about Active Management of
Third Stage of Labor with Women
Joanne Motino Bailey, PhD, CNM
Director Midwifery Service,
University of Michigan Health System
What did you set out to change or improve?
Based on changes to global recommendations for use active management of third stage of labor we wanted to offer this as a potential standard of care using 10u IM Pitocin. The goal was that all women in our practice be offered AMTSL post vaginal birth and then eventually this standard would be available ultimately for every woman who has a vaginal birth at our institution.
How did you change it?
We initially reviewed the relevant literature within the midwifery group. We demonstrated that it is the only medical intervention in routine birth care that is evidence based. We agreed as a group to start offering it to all women in the midwife practice. A small number of women declined. We started collecting data within the midwife service to assess whether it was done or not at each birth and sharing this information at staff meetings.
After doing this for a year with good success in reducing blood loss, we brought the protocol to our Perinatal Joint Practice Committee meeting. We briefly discussed the evidence and approved this for routine use. We then sent an email out to the OB department noting this recommended change. We had to adapt our routine order set to include 10units of IM Pitocin because prior to that only 20 units of Pitocin mixed in a 1 liter bag of LR was listed.
Who was involved in making the change and what was each person’s role?
Director of midwifery service- brought personal work and research experience with AMTSL as well as literature review to the midwifery service. Individual midwives agreed to try it out.
For implementation across all vaginal births— the director of the birth center, nurse managers endorsed the change. OB physicians were used to using IV Pitocin in a liter of LR after delivery of the placenta so the change was not as significant as for the midwives who were used to managing third stage physiologically.
How did you determine if the change worked?
Within the midwife service we were able to track outcomes for women who had vaginal births using AMTSL or not. We saw an increase from 20%-to almost 90% over a two year period. Anecdotally midwives that were more skeptical also shared at staff meetings that they had noted a decrease in vaginal bleeding immediately postpartum as well as fewer situations where clots needed to be manually removed from the vagina in the 1-3 hour post partum period.
Unfortunately we are unable to easily track implementation across the other birth providers.
What was the biggest barrier to making the change?
Overcoming midwives resistance to more intervention during normal birth. We also have some patients refuse AMTSL
How did you overcome that barrier?
Discussing the evidence with the midwife group as a whole made them interested in considering the practice change. We continued to follow up on the change by checking in during staff meetings.
We believe that women have a right to decline interventions so we discuss the use of AMTSL during a prenatal visit and then document the woman’s decision about its use for her in her medical record. This allows women an opportunity to consider the information and to determine if they want to decline AMTSL. This was the approach we used to support shared decision making with women in our practice. This can be a challenging decision for women to make when presented with the information during birth. Having a discussion and providing a hand out about the topic allows women more opportunity to consider the issues.
If you have data or other evidence that your change was successful, please provide that data.
AMTSL used in CNM service at University of Michigan for vaginal births
Number of births
% using AMTSL
2011* 6 months only
If you had one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?
Because this is a global recommendation with a robust body of literature to support its routine use making the case for implementation was easy.
I would recommend that the practice change be discussed within an interdisciplinary group to ensure that there is both provider and RN understanding of the benefits as well as the specifics of the practice.