Survey of prophylactic use of uterotonics in the third stage of labour in the Netherlands
Introduction
Postpartum haemorrhage, PPH, defined as more than 1000 ml after childbirth contributes to substantial numbers of maternal deaths and morbidities worldwide (World Health Organisation, 2007). The incidence of postpartum haemorrhage caused by uterine atony is increasing in industrialised countries (Knight et al., 2009). In the Netherlands, if pregnancy is uncomplicated and no elevated risk has been identified, birth can take place either at home or in hospital, both supervised by a midwife. In fact, 33% of all women give birth under supervision of a midwife. Although 5.9% of births in the Netherlands are complicated by PPH, the incidence of PPH in low risk (home) births is approximately 3.4% (Perinatal Care in the Netherlands, 2008). Management of the third stage of labour has roughly two approaches. Expectant management involves waiting for signs of placental separation and allowing the placenta to deliver spontaneously or assisted by gravity or nipple stimulation (Leduc et al., 2009). Active Management of Third Stage of Labour, AMTSL, includes prophylactic use of uterotonics, cord clamping and Controlled Cord Traction, CCT (International Confederation of Midwives, I.F.o.G.a.O., 2003, National Institute for Health and Clinical Excellence (NICE), 2007, Knight et al., 2009, Begley et al., 2011, Jangsten et al., 2011). It is assumed that prophylactic use of uterotonics halves the risk of PPH (Cotter et al., 2001). It is unclear what the impacts of the other components of AMTSL (cord clamping and CCT) are in the reduction of PPH (Mc Donald and Middleton, 2008, Begley et al., 2011). Active management has often been compared to expectant management (Prendiville et al., 1988, Leduc et al., 2009, Soltani et al., 2010, Begley et al., 2011, Jangsten et al., 2011). A recent review shows that if AMTSL is the standard care for all women, the incidence of PPH (>1000 ml) and anaemia is significantly reduced. However, AMTSL increased maternal blood pressure, postpartum contractions, nausea, vomiting and use of drugs for pain relief. These side-effects were probably due to the use of ergot compounds. For women at low risk of bleeding, there was no difference in the risk of PPH>1000 ml and side effects were similar (Begley et al., 2011). The International Confederation of Midwives (ICM), the International Federation of Gynaecologists and Obstetricians (FIGO), the World Health Organisation (WHO) and guidelines on the third stage of labour in many countries, advocate AMSTL for all women (International Confederation of Midwives, I.F.o.G.a.O., 2003, National Institute for Health and Clinical Excellence (NICE), 2007, World Health Organisation, 2007, RCOG, 2009, Department of Health, NSW, 2010, Begley et al., 2011). However, in the United Kingdom, the Royal College of Midwives (RCM) and the New Zealand College of Midwives do not recommend AMSTL but uterotonics on indication (New Zealand College of Midwives (NZCOM), 2006, Munro and Jokinen, 2008). In the Netherlands, prophylactic administration of uterotonics is recommended by the Dutch Society of Gynaecologists and Obstetricians (NVOG) (Dutch Society of Obstetrics and Gynaecology (NVOG), 2006). At present, The Royal Dutch College of Midwives, KNOV, has no protocol on management of the third stage of labour. In 1995, a survey among all obstetricians and midwives in the Netherlands showed that 55% of the obstetricians versus 10% of midwives administered oxytocin as a prophylaxis (de Groot et al., 1996). Insufficient evidence on the effectiveness of some components of AMTSL, the conflicting recommendations and the absence of a guideline for midwives in the Netherlands may result in variation in practice.
Aim of this study was to investigate current knowledge and practice regarding AMTSL in midwifery practices and obstetric departments in the Netherlands.
Section snippets
Methods
A questionnaire was developed and tested by two midwives and an obstetrician and sent to all hospitals with obstetric departments (n=91) and all midwifery practices (n=528) in the Netherlands. The questionnaire was sent to every midwifery practice and to the chief consultant of all obstetric departments. Recipients were asked whether he or she was currently working in obstetrics or midwifery. Secondly, the presence of an oral or written protocol concerning the management of the third stage of
Findings
Of the obstetric departments, 84 out of 91 (92.3%) responded to the questionnaire as compared to 436 out of the 528 midwifery practices (82.6%) (p<0.01). All respondents were currently working as obstetrician or midwife. Within the 436 midwifery practices, 51.8% reported the presence of an oral or written protocol regarding management of third stage of labour (consisting of either an active management or expectant management) compared to 91.7% of all 91 obstetric departments (p<0.01).
As shown
Discussion
Compared to 1995, the routine use of uterotonics in the Netherlands has significantly increased for both midwifery practices as well as for obstetric departments. The magnitude of the increase in the use of routine uterotonics found is such that one can assume that a true shift in policy has taken place. Reasons for this change in policy are various and include the implementation of a guideline for obstetricians in 2006, the introduction of the Managing Obstetric Emergencies and Trauma course
Key conclusions
Routinely administering oxytocin directly after childbirth has significantly increased both for midwives and obstetricians in low and high risk pregnancies in the Netherlands since 1995. In low-risk births supervised by midwives, it is not standard practice. Most obstetricians administer oxytocin routinely (97.6%). The evidence for the routine administering of uterotonics is convincing for women who are at risk of PPH, but concerning low-risk (home) birth we advise further research on the
Acknowledgements
The authors would like to express their gratitude to all respondents, midwives and obstetricians, who took the effort to respond to the questionnaire. We thank Chantal Hukkelhoven (Perinatal Registry) and Joost von Schmidt auf Altenstadt for supplying data from the Perinatal Registry on postpartum haemorrhage in the Netherlands.
We are grateful for the help of Gladys Laterveer and Jacqueline Blom, for assistance in the postal mailing and the collection of data.
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