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Cochrane Database of Systematic Reviews

Active versus expectant management for women in the third stage of labour

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Información

DOI:
https://doi.org/10.1002/14651858.CD007412.pub3Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 09 noviembre 2011see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Embarazo y parto

Copyright:
  1. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Cecily M Begley

    Correspondencia a: School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland

    [email protected]

  • Gillian ML Gyte

    Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK

  • Declan Devane

    School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland

  • William McGuire

    Centre for Reviews and Dissemination, Hull York Medical School, University of York, York, UK

  • Andrew Weeks

    Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK

Contributions of authors

Cecily Begley (CB) drafted the background section and all other authors contributed to editing the text. All authors contributed to the drafting of the inclusion criteria for the review. Gill Gyte (GG) and Declan Devane (DD) added the methodology section with other authors commenting. CB and GG abstracted and pooled data. William McGuire checked data entry, DD prepared the 'Summary of findings' table, which was checked by Andrew Weeks. GG, DD and CB wrote the results section with other authors commenting. CB and GG wrote the discussion and implications sections, with input from all authors.

Sources of support

Internal sources

  • (GG) The University of Liverpool, UK.

External sources

  • (GG) National Institute for Health Research, UK.

    NIHR NHS Cochrane Collaboration Programme Grant Scheme award for NHS‐prioritised centrally‐managed, pregnancy and childbirth systematic reviews: CPGS02

Declarations of interest

Cecily Begley was the lead researcher on the 'Dublin trial' (Begley 1990).

Gill Gyte has written extensively on third‐stage management and is currently involved in the development of trial protocols to assess the impact on mother and infant of deferred cord clamping in preterm infants.

William McGuire is also involved in the development of the same trial protocols to assess the impact on mother and infant of deferred cord clamping in term and preterm infants.

Andrew Weeks is also on the same trial team related to the timing of cord clamping as well as investigating the use of misoprostol for PPH prophylaxis in rural Uganda. He is also one of nine inventors of a small resuscitation trolley (the BASICS trolley) that allows neonatal resuscitation with an intact cord.

Acknowledgements

We acknowledge the work of the previous review team, upon which the protocol was based (Prendiville 2000), and also the contribution of Deirdre Murphy and Sue McDonald in the previous version of this review. We thank the trial authors who provided additional information on request: Beck (on behalf of Muller), Begley, Hoffman, Rogers/Elbourne, Thilaganathan.

Particular thanks to Therese Dowswell, who contributed greatly to data extraction and tables.

As part of the pre‐publication editorial process, this review has been commented on by three peers (an editor and two referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

Thanks to Nazie AmirAnsari and Alireza Karbalaei who translated Vasegh 2005a and Emily Lemon who translated Muller 1996.

Version history

Published

Title

Stage

Authors

Version

2019 Feb 13

Active versus expectant management for women in the third stage of labour

Review

Cecily M Begley, Gillian ML Gyte, Declan Devane, William McGuire, Andrew Weeks, Linda M Biesty

https://doi.org/10.1002/14651858.CD007412.pub5

2015 Mar 02

Active versus expectant management for women in the third stage of labour

Review

Cecily M Begley, Gillian ML Gyte, Declan Devane, William McGuire, Andrew Weeks

https://doi.org/10.1002/14651858.CD007412.pub4

2011 Nov 09

Active versus expectant management for women in the third stage of labour

Review

Cecily M Begley, Gillian ML Gyte, Declan Devane, William McGuire, Andrew Weeks

https://doi.org/10.1002/14651858.CD007412.pub3

2010 Jul 07

Active versus expectant management for women in the third stage of labour

Review

Cecily M Begley, Gillian ML Gyte, Deirdre J Murphy, Declan Devane, Susan J McDonald, William McGuire

https://doi.org/10.1002/14651858.CD007412.pub2

2008 Oct 08

Active versus expectant management for women in the third stage of labour

Protocol

Cecily M Begley, Declan Devane, Deirdre J Murphy, Gillian ML Gyte, Susan J McDonald, William McGuire

https://doi.org/10.1002/14651858.CD007412

Differences between protocol and review

We did not carry out additional searching as proposed. We decided after looking at the variation in the interventions and controls used in the studies that we had clinical heterogeneity between the studies (Table 1) and so we have used a random‐effects meta analysis throughout the review.

We have changed the labels on the secondary outcomes of 'Primary postpartum haemorrhage (> 500 mL)' and 'Secondary postpartum haemorrhage (> 500 mL)' to 'Primary maternal blood loss > 500 mL' and 'Secondary maternal blood loss > 500 mL' respectively. This is because we believe that in research the term 'haemorrhage' should be reserved for excessive blood loss. This is also in keeping with the terminology used in the ongoing trial in low‐income countries (Gülmezoglu 2009). We have also included reference to the mean Hb values in order to provide an outcome that was calculated by blinded personnel.

