Begley Cecily M, Gyte Gillian M L, Devane Declan, McGuire William, Weeks Andrew
School of Nursing and Midwifery, Trinity College Dublin, 24, D'Olier Street, Dublin, Ireland, Dublin 2.
Cochrane Database Syst Rev. 2015 Mar 2(3):CD007412. doi: 10.1002/14651858.CD007412.pub4.
Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries.
To compare the effectiveness of active versus expectant management of the third stage of labour.
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2014) and reference lists of retrieved studies.
Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour.
Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.
We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women, GRADE:very low quality) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women, GRADE:low quality). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 infants, GRADE:low quality) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 infants, GRADE:very low quality). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both, and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here.
AUTHORS' CONCLUSIONS: Although there is a lack of high-quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.
第三产程的积极处理包括预防性使用宫缩剂、早期脐带夹紧和控制性脐带牵引以娩出胎盘。期待疗法是等待胎盘剥离征象出现，然后胎盘自然娩出。引入积极处理是为了减少出血，出血是低收入国家孕产妇死亡的主要原因。
比较第三产程积极处理与期待疗法的效果。
我们检索了Cochrane妊娠与分娩组试验注册库（2014年9月30日）以及检索到的研究的参考文献列表。
比较第三产程积极处理与期待疗法的随机对照试验和半随机对照试验。
两位综述作者独立评估纳入研究，评估偏倚风险并进行数据提取。
我们纳入了7项研究（涉及8247名妇女），所有研究均在医院进行，6项在高收入国家，1项在低收入国家。4项研究比较了积极处理与期待疗法，3项研究比较了积极处理与混合处理方法。由于临床异质性，我们在分析中使用了随机效应模型。根据GRADE评估，我们的主要结局缺乏高质量证据。证据表明，对于出血风险各异的妇女，积极处理在出生时显示出降低产妇原发性大出血（超过1000 mL）的平均风险（平均风险比（RR）0.34，95%置信区间（CI）0.14至0.87，3项研究，4636名妇女，GRADE：极低质量）以及出生后产妇血红蛋白（Hb）低于9 g/dL的风险（平均RR 0.50，95%CI 0.30至0.83，2项研究，1572名妇女，GRADE：低质量）。我们还发现新生儿入住新生儿病房的发生率无差异（平均RR 0.81，95%CI 0.60至1.11, 2项研究，3207名婴儿，GRADE：低质量），以及需要治疗的婴儿黄疸发生率无差异（0.96，95%CI 0.55至1.68，2项研究，3142名婴儿，GRADE：极低质量）。关于我们其他主要结局，即出生时非常严重的产后出血（PPH）（超过2500 mL）、孕产妇死亡率或需要治疗的新生儿红细胞增多症，没有数据。积极处理还显示，出生时大于500 mL的原发性失血量、第三产程或出生后24小时内或两者兼有的产妇平均失血量、产妇输血和治疗性宫缩剂均显著减少，产妇舒张压、出生后呕吐、产后痛、从出生到分娩病房出院期间使用镇痛剂以及更多妇女因出血返回医院（结局未预先设定）显著增加。积极处理还导致婴儿出生体重下降，这反映了干扰胎盘输血导致血容量降低。
在出血风险低的妇女亚组中，也有类似的发现，但在严重出血或产后24至72小时产妇Hb低于9 g/dL方面，两组之间未发现显著差异。
通过对积极处理方案进行调整，例如省略麦角制剂和延迟脐带夹紧，可能避免高血压和对胎盘输血的干扰，但我们在此没有直接证据。
尽管缺乏高质量证据，但第三产程的积极处理降低了出血风险各异的妇女群体在出生时超过1000 mL出血的风险，但也发现了不良影响。应向妇女提供两种方法的益处和危害的信息，以支持她们做出明智的选择。鉴于对早期脐带夹紧以及某些宫缩剂潜在不良影响的担忧，现在审视第三产程管理的各个组成部分至关重要。低收入国家也需要提供数据。
