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New Zealand College of Midwives • Journal 41 • October 2009
20
Midwives care during the Third
Stage of Labour:
An analysis of the New Zealand College of Midwives Midwifery
Database 2004- 2008
NEW ZEALAND RESEARCH
ABSTRACT:
Background and purpose: e third stage of labour
is the period of time following the birth of the baby
when the placenta separates and is expelled from the
uterus. ere are two options or care pathways that
can be provided. e first is a physiological pathway
for the third stage (also called expectant management).
e second is an actively managed third stage
pathway. Midwives in New Zealand provide both
types of care for women during the third stage of
labour. e purpose of this research was to describe,
analyse, and compare the outcomes of the two
different management pathways for the third stage of
labour following a normal physiological birth.
Methods: Aggregated data from a sample of 33,752
women over a period of five years were used to
identify the type of third stage provided. Selection
criteria were applied so that only normal labour
and births were included. Comparisons were made
between women who received physiological care in
third stage and those who received active management
of the third stage of labour. Results: ere were
16,238 (48.1%) women who received physiological
management and 17,514 (51.9%) who received
active management. Women who gave birth at home
or in a primary birthing unit were more likely to have
a physiological third stage than those who gave birth
in a secondary or tertiary unit. Overall, the majority
of women had a blood loss of less than 500 mls
following birth. For those women who lost less than
500ml of blood, more women received physiological
management (96.3%) than active management
(93.1%), Z=12.7, p< 0.05). A physiological third
stage took longer than an actively managed third stage
with a length of more than 40 minutes for 11.3%
of the physiological managed group compared to
5.4% of the actively managed group. For women
in the active management group a longer time to
the delivery of the placenta was associated with
an increased blood loss (x
2
= 221, df=2. p,0.001).
Conclusions: e data demonstrates that following
a physiological labour and birth, physiological care
for the third stage results in less blood loss than active
management and a lower incidence of post partum
haemorrhage of between 500mls and 1000mls (3.1%
compared to 5.3%) and more than 1000mls (0.5%
compared to 1.5%).
KEY WORDS:
Midwifery care, physiological (expectant
management) third stage, active management, third
stage of labour, home birth, place of birth, blood loss,
length of third stage.
INTRODUCTION
e New Zealand College of Midwives (NZCOM)
defines the third stage of labour as “the period from
the birth of the baby until the complete birth of
Authors:
• Lesley Dixon RM, BA (Hons) MA Midwifery
PhD Candidate Victoria University,
Wellington
Midwifery Advisor: The New Zealand
College of Midwives.
Email: practice@nzcom.org.nz
• Lynn Fletcher, BSC DipStat MSc
Independent contract Biostatistician
• Sally Tracy DMid MA BNurs RGON RM
Professor of Midwifery
University of Sydney Centre for Women’s
Health Nursing and Midwifery
Australia
• Karen Guilliland RM, MA Midwifery
Chief Executive Ofcer
The New Zealand College of Midwives
• Sally Pairman DMid, MA, BA, RGON
Head of School of Midwifery
Otago Polytechnic, Dunedin
• Chris Hendry RM, MPH, D Mid
Executive Director
The Midwifery and Maternity Providers
Organisation (MMPO)
the placenta/whenua and membranes” (NZCOM,
2006). ere are two pathways of care that can be
followed during the third stage of labour. e first
is a physiological third stage (also called expectant
management). e second is active management of
the third stage. e physiological third stage involves
supporting the woman’s physiology during the third
stage, with the major and important difference that
a prophylactic uterotonic is not given and controlled
cord traction is not used (NZCOM, 2006). Instead
the midwife watches and waits for the placenta to
separate and deliver spontaneously or with maternal
effort alone (Festin et al., 2003; Gyte, 1994a;
Henderson & MacDonald, 2004; McDonald, 2007;
orpe & Anderson, 2006). Active management
of the third stage of labour includes the use of a
prophylactic uterotonic drug (prior to the delivery of
the placenta), clamping and cutting of the umbilical
cord and controlled cord traction to aid delivery of the
placenta (International Confederation of Midwives
(ICM) & International Federation of Gynaecology
and Obstetrics (FIGO), 2006).
