Hi Sally
The hospital in which I work has a policy relating to all women having
active management of third stage as a result of the Cochrane findings. Women
have to be informed of the 'risk' of physiological third stage and this is
supposed to be documented in the notes. Trying to keep a more reasonable
approach to this issue, I did a session for delivery suite midwives on this
topic.
The Cochrane review is predominantly based on the Bristol trial and the
Hinchingbrooke trial (designed to combat the biases in the Bristol trial). I
concentrated on analysing the research. The Bristol trial has a number of
flaws of which you are no doubt aware, but the biggest one was that midwives
were not trained to do it. The Hinchingbrooke trial states that it addressed
this with education sessions etc. However, Michel Odent's article "Don't
manage the third stage", talks about the optimum requirements for a
physiological third stage (dimmed lights, warmth for the mother, the woman
not feeling observed etc). This criteria was not part of the Hinchingbrooke
trial so you have to question how 'physiological' the 'expectant' management
group really was. Women who used pethidine were also included in the study,
but due to its relaxing effect on the uterus (we have all seen this when it
can 'knock' women out of early labour), this also has to be questioned. The
other big thing with this trial was the intention to treat analysis. Whilst
this is appropriate, it meant that any women who had a mix of both active
and expectant management (PPH rate approx. 22%) were included in the
expectant management group, greatly increasing the overall PPH rate. The one
thing that it did show us is that, if the plan is for physiological
management but you then cut and clamp the cord early (eg. Need for baby
resus on the resuscitaire away from the bed), you should give synto.
The other big part of my presentation was presenting the Birthing Centre
stats. Their PPH rate for women having a physiological third stage is less
than that of women having active management. The numbers are also large with
40% of women choosing a physiological third stage, so the research needs to
be put in a clinical decision making context, based on the woman's desires,
past history and events in labour (not that you don't know this). You would
probably find that presenting your stats on third stage would be more
meaningful and put it in context for the staff.
Sorry, I seem to have 'gone on' a bit here. Unfortunately I don't have any
of the references to hand, but if you want them I should be able to get them
for you. Hope my ravings have been of some benefit.
Cheers
Bec
----------
From: Sally Westbury
Sent: Wednesday, 29 August 2001 16:52
To: [EMAIL PROTECTED]
Subject: physiological 3rd stage
Anyone know of some good research about physiological 3rd stage that
I could present to the local hospital.
thanks
Sally Westbury
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