Active versus expectant management of the third stage of labour (all women).
Population: All women who expected a vaginal birth at 24 weeks’ gestation or later
>Intervention: Active management of the third stage of labour
Comparison: Expectant management of the third stage of labour
| Outcomes | Illustrative comparative risks* (95% CI) |
Relative effect (95% CI) | No of Participants (studies) | Quality of the evidence (GRADE) | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| Expectant management Active management of of the third stage of the third stage of labour labour | ||||||
| Severe primary postpartum haemorrhage (PPH) (clinically estimated or measured blood loss ≥ to 1000 mL at time of birth) | 24 per 1000 | 8 per 1000 (3 to 21) | RR 0.34 (0.14 to 0.87) | 4636 (3 studies) | ⊕○○○ very low1 | |
| Very severe primary PPH (clinically estimated or measured blood loss ≥ to 2500 mL at time of birth) | See comment | See comment | Not estimable | 0 (0) | See comment | No data |
| Maternal mortality | See comment | See comment | Not estimable | 0 (0) | See comment | No data |
| Maternal Hb <9 g/dL 24 to 72 hours postpartum | 71 per 1000 | 36 per 1000 (21 to 59) | RR 0.5 (0.3 to 0.83) | 1572 (2 studies) | ⊕⊕○○ low2 | |
| Admission to neonatal special/intensive care | 52 per 1000 | 42 per 1000 (31 to 58) | RR 0.81 (0.6 to 1.11) | 3207 (2 studies) | ⊕⊕○○ low3 | |
| Neonatal jaundice requiring phototherapy or exchange transfusion | 49 per 1000 | 47 per 1000 (27 to 83) | RR 0.96 (0.55 to 1.68) | 3142 (2 studies) | ⊕○○○ very low4 | |
| Neonatal polycythaemia treated with dilutional exchange transfusion | See comment | See comment | Not estimable | 0 (0) | See comment | No data |
The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
Risk of bias: Of the 3 trials providing data for this outcome, all 3 are at low risk of bias for sequence generation (selection bias), allocation concealment (selection bias) and for incomplete outcome data (attrition bias). Two are at low-risk of selective reporting (reporting bias) and one is unclear. One study is at high risk of other bias (see Risk of bias tables).
Inconsistency: There is some overlap of confidence intervals of the 3 trials. However, Tau² = 0.38, the P value for the Chi² test of heterogeneity is 0.08 and I² = 60%. These suggest the presence of heterogeneity, which cannot be explained by any of the subgroups or sensitivity analyses performed.
Indirectness: Directly answers the question.
Imprecision: Total (cumulative) sample size 4,636 is less than the optimal information size (OIS) of 18,590 (assuming α = 0.05, 1-β = 0.80, relative risk reduction (RRR) of 25% from control event rate).
Risk of bias: Of the 2 trials providing data for this outcome, both are at low risk of bias for sequence generation (selection bias) and allocation concealment (selection bias), One is at low risk of bias for incomplete outcome data (attrition bias) while the other is high-risk. One is at high-\-risk of selective reporting (reporting bias) and one is unclear. Both studies are at high risk of other bias (see Risk of bias tables).
Inconsistency: The confidence intervals of the 2 trials overlap. Tau² = 0.02, the p value for the Chi² test of heterogeneity is 0.31 and I² = 3%. Although Tau² is non-zero, tests suggest an absence of unexplained heterogeneity. Indirectness: Directly answers the question.
Imprecision: Total (cumulative) sample size 1,572 is less than the optimal information size (OIS) of 5,804 (assuming α = 0.05,1-β = 0.80, RRR of 25% from control event rate).
Publication bias: Assessment of funnel plot asymmetry not performed due to <10 studies included for this outcome.
Risk of bias: Of the 2 trials providing data for this outcome, both are at low risk of bias for sequence generation (selection bias), allocation concealment (selection bias) and for incomplete outcome data (attrition bias). One is at low-risk of selective reporting (reporting bias) and one is unclear. One study is at high risk of other bias and the other is at low-risk of bias (see Risk of bias tables).
Inconsistency: The confidence intervals of the 2 trials overlap. Heterogeneity: Tau² = 0.00; Chi² P value = 0.40, I² = 0%. This suggests an absence of unexplained heterogeneity.
Indirectness: Directly answers the question.
Imprecision: Total (cumulative) sample size 3,207 is less than the optimal information size (OIS) of 8,066 (assuming α = 0.05, 1-β =0.80, RRR of 25% from control event rate).
Publication bias: Assessment of funnel plot asymmetry not performed due to <10 studies included for this outcome.
Risk of bias: Of the 2 trials providing data for this outcome, both are at low risk of bias for sequence generation (selection bias), allocation concealment (selection bias) and for incomplete outcome data (attrition bias). One is at low-risk of selective reporting (reporting bias) and one is unclear. One study is at high risk of other bias and the other is at low-risk of bias (see Risk of bias tables).
Inconsistency: There is some overlap of confidence intervals of the 2 trials. However, Heterogeneity: Tau² = 0.11, P value for heterogeneity = 0.09) and I² = 66%. These suggest the presence of heterogeneity, which cannot be explained by any of the subgroups or sensitivity analyses performed.
Indirectness: Directly answers the question.
Imprecision: Total (cumulative) sample size 3,142 is less than the optimal information size (OIS) of 8,584 (assuming α = 0.05, 1-β = 0.80, RRR of 25% from control event rate).
Publication bias: Assessment of funnel plot asymmetry not performed due to <10 studies included for this outcome.