Med. J. Cairo Univ., Vol. 80, No. 2, June: 179-188, 2012
www.medicaljournalofcairouniversity.com
Assessment of Routine Management of Third Stage of Labor for
Normal Delivery in Women's Health Center (University Hospital)
and El-Eman Hospital (Ministry of Health Hospital)
for Obstetrics and Gynecology
MONA IBRAHIM, M.Sc.*; AHMED M. MAKHLOUF, M.D.**; MERVAT A. KHAMIS, D.N.Sc.*** and
EMAN R. AHMAD, D.N.Sc.***
The Departments of Ministry of Health Head Nurse*, Obstetrics & Gynecological Medicine**, Faculty of Medicine,
Assuit University and Obstetrics & Gynecological Nursing***, Faculty of Nursing, Assuit University
Ministry Hospital. It is miserable that the majority of women
attended the ministry hospital had certain aspects of managing
third stage of labor by auxiliary workers.
Abstract
In the Arab world, most research efforts and programmatic
interventions have understandably focused on complicated
deliveries. However, globally normal deliveries represent
85% of births. Few studies have documented routine facility
practices for normal labor in developing countries, little is
known regarding facility-based normal labor in the Arab
world. This study was unable to find data regarding actual
(vs. reported) third-stage management in Egyptian facilities.
This study was carried out to assess the routine management
of third stage of labor and to identify gaps that required
improving clinical care at Women's Health Center (University
Hospital) and El-Eman Hospital (Ministry of Health Hospital)
for Obstetrics and Gynecology. With respect to: Assess maternal outcome as regards to sequence of third stage of normal
labor, these hospitals were selected for data collection. The
sample comprised of 1000 women (500 women in each hospital
as A & B respectively) who were delivered normal vaginal
delivery in Emergency wards. The study applied a descriptive
cross sectional design in which two tools were used for data
collection. A special structured questionnaire was designed
to entail data related to sociodemographic, previous and
current obstetric history and the second tool included observation of health care providers' practices related to third stage
management among two hospitals. The results demonstrated
that about three-quarters (72.8%) of women in group (A)
received active management of third stage of labor compared
with (43.2%) of women's in in group (B). Almost all women
managed by active method received uterotonic drugs (Oxytocin) during the third stage of labor. The minority among both
groups had postpartum haemorrhage, only tears were apparent
significantly increase among women received expectant
management of third stage than active management group.
Obstetricians encourage the women to pass urine for the
majority of sample among group (A) (97.8%) compared with
less than half (48%) among group (B).
Key Words: Routine management - Third stage of labor Normal delivery
Introduction
THE third stage of labor is defined as the period
between delivery of the fetus and delivery of the
placenta. It is considered to be the most critical
part of childbirth due to the risk of post partum
hemorrhage (PPH) [1] .
Two approaches, active and expectant, have
been proposed for the management of the third
stage of labor. Active management involves administration of prophylactic oxytocin before delivery
of the placenta, early cord clamping and cutting,
and gentle cord traction with uterine contraction
when the uterus is well contracted (Brandt-Andrews
maneuver) and massage of the uterus after delivery
of the placenta, with palpation of the uterus to
assess the need for continued massage for the two
hours period following delivery of the placenta [13] . Active management of the third stage of labor
(AMTSL) is a feasible and inexpensive intervention
that can help save thousands of women's lives [4,5] .
Expectant management involves waiting for
signs of placental separation and allowing the
placenta to be delivered spontaneously or aided
by gravity or nipple stimulation [3] . The goals of
third stage are expulsion of the placenta and prevention of postpartum hemorrhage [6] .
Conclusion: 'Active management' is superior in use to
'expectant management' at University Hospital compared with
Correspondence to: Dr. Eman R. Ahmad, Obstetrics &
Gynecological Nursing, Faculty of Nursing, Assuit University
179
180
Assessment of Routine Management of Third Stage of Labor for Normal Delivery
Egypt has an improved but relatively high
maternal mortality ratio of 84 maternal deaths per
100,000 live births [7] , although 60% of births are
medically assisted and 49% are facility-based [8] .
Postpartum hemorrhage is the leading factor contributing to 27% of maternal deaths, with poor
obstetric management cited as the most frequent
avoidable factor, contributing to 43% of maternal
deaths [7] .
In the Arab world, most research efforts and
programmatic interventions have understandably
focused on complicated deliveries. However, globally normal deliveries represent 85% of births.