Brucker (2001) suggests that the difference
in approaches between active and expectant
management of the third stage of labour reflects the
difference between two paradigms; the ‘normal birth’
paradigm and the ‘birth is normal in retrospect’
paradigm. Physiological management of the third
stage of labour is situated within the paradigm
that considers childbirth a normal physiological
process that does not require routine intervention.
is approach supports the woman’s own body to
provide endogenous oxytocin by encouraging skin
to skin contact, warmth and calm. It is based on the
assumption that protecting physiology promotes
safety for both the woman and the baby because
the woman’s body has been designed to give birth
successfully. e aim of care is to enhance the
physiological processes that protect and support
health holistically and only to intervene with
treatment if and when required.
Active management is situated within the paradigm
that sees childbirth as normal only in retrospect
and where interventions are required to prevent
the possibility of an adverse event. It is based on an
New Zealand College of Midwives • Journal 41 • October 2009 21
assumption that safety is increased by the provision
of exogenous oxytocin to increase contractility of the
uterus and shorten the time length for the third stage,
thereby minimising blood loss (Brucker, 2001). Active
management became widely used in Europe during
the 1950’s and 60’s following the introduction and
widespread availability of uterotonic drugs (Begley,
1990) with controlled cord traction advocated as a
method of separating the placenta when there was a
delay in placental delivery (Kimbell, 1968).
In New Zealand it is recognised that when a
woman has had a physiological labour and birth, a
physiological third stage can be expected and midwives
need to be competent in both care options (NZCOM,
2006). For the majority of women, giving birth is a
normal physiological process in which the woman’s
body adapts to the changes required for the pregnancy
and birth. e midwifery philosophy is to work with
women to enhance the physiology of the labour and
birth which includes the third stage of labour.
When considering which option of third stage of
labour to provide, the evidence to date has suggested
that active management of the third stage is the
optimum approach for women in hospital settings
(Prendiville, Elbourne, & McDonald, 2000). Both
internationally and nationally, many hospital policies
and professional guidelines recommend the use of
active management for the third stage of labour (ICM
& FIGO, 2006; National Collaborating Centre for
Women's and Children's Health, 2007; Schuurmans,
MacKinnon, Lane, & Etches, 2000; e WHO
Reproductive Health Library, 2009; World Health
Organisation, 2007). ese recommendations have
been based on the results of a systematic review of
active versus expectant management of the third
stage of labour (Prendiville et al., 2000). ere has,
however, been criticism of the randomised control
trials that were part of the review, with the suggestion
that alternative interpretations could be made and that
in many of the trials there was a piecemeal approach
to the third stage, with components of both active and
expectant management applied in each arm of the
studies (Gyte, 1994b; Soltani, 2008). e Cochrane
review (Prendiville et al., 2000) has subsequently
been withdrawn and a protocol for a new review has
been set up and is underway.
PRACTICE REALITIES
Whilst there are moves to standardise components
of active management so that all health professionals
are providing standardised care, the reality in practice
is that there are a variety of interpretations of active
management of the third stage. In a survey of 14
European maternity hospital policies on active
management of the third stage, Winter et al. (2007)
found variations in the pharmacological agents used,
the timing of cutting and clamping of the cord and
the use of controlled cord traction. A global survey
and observational study of 15 university-based
obstetric hospitals in both developing and developed
countries, found only 24.6% of the births observed
utilised all three components of active management
of the third stage (Festin et al., 2003). Furthermore,
observational research in an Egyptian teaching hospital
found that only 15% of the births observed used all
three components of active management. e most
common deviation was the giving of a uterotonic after
the expulsion of the placenta (65%) and not using
controlled cord traction (49%) (Cherine et al., 2004).
An Australian study found high use of prophylactic
uterotonics (91%) and controlled cord traction but
variations in the type of uterotonic used along with
differences in the timing of administration (Roberts,
Lain, & Morris, 2008). e outcomes of the various
individual components of active management of the
third stage have not been fully evaluated so it is difficult
to assess which components are most effective.
In practice, and when midwives are able to work
autonomously, it appears they are more likely to
facilitate a physiological approach to the third stage.
