Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study.

Question: Is 'holistic psychophysiological care' in the third stage of labour safe for women at low risk of postpartum haemorrhage?

Background: Although there have been four randomised trials and a Cochrane Review on the safety and effectiveness of care during the third stage labour, no previous study has focussed only on women at low risk of postpartum haemorrhage and no previous study has tested a form of physiological third stage care that is provided by skilled midwives in an appropriate setting.

Design: Retrospective cohort study involving a maternity unit at a tertiary referral hospital and a freestanding, midwifery-led birthing unit.

Participants: All low risk women who gave birth at either unit in the period July 2005-August 2008.

Interventions: 'Active management' of the third stage of labour compared with 'holistic psychophysiological third stage care'.

Results: At the tertiary unit, 344 of 3075 low risk women (11.2%) experienced postpartum haemorrhages (PPH). At the midwifery-led unit, PPH occurred for 10 of 361 women (2.8%), OR=4.4, 95% CI [2.3, 8.4]. Treatment received analysis showed that active management (n=3016) was associated with 347 postpartum haemorrhages (11.5%) compared with receiving holistic psychophysiological care (n=420) which was associated with 7 (1.7%) PPH OR=7.7, 95% CI [3.6, 16.3].

Conclusion: This study suggests that 'holistic psychophysiological care' in the third stage labour is safe for women at low risk of postpartum haemorrhage. 'Active management' was associated with a seven to eight fold increase in postpartum haemorrhage rates for this group of women. Further prospective observational evaluation would be helpful in testing this association.