Place of birth affects the outcomes and life chances for women, their infants and families globally, and is an enduring topic for debate and challenge. In middle and high income countries, debates about place of birth, either home, birth centre or hospital have been contentious regarding issues such as safety, costs and the right of women to make a choice over where, and how they give birth. Women’s social, cultural and economic rights also influence access to support and professional expertise, and national or local policies constrain possibilities. Many pregnant women worldwide do not have options or choices about place of birth. As we move towards 2015, the year in which the Millennium Development Goals (MDG) are set to be achieved, research and evidence about place of birth is highly relevant. Place of birth is clearly key for the MDG targets which seek to reduce by three quarters the maternal mortality ratio and increase the proportion of births attended by a skilled health professional, which in most cases should be a midwife. In sum, the politics of maternity care are being played out around the place of birth issue worldwide. With this as the background, we have commissioned this special issue of Midwifery to bring together diverse perspectives about place of birth from different country settings. We received over 40 submissions and the final selection of papers cover a range of high and low income countries, using a range of approaches to consider questions and generate evidence relevant to place of birth. These papers contribute to a significant body of global evidence around the processes and outcomes of place of birth. Other papers which were accepted will be published in future issues of Midwifery. Some key themes in this special issue include: methodological issues to be considered when assessing place of birth outcomes; addressing influences and the potential for women to make decisions about where they give birth; why women choose to give birth outside the health system; evaluation of new forms of organisation such as midwife units and home birth services in countries where they are not the social and cultural norm; how care providers negotiate how they work in these new modes of delivery and develop strategies to sustain safe services. It appears from published evidence that women who are low risk have good outcomes in out of hospital settings, and costs appear to be lower, but systems need to be in place to support early diagnosis and transfer if problems emerge. Midwives with the skills and competencies to support normal birth and to manage emergencies are key to delivering quality outcomes for all women, babies and families. In some health systems these