For example, a survey of 497 maternity practitioners
in British Columbia found that midwives were less
likely to use prophylactic oxytocin routinely when
compared to family physicians and obstetricians (Tan,
Klein, Saxell, Shirkoohy, & Asrat, 2008), and a survey
of Dutch midwives found that only 10 percent used
prophylactic oxytocin routinely during the third stage
compared to 55 percent of obstetricians (de Groot,
van Roosmalen, & van Dongen, 1996). Two small
studies conducted in the United Kingdom found that
midwives were more likely to use physiological third
stage care when providing care in birth centres or if
providing continuity of care to women (Benjamin,
Walsh, & Taub, 2001; Kanikosamy, 2007).
Furthermore, focus group research with 32 Swedish
midwives found that the midwives felt confident in
evaluating the physiological labour and birth and
endeavoured to leave the third stage undisturbed
when there were no apparent risks (Jangsten,
Hellstrom, & Berg, 2009).
In New Zealand, women have a Lead Maternity Carer
(LMC), usually a midwife, providing continuity of
care in a variety of settings. Women can choose to
give birth at home, in a primary birthing unit/facility,
a secondary hospital maternity facility or a tertiary
hospital maternity facility and LMC midwives are able
to provide care in any of these settings
1
. Access to a
birthing unit or hospital is often dependent on where
the woman lives as availability of both primary and
secondary or tertiary maternity facilities varies between
regions. When options are available women will make
informed decisions about where to give birth.
Women are also provided with evidence and are
encouraged to make choices for care based on
their own circumstances and requirements and in
collaboration with their caregiver. erefore, care
will be individual to each woman depending on her
circumstances. In New Zealand, when the labour
and birth have progressed normally and without
intervention, the choice of care pathway for the third
stage of labour lies with the woman in partnership
with the midwife. When presented with the available
research evidence and the subsequent critiques,
women may choose physiological third stage care.
e midwifery partnership recognises that midwives
make professional judgements about care, so if, for
example, a labour is no longer normal and required
intervention then it is unlikely that physiological
third stage will remain appropriate. Women are
therefore involved in the decision making but if there
are clinical reasons for differing from the decision
the midwife will inform the woman as to the reasons
for the change in care. ird stage care provision
is an individual decision made by each woman in
partnership with her midwife.
e purpose of this study was to assess and compare
the two care pathways options for managing the third
stage of labour for all normal physiological births
in the NZCOM dataset from 2004 to 2008. In
particular differences between where women gave
birth, the amount of blood they lost, the time it
took to birth the placenta and the influence of pain
management during labour on the third stage, was
analysed. Ethical approval was received in March
2009 from the Multi-region Ethics Committee of
the Health and Disability Ethics Committee of New
Zealand (MEC/09/016/EXP).
METHOD
e NZCOM database is an aggregated collection
of clinical data from all midwife LMC’s who
are members of the Midwifery and Maternity
Provider Organisation (MMPO). e MMPO
was established and is supported by the New
Zealand College of Midwives to provide an efficient
maternity practice management system for midwives.
e majority of LMC’s are self employed and use
the MMPO to organise and support their practice.
Each midwife LMC has a set of maternity notes for
each client that comprises the contemporaneous and
permanent record of maternity care outcomes, as
required for quality assurance and review purposes.
Each woman has her full maternity episode recorded
and managed by her LMC, from registration with
the midwife in pregnancy to four to six weeks
postpartum. e LMC enters the woman’s data
(either electronically or manually) in the woman’s
maternity notes at each contact with the women. At
the birth, the midwife records whether the third stage
1. Primary birthing facilities provide labour, birth and postnatal care (midwife led); secondary maternity facilities provide antenatal, labour, birth and postnatal care with obstetric, anaesthetic and paediatric services available; tertiary maternity
facilities are as per secondary facilities with the addition of a Neonatal Intensive Care Unit.
New Zealand College of Midwives • Journal 41 • October 2009
22
has been physiological or actively managed as part
of the labour summary, along with the blood loss
volume. As each page is completed it is forwarded
to the MMPO for entry into the MMPO claiming
system and the NZCOM clinical database. ere are
various checks and balances built into the system that
ensures data is entered accurately and appropriately.
Each woman’s data forms an anonymised database
of clinical information about the mother and baby
at various stages of the childbearing process that can,
if necessary, be checked manually for accuracy. is
study has used the aggregated data from the MMPO
database for all women under the care of midwife
LMC members of the MMPO for the years 2004 to
2008 inclusive.
