September 22, 2002

Third Stage of Labour

There was an interesting post to the ozmidwifery list recently that described one hospital’s policy about the management of the third stage of labour. It appears that this unit insists that all women will have an actively managed third stage of labour and that any woman who refuses (in advance presumably) will have to seek maternity care elsewhere.

This is an outrageous position on a number of levels. First, the denial of informed choice is surprising, given that hospital managements are usually keen to avoid potential litigious situations. The hospital, however, possibly takes the stand that they inform everyone of this policy in advance, so that anyone not willing to comply has time to find another hospital for the birth, thus enabling the “informed choice” to be make early in the pregnancy. I wonder how many parents would haven even thought about third stage of labour at that point, or knows what the implications are? As the hospital’s name is not revealed it is not known where it is, but I suspect that it is a rural unit and therefore the ability of the parents to go elsewhere may be severely limited. Choice may simply not exist.

Secondly, the evidence for managing the third stage with oxytocics is a contentious issue. If the birth has been normal (that is, no oxytocics for induction or augmentation, no pain medications, no obstetric interventions) there is very little chance of a haemorrhage after the baby is born. Expectant management should be the approach, rather than “just in case” measures. If there have been interventions during the labour and birth, and this will be the case for probably 90%+ of all women giving birth in a hospital setting, then there is an increased risk that she will bleed heavily after the birth, but this is not a certainty. Many women and midwives would still prefer to wait until there is a medical need for intervention, because the giving of oxytocics is not without its own risks.

This is a good example of where midwives often collude with the doctors during labour and birth. Midwives (and doctors) don’t always know how to manage a third stage physiologically; they are often rushed and short staffed and want to get the woman cleaned up and on her way out of labour ward fast; they don’t know the ramifications of giving oxytocics to mothers and the effects it may on the establishment of breastfeeding, for example. They may be unwilling to take a stand on the issue perhaps because they fear a lack of support from their colleagues. It is a shameful state of affairs, and the woman and her baby are the victims of poor professional practice.

These policies need to be challenged. They should be discussed in the pre-natal classes where the parents can be acquainted with strategies to ensure they are not treated in this “conveyer belt” fashion. Parents must know that no-one can lay a hand on them, at any time, without their expressed permission Signing “consent forms” in advance does not lock them into acceptance - they can always change their minds. Informed consent must also be freely given, not extracted under a threat of the withdrawal of services, as is apparently happening in this instance.

Midwives should be challenging their medical colleagues and their management to rethink this policy in the light of the medical evidence and the potential for parent dissatisfaction. Yes, I know that the Cochrane Library suggests that oxytocics should be given routinely, but they do not recommend that they be given against parental wishes. Their recommendations are just that, and should be seen as guidelines, not as hard and fast rules.

The giving of oxytocics for third stage is a classic example of the double standards in maternity care: on the one hand we say “let’s keep birth normal by not interfering with the normal process” and then in the next breathe we say “but you will be given routine syntometrine for third stage as it is our policy in this unit”. Ridiculous! No wonder parents are confused and many are looking for alternatives away from such a crazy and uncaring system.

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