Few studies have documented routine facility
practices for normal labor in developing countries
[9,10] . Excepting data from Lebanon by interviewing providers [11] and observations of midwives in
Morocco, [12] little is known regarding facilitybased normal labor in the Arab world. We were
unable to find data regarding actual (vs. reported)
third-stage management in Egyptian facilities.
Increasing the effectiveness and efficiency of
health services is important everywhere but particularly so in developing countries with limited [13] .
There are remarkably few reports on the benefits
of clinical audit in the developing world, though
audit has been used in maternity care as a part of
the Safe Motherhood Initiative [14] .
Based on the data from the reviewed studies,
active management of the third stage of labor
should be routine after uncomplicated vaginal
deliveries in a hospital setting. Instituting the
routine practice of active management of the third
stage is simple and inexpensive, and it confers
significant clinical benefit in reducing maternal
complications with minimal risk. Uterotonic agents
already are available on all maternity units for
treatment of postpartum hemorrhage [15] .
Current practice guidelines recommend active
management of the third stage of labor. This paper
describes current practice during the third stage of
labor. We compared practices of two maternity
care provider disciplines in management of thirdstage labor and the justifications for their approach.
As maternal mortality and morbidity are avoidable with effective obstetric interventions. The
challenge is ensuring low-cost procedures of proven
benefit as standardized guidelines. Relying on risk
factors to identify women at risk for hemorrhage
has not decreased postpartum hemorrhage mortality,
as two-thirds of such cases globally occur in women
with no identifiable risk factors; the literature
suggests where maternal mortality from hemorrhage
is high, evidence-based practices that reduce hemorrhage incidence, such as active management of
the third stage of labor [5] . Reducing the incidence
of PPH can lead to a reduction in maternal mortality
in the developing and developed world [16] .
Subjects and Methods
Objectives: The aim of this study was to assess
the routine management of third stage of labor
after spontaneous vaginal deliveries and to identify
gaps that required improving clinical care at different levels of health care Women's Health Center
and El-Eman hospital for Obstetrics and Gynecology from May (2009) to October (2009) With
respect to: Assess maternal outcome as regards to
sequence of third stage of normal labor.
Significance of the study:
Worldwide, around 515,000 women die annually from maternal causes many within 4 hours of
delivery, often from postpartum hemorrhage (PPH)
following uterine atony. Most deaths occur in
developing countries where women may receive
inappropriate care during labor or during the postpartum period [17] . Currently, very little is known
about the actual practice of managing third stage
of labor. This study provided descriptive information necessary to assess routine management of
third stage of labor and AMTSL practices and
identify major barriers to its use.
Research design: The present study is a descriptive cross-sectional study.
Research setting: The study was conducted at
Women's Health Center and El Eman Hospital,
through emergency ward. Women's Health CentreAssuit University Hospital is a Teaching Hospital
provides tertiary level of care equipped with a
facility for operative procedures together with an
efficient blood bank, it conducts on the average
14,000 delivery a year and had a caesarean delivery
rate of 40% (unpublished from official records).
This hospital was selected because it is attended
by a large number of patients who represent different classes in urban and rural areas. El-Eman
Hospital for Obstetrics and Gynecology is a secondary level hospital, this hospital was selected
as one of the ministry hospitals which provides
services for all cases that come from rural and
urban areas in Assiut governorate.
Participants: A total sample of 1000 women
were recruited for this study (500 women from the
Women's Health Center represents group A and
Mona Ibrahim, et al.
the other 500 women recruited from El Eman
Hospital which represents group B) at the period
1/5/2009 to 31/10/2009. Interview was carried out
with health care providers (HCP) at the maternity
ward to explain the nature of research, and obtain
their acceptance to participate. The study sample
was selected according to the following criteria.
Inclusion criteria: Low-risk case (Expected to
have normal labor) as the following:
1- At term (>37 weeks).
2- Anticipated normal labor.
3- Single fetus presented by vertex (occipitoanterior position).
Exclusion criteria: High risk pregnancy
1- Ante partum hemorrhage (after 20 weeks gestations).
2- Free from medical any medical or obstetric
complications.
3- Any indication for Cesarean section (C.S) delivery for example, previous C.S, malposition
and malpresentation.
