Third stage of labour management practices: A secondary analysis of a prospective cohort study of Australian women and their associated outcomes

Objective: This study aimed to describe practices used during the third stage of labour in a cohort of Australian women and explore clinical outcomes such as postpartum hemorrhage and clinical decision making associated with these practices.

Design: This study employed a prospective cohort design and reports a secondary analysis of a primary study that examined factors associated with PPH; specifically relating to third stage management practices.

Setting: It was conducted in three linked sites, in Queensland, Australia: a regional hospital, rural hospital and a private-practising midwifery service.

Data collected: type of third stage management chosen by the care provider, and why; use of uterotonic medications (including administration timing); determination of cord-clamp timing and why; and, use of controlled cord traction.

Participants: Convenience sample of women birthing vaginally between October 2015 and April 2016 (n = 522).

Findings: Active management was the most common self-reported third stage management practice across these birth settings despite local health service guidelines advocating modified active management for all births. Modified active third stage was associated with least risk of PPH; however considerable variation in modified active practices was evident, particularly relating to cord clamp timing and oxytocic administration. Professional discipline, birth setting and complications during labour were significantly associated with differences in third stage management. Midwives were more likely to engage in expectant management than obstetricians; while active management was more commonly used in the rural setting and when complications during labour were experienced.

Key conclusions: Modified active management was not associated with an increased risk of PPH consistent with contemporary evidence. However, a considerable proportion of providers may not be following evidence-based guidelines supporting modified active management which may be attributed to uncertainty around third stage practice definitions which has implications for education, practice, and policy.

Implications for practice: Despite evidence-based guidelines, differences exist within modified active management including cord clamp timing, uterotonic administration and use of controlled cord traction. Modified active management was not associated with an increase in PPH.