A typical childbirth scene as portrayed by the media includes a doctor or midwife urging a labouring woman to take a deep breath, hold it as long as possible and push with all her might. This was once common practice in the UK, but there is no current evidence to support it. Indeed, this Valsalva manoeuvre, as it is known is now associated with fetal compromise due to the reduction in oxygen- ated maternal blood crossing the placenta during the manoeuvre (Thompson 1993; Roberts 2002). Current evidence suggests that instinctive, physiological pushing behaviour is less harmful to the fetus and the woman (Sleep 1990).
Midwifery care in the third stage of labour
heavily, there is no cause for concern. There is a suggestion that blood loss in the postnatal period is less for women who have had a physiological third stage (Wickham 1999), although it is clear from the evidence that a physiological third stage is associated with a higher blood loss during the actual delivery (Prendeville et al.
2004).
There is some debate about when is the best time for the umbil- ical cord to be clamped and cut, and further research is needed. As Inch (1985) points out in keeping with the principles of expectant management, the cord should not be clamped and cut until after the placenta and membranes have been expelled. It has been shown that there are benefi ts to doing this in relation to the baby continu- ing to receive oxygenated blood via the cord (Harris 2004). This is of particular importance if the baby is born prematurely (Kinmond et al. 1993). However, if the cord is particularly short, then not cutting it means that the woman is unable to hold her baby. A compromise in this situation is for the midwife to wait until the cord has stopped pulsating (usually after 5–10 minutes) and then clamp and cut it.
The woman should be encouraged to breastfeed her baby as soon as possible while waiting for the placenta to be delivered as the natural oxytocin released as the baby sucks will stimulate contrac- tion of the uterine muscle.
The maternal end of the cord should not be clamped but should be left to drain into a suitable receptacle. This will mean that blood can drain from the placenta and reduce its overall size which will further help to facilitate delivery (Johnson and Taylor 2006).
However, any blood which drains from the placenta should not be included in the fi nal estimate of blood lost during the delivery as it is placental rather than maternal blood (Johnson and Taylor 2006).
When the uterus contacts the woman may feel some abdominal pain and will then have an urge to bear down again. She should be encouraged to do this and she may want to move into a more upright position (standing or squatting) so that gravity can assist the process (Rogers et al. 1998). A rush of blood will be seen and the cord may appear to lengthen as the placenta moves into the vagina.
The woman will then spontaneously push the placenta and mem- branes out.
Active management of the third stage of labour
Active management of the third stage of labour includes giving the woman an oxytocic drug, the early clamping and cutting of the umbilical cord and controlled cord traction (Baston 2004).
A systematic review of four studies comparing active manage- ment of labour with physiological management suggests that active management should be the recommended option in the hospital setting (Prendeville et al. 2004). The review concluded that there was an overall reduction in maternal blood loss in those women having active management of the third stage compared with those women undergoing physiological third stage with no intervention. The rate of postpartum haemorrhage was also signifi cantly lower in the actively managed women. The situation regarding the homebirth or birth centre setting is less clear (Enkin et al. 2000). The review also showed that side-effects of the oxytocic drugs used in the third stage include severe nausea and vomiting for some women, headache and raised blood pressure. Women who receive oxytocic drugs also sometimes complain of abdominal pain (‘after-pains’) due to the sustained contraction of the uterus which these oxytocic drugs induce.
The midwife must ensure that the woman knows what options are available to her in relation to the third stage of labour and that this information is presented in a clear, unbiased way so that she can make an informed decision (Anderson 1999; Rogers and Wood 1999). For some women, it is very important that they experience the whole childbirth process with minimal intervention and studies have highlighted the great satisfaction that a totally drug-free labour may give (Rogers and Wood 1999). The choice of whether to have a physiological third stage may be the only one left to a woman who has had to abandon her ideal birth options. For example, a woman may have hoped for a homebirth but due to slow progress in labour may have been transferred to a hospital unit (Baston 2004). Other women may be concerned about the unpleasant side-effects of the oxytocic drugs and for this reason would prefer to avoid them.
For these reasons, it is preferable that care options are discussed with the woman during the antenatal period so that she has time to consider the issues and include her wishes on her own birth plan. It is suggested that it is the midwife’s role to discuss the advantages and disadvantages of the available options with their clients and then to ensure that they are suitably skilled to support the women in whatever choice they eventually opt for (Anderson 1999).