Tools of data collection:
Data were collected using two tools:
Tool I: An interview questionnaire tool that
was designed by the investigators and pretested
for comprehension and validity on 10% of participants in each group. It is designed to collect the
necessary data based on review of related literatures
and reviewed by 5 experts from Obstetrics and
Gynecological Nursing Department and a medical
related specialist, a questionnaire was divided into
two parts.
Part I: Socio-Demographic data: Name, age, level
of education, occupation, address.
Part II: Obstetric history data which includes:
- Data related to past obstetric history: Number of
parity, abortion, still births, abnormal labor,
neonatal death before 7 days and date of admission.
- Data related to Current obstetric history.
- Data related to past history:
• Medical disorders such as: Hypertension, Diabetes mellitus (D.M), Heart disease (HD),
Drugs: Especially in early pregnancy, any previous operations.
Tool II: A checklist tool is modified according
to guidelines standard of essential obstetric care
181
(Protocol for physicians) and maternal and child
health nursing care (maternity nursing protocol)
and this publication was made possible through
support provided by office of health and population,
United States Agency for international Development, Egypt, under the terms of contract with John
Snow (JSI) INC (JSI), as the following:
• Way of placental separation.
• Did nurse give the mother 5 international unit
(IU) oxytocin after delivery of fetus as doctor
order?
• Did doctor or nurse apply two forceps on umbilical
cord, and out in between?
• Who did the cutting?
• Perform controlled cord traction?
• Inspect vagina, perineum, and labia for lacerations
and tears.
• Inspect the vulva for bleeding, edema and hematoma.
• Palpate the height of the fundus.
• Estimate the average blood loss.
• Clean and dry the vulva, buttocks and thighs and
apply a sterile pad.
• Remain beside the woman after delivery.
• Check and record the maternal vital signs every
15 minutes.
• Observe the amount of lochia.
• Encourage the woman to pass the urine.
• Perform the uterine massage every 15 minutes.
Pilot study: It was preformed to evaluate the
questionnaire validity and reliability. It was carried
out on 10% of a sample 100 women 50 women
from each group who were excluded from the
study. Some questions were added and others
needed more clarifications.
Methods: In this descriptive study, 1000 women
were recruited from two hospitals (Women's Health
Center and El Eman Hospital as 500 women for
each), through emergency ward. An official permission was obtained from committee of Department of Obstetrics and Gynecology, Women's
Health Center and El-Eman Hospital for Obstetrics
and Gynecology. Women were informed about the
aims of the study, and they participated voluntarily
in this study. The investigator obtained women's
consent for the entire studied sample as well as
health care providers' acceptance to participate
voluntarily in this study. All women were interviewed and explained nature of the study after
182
Assessment of Routine Management of Third Stage of Labor for Normal Delivery
admission (during early 1 st stage of labor) by
investigators in face to face communication using
tool (I) to collect data related to socio-demographic
status as name, age, occupation, residence, and
level of education. The investigators read the
question to the women, according to her educational
level and record the women's answer. Past and
current obstetrical history was taken from the
women e.g. number of gravidity, parity, abortion,
still birth, no. of newborn death before 7 days after
birth, and duration of the pregnancy in weeks.
Each interview was taken about 10-15 minutes.
Also, the investigators interviewed the medical
and nursing staff (who) introduced the care for the
woman and newborn from admission to the delivery
of the placenta, obtained their number, category
and qualifications, explained to them the nature of
the study and taken their approval to participate
in the study. The investigator observed, recorded
and followed all guidelines using tool (II) for
assessing routine management of third stage of
labour and recorded manner of performance and
if not done ask about the rational for not doing any
of them and the barriers faced HCPs. Observation
checklist was applied for actively laboring woman
during the third stage for those who arrived at the
hospital with a 3-6cm cervical dilatation, with a
single, vertex-presentation, full-term fetus and
with complication-free obstetric histories and the
observation ends after the placenta was delivered
each observation take about 15-20 minutes. The
investigator recorded maternal and fetal outcomes
and any complications related to management of
third stage of labor.
Ethical consideration:
Confidentiality is obtained, only available to
the investigators and the participants.
Statistical analysis:
The statistical analysis was done using SPSS16 statistical software package and excel for figures.
The contents of each tool were analyzed, categorized by the investigator. Data were presented using
descriptive statistics in the form of number and
percentages for qualitative variables. Means and
standard deviations were applied for quantitative
variables. Statistical significance was considered
at (p<0.05), high significance if less than 0.01, or
insignificant if more than 0.05.