A physiological third stage can be expected when
there has been a physiological labour and birth
so an extensive exclusion criterion was applied to
ensure that only physiological labour and birth were
included in the study cohort. Over the five year
period 88,781 women under the care of midwife
members of the MMPO had their data included in
the NZCOM database. Once the inclusion/exclusion
criteria were applied the study cohort was reduced
to 33,752 women. All women who had a normal
vaginal birth (spontaneous onset of labour after
37 completed weeks of pregnancy with a cephalic
presentation of a single live baby) between the years
2004 to 2008 inclusive, and had data provided
to the MMPO database by a midwife during this
time, were included in the sample. Women were
excluded if they were identified as having a multiple
pregnancy, a history of previous post partum
haemorrhage, a previous caesarean section, a breech
birth (non-cephalic presentation), an intrauterine
death, an instrumental or operative birth, induction
or augmentation of labour.
Data analysis was completed using the data from the
NZCOM database. Descriptive statistical analysis
and comparative analysis was then used to describe
and compare the type of third stage management
used by the midwives during the third stage. All
data has been analysed using SPSS v16. Chi-square,
Z-tests and Mann-Whitney tests have been used to
analyse the data.
FINDINGS
ere were 33, 752 women in the NZCOM
study cohort who met the inclusion criteria and of
these 16,238 (48.1 percent) received physiological
management of the third stage and 17,514 (51.9
percent) received active management. e 16,238
women who had a physiologically managed third
stage included 990 women who declined an
uterotonic when recommended by the midwife.
e majority of the cohort were of New Zealand
European ethnicity (69.9%) with 19.5% identified as
Maori, 4.1% as Pacific Islanders, 3.8% as Asian, 2.2%
Physiological Active
No. (%) (48.1) No. (%) (51.9)
Ethnicity
NZ/European
11789 (50) 11805 (50)
Maori
3029 (46.1) 3544 (53.9)
Pacic Island
488 (35) 906 (65)
Asian
513 (40) 771 (60)
Other
342 (45.1) 416 (54.9)
Not stated
77 (51.7) 72 (48.3)
Total
16238 17514
Table 1: Ethnicity and third stage management
Figure 1: Place of birth and third stage care
Primary Birthing Unit
Secondary Hospital Tertiary Hospital Home Birth
57.8
36.3 34.1
42.2
63.7 65.7
18.3
81.7
0
10
20
30
40
50
60
70
80
90
Physiological Active % of total cohort
Blood Loss
Volume
Primary
Facility
Secondary
Facility
Tertiary
Facility
Home Birth
Total x
2
P-value
df=3
1 - 500 ml
6907 12928 6645 4313 30793
95.0% 94.7% 93.3% 96.2% 94.7% 0.167
501 -
1000ml
299 569 372 144 1384
4.1% 4.2% 5.2% 3.2% 4.3% < 0.001
1000ml+
62 158 105 25 350
0.9% 1.2% 1.5% .6% 1.1% < 0.001
Total
7268 13655 7122 4482 32527
100.0% 100.0% 100.0% 100.0% 100.0%
Table 2: Est. Blood Loss volume by Birth Place setting
*Excludes 990 women who declined an uterotonic and missing data of blood loss volume.