We have modified the wording in the methods sections for 'Assessment of heterogeneity', 'Assessment of reporting biases' and 'Data synthesis' to update them with the new methods being used by the group, developed in conjunction with the group's statisticians, Simon Gates and Richard Riley. We have used these new methods in the review.

We decided to reduce the number of outcomes, in line with the Cochrane Handbook of Systematic Reviews of Interventions recommendations. We made the following changes to outcomes.

Nine primary outcomes reduced to seven

Clinical signs of severe blood loss at the time of birth, e.g. woman feeling breathless, weak, faint, pale, exhausted: moved to secondary outcomes list.

Evidence of acidaemia indicated by a pH less than seven or base deficit greater than 12 mmol/L in umbilical arterial cord blood, or (c) neonatal blood sample in first hour of life, or both: removed.

Apgar score less than seven at five minutes, and neonatal ('hypoxic ischaemic') encephalopathy assessed using Sarnat staging: moved to secondary outcomes list.

Changes to primary outcomes

All PPH amounts and mean blood losses are now expressed at three time periods "at the time of the birth", "after delivery of placenta and up to 24 hours", and "at the time of birth and up to 24 hours." This was done because it was noted that the two primary outcomes "Severe primary PPH (clinically estimated or measured blood loss greater than or equal to 1000 mL at time of birth and up to 24 hours)" and "Very severe primary PPH (clinically estimated or measured blood loss greater than or equal to 2500 mL at time of birth and up to 24 hours)," which were based on the international definition of PPH could, in fact, provide misleading results if study authors measured or estimated blood loss at birth, and over a period of some hours in the first 24 hours, and added all amounts together to provide an overall PPH rate. While this estimate could also be useful, it raises the PPH rate artificially in comparison with studies that do not do this. Accordingly, we have changed the first two primary outcomes to “Severe primary postpartum haemorrhage (PPH) (clinically estimated or measured blood loss greater than or equal to 1000 mL at time of birth)” and “Very severe primary PPH (clinically estimated or measured blood loss greater than or equal to 2500 mL at time of birth)” and have included the original definitions as secondary outcomes.

"Maternal Hb concentration less than 9 g/dL 24 to 48 hours postpartum" changed to "Maternal Hb concentration less than 9 g/dL 24 to 72 hours postpartum" ‐ as Hb levels may be taken within the first three days postnatal, rather than the first two.

Secondary outcomes deleted (to reduce number of outcomes)

  1. Iron therapy during the puerperium.

  2. Length of the third stage greater than or equal to 60 minutes.

  3. Nausea between birth of baby and discharge from the labour ward.

  4. Headache between birth of baby and discharge from the labour ward.

  5. Maternal views of third‐stage management (assessed using a validated questionnaire).

  6. Maternal Hb concentration less than 9 g/dL postdischarge and up to six weeks.

  7. Sequelae of PPH (length of stay; infection; re‐admission).

  8. Infant Hb level and iron indices beyond three months.

Changes to secondary outcomes

"Administration of oral or rectal analgesia (e.g. paracetamol, codeine, non‐steroidals) between birth of the baby and discharge from the labour ward" and "Administration of opiate analgesia between birth of the baby and discharge from the labour ward" combined as "Administration of any analgesia between birth of the baby and discharge from the labour ward".

"Secondary blood loss equal to or greater than 500 mL (clinically estimated or measured after 24 hours and before six weeks)" and "Any vaginal bleeding needing treatment (after 24 hours and before six weeks)" and "Uterotonic treatment after 24 hours and before six weeks" combined as "Secondary blood loss/any vaginal bleeding needing treatment (after 24 hours and before six weeks)".

"Infant Hb level (Hb) at 24 to 48 hours" changed to "at 24 to 72 hours," as Hb levels may be taken within the first three days postnatal, rather than the first two.

"Intraventricular haemorrhage (preterm infants): (i) grade III/IV; (ii) all grades (Sarnat 1976)" changed to "Papille grade III/IV intraventricular haemorrhage (for infants born before 34 weeks gestation only)."

"Transfusion requirements (preterm infants): (i) number of infants exposed to one or more red blood cell transfusions; (ii) number of transfusions per infant; (iii) number of donors to whom the infant was exposed" changed to "Number of infants who received a red blood cell transfusion."

"Breastfeeding at discharge from hospital and at interval assessments until six months" changed to "Exclusive breastfeeding at discharge from hospital"

New secondary outcomes included

"Neonatal mortality" included.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.