Results
A total of 1000 women were recruited into the
study, 500 each recruited from Women's health
centre and El-Eman hospital. Their demographic
data were presented in Table (1). The two groups
were similar in age & occupation, however a significant difference was observed regarding residence and level of education. As regards the health
care providers' characteristics, it is clear that the
total no. of health care providers was 38 for group
(A) compared with 34 for group (B) with no differences however concerning the variable categorization & qualifications among both groups no
differences was apparent between nurses and doctors.
Regarding obstetric history of the studied women, Table (2). Illustrates that both groups had similar
number of pregnancies, abortions, stillbirth, previous CS deliveries and also number of new born
deaths before 7 days after birth, number of living
children and number of twins with no significant
differences.
As regards optional management of third stage
of labor Table (3) delineates that slightly less than
three-quarters (72.8%) among group (A) had active
management of third stage of labor versus only
less than half (43.2%) among group (B) with a
highly statistical difference. Concerning the practices related to third stage management, cutting
the umbilical cord were practiced for all the studied
sample among both groups and the nurse represented the responsible person for practicing this maneuver for the majority of women among both
groups (A & B) (80.2% & 78.4% respectively),
furthermore, the majority of women among both
groups (A & B) had cutting of the umbilical cord
early (88.8% & 85.4% respectively). However as
regards controlled cord traction a highly significant
difference was observed among both groups as the
majority (92.3%) of group (A) who managed actively practiced controlled cord traction compared
with slightly more than one-third (35.2%) among
group (B) who managed actively for third stage of
labor. The HCP stated that the rationale behind
that they did not used to do controlled cord traction.
As regards HCP practices after delivery of the
fetus, this table shows that all Women among both
groups received IM syntometrine after delivery of
the fetus.
Concerning HCP practices after delivery of the
placenta Table (4) reveals that the placenta and
membrane examined for the majority of women
(84.4%) among group (A) compared with slightly
more than one-fourth (26.6%) among group (B)
with highly statistical significant differences. Furthermore, the obstetrician was the only person who
examined the placenta and membrane and who
Mona Ibrahim, et al.
183
estimated the average of blood loss for the vast
majority of the women with no statistical significant
differences among both groups (A & B) (98.6% &
98.2% respectively). Furthermore, regarding clean
and dry the vulva, buttocks and thighs and apply
a sterile pad, it is clear that all women among both
groups received this care, however the assistant
nurse represented less than half (45,4%) among
group (A) compared with the minority among
group (B) (9.8%). However the workers give this
care for more than half (54.6%) among group (A)
and the majority (90.2%) among group (B) with
highly statistical significant difference.
As regards the relationship between optional
management of third stage of labor and maternal
outcomes, Table (5) shows that no significant
difference was observed among women of both
groups regarding hemorrhage (p=0.147), however
a significant difference was observed regarding
occurrence of tears among group (A & B) with
highly significant difference (11.2% & 17.6%
respectively) p=0.004.
Table (1): Socio demographic characteristics of the studied women & health care providers.
Group A n=500
Group B n=500
Sociodemographic characteristics
Age: (years)
<20
20 - <30
30 - <40
≥40
No.
%
No.
%
30
278
166
26
6.0
55.6
33.2
5.2
17
277
171
35
3.4
55.4
34.2
7.0
Mean ± SD
28.0±6.2
X2
p-value
5.000
(0.172)
t=0.401 (0.527)
28.2±5.9
Occupation:
Housewife
Employee
Working for tips
435
23
42
87.0
4.6
8.4
450
11
39
90.0
2.2
7.8
4.601
(0.100)
Residence:
Rural
Urban
419
81
83.8
16.2
453
47
90.6
9.4
10.357
(0.001*)
Level of education:
Illiterate
Read & write
Primary
Preparatory
Secondary
University
177
42
33
42
195
11
35.4
8.4
6.6
8.4
39.0
2.2
125
22
22
59
253
19
25.0
4.4
4.4
11.8
50.6
3.8
Health care providers Characteristics:
No.= 37
%
No.= 38
%
Doctors' no.
20
54.1%
22
57.9%
Qualifications of doctors:
• Resident
• Assistant lecturer/* *Assistant specialist
• Lecturer/** Specialist
8
7
5
40.0%
35%
25%
9
8**
5**
41.0%
36.4%
22.7%
Nurses' no.
17
45.9%
16
42.1%
Qualifications of nurses:
• Diploma Nurses
• Assistant nurse
14
3
82.3%
17.6%
16
0
100.0%
0.00%
* Highly statistical significant difference.
