Active management of 3rd stage of labour involve all except
Ans D Ref 1 = WHO Recommendations for Active Management of the Third Stage of Labour (AMTSL), 2012 The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. In settings where skilled birth attendants are available, controlled cord traction (CCT) is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important. In settings where skilled birth attendants are unavailable, CCT is not recommended. Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. CCT is the recommended method for removal of the placenta in caesarean section. Ref 2: Sheila Balakrishnan obs page 149 Active management of third stage Early cord clamping Prophylactic oxytocin before delivery of placenta 0.25 mg ergometrine or 0.2 mg methergine slow IV At the delivery of anterior shoulder along with IV oxytocin Delivery of placenta by controlled cord traction after placental separation has been confirmed Examination of birth canal for any injuries and suturing the same. Ref 3= Post-partum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Since more than 50 years AMTSL has been proposed for the prevention of PPH and is still recommended in current guidelines. The 3 key components of AMTSL are the prophylactic administration of oxytocin, clamping and cutting of the umbilical cord immediately after delivery of the baby and controlled cord traction. AMTSL has proven to reduce the rate of severe PPH by 70%. Despite of the long tradition of AMTSL it is still unclear, which of the 3 components significantly contributes to the reduction in PPH. Cochrane analyses and a recent metaanalysis gave strong evidence, that prophylactic oxytocin administration reduces the risk of PPH significantly, however, the optimal dose and mode of application is still a matter of debate.Until a little while ago no randomized controlled studies exist regarding the significance of controlled cord traction and the time of cord clamping in AMTSL. A randomized WHO trial 2012 and the 2013 published TRACOR (Traction of the CORd)-trial from France could clearly demonstrate that controlled cord traction is not associated with a significant reduction in postpartum blood loss and in the risk of severe PPH. A Cochrane analysis 2008 and a recent randomized trial from Sweden came to the conclusion, that there are no significant -differences between early (< 15 s) and delayed (> 1-3 min) cord clamping in the reduction of PPH and severe PPH. Uterine massage after delivery of the placenta, placental cord drainage and umbilical vein injection of uterotonics after delivery of the baby as part of AMTSL are not evidence-based methods. It has taken 50 years since AMTSL was first described for it to become clear that prophylactic oxytocin is the most important and the only evidence-based component of AMTSL. Future guidelines and textbooks should consider these new -findings.
IV oxytocin
Early cord clamping
Controlled cord traction
Uterine massage