Figure 2: Estimated blood loss volumes more than 500mls and place of birth
501 - 1000 >1000ml
Primary Birthing Unit Secondary Hospital Tertiary Hospital Home Birth
4.1
3.2
5.2
0
1
2
3
4
5
6
0.9
4.2
1.2
1.5
0.6
New Zealand College of Midwives • Journal 41 • October 2009 23
Duration of
Third Stage
Physiological Active
<500 501 -
1000
1000 + Total <500 501 -
1000
1000 + Total
0 - 10 mins 5069 154 27 5250 11231 500 127 11858
96.6% 2.9% 0.5% 94.7% 4.2% 1.1%
11 - 20 mins 4845 168 19 5032 2948 179 40 3167
96.3% 3.3 0.4% 93.1% 5.7% 1.3%
21-30 mins 2232 72 13 2317 628 55 14 697
96.3% 3.1% 0.6% 90.1% 7.9% 2.0%
31-40 mins 1177 34 61217 262 21 6289
96.7% 2.8% 0.5% 90.7% 7.3% 2.1%
>40 mins 1688 56 26 1770 711 147 73 931
95.4% 3.2% 1.5% 76.4% 15.8% 7.8%
Missing 90097108
Total 15020 484 91 15595 15787 903 260 16950
%96.3 3.1 0.5 100 93.1 5.3 1.5 100
Table 3: Third stage Management Group Blood Loss (ml)
Physiological 501 - 1000 Active 501 to 1000
Figure 4: Blood loss 501mls to 1000mls, duration and third stage
care provision
2.9 3.3 3.1 2.8 3.2
4.2
5.7
7.9 7.3
15.8
0
2
4
6
8
10
12
14
16
18
0 - 10 mins 11 to 20 mins 21 to 30 mins 31 to 40 mins >40 mins
Figure 5: Blood loss of more than 1000mls, duration and third stage
care provision
Physiological 1000+ Active 1000+
0.5 0.4 0.6 0.5
1.5
1.1 1.3
22.1
7.8
0
1
2
3
4
5
6
7
8
9
0 - 10 mins 11 to 20 mins 21 to 30 mins 31 to 40 mins >40 mins
Physiological Active
14.9
7.8
11.3
70
18.7
5.4
32.2
1.7
4.1
0
10
20
30
40
50
60
70
80
0 - 10 mins 11 to 20 mins 21 to 30 mins 31 to 40 mins >40 mins
Figure 3: Duration of third stage, blood loss of less than 500 mls and
type of care provision
other and 0.4% not stated. More Maori, Asian and
Pacific Island women had active management of the
third stage but New Zealand European women were
divided equally in their choice (Table 1).
In the study cohort (which included only physiological
births), the majority of women gave birth in a
secondary hospital maternity facility (42.5%) with
primary units and tertiary hospitals having similar
percentages (22.2 and 22.1 respectively) and 13.1
percent gave birth at home. For women who gave
birth at home 81.7% had physiological care for the
third stage of labour with only 18% having an actively
managed third stage. Women who gave birth in a
tertiary hospital or a secondary hospital had a higher
incidence of active management for the third stage
(65.7% and 63.7% respectively) with fewer women
(34.1% and 36.3%) having physiological care. For
women who gave birth in a primary unit 57.8% had
physiological care compared to 42.2% who had active
management (Figure 1).
Regardless of third stage management or place of
birth 94.7% of all the women had a blood loss of less
than 500mls (Table 2). However, for women who
gave birth at home 96.2% had a blood loss of less
than 500mls compared to 93.3% for women who
gave birth in a tertiary facility. Primary and secondary
facilities had similar outcomes (95% and 94.6%) for
blood loss of less than 500mls (P = NS). Of clinical
interest are the women who have a blood loss of
greater than 500 mls. For the women who gave birth
at home 3.2% (n=144) had a blood loss of between
500mls and 1000mls and 0.6% (n=25) had a blood
loss of more than 1000mls. Of the women who
gave birth in a tertiary hospital 5.2% (n=372) had a
blood loss of between 500 and 1000 mls and 1.5%
(n= 105) had a blood loss of more than 1000mls.
Birth place settings with the highest level of blood
loss of more than 1000 mls were the tertiary facilities
(1.5%, n=105) followed by secondary facilities (1.2%,
n=158), then primary facilities (0.9%, n=62) and
then home births (0.6%, n=25) (Figure 2). A separate,
weighted chi-squared test was performed within
each blood loss category to investigate whether the
proportions of women within each birthing facility
differed significantly from expected. For women in
the less than 500ml category there was no significant
difference between the proportions observed within
each facility and those expected. For women who
lost 501-1000ml of blood there were significantly
more than expected in the tertiary facility and less
than expected having a home birth (x
2
= 28, df=3,
p<0.001). is pattern was also seen for women in
the highest blood loss group (x
2
= 26, df=3, p<0.001).
e length of the third stage and type of third stage
care given was examined in more detail looking at
the length of time for the placenta to be delivered
along with the estimated blood loss and type of third
stage care provided (Table 3).Overall the majority of
33.7
New Zealand College of Midwives • Journal 41 • October 2009
24
Table 4: Pain management and third stage care
women had a blood loss of less than 500 mls. Of the
women who had physiological third stage, 96.3%
(15,020) had a blood loss of less than 500mls
compared to 93.1% (15,787) of women who had
an actively managed third stage (Z=12.7, p<0.05).