** Qualifications for doctors recruited for the ministry of hospital.
29.907
(0.000*)
0.303
(0.985)
3.11
(0.078)
184
Assessment of Routine Management of Third Stage of Labor for Normal Delivery
Table (2): Distribution of the studied women according their obstetric history
Group A
(n= 500)
Group B
(n= 500)
p-value
Number of pregnancies:
Mean ± SD
Range
(n=500)
2.95± 1.47
1-8
(n=500)
2.93± 1.60
1-7
0.805
Number of abortions:
Mean ± SD
Range
(n=104)
1.11 ±0.31
1-2
(n=102)
1.13±0.34
1-2
0.630
(n=2)
(n=0)
Number of stillbirths:
Mean ± SD
Range
–
1.00±0.00
1-1
–
1.00±0.00
1-1
(n=5)
1.00±0.00
1-1
–
Number of new born deaths before 7 days after birth:
Mean ± SD
Range
(n=10)
1.00±0.00
1-1
(n=16)
1.00±0.00
1-1
–
Number of living children:
Mean ± SD
Range
(n=500)
2.69± 1.38
1-7
(n=500)
2.67± 1.54
1-7
0.795
Number of twins:
Mean ± SD
Range
(n=3)
1.00±0.00
1-1
(n=7)
1.00±0.00
1-1
–
Number of normal vaginal deliveries:
Mean ± SD
Range
(n=500)
2.70± 1.38
1-7
(n=500)
2.67± 1.50
1-7
0.742
Number of previous CS deliveries:
Mean ± SD
Range
(n=3)
Table (3): Distribution of the studied women according to optional management of third stage of labor & practices related to
management of third stage of labor.
Group A (n= 500)
Active
Passive
X 2 (p-value)
Group B (n= 500)
No.
%
No.
%
364
136
72.8
27.2
216
284
43.2
56.8
89.918 (0.000)*
Cutting the umbilical cord:
Done
Not done
500
0
100.0
0.0
500
0
100.0
0.0
–
Person who did the cutting:
Doctor
Nurse
Assistant nurse
105
392
3
21.0
78.4
0.6
99
401
0
19.8
80.2
0.0
3.279
(0.194)
Time of cutting:
Early
Late
444
56
88.8
11.2
427
73
85.4
14.6
2.572
(0.109)
Controlled cord traction:
Done
Not done º
No. 364
336
28
%
92.3
7.7
No. 216
76
140
%
35.2
64.8
386.219
(0.000)*
Person who did the Controlled cord traction:
Doctor
Nurse
No. 336
336
0
%
100
0.0
No. 76
76
0
%
100
0.0
–
Practices after delivery of the fetus for active management
Women receive IM syntometrine:
Done
Not done
(n=364)
º Not done because they are not used to do.
364
0
(n= 216)
100.0
0.0
* Highly statistical significant difference.
216
0
100.0
0.0
–
Mona Ibrahim, et al.
185
Table (4): HCP practices and skills after delivery of the placenta.
Group A (n= 500)
Group B (n= 500)
No.
%
No.
%
X2
p-value
Examine the placenta and membrane:
Done
Not done º
422
78
84.4
15.6
133
367
26.6
73.4
338.176
(0.000)*
Person who examine the placenta and
membrane:
Doctor
Nurse
422
0
100.0
0.0
133
0
100.0
0.0
–
Estimate the average of blood loss:
Done
Not done º
493
7
98.6
1.4
491
9
98.2
1.8
0.254
(0.614)
Person who estimate the average of blood loss:
Doctor
Nurse
493
0
100.0
0.0
491
0
100.0
0.0
–
Clean and dry the vulva, buttocks and thighs and
apply a sterile pad:
Done
Not done
500
0
100.0
0.0
500
0
100.0
0.0
–
Person who clean and dry the vulva, buttocks
and thighs and apply a sterile pad:
Assistant nurse
Worker
227
273
45.4
54.6
49
451
9.8
90.2
158.56
(0.000)*
Record vital signs:
Done
Not done º
0
500
0.0
100.0
0
500
0.0
100.0
–
Perform uterine massage every 15 minutes:
Done
Not done º
488
12
97.6
2.4
455
45
91.0
9.0
20.260
(0.000)*
Person who perform uterine massage:
Doctor
Nurse
488
0
100.0
0.0
455
0
100.0
0.0
–
Encourage the women to pass the urine:
Done
Not done º
489
11
97.8
2.2
240
260
48.0
52.0
813.835
(0.000)*
Persons who encourage the women to pass
the urine:
Doctor
Nurse
464
25
94.9
5.1
240
0
100.0
0.0
12.706
(0.000)*
* Highly statistical significant difference
º Not done because they are not used to do.
