Placental Expulsion - Active vs. Physiological Management

After the birth of a baby, the placenta is pushed out or delivered through the vagina - the third stage of labor. There are two options for placenta delivery - active management and physiological management.

Active management is a fairly quick process. During active management, a drug, oxytocin, is injected into the thigh of a woman who is going to give birth to a baby. The umbilical cord is clamped and cut in about 1 to 5 min after the baby is born. When the placenta is separated from the uterus wall, the midwife pulls it out.

In physiological management, injection is not used. When the cord stops pulsating, it is clamped and cut. Women giving birth to babies push and move the placenta out of the uterus; it may take about 1 hour to deliver the placenta through vagina. Both the options have advantages and disadvantages.

Active Management

There are many variations to the active management approach:

• Use of different drugs, for example, syntometrine, oxytocin, misoprostol, and ergometrine.
• Timing of using the drug, i.e., right after the baby is born or before anterior shoulder birth or after the baby is born but before delivery of the placenta.
• Timing of clamping and cutting the cord, i.e., immediately after the birth of the baby or within 30 s or 1 min.
• Timing of initiation and control of cord traction—to wait or not to wait for the signs of placental separation.

To reduce the threat of severe bleeding after the baby is born, active management is suggested. Active management reduces severe postnatal bleeding risks by 50% across women of all risk types.

Studies have found that adopting an active management approach does not provide benefits to either the women or the baby in the case of normal births among low-risk women.

The use of interventions such as uterotonic drugs and the practice of clamping the cord early may lead to some unfavorable effects.

For the Mother

There can be a situation where medicines may need to be used for alleviating pain during the postnatal period. The risk of hypertension may increase and the women may have vomiting and nausea when using uterotonic drugs.

There is a greater likelihood of the women getting readmitted to the hospital because of vaginal bleeding. It is believed that the risk of placenta getting trapped in the uterus is higher. In that case, the placenta will be removed manually. Another disadvantage is the lower breastfeeding rate, i.e., 48 h after the baby is born.

For the Baby

Babies are found to have lower birth weight as they lose about 80 ml of blood. In fact, the blood that is lost stays in the placenta as the cord is clamped early, resulting in reduced placental blood transfusion; the risk of hypotension is higher for such babies. As the baby does not get enough oxygenated blood, there is a risk of baby becoming anemic during infancy.

Recommendations from WHO

The World Health Organization (WHO) has suggested the use of uterotonics (oxytocin) in all births to prevent postpartum hemorrhage (PPH). WHO recommends controlled cord traction (CCT) for vaginal births if skilled birth attendants are available. However, CCT is not suggested in a situation where skilled birth attendants are not available.

When a woman receives prophylactic oxytocin, then sustained uterus massage is not advised; this is done to prevent PPH. To identify uterine atony early, postpartum abdominal uterine tonus evaluation is suggested for all women. In the case of cesarean delivery, CCT is suggested for removing the placenta.

Physiological Management

In physiological management, the placenta is separated from the uterine wall and moved downward to the birth canal and expelled naturally through vagina.

This approach is recommended for women with low risk of bleeding. The hormone oxytocin is released naturally when women are relaxed. Studies have found that women need a warm, calm, quiet, and private environment that supports the release of oxytocin. When the baby is breastfed, the skin-to-skin contact increases the release of oxytocin, facilitating the natural delivery of the placenta.

Ultrasound studies have shown that in many usual cases, the placenta gets detached from the uterine wall within 10 min. After separation, the placenta has to come out through vagina, else it can be dangerous. Women are actively involved in delivering the placenta. They change positions and use techniques as suggested by midwives, such as a warm bath or blowing into a bottle, to get the placenta out of the uterus naturally.

However, if there is an increase in blood loss or if the waiting period is more, then drugs are administered for placental delivery.

The time taken for placental delivery is longer in physiological management compared with that in active management, which increases average blood loss.

Studies have found that in physiological management, blood loss of about 500 ml or more is observed in 16.5% of women, whereas in active management, it is observed in about 6.8% of women.