Update to the Cochrane review on approaches to the birth of the placenta

An updated version of the Cochrane review on Active versus expectant management for women in the third stage of labour has just been published, although the main conclusions have not changed.

As before, it is deemed important to differentiate between the situation for women who are healthy and have a low chance of excessive bleeding and women who have a higher chance of excessive bleeding after birth, but in both situations the quality of the evidence is low and uncertainty exists. “In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours).” (Begley et al 2019). And, “For women at mixed levels of risk of bleeding, it is uncertain whether active management reduces the average risk of maternal severe primary PPH (more than 1000 mL) at time of birth (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, 3 studies, 4636 women, I² = 60%; GRADE: very low quality).” (Begley et al 2019).

The aim of this review was to compare the effects of active versus expectant management of the third stage of labour (and also the effect of the various packages of management) on severe primary postpartum haemorrhage (PPH) and other maternal and infant outcomes. The review includes eight studies, “involving analysis of data from 8892 women. The studies were all undertaken in hospitals, seven in higher‐income countries and one in a lower‐income country. Four studies compared active versus expectant management, and four compared active versus a mixture of managements.” (Begley et al 2019). However, “There was an absence of high‐quality evidence according to GRADE assessments for our primary outcomes, which is reflected in the cautious language below.” (Begley et al 2019). The authors also note that, “It must be emphasised that this review includes only a small number of studies with relatively small numbers of participants, and the quality of evidence for primary outcomes is low or very low.” (Begley et al 2019).

Another key point is that, as with all interventions, active management has downsides as well as benefits:

“Active management reduces mean maternal blood loss at birth and probably reduces the rate of primary blood loss greater than 500 mL [but please also see this post on the problems with measuring blood loss, because there are also wider issues to consider], and the use of therapeutic uterotonics. Active management also probably reduces the mean birthweight of the baby, reflecting the lower blood volume from interference with placental transfusion. In addition, it may reduce the need for maternal blood transfusion. However, active management may increase maternal diastolic blood pressure, vomiting after birth, afterpains, use of analgesia from birth up to discharge from the labour ward, and more women returning to hospital with bleeding (outcome not pre‐specified).” (Begley et al 2019).

This is one of many areas in which the quality of evidence is low, and it isn’t very helpful for women who need to make decisions (which is, of course, absolutely not the fault of the review authors), but perhaps in this case the authors’ call for further research which looks at the different components of the ‘active management’ package will lead to better studies. It is important to note that the key studies in this area were conducted before it was widely recognised that it was important not to clamp and cut the cord too early, to ensure that the baby got its full complement of blood.

Now available! A guide to the different approaches to birthing the placenta. Includes discussion of evidence, experience and the wider issues. For women and birth workers alike!

Ultimately, it is always the woman’s decision and, as the review authors note, “Women should be given information before they give birth to help them make informed choices.” (Begley et al 2019).

The full review can be found here and, if you are looking for more information and woman-centred discussion of this topic to help support your decision in this area (or the decisions of others), then you might enjoy Birthing Your Placenta: the third stage of labour, which I co-authored with Nadine Edwards.