At a time when obstetricians are fighting to bring down the incidence of post-partum haemorrhage (PPH), the leading cause of maternal mortality in India, a recent advisory issued by the Union Health Ministry to States to adopt the Gujarat model of “non-interventional approach during the final stages of labour” as the best obstetric practices has kicked up a storm.
Obstetricians say the advisory runs contrary to WHO recommendations and the best of proven international advisories and this can undo all their efforts to reduce PPH and prevent mothers bleeding to death.
The Indian Medical Association (IMA) leadership demands that the Centre leave clinical decision-making to doctors and that the advisory be withdrawn as it sends out contradictory messages to nurses and birthing assistants.
Kerala managed to bring down the PPH numbers drastically when in 2013 it developed and implemented the Quality Standards in Obstetric Care, in association with the NICE International. One of the key principles adopted is the WHO-recommended strategy of “active management of third stage of labour” (AMTSL).
The third stage is the time between the delivery of the baby and the expulsion of the placenta and its duration could be approximately six to 30 minutes. The volume of blood loss during this time depends on how long it takes the placenta to separate from the uterine wall and how effectively the uterine muscle contracts in the immediate post-partum period. This can be quite tricky. So in 2012, the WHO reaffirmed AMTSL, with the use of uterotonics (drugs to contract uterus and reduce bleeding) as the best critical measure.
The new advisory, however, advocates the physiological management or the “hands-off” approach during the third stage of labour. It says to delay the clamping and cutting of umbilical cord till placenta separates naturally and is expelled from the uterus. And that the uterotonic oxytocin be administered only after the placenta is expelled.
“Our concern is about the delayed administration of oxytocin. Uterine atony (failure of uterus to contract), followed by massive haemorrhage, occurs in the third and fourth stage. Immediate administration of oxytocin as soon as foetus is delivered contracts the uterus and helps the expulsion of placenta without blood loss,” says V. P. Paily, an obstetrician and State coordinator, Confidential Review of Maternal Deaths.
The WHO-recommended protocol of delaying cord clamping by one to three minutes after birth is enough to achieve the aim of allowing the foetus more blood from placenta, Dr. Paily says.
The Ministry says its advisory is meant to make childbirth a “natural and positive experience” for women.