Active Management vs. Expectant Management

Simply, active management is doing something to everyone, regardless of circumstances; expectant management is waiting to see if that something is necessary, and using it only if needed.

An example: My first birth was at home, attended by a Certified Nurse Midwife. I ended up having PPH (postpartum hemorrhage), and she gave me a shot of Pitocin to stop the bleeding. I don’t know how much blood I lost, but it was enough that I had to lean against the wall for support when I went to the bathroom about a half hour after birth or so, and felt like I was about to faint. She used “expectant management” — that is, she did not give me a shot of Pitocin until it was obvious that it would be beneficial. Most hospitals use “active management” in this area — they give a shot of Pitocin to the mom as soon as the baby’s anterior shoulder is born, whether the mom needs it or not.

I read an excellent article in the Journal of the New Zealand College of Midwives about the use of active vs. expectant management of postpartum hemorrhage (beginning p. 25). Quite thought-provoking. Among other things, the author notes significant differences between the average Western woman (who will be healthy, well-fed, have access to clean water and medications) and the average woman from a developing nation (who will likely not have access to clean water, may not have sufficient food, may be suffering from illnesses, and may be “at the bottom of the totem pole” when it comes to getting medications). She notes that Western women who are least likely to suffer from ill effects of pregnancy or birth to start with, are also going to be most likely to have drugs used on them (actively, whether needed or not); while women who are most likely to have problems, will have the least access to drugs — either not being able to afford them, or what little supply of drugs the country has will be given to men who are considered more important, or (in the case of uterotonic drugs like Pitocin) may be put on the black market for use in abortions and therefore not available to the women who need them.

She questions the usefulness of active management in the healthy low-risk women, but not necessarily its usefulness in the high-risk women. However, she makes the point that because these women are not getting the full active-management package, then what they are getting may be making problems worse. For instance, they may not have Pitocin for the reasons stated above; yet their health professionals are being taught to use active management of the third stage (after the birth of the baby — the birth of the placenta), which includes immediate clamping of the cord and cord traction. She notes that immediate clamping of the cord may seriously damage the at-risk baby in these poor countries of the world by depriving him of his full supply of placental blood; but more importantly, she says that controlled cord traction (CCT) in the absense of uterotonic drugs may actually increase the rate of PPH. But these things are aggressively being promoted as being beneficial (since they are part of the active management package) without regard to the fact that these people do not have the drugs. It should be noted that the World Health Organization‘s “Safe Motherhood” Guidelines place all three aspects of “active management of the third stage” into the category of “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue.”

Yet she calls into question the use of active management for your average, healthy Western woman, because we are unlikely to benefit from it, and puts forth a few studies which demonstrated a lower rate of PPH in expectant management (also called “physiologic management”) of the third stage, as opposed to active management. I was reminded of a discussion I read among midwives about cord clamping, and one midwife noted that it was her practice to leave the umbilical cord alone until it stopped pulsing at least, possibly until the placenta was actually born, and that the only case of PPH that she had personally had among her clients was the one time she had to clamp and cut the cord because of a tight nuchal cord. While that is anecdotal evidence, it stuck out in my mind, because I knew that that flew in the face of what is commonly accepted in obstetrics — that PPH happened without active management (immediately cutting the cord, giving a shot of Pit, and pulling on the cord to get the placenta out). Yet this is in accord with the studies the New Zealand midwife mentioned.

Why is expectant management not used more? Oh, I know the typical OB’s answer — “Because years of research has shown that active management reduces PPH.” Well, maybe — in high-risk, unhealthy women. Or in births that have had the normal, physiological, natural actions circumvented. Let’s say that the above midwife’s reasoning, based on her anecdotal account, is accurate — that the majority of cases of PPH in healthy women occur because the umbilical cord is clamped too soon. What if that is true? Immediate clamping began decades ago when childbirth went industrial, without any studies on its safety, risks, or benefits. I can assume that it happened in lock-step with the rest of the medicalization and mechanization of childbirth, along with general anesthesia and forceps for all births — that doctors prided themselves on getting the baby out as fast as possible, and then cutting the cord immediately in a rite to signify his complete independence of the mother. Only recently have questions been raised about whether it causes any problems, for instance, with depriving the baby of the full amount of blood which rightly should be his, or whether immediate clamping causes problems because of the oxygen deprivation that occurs when it is done before breathing begins. What if most of the cases of PPH in healthy women in America and other developed countries are caused by active management? — which then necessitates more active management to “cure” it. What if PPH could be almost entirely avoided by the simple matter of leaving the cord intact? Quite an interesting train of thought, and one which I hope will be studied. It is already recognized that delaying cord clamping has no risk to the baby, and in the case of premature infants carries with it some benefit. I strongly suspect that delayed cord-clamping has benefits to all babies, but whether this will ever be studied remains to be seen. Isn’t it sad that immediate cord clamping became the norm without any studies whatsoever, but now keeping the cord intact even as long as two minutes, which is only natural, has to be the action that is proved before it is used? [The WHO document I mentioned above says that “physiological” treatment of the umbilical cord — i.e., delayed clamping or not clamping at all — should be considered normal, while early clamping should be made to defend itself.]

But back to the article… the author is promoting the idea of teaching physiological management in these low-resource countries, because she understands that, while it’s all nice and good in Pollyanna’s world that all women who need drugs will get them, in the real world that’s not the case; and if more harm than good is done by half-measures of active management, then another way should be promoted. Active management of the third stage of labor will reduce maternal deaths due to PPH in women in developing countries; but if it is true that in the absence of Pitocin, that the rest of active management will increase deaths due to PPH, then something else must be done. You can’t just blithely say, “Let them eat cake” when they have no bread. And if immediate clamping of the cord and controlled cord traction increase PPH in the absence of uterotonic drugs, then birth attendants in other parts of the world need to understand this, so that they don’t make maternal mortality worse. Active management may not increase maternal mortality in high-resource countries, because we’ve got the ability to keep PPH from turning deadly, in the form of easily available drugs, and quick access to hysterectomies if required. They don’t. And I think it’s time to start recognizing that there is a difference between the United States and Sierra Leone, and trying to work with what they’ve got, and improve the quality of care with the resources they have, not just some sort of “pie in the sky” wishful thinking of what might be the case if they had X, Y, or Z. Because they don’t. And if active management without Pitocin increases PPH (which will increase maternal mortality, because they can’t handle the blood loss like we can), then continuing to spread it without ensuring that they have all the pieces of AML, is causing the deaths of women all over the globe. And it needs to stop.

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