ABSTRACT: Background: Management of the third stage of labor, the period following thebirth of the infant until delivery of the placenta, is crucial. Active management using synthetic oxytocin has been advocated to decrease blood loss. It has been suggested, but not studied, thatoxytocin may increase afterpains. The aim of this study was to compare women’s experience of pain intensity when the third stage of labor was managed actively and expectantly and their experience of afterpains. Methods: A single-blind, randomized, controlled trial was performed at two delivery units in Sweden in a population of healthy women with normal, singleton pregnancies, gestational age of 34 to 43 weeks, cephalic presentation, and expected vaginal delivery. Women (n = 1,802) were randomly allocated to either active management or expectant management of the third stage of labor. Afterpains were assessed by Visual Analog Scale(VAS) and the Pain-o-Meter (POM-WDS) 2 hours after delivery of the placenta and the day after childbirth. Results: At 2 hours after childbirth, women in the actively managed group had lower VAS pain scores than expectantly managed women (p = 0.014). Afterpains were scored as more intense the day after, compared with 2 hours after, childbirth in both groups. Multiparas scored more intense afterpains, compared with primiparas, irrespective of management(p < 0.001). Conclusions: Active management of the third stage of labor does not provoke more intense afterpains than expectant management.

Management of the third stage of labour and risk factors for blood loss have been the focus of investigation for a long time. The overall aim of this thesis was to investigate management of the third stage of labour and its infl uence on blood loss and women’s experience of afterpains in both a low- and a high-income country, as well as midwives’ experience of managing this stage. The studies were performed in hospital-based sett ings in Angola and Sweden. The first two studies (Papers I and II) were performed at the University Hospital in Luanda, the capital of Angola. Blood lost during the third stage of labour was collected and measured up to two hours post partum. In a prospective, comparative study, 782 parturients handled with expectant management of the third stage of labour (EMTSL) were compared to 814 parturients handled with active management of the third stage of labour (AMTSL). The latter were given 10 IU oxytocin with the Unij ect™, a disposable injection device. Postpartum haemorrhage (PPH) ( ≥ 500 mL) occurred in 40.4% and severe PPH (>1000 ml) occurred in 7.5% before introduction of AMTSL. These figures declined to 8.2% and to 1%, respectively, after the introduction of AMTSL (Paper I). The occurrence of afterpains and discomfort was compared in 51 expectantly managed and 51 actively managed women. Verbal Rating Scale (VRS) responses to semi-structured questions showed that AMTSL did not cause significantly more afterpains (Paper II). In the third study, experienced midwives in Sweden participated in focus group discussions concerning their experiences of the management of the third stage of labour. The midwives exhibited self-confidence in evaluating the physiological process and endeavoured to leave it undisturbed if no risks were apparent, thus questioning the recommendation that AMTSL be implemented in all healthy women with normal deliveries in high-income countries. Their decision-making concerning management was based on a combination of previous experience, hospital guidelines, risk assessment and sensitivity to each woman’s needs (Paper III). A randomised controlled trial (RCT) was conducted at two delivery units in a university hospital in Sweden (Papers IV and V). Women were randomised to either AMTSL (n=903) or EMTSL (n=899). The blood lost was collected and measured at the time of delivery and up to two hours post partum. The mean blood loss was less in actively managed women. Blood loss >1000 mL occurred in 10% of AMTSL and 16.8% of EMTSL, although the number of blood transfusions did not differ between the two groups (Paper IV). After pains were assessed at four occasions: twice at two hours after delivery and twice the day after delivery. The intensity of the afterpains was assessed with the Visual Analogue Scale (VAS) and the Pain-o-Meter with Word Descriptors (POM-WDS) was used for describing afterpains. A significant difference in experience of aft erpains was detected between the two groups and multiparas scored higher than primiparas, irrespective of management (Paper V). This thesis demonstrates that AMTSL is related to significantly less blood loss and does not aggravate afterpains. Furthermore, nulliparous women have a higher risk for PPH. This supports the standpoint that AMTSL is appropriate for women giving birth vaginally in hospital settings, both in Angola and Sweden, i.e. in both low- and high-income settings.