Syntometrine (1 ml) is an oxytocic drug often used in active management of the third stage. It contains 500 µg of ergometrine and 5 units of oxytocin. The oxytocic component of the drug induces a strong contraction of the upper uterine segment after approximately 2–3 minutes of administration. This effect lasts 5–15 minutes (Baskett 1999). In contrast the ergometrine component induces a strong sustained contraction of the uterine muscle 6–8 minutes after
administration (Sorbe 1978). This effect lasts for approximately 60–90 minutes.
If a woman is known to have raised blood pressure or cardiac problems, then syntocinon is the drug of choice (DH 1994) as it does not cause sustained contraction of muscle fi bres in the way that the ergometrine component of syntometrine does. If a women with a raised blood pressure is given an oxytocin-containing ergometrine, then contraction of muscles within her blood vessels will lead to her blood pressure being raised even more. Syntocinon can be given either intravenously (5 iu) or intramuscularly (5–15 iu). Syntocinon also has fewer side-effects such as the nausea and vomiting associ- ated with syntometrine.
If a woman is to have an active management of the third stage, the oxytocic drug is traditionally administered intramuscularly by the midwife as the baby’s anterior shoulder delivers. It is usually given in the upper outer part of the woman’s leg. However, if the midwife is alone during the birth, then giving the drug at this precise time is not possible. In this case the midwife will administer the drug following the birth of the baby. In either case, the drug should always be given following the delivery of the baby’s shoulder to ensure that shoulder dystocia (the shoulders trapped behind the woman’s pubic bone) is not a possibility (Baston 2004).
The umbilical cord should be clamped using specially designed umbilical clamps and then cut as soon as possible after the delivery of the baby. This is because the oxytocic drug causes a contraction of the uterus which forces placental blood into the baby’s circulation.
This overloads the infant’s circulatory system (indeed the baby can receive up to half of his whole blood volume again) and may cause hyperbilirubinaemia (high levels of bilirubin in the blood stream), leading to neonatal jaundice (Johnson and Taylor 2006).
The woman’s partner may ask to cut the cord and this request can usually be facilitated with the support of the midwife. In cases of an instrumental delivery, the midwife may need to remind the obstetri- cian who is undertaking the delivery of the couple’s request so that it can still be accommodated if the condition of the woman and her baby allows. As Baston (2004) points out, the memory of the birth and the couple’s involvement in it will remain with them forever so it is important to respect such requests if possible.
Following clamping and cutting of the cord, the midwife should place her hand on the woman’s abdomen and wait for signs that the uterus has contracted. She will feel that this has occurred when the uterus hardens underneath her hand; it will feel like a smooth hard, cricket ball. It is important at this time that the midwife avoids so- called ‘fundal fi ddling’ (that is unnecessary touching of the uterus)
which may lead to the placenta only partially separating from the uterine wall (Johnson and Taylor 2006), which may in turn be a cause of excessive bleeding and postpartum haemorrhage. Spencer (1962) suggested controlled cord traction (CCT) should be com- menced as soon as the uterus contracts and this was a traditional aspect of an actively managed third stage. However, since then Levy and Moore (1985) have suggested that it is preferable to wait for further signs that placental separation has occurred.
Signs of separation include the rising of the fundus and the hard- ening of the uterus as described above, coupled with a gush of blood from the vagina and a lengthening of the umbilical cord. Levy and Moore (1985) found no signifi cant difference in the incidence of postpartum haemorrhage (PPH) or the length of the third stage between those who commenced CCT immediately they felt the uterus contract and those who waited for signs of separation.
However, the incidence of PPH did increase signifi cantly when the midwife unsuccessfully applied CCT without waiting for signs of placental separation.
CCT involves the midwife either wrapping the cord around her fi ngers or using a clamp to apply downward, sustained pressure until the placenta becomes visible at the vulva. Once the placenta can be seen, the traction is applied upwards to follow the curve of the vagina. The placenta is then delivered into a bowl. Care should be taken of any trailing membranes and the midwife may need to use forceps to gently tease the membranes out of the vagina. Alter- natively, twisting the trailing membranes into a rope may be useful and some midwives ask the woman to cough gently to assist this process.
Some midwives place their hand above the symphysis pubis while undertaking CCT and push the uterus upwards. This is known as
‘guarding the uterus’ and is thought to prevent the uterus being pulled inside out (uterine inversion). However, there is no evidence to suggest that this is necessary (Harris 2004).