Outcomes of blood loss post physiological birth with physiological management in the third stage of labour at a maternity home in Japan

A Corresponding Author: hopeful1@ hotmail.co.jp B Takasaki University of Health and Welfare, Japan C Tokyo Medical University, Japan D Yamamoto Maternity Home, Japan INTRODUCTION Active management versus physiological management of the third stage of labour has been debated in the literature since the 1980s (Begley, 1990; Dixon, Fullerton, Begley, Kennedy, & Guilliland, 2011; Jangsten, Mattsson, Lyckestam, Hellstrom, & Berg, 2011; Prendiville, Harding, Elbourne, & Stirrat, 1988; Rogers et al., 1998; Thilaganathan, Cutner, Latimer, & Beard, 1993). Active management has been identified as consisting of three interventions: prophylactic uterotonic administration, early cord clamping before cord pulsation ceases, and controlled cord traction (Begley, Gyte, Devane, McGuire, & Weeks, 2015). In physiological management the placenta is delivered spontaneously with the aid of gravity and sometimes by maternal effort without those three interventions (Begley et al., 2015). In their Cochrane systematic review aimed at assessing the effectiveness of active or expectant management of the third stage of labour, Begley et al. (2015) found active management of the third stage reduced the risk of a haemorrhage greater than 1000ml. They concluded that active management has benefits for women at mixed levels of risk for bleeding, although “there was an absence of high-quality evidence” (Begley et al., 2015, p.1), but that adverse effects were also identified. The studies included in the review involved births in hospital only settings with women often experiencing intervention during the first and second stages Background: Debate continues as to whether active or physiological management of the third stage of labour reduces the risk of postpartum haemorrhage for healthy well women. However, little attention has been paid to what volume of blood loss should be considered within normal range when the birth has been physiological, including physiological management of the third stage. At midwife-run maternity homes in Japan, midwives support physiological labour and birth, including the third stage, with protocols in place which govern when to intervene, refer and transfer to hospital obstetric care. Objectives: To describe and quantify and gauge the significance of blood loss volume following birth when labour, birth and third stage have been physiological at one Japanese maternity home. Method: Retrospective cohort study with data being extracted from the birth records of 512 women who gave birth at a maternity home between January 2007 and February 2010. Blood loss was measured up to two hours postpartum. Findings: Among the 512 births, we determined the means of parity as 2.2 (SD=0.86), blood loss up to two hours post-delivery as 608.7ml (SD=403.1), and length of the third stage of labour as 12.9min (SD=7.7). Blood losses of between 0-499ml, 500-999ml, 1000-1499ml, 1500-1999ml and ≥2000ml were 52.3%, 31.6%, 11.3%, 4.1% and 0.6%, respectively. Therapeutic intravenous uterotonics were provided to 3.1% of women when blood loss was <1000ml but given to 83.3% when blood loss exceeded 1500ml. Furthermore, 5.6% of the women received IV iron therapy when blood loss was <1000ml, while all the women did when blood loss exceeded 1500ml. Mean haemoglobin level at four days postpartum with blood loss >1500ml was 8.3 g/dl (SD=1.0) which was significantly lower than the mean of 9.8 g/dl (SD=1.2) calculated for the women who had a blood loss of 1000-1499ml and the 9.6 g/dl mean (SD=0.9) for the women with a blood loss of 500-999ml (F=27.92, p<0.001). Of those reported (n=11), mean haemoglobin levels in all groups increased to almost 11 g/dl after two weeks. Conclusion: Although these data are only from one maternity home in Japan, they clearly demonstrate that for these women, when births were physiological and the third stage was physiologically managed, blood loss during the third stage and up to two hours postpartum could be more than 500ml and may be as much as 1000ml without adversely affecting them.