Table (5): Relationship between optional management of third stage of labor and maternal outcome
Active (n= 580)
Passive (n= 420)
No.
%
No.
%
X2
p-value
Hemorrhage:
Yes
No
23
557
4.0
96.0
25
395
6.0
94.0
2.104
(0.147)
Tears:
Yes
No
65
515
11.2
88.8
74
346
17.6
82.4
8.369
(0.004) *
Types of tears:
Cervical
Vaginal
Perineal
6
22
37
9.2
33.8
56.9
8
20
46
10.8
27.0
62.2
0.777
(0.678)
* Highly statistical significant difference
186
Assessment of Routine Management of Third Stage of Labor for Normal Delivery
Discussion
Management of third stage of labour appears
to vary greatly between countries studied. Prophylactic use of a uterotonic drug, generally oxytocin,
during the third stage of labour is nearly universal.
The practice of fundal massage immediately after
delivery of the placenta and follow-up palpation
is low in most countries, suggesting insufficient
surveillance of women during the hours when most
maternal deaths occur worldwide [18] .
Regarding the sociodemographic characteristics
of the studied sample, the present study revealed
that the mean maternal age was 28.0 ±6.2 years in
group (A) and 28.2 ±5.9 years among group (B)
with no significant difference in both groups. This
finding is concurrent with Cynthia et al., [18] in
their study about the use of active management of
the third stage of labour in seven developing countries showed that the mean age in women 20-30
years was 60.6%. However, as regards maternal
occupation, the majority of women among both
groups were house wives (87.0 and 90.0% respectively). However, concerning health care providers
the present study revealed no differences regarding
both groups in respect to total number of doctors
and nurses who were requited for managing labor
among both groups.
As regards maternal parity, this study showed
that about half among both groups had 1-2 deliveries; however the vast minority among both groups
had 6-8 deliveries. These findings were in agreement with Cherine et al., [19] who studied management of third stage of labour in Egyptian teaching
hospitals. They found that (34%) of women were
primigravida, (53%) had 1-2 deliveries. Furthermore, Ashebir [20] in his study of evaluating the
management of third stage of labour and its action
on postpartum haemorrhage found that (40.7%)
were primigravidas, (53.5%) had 2-5 deliveries
and only (6.3%) had >5 deliveries.
The third stage of labour is managed differently
around the world. Over the years, preventive clinical management of the third stage of labor varies
from the purely expectant to an active approach,
or some variation thereof [21,22] .
Regarding optional management of third stage
of labour, the present study revealed that about
three-quarters of women who attended the university hospital (Women's maternity Hospital) group
(A) received active management however only less
than one-third received expectant management of
the third stage of labor. This finding supported by
Astrit et al., [23] who found that 78% using active
management, and 22% using physiological care.
However, Prendivill et al., [1] who studied active
versus expectant management of third stage of
labour reported that 95% of cases actively managed
with highly significant difference.
On the other hand, management of third stage
of labor among group (B) who attended El-Eman
Hospital (Ministry of Health hospital) found that
less than half of women received active management compared with more than half (Table 3) of
them managed by expectant method with highly
statistical significant difference. This result disagreed with Cherine et al., [19] who studied management of the third stage of labour in an Egyptian
teaching hospital reported that the passive management of third stage was not done for any observed
delivery.
Concerning practices related to third stage
management, the present study revealed that the
most of women in group (A) had got controlled
cord traction (CCT) versus about one third in group
(B) with highly significant differences among both
groups. In the same line, Cynthia et al., [18] reported
that CCT were done in (80.3%) of women in Indonesia while CCT was done in El Salvador and
Nicaragua were (26.4% and 17.9% respectively).
Another study was done by Matter et al., [24] who
studied polices for care during the third stage of
labor: A survey of maternity units in Syria, reported
that cord clamping was done within 20 seconds at
42 hospitals (64%) for vaginal births and controlled
cord traction was never used in a quarter of hospitals for vaginal births. Furthermore, Astrit et al.,
[23] studied the care during the third stage of labour
in an Albanian maternity hospital reported that
controlled cord traction was used for 49% of births.
