Is active (vs expectant) management of a persistent PUL more effective?

A randomized trial of active versus expectant management of the third stage of labor

Cost-effectiveness analysis of expectant vs active management for treatment of persistent pregnancies of unknown location

Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. To compare the effectiveness of active versus expectant management of the third stage of labour. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2014) and reference lists of retrieved studies. Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women, GRADE:very low quality) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women, GRADE:low quality). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 infants, GRADE:low quality) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 infants, GRADE:very low quality). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both, and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here. Although there is a lack of high-quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.

BackgroundPrevious research examining the birth of the placenta has focussed on quantitative outcomes comparing active and expectant (physiological) management. However, it is also important to understand women’s experiences of birthing the placenta.MethodsThe participant group consisted of 11 women who had expectant management, eight who had active management and one who was unsure. Participants were interviewed in-depth and the data analysed using thematic analysis.ResultsSeven themes were identified in the data relating to before, during and after the birth of the placenta. Before birth themes focused on making decisions and included ‘doing the research’ and ‘natural birth’. During the birth of the placenta themes were ‘boundaries of time’, ‘focusing on baby’ and ‘sensations’. After the birth themes consisted of ‘looking’ and ‘keeping’.ConclusionMost of the women considered a physiological birth of the placenta to be an intrinsic element of natural birth. Active management was considered to be an intervention used if complications occurred. In contrast, women who chose active management did not consider the placenta to be an important element of natural birth, and chose active management in order to prevent complications. Decisions about birthing the placenta were informed by Internet sources and previous personal experiences rather than care providers. During the birth of the placenta care providers managed the boundaries of time whilst women focused on their baby. The sensations women described were consistent across both types of management. Women valued seeing their placenta and having the opportunity to keep it, and placenta encapsulation was popular. The findings of this study contribute the experiences of women to the body of knowledge informing practice during the birth of the placenta.

Background: Prelabour Rupture of Membranes (PROM) at term complicates 10% of all pregnancies, leading to a number of possible fetomaternal complications. No set management plan has yet been devised whether to deliver such women immediately or to wait for spontaneous labour. Objective: To compare fetomaternal outcome with immediate/active versus expectant management in pregnancies complicated with pre labour rupture of membranes at term. Methodology: A randomized prospective controlled trial conducted in Obstertics & Gynaecology department of Benazir Bhutto Hospital, Rawalpindi. All women presenting with PROM at term and fulfilling the defined inclusion criteria were recruited and randomized equally to Group-A and Group-B for Active versus Expectant management. The latency period for onset of labour, mode of delivery, maternal and fetal complications were compared in two groups. Results: During study period, 190 women were recruited. The mean maternal age was 26.16 years. Out of total, 45% were primigravidas, 40% multigravidas and 15% were grand multiparas. There was no statistically significant difference in mode of delivery between two groups (p-value The latency period was significantly prolonged (>24 hours) in 57.9 % of the patients with expectant management (p-value <0.05). The rate of PPH (p-value 0.004) and chorioamnionitis (p-value 0.005) was higher in expectant group and while neonatal complications were comparable in both groups (p-value >0.05). Conclusion: The active management of PROM is the preferred management option due to a shorter latency period, lesser maternal complications, without any significant increase in the rate of operative delivery. Key words: Active management, Expectant management, Latency period, Premature rupture of membranes, PROM.

Active versus expectant management of third stage of labour

Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial

Approximately one in five recognized pregnancies are spontaneously miscarried in the first trimester and an additional 22% end in induced abortion. Incomplete abortion occurs when there are retained products of conception (POC) after induced abortion (whether by unsafe or safe methods) or after spontaneous abortion, also known as miscarriage. Some women may resort to self-induction. These conditions increase the likelihood that women will experience abortion complications and will seek treatment for incomplete terminations. Incomplete abortion can be treated with expectant management, which allows for spontaneous evacuation of the uterus, or active management, using surgical or medical methods. Expectant management is not preferred by many providers due to its relatively low efficacy and the fact that the time interval to spontaneous expulsion is unpredictable.The study was performed in a Durgapur Steel plant hospital, a tertiary care Hospital in West Bengal, India. The institute caters a huge area, both rural and urban. The study was done between 1st January2019 to 31st October 2020.Study population was drawn from patients attended OPD and patients admitted with incomplete abortions, either of spontaneous or, induced etiology in the Dept. Of Obst, & Gynae, Durgapur Steel plant hospital. A total of 80 women were randomised to either a single dose of 600 micrograms of oral misoprostol or MVA.160 women were recruited to the trial, of which 80 women were grouped into misoprostol group & another 80 to MVA group. Immediately after abortion, all the patients were available & data collected from all the patients. But during next follow-up after 1-2 wk, 33 in the MVA group & 27 in the misoprostol group did not come (Lost to follow up n=33) for follow-up. So, approximately 41% (33) of participants in MVA group & 34% (27) in the misoprostol group were lost to follow-up.In our study both MVA & Misoprostol groups had similar age distribution. Mean age in MVA group 23.5 years (± 4.5) and in MISO group 23.4 Years (± 4.8). For treatment of first-trimester uncomplicated incomplete abortion, both manual vacuum aspiration and 600 µg oral misoprostol are safe, effective, and acceptable treatments. However, misoprostol appears to be somewhat better option than MVA, in regards to availability, low cost of therapy, less pain, less need of expert manpower or specialised instruments.