When comparing the time span for the third stage
those in the active management group were more
likely to have the placenta delivered within 10
minutes (70.0%) with a further 18.7% delivered
within 20 minutes and only 5.4% taking over 40
minutes. For the physiological group the time span
was more widespread with 33.7% being delivered
within 10 minutes, 32.3% within 20 minutes,
22.7% between 20 and 40 minutes and a further
11.3 % over forty minutes (Figure 3 - previous
page). For women who had a blood loss of more
than 500mls and less than 1000mls, a significantly
higher proportion fell into the active management
group 5.3% (n=903) than in the physiological group
3.1% (n=484); Z=9.9, p< 0.001). Looking at this
in more detail it appears that as time increases there
are more women who experience blood loss between
500mls and 1000mls in the actively managed group
when compared to the physiological group (Figure
4 - previous page).
ere were a small number of women in both
management groups who had a blood loss of
more than 1000mls (351 women) but it is again
worth comparing the length of time for the third
stage (Figure 5). For those women who had a
blood loss of more than 1000mls there were
significantly less in the physiological group 0.5%
(n=91) compared to the actively managed group
1.5% (n=260); Z= 8.2, p< 0.001). However,
when looking at the length of time of the third
stage it becomes apparent that for women in the
active management group a longer time to the
delivery of the placenta was associated with an
increased blood loss (X2= 221,df=2. p,0.001). Of
the women who had active management, and a
time to delivery of the placenta of more than 40
minutes, 147 (15.8%) had a blood loss between
500ml and 1000mls with a further 73 (7.8%) who
had a blood loss of more than 1000mls.
All of the women in the study cohort had
physiological labour and birth and some had
epidural, pethidine or water immersion for pain
management. e type of pain management
was explored in relation to third stage care
and outcomes. e timing of when the pain
management was provided was not explored. Only
a very small proportion 2.9% (n=992) of women
in the study cohort had an epidural for pain
management. ere was no significant difference
in blood loss for those women who had an epidural
between management groups (p=0.06) (Table 4).
ere were 7.2% (n=2409) who used Pethidine to
help with pain management during labour. Analysis
of blood loss volume found no significant difference
between management groups in blood loss volumes
for those women who were given pethidine
(p=0.06). A total of 7734 (23.3%) of women
used water immersion for pain management in
this cohort. For women who used water, those in
the active group had a significantly higher mean
rank of blood loss than those in the physiologically
managed group (p<0.0001) (Table 5).
DISCUSSION
is research has explored the care practices of
LMC midwife members of the MMPO in relation
to the third stage of labour. e midwives in the
NZCOM database have recorded the use of either
physiological or active management of the third
stage. is data when aggregated over a period
of five years have demonstrated that a similar
proportion of women are having a physiological
and active management of the third stage. is is a
significant finding and one that may be impossible
to replicate in other countries where some form of
active management of the third stage management
is usual practice. With the majority of midwives in
the MMPO database being self employed there is
increased autonomy and accountability for clinical
practice. is study suggests that when women
are given information and empowered to make
informed decisions by health professionals, a large
proportion will choose physiological third stage
when it has been preceded by a physiological labour
and birth.
In this study 35.3% of women gave birth either at
home or in a primary unit. Availability of a birthing
facility may also have influenced the woman’s
options and while not explored in this research the
lack of access to alternative birthing options may
be reflected in the high number of women who
gave birth in a secondary hospital. Unsurprisingly
the highest rate of physiological third stage was
seen in women giving birth at home, followed by
those who gave birth in a primary unit. ese are
areas in which midwives work together and there
is little input from medical colleagues. However,
midwives also provide midwife-led continuity
of care in secondary and tertiary hospitals. e
settings with the highest rate of active management
were the tertiary hospital followed closely by
secondary facilities, suggesting that the policies and
expectations within these hospitals may influence
midwifery care provision. is research has not been
able to examine the differences between midwifery
practice and whether there are changes to practice
depending on place of birth. Of interest though was
that women who gave birth in a tertiary hospital
had higher rates of blood loss volumes more than
500mls than those women in secondary, primary
Physiological Active Total of cohort
Pain relief in labour No. (%) No. (%) No. (%)
Epidural
126 (0.7) 866 (4.9) 992 2.9
Pethidine
667 (4.1) 1742 (9.9) 2409 7.2
Water Immersion
4388 (27.0) 3346 (19.1) 7734 23.3
None of the above
11057 (68.1) 11560 (66.0) 22617 67.0
Total
16238 100 17514 100 33752 100
Water Percentile Blood Loss (ml)
Active (N=17,212) Physiological (N=16,036)
10th 25th Median
50th
75th 90th 95th 10th 25th Median
50th
75th 90th 95th
Ye s
(N=7,734)
100 200 250 350 500 700 100 150 200 300 400 500
No
(N=25,514)
100 150 200 300 450 600 100 150 200 300 400 500
Table 5: Percentiles of blood loss for women who used water as pain
management.