As regards the responsible person for managing
third stage of labor, the present study revealed that
doctor was the only person who is responsible for
CCT among both groups. However Ashebir [20] in
his survey on based-facility management of third
stage of labour and actions of postpartum hemorrhage revealed that CCT was practiced in (70%)
of observed women and attended by physicians
and midwives (73% and 68% respectively), clinical
officers and nurses were the least likely to use
CCT.
As regards maternal outcome, this study revealed that the majority among group (A) and
slightly less than four fifths among group (B) had
no maternal complications and the vast minority
among both groups (A & B) had retained placenta.
In the same line, Metin et al., [ 25] reported that
retained placenta was occurring in 3.0%-4.0% with
Mona Ibrahim, et al.
expectant management of third stage of labor.
Furthermore, Neebha et al., [26] who make prospective study about active management of third stage
of labour by oxytocin found that there was no
retained placenta. The present study revealed that
no difference between two methods in both groups
(A & B) regarding the prevalence of postpartum
haemorrhage (4.4% & 5.2% respectively). Similarly, Judith et al., [27] who studied the effect of active
management of third stage of labour on facility
costs in Guatemala and Zambia found that only
5% had postpartum hemorrhage in both Guatemala
and Zambia.
During third-stage of labor, the uterine muscles
contract and the placenta gradually separates from
the uterine wall, it can be managed either passively
or actively. The volume of blood loss depends on
how quickly this occurs. If the uterus becomes
atonic and does not contract normally, blood vessels
at the placental site cannot constrict adequately
and severe bleeding results [28] . The present study
revealed that the vast majority of the sample among
both groups (A & B) (98.6% & 98.2% respectively)
had estimation of blood loss and doctor was the
only person who is responsible for estimation of
blood loss among both groups.
As regards timing of administration of prophylactic uterotonic in the present study, all women
who received active management among both
groups had IM prophylactic uterotonic (oxytocin)
after delivery of the fetus. In the same line Neebha
et al., [26] reported that the use of oxytocics immediately after the delivery of the baby is one of the
most important interventions to prevent blood loss.
The present study revealed that the doctors are the
responsible person for examining the placenta and
membrane for all women among both groups.
Regarding cleaning and drying of the vulva,
buttocks and thighs, and applying sterile pad, all
women among both groups received this care,
about half of women among group (A) received
this care by assistant nurse or worker however the
most among group (B) received this care by workers
and only the minority of the women received this
care by the assistant nurse with highly significant
differences among both groups that may reflect
the low level of care that was given for women
attended ministry hospital. The HCP who didn't
practice placental and membrane examination and
clean and dry the vulva, buttocks and thighs and
apply a sterile pad stated that the rationale behind
that, because they did not used to do it.
As regards taking and recording of maternal
vital signs after delivery every 15 minutes, the
187
health care providers were not do it for both groups,
however the most of group (A) and group (B) had
uterine massage, all received by obstetricians,
furthermore, obstetricians encourage the women
to pass the urine for the most among group (A)
and less than half among group (B) with high
significant difference.
Conclusion:
Based on the findings of the present study it
was concluded that:
'Active management' is superior in use to 'expectant management' at University hospital. Both
maternity units report using Syntometrine®, usually
given after delivery of the fetus, clamping the cord
early, and using controlled cord traction for all
women received active management of third stage
of labor. Although active management of the third
stage of labour is widely recommended for reducing
the risk of postpartum hemorrhage, there remains
low use at the ministry of health hospital in Egypt.
Furthermore, encouraging the women to pass urine
applied only for less than half for women attending
ministry hospital, also it is miserable that the
majority of women attended the ministry hospital
had cleaning and drying of the vulva, buttocks and
thighs, and applying sterile pad by workers.
Recommendations:
On the basis of the most important findings of
the study, the following recommendations are
suggested:
• Consider active management of third stage of
labour as a routine management of third stage of
labour especially at ministry of health hospitals.
• Nurses must be educated and trained on managing
3 rd stage of labor and great emphasis should be
put about their roles and responsibilities during
third stage of labour.
• Consistent documentation and reporting of data
that indicates maternal morbidities & mortalities
caused by postpartum complications.
• Strict control on following guidelines for managing third stage of labor on health care providers
and preventing workers to be a part of labour
care at ministry of health hospital.
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