Editor’s Choice

We thank Dr. Sentilhes and coworkers for their interest in the results from the observational part of the Swedish ICP study, in which we demonstrated that fetal risk correlated with maternal bile acid levels. We stratified a large patient material (n = 690) of pregnant women with pruritus into three groups: no ICP (serum bile acids <10μmol/L), mild ICP (10-39 μmol/L) and severe ICP (≥40μmol/L). Spontaneous preterm delivery; asphyxial events (operative delivery due to asphyxia, arterial umbilical pH <7.05, or Apgar score <7 at 5 minutes); and meconium staining of amniotic fluid, placenta, and membranes were found to be significantly increased in the group with severe ICP compared with the groups with no ICP and mild ICP. No differences in these variables were detected between the group with no ICP and the group with mild ICP. Furthermore, a higher frequency of intrauterine fetal death (IUFD) in prior pregnancies was reported by women in the group with severe ICP (4.1%) compared with the groups with no ICP (0.6%) and mild ICP (0.8%) (P < .001). The rates of IUFD in the group with no ICP and the group with mild ICP did not differ significantly from the overall IUFD rate in Sweden (0.4%). In their comments, our French colleagues referred to the fact that one of our IUFD cases had bile acid levels below 40 μmol/L (27 μmol/L). This case was a twin pregnancy, in which one fetus died and the other survived. At delivery, a tight knot on the umbilical cord of the dead twin was found. Fetuses in twin pregnancies are indeed exposed to a higher risk, and all cases of IUFD in ICP pregnancies are not necessarily related to the disease. A recent study by Williamson et al.1 investigated fetal outcome in women with ICP, and they reported high fetal complication rates. However, in this study several confounding factors were present. Their patient material was based on a questionnaire survey in women with ICP that were identified by a patient support group. As the authors themselves stated in the article, this fact may indicate that the material was enriched by pregnancies in which complications had occurred. It should be pointed out that induction of labor, especially before term, is associated with an increase of fetal and maternal risk in terms of prolonged labor, higher frequencies of emergency cesarean section, and fetal asphyxia. We agree that the slight increase in risk of respiratory distress syndrome in the neonate is not an important issue when deciding to induce labor. Nevertheless, it should be underlined that inductions of labor should be conducted only in cases in which benefits outweigh risks. Our study proved that fetuses in pregnant women with bile acid levels exceeding 40 μmol/L were exposed to an increased risk, and in this group it seems reasonable to propose active management (pharmacological treatment or induction of labor). Because we could not find any increase of fetal risk in our large study population of women with ICP and bile acid levels 10 to 39 μmol/L, we cannot find any evidence to support that these women would benefit from routine induction before term. To further address this issue, a randomized study between active and expectant management should be conducted in this specific group. Anna Glantz M.D.*, Hanns-Ulrich Marschall M.D. Ph.D.*, Lars-Åke Mattsson M.D., Ph.D.*, * Dept of Obstetrics/Gynaecology, Sahlgrenska University Hospital/East, Göteborg, Sweden.

Although the focus at delivery may naturally shift to infant transition, continued maternal vigilance during stage 3 is imperative to accomplish a safe outcome for the mother and her newborn. The third stage of labor is a normal physiological progression of birth that may be compounded by serious complications. The most common complication is postpartum hemorrhage due to uterine atony. Clinicians choose either active management or expectant management for stage 3 to prevent excessive maternal blood loss. Rapid identification and response to a postpartum hemorrhage are critical. A multidisciplinary perinatal team at a large Midwest tertiary center led the transition from an expectant to an active-management protocol within the obstetric service. Outcomes included a decrease in the postpartum hemorrhage rate and decreased usage of additional uterotonic medications during the immediate recovery period.

Objective To compare the type of management (active versus expectant) for preterm premature rupture of membranes (PPROM) between 34 and 36 + 6 weeks of gestation and the associated adverse perinatal outcomes in 2 tertiary hospitals in the southeast of Brazil.Methods In the present retrospective cohort study, data were obtained by reviewing the medical records of patients admitted to two tertiary centers with different protocols for PPROM management. The participants were divided into two groups based on PPROM management: group I (active) and group II (expectant). For statistical analysis, the Studentt-test, the chi-squared test, and binary logistic regression were used.Results Of the 118 participants included, 78 underwent active (group I) and 40 expectant management (group II). Compared with group II, group I had significantly lower mean amniotic fluid index (5.5 versus 11.3 cm,p = 0.002), polymerase chain reaction at admission (1.5 versus 5.2 mg/dl,p = 0.002), time of prophylactic antibiotics (5.4 versus 18.4 hours,p < 0.001), latency time (20.9 versus 33.6 hours,p = 0.001), and gestational age at delivery (36.5 versus 37.2 weeks,p = 0.025). There were no significant associations between the groups and the presence of adverse perinatal outcomes. Gestational age at diagnosis was the only significant predictor of adverse composite outcome (x2[1] = 3.1,p = 0.0001, R2Nagelkerke = 0.138).Conclusion There was no association between active versus expectant management in pregnant women with PPROM between 34 and 36 + 6 weeks of gestation and adverse perinatal outcomes.

Reply of the Authors

Textbooks often restrict discussion about the placenta to its function, possible dysfunction, and expectant and active management, with little to no mention of cultural placental practices. Equally, midwives practising in hospital settings, where the placenta is viewed as clinical waste,1 afterbirth rituals than homebirth practitioners. are less likely to facilitate 1,2 This can lead to maternal requests for practices including placental burial, cord burning ceremonies2 and placentophagy being viewed as unconventional or incompatible with clinical guidelines. Yet since the National Institute for Health and Care Excellence (NICE) assert that women and birthing people must be asked about their preferences for the third stage of labour,3 midwives and students should be prepared to discuss and facilitate culturally significant placental rites.

Active versus expectant management of third stage of labour