New Zealand College of Midwives • Journal 41 • October 2009 25
and home births. is may be related to the higher
incidence of active management in these hospitals
or equally could be related to other stressors and
practices that may occur within these institutions.
e findings show that there was a very low level of
epidural (2.9%) and Pethidine (7.2%) use as a pain
management method with water immersion the
most commonly used pain management technique
(23.3%). ere appears to be no differences in
outcomes for blood loss during the third stage, when
epidural or pethidine has been used, regardless of
the third stage care provided. However, for those
women who used water as pain management, active
management resulted in a statistically significant
increase in blood loss. is is an interesting finding
and one that requires further research and analysis to
explore the reasons why. For all pain management
techniques there was no ability to determine at
what time during labour the pain management was
provided and timing to birth may have an impact on
results that this research has not been able to uncover.
Unsurprisingly the length of the third stage was found
to be longer when physiological third stage care was
provided, taking twice as long for women having
physiological care when compared to women who
received active management. However, despite a longer
third stage duration there was no apparent increase in
the number of women who had a blood loss of more
than 500 mls when compared to active management.
e data demonstrates that following a physiological
labour and birth, physiological care for the third stage
results in less blood loss than active management and a
lower incidence of post partum haemorrhage of between
500mls and 1000mls (3.1% compared to 5.3%) and
more than 1000mls (0.5% compared to 1.5%).
LIMITATIONS
Blood loss volumes described in this research have
been estimated by the attending midwife immediately
following birth and documented in the woman’s
maternity notes. It is possible that blood losses have been
underestimated and underestimation is more likely with
higher blood loss volumes (Bose, Regan, & Paterson-
Brown, 2006; Glover, 2003). ird stage care is a self
report by the midwife directly following care provision.
Other than the use or non use of an uterotonic there
was no ability to know how the midwives provided the
active or physiological care or which components of
active or physiological care were used.
IMPLICATIONS
Whilst there are methodological flaws in any
descriptive research the size of this sample and ability
to make comparisons provides support to midwives
to continue to offer physiological third stage care to
women following a physiological labour and birth.
e findings suggest a need to re-evaluate physiological
third stage care and a need for further prospective
research to clarify which components of physiological
third stage care are important in care provision.
CONCLUSION
In New Zealand midwifery care is provided in
partnership with the woman and each woman’s
right to informed decision making is promoted
and protected through the provision of continuity
of care (NZCOM, 2008). e NZCOM data
has demonstrated that midwives in New Zealand
are providing choices for women regarding third
stage care with as many women choosing to have
physiological care following a normal physiological
labour and birth as have chosen active management.
e results of this research suggest that active
management of the third stage following a
physiological labour and birth results in higher blood
loss when compared to physiological care. Patience
is required when providing physiological third stage
care with the data suggesting that a physiological
third stage takes longer than an actively managed
third stage. Despite this physiological care resulted
in lower blood loss volumes. e outcomes of this
research demonstrate that provision of physiological
care during the third stage of labour to women who
have had a physiological labour and birth results in
reduced blood loss volumes.
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Accepted for publication August 2009
Dixon, L., Fletcher, L., Tracy, S., Guilliland, K.,
Pairman, S., Hendry, C., Midwives Care During
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ACKNOWLEDGEMENTS
e New Zealand College of Midwives and the
Midwifery Maternity Provider Organisation would
like to thank all the midwives and women who have
contributed to the MMPO database.
