الفهرس 
Physiological ConsiderationOnly 14 pages are availabe for public view
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Abstract
T
he implementation of active management of third-stage labor remains controversial, despite the evidence of its efficacy in randomized trials (Vivio and Williams, 2004). The issue of active management of third-stage labor is further clouded by the lack of consensus on what the order of the actual steps are: uterotonic, plus controlled cord traction, plus fundal massage (ICM, 2004) or uterotonic, plus early cord clamping, and controlled cord traction? (Festin, 2003). In addition, there is a variation of opinion of which uterotonic is most appropriate for low-resource centers and which route (parenteral, oral, or rectal) is to be used.
Active management of third-stage labor is a multiple-step intervention, further research should be conducted to determine which aspects give the most protection against postpartum hemorrhage and which might hold some risk if used incorrectly or alone. Evidence also supports the use of IM oxytocin injection when conditions are favorable for safe injection. When they are not, the use of oral or rectal misoprostol seems promising.
Although the randomized trials at the facility level indicate that oral misoprostol for prevention and rectal misoprostol for treatment are adequately evidence based, it is important to await the results of in-progress community-based studies before recommending widespread use of these medications at the community level (Miller, 2003).
Postpartum hemorrhage is an unpredictable and rapid cause of maternal death worldwide. Current evidence indicates that—where appropriately trained birth attendants, necessary equipment, and injection safety can be ensured—active management of the third stage of labor (uterotonic drugs, cord, controlled cord tension and uterine massage) will significantly reduce the incidence of PPH (Gulmezoglu, 2001). Together with the prevention and treatment of anemia and skilled attendance at all deliveries, active management can prevent PPH in thousands of women worldwide each year. Those cases that cannot be prevented require the immediate intervention of skilled, well-equipped providers. Ongoing operations research is helping to determine the best approaches for managing postpartum bleeding and its complications in various settings, including the service delivery requirements for safe and effective active management of the third stage of labor.
As the information that providers need to prevent and manage PPH is disseminated through new national guidelines, more women will receive the obstetric care they need. Resources such as Managing Complications in Pregnancy and Childbirth can further fulfill the need for clear and accurate information (WHO, 2000). When included in a continuum of pre- and post-natal care, appropriate management of the third stage of laborwill improve the survival and quality of life of mothers and infants worldwide.
PPH is a common complication of childbirth and a leading cause of maternal morbidity and mortality. Clinicians should identify risk factors before and during labor so that care may be optimized for high-risk women. However, significant life-threatening bleeding can occur in the absence of risk factors and without warning. All caregivers and facilities involved in maternity care must have a clear plan for the prevention and management of PPH. This includes sound resuscitation skills and familiarity with all medical and surgical therapies available.
Although postpartum hemorrhage carries the potential for serious maternal morbidity-even mortality-it generally can be managed successfully if it is approached in a systematic manner. The first step is determining the cause of bleeding: uterine atony, genital-tract laceration, retained placenta, or coagulopathy. While the cause of bleeding usually is singular, things aren’t always that simple. A laceration may accompany uterine atony, or retained placenta may contribute to persistent uterine atony (Steven, 2002).
Uterine compression, oxytocin infusion, and/or other medical management often are effective approaches to atony (Clark, 2002).
Surgical intervention is undertaken for direct indications, such as uterine curettage for suspected retained placental tissue, or for hemostasis if medical therapy fails. Obstetric lacerations are repaired by placing the initial suture above the apex of the laceration to control retracted arteries. Uterine artery ligation may be performed at laparotomy. Hypogastric artery ligation may be performed to reduce the arterial pulse pressure to pelvic organs. According to the report, hypogastric artery ligation is technically difficult and is successful in fewer than one half of patients. This intervention is increasingly being replaced by other forms of management. The most common indications for emergency hysterectomy include uterine atony, placenta accreta, uterine rupture, extension of a low transverse uterine incision and leiomyomata (ACOG, 1998).