Active Management of Third Stage of Labor: Acog Guidelines
Acog (Advanced Caregivers Organization) is a non-profit organization founded in 1989 by nurses with expertise in advanced caregiving. They are the leading organization in the field of advanced caregiving. Their goal is to improve quality of life for older adults through education, research, advocacy and policy development.
The Acog website provides information about various topics related to advanced caregiving. They have a section called “Active Management” which is related to the third stage of labor.
The Acog guidelines for “active management” of the third stage of labor states that:
1. The health care provider should provide continual support to the woman’s perineum while she pushes.
2. The health care provider should take measures to avoid an episiotomy.
3. The health care provider should perform an episiotomy if it is required.
4. The health care provider should identify and provide immediate attention to any postpartum hemorrhage.
5. The health care provider should suture the perineum if it tears or is not well compressed.
6. The health care provider should give antibiotics to women with prolonged or obstructed labor.
7. The health care provider should give antibiotics to women who have an infected episiotomy or tears.
8. The health care provider should identify and provide immediate treatment for any newborn with signs of illness.
9. The health care provider should encourage early breastfeeding.
10. The health care provider should encourage women to have someone else (support person) with them for the first 24 hours after birth.
It also provides the following information on “Expectant Management”
1. No routine testing is required.
2. The woman and her support person should be encouraged to participate in care provided during the 3rd stage and birth of the placenta.
3.The health care provider should provide information about:
a. postpartum recovery
b. normal changes during late pregnancy and labor
c. early infant care
d. common concerns
These guidelines are in line with the recommendations of the World Health Organization. In fact, these guidelines are primarily based on the WHO’s “Safe Childbirth Checklist” (referred to by the WHO as the “Safe Childbirth Tool”) which was designed to improve maternal and newborn health.
The WHO’s Safe Childbirth Checklist is simple ten-item set of practical and easily applicable guidelines designed to improve maternal and newborn health. These steps can be taken to make birth safer and can be implemented at minimal cost. The ten steps which make up the WHO’s Safe Childbirth Checklist are as follows:
1. Learn antenatal care from a skilled provider
2. Give antibiotics to women with active infection
3. Give tetnus vaccine during pregnancy
4. Monitor blood pressure during pregnancy
5. Give steroids for babies at risk of breathing problems
6. Deliver in a health facility
7. Avoid vaginal exams during labor
8. Check mateet’s condition after birth
9. Cut the cord immediately
10. Encourage skin-to-skin contact
These guidelines are also consistent with those provided by the American College of Obstetricians and GYNecologists (ACOG). In fact, some of the information provided by the ACOG regarding labor and delivery is very similar to that provided by the WHO.
For example, the ACOG states that in normal pregnancies:
1. Effective pain control is essential
2. Support persons should be present
3. Avoid routine vaginal exams
4. Limited use of episiotomy
5. Promote a oxygent environment
6. Encourage feeding and bonding immediately after birth
7. Continue prenatal care after birth
While the WHO and ACOG provide similar guidelines, there are some important differences. For example, the WHO does not provide specific information on when to cut the umbilical cord. It simply states that the cord should be cut soon after the baby is delivered.
This lack of specificity is probably a reflection of different cultural practices in different regions. In the U.S. and certain other regions, clamping the cord almost immediately after birth is common practice, while in other regions the cord is not clamped until it stops pulsating.
As another example, the WHO guidelines suggest that health care providers inform women about “normal changes during late pregnancy and labor.” However, such information is not provided by the ACOG. In this case, the WHO seems to be providing more detailed guidance for health care providers regarding what to tell women about labor and delivery.
One criticism of the Safe Childbirth Checklist is that some of the items are not specific to maternal and newborn health. For example, many of the guidelines included in the checklist are general health recommendations that could apply to people of all ages, not just pregnant women.
Despite this limitation, it seems quite clear that the Safe Childbirth Checklist (and by extension the WHO’s guidelines for “safe childbirth”) is an important step towards improving maternal and newborn health.
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Sources & references used in this article:
- How effective are the components of active management of the third stage of labor? (WR Sheldon, J Durocher, B Winikoff, J Blum… – … pregnancy and childbirth, 2013 – Springer)
- Preventing postpartum hemorrhage: managing the third stage of labor (KL Maughan, SW Heim, SS Galazka – American family physician, 2006 – aafp.org)
- Sublingual misoprostol versus methylergometrine for active management of the third stage of labor (N Vimala, S Mittal, S Kumar… – … of Gynecology & …, 2004 – Wiley Online Library)