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Article on Third Stage by Victoria, Australia Midwives

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Discussion on physiological management of Third stage (of labour) by independent midwives in Victoria, Australia

In order to support women birthing their babies at home we midwives need to be confident about our role in providing the woman with non-medical forms of pain relief, and physiological (expectant) management of third stage. I think we need to speak up about specific aspects of private practice, and the rationale for our practices.

The Cochrane Library has a review of trials comparing: Active vs expectant management of the third stage of labour (1996) Although the conclusions were that routine 'active management' resulted in less blood loss, the reviewer stated the "The implications are less clear for other settings including domiciliary practice ... and maternity units in which expectant management is the usual practice". It was noted that the midwives involved in the trials included in this research may have been more familiar with active management (prophylactic oxytocin after the birth, early clamping and cutting of the cord, and controlled cord traction). The only details of expectant management given in the review are waiting for signs of separation and allowing the spontaneous expulsion of the placenta aided by gravity (+- nipple stimulation).

The basic reasoning behind the physiological management that is practiced in homebirths I have been involved in seems to be NOT clamping and cutting the cord until all pulsation has ceased, and often not until after the placenta has been born. The retro-placental clot that is formed in this pattern of management is obviously very different from the bleeding that occurs with early clamping, while the placenta is still functioning. My conclusion, in the light of this evidence, is that although active management has been recommended as the preferred option in hospitals, there is no evidence to discourage the continuation of physiological management in homebirth practice.

Reasonable midwifery practice includes having oxytocics for use when indicated. There are unpleasant side-effects (including nausea, vomiting, and increased levels of pain) in active management. Advantages of physiological management include early establishment of nurture/bonding/breastfeeding which may be compromised if the mother is having to deal with nausea &c.

Joy Johnston FACM IBCLC

Joy Johnston, midwife
Melbourne, Australia

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