Third Stage of Labour (ThiStL) Study, Version 1.0
Research type
Research Study
Full title
Third Stage of Labour Management for Low-risk Women: an Exploratory Study of Midwife-led Care
IRAS ID
243366
Contact name
Michele Freed
Contact email
Sponsor organisation
Durham University
Duration of Study in the UK
1 years, 4 months, days
Research summary
Summary of Research
Following delivery of their baby most UK women receive an injection of synthetic oxytocin to accelerate placental expulsion (‘third stage’ of labour) and reduce postpartum haemorrhage risk. Per NICE guidance, women who are considered low-risk for labour/postpartum complications can opt-out of this intervention. Some research also suggests that, for women experiencing low-risk pregnancies/labours, intervention in the third stage of labour may not improve postpartum outcomes when compared to a non-intervention approach (physiological). Nevertheless, anecdotal evidence from midwives suggests that few low-risk women in the UK currently receive non-intervention (physiological) care in their third stage of labour, even in midwife-led care setting where other interventions in labour and delivery are uncommon.The primary aim of this study is to understand why and how decisions are made around third stage of labour care for women experiencing low-risk pregnancies and labours in a midwife-led maternity care setting, and how medical intervention in the third stage of labour fits into a clinical environment that otherwise promotes physiological, non-intervention based care. Using a holistic methodology, this research aims to gain insight into the complex clinical landscape surrounding third stage of labour management for low-risk pregnancies/births, and to understand the different perspectives, pressures, and forms of knowledge at play in the current model of midwifery care in the third stage of labour care for low-risk women.
Research will involve a mixed, primarily qualitative methodology, which will account for multiple viewpoints and experiences, including those of pregnant women and postpartum mothers, and of midwives. This study will involve:
1) Observing prenatal parent education classes on childbirth;
2) Surveying and interviewing low-risk pregnant women and post-partum mothers;
3) Interviewing and surveying midwives practicing in a midwife-led care setting;
4) Surveying community midwives.Summary of Results
46 participants took part in this study. The study sample was comprised of 10 midwives practicing in a hospital, 34 low-risk patients (15 were interviewed and 19 answered an online survey), and 2 community midwives. As this study was qualitative and exploratory in nature, there are no finite results. However, to very briefly answer the guiding research questions:- What are women’s perceptions and experiences of the third stage of labour and its management?
Perceptions and experiences of third stage management varied among patients, however certain common themes were present for many participants. These included a lack of interest in the third stage of labour as well as a distinct lack of knowledge and education (see next question) about this part of childbirth. Many participants viewed the third stage of labour as separate from birth, and therefore not deserving of attention or care. Patients also often defaulted toward their midwife's recommendation or preference for third stage of labour care, which seems to be almost universally active management.
- How much information are pregnant and/or labouring women given regarding their choices for third stage of labour management?
Many patients were not given adequate information either antenatally or intrapartum (during labour) about the third stage of labour and their options for its management. Patients who attended independent (non-NHS) antenatal classes had a better understanding of the third stage of labour and their care options than those who only attended NHS classes, spoke to their community midwives, or read NHS educational materials. The third stage of labour (or at least an in-depth discussion of care options) seemed to be omitted by some community midwives and other NHS antenatal educators when speaking to patients about birth. Discussions of third stage management often omitted any mention of the potential benefits of physiological management of the third stage of labour, while emphasising the dangers of forgoing intervention and the benefits of active management. There is also very little information about third stage of labour management options available through NHS-provided materials. As a result, even low-risk patients who are eligible for physiological management for their third stage of labour may be persuaded, and in some cases possibly coerced, toward active management by claims that it is universally safer and quicker. Further, discussions of third stage management during labour sometimes skirt the line of what could be considered informed consent, with midwives often only asking if patients are "happy to have" an injection for their third stage without routinely explaining what the injection is or what the alternatives are. For patients who may not have any prior information about the third stage of labour or how it can be managed, this is not what the researcher would consider fully informed consent.
- What are midwives’ views and experiences of managing the third stage of labour?
All midwives who participated in this study routinely practice active management of the third stage of labour and many felt uncomfortable with the idea of practicing physiologically. Physiological management was a source of fear and anxiety for some midwives, as they were concerned about the potential for postpartum haemorrhage and possible resulting litigation issues. Therefore practicing routine active management was part of 'defensive' midwifery practice used to combat the potential for legal action against them. Some midwives were also concerned about how long physiological management of the third stage of labour can take as compared to active management, and preferred to have the third stage of labour finished quickly. Much of midwives' anxiety around physiological management of the third stage seemed to result from a lack of training and experience in practicing this way. Many midwives did not even view active management of the third stage as an intervention, but saw it as a part of 'normal' birth, suitable for all low-risk patients having otherwise physiological labours.
- How much training, experience, and confidence do midwives caring for low-risk women have in facilitating physiological management of the third stage?
All of the midwives who participated in this study lacked significant experience with practicing physiologically in the third stage of labour. Some who had practiced for many years had managed a handful of third stages physiologically, but the general trend was toward midwives not having practiced physiologically more than a few times over the span of their careers. Some midwives who had recently qualified had only ever seen or practiced physiological management once throughout their training. This lack of training and experience led to what many midwives described as a lack of confidence and comfort with practicing physiologically, which made them less inclined to recommend this option to low-risk patients.
- How do midwives make decisions regarding 3rd stage intervention? How is third stage management negotiated between women and midwives?
It is the researcher's opinion that midwives do not normally make decisions about care in the third stage of labour. Active management is so routine that there is not, on a day to day basis, any kind of choice being made by midwives about how to manage the third stage. Patients can of course request physiological management for their third stage, but this is extremely rare. And in these rare cases, a decision between physiological and active management in the third stage is up to the discretion of the midwives depending on various circumstances during labour, etc. Patients routinely request or agree to active management of the third stage, as is their prerogative. However, as previously stated, patients are often not given adequate information regarding their choices of care in the third stage of labour, and may therefore request or agree to active management because they have been persuaded toward this management method.
REC name
North East - York Research Ethics Committee
REC reference
19/NE/0036
Date of REC Opinion
5 Apr 2019
REC opinion
Further Information Favourable Opinion