RCM Evidence based Guidelines for Midwifery-led Care in Labour Mervi Jokinen

1. RCM Evidence based Guidelines for Midwifery-led Care in Labour Mervi Jokinen Practice and Standards Development Advisor APPG 20th November 2012

2. Management of Third Stage of Labour • Active management involves giving a prophylactic uterotonic, cord clamping and controlled cord traction • Physiological management involves no administration of a prophylactic uterotonic, no clamping and cutting of the cord until the placenta is delivered and promoting use of gravity to assist delivery of the placenta in a timely manner with maternal effort

3. Management of Third Stage of Labour • Historically third stage was actively managed with Ergometrine in 1940s then changing into Syntometrine with fast acting oxytocin and longer lasting Ergometrine in 1960s . Most recently move into Syntocinon 10u i/m • Effective care in pregnancy and childbirth looking at evidence-based obstetrics in and 1989 questioned the value of  active management • Side effects: hypertension headaches nausea vomiting, pulmonary oedema, cardiac arrest, myocardial infarction • Ergometrinelowering effect on serum prolactin levels • Free bleeding from the placental end of the cord is associated with reduced risk of feto-maternal transfusion linked to iso-immunization note Rh-negwomen • On conclusion the reduced risk of amount of bleeding overrode the harms

4. Management of Third Stage of Labour • Evolvement of women’s choices and increased information sharing with informed decision-making • Requests from women to allow cord stop pulsating prior clamping • Professionals’ concerns re Syntocinon and polycytheamia • Gradual increase in physiological births

5. Management of Third Stage of Labour • Neonatal outcomes v. maternal outcomes • Evidence shows that cord clamping timing significantly affects the haematological status of term neonates improving their iron status up to 6 months (important in areas of malaria/aneamia) • There are benefits to neonatal resuscitation with the umbilical cord intact whenever possible • Physiological labour; are we introducing an intervention that may have an adverse effect? • Healthy mothers are well able to tolerate blood loss up-to 1000mls • Does the administration of oxytocin delay bleeding?; impact on current early discharge policy • Does Syntocinon as well as ergometrine affect prolactin levels or breastfeeding reduced natural oxyticins?

6. Practice Issues • One person present at birth • Skin-to skin contact, newborn thermoregulation, breastfeeding maternal position (waterbirth) • Artificial oxytocin v. natural • Timing of oxytocin

7. Practice issues • Little evidence of increase in neonatal jaundice • Rh –ve mothers; should we make specific recommendation?

8. Practice guideline updated • Delayed cord clamping is currently the recommended practice known to benefit the neonate improving iron status up to 6 months but with a possible risk of jaundice that requires phototherapy. • Timing is not prescribed as will always depend on clinical decision making and agreement with mother

9. Thank you http://www.rcm.org.uk/college/policy-practice/guidelines/practice-guidelines/