Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is best practice for third stage management during childbirth?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Active management versus physiologic managment of the third stage of labor

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

All childbearing women

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

No - this applies to all childbearing women

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Reduced postpartum hemorrhage and morbidity related to postpartum hemorrhage

Describe any health-related risks, side effects, or harms that you are concerned about.

Active management may be imposing interventions that could cause increased morbidity for those women who do have a postpartum hemorrhage.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

no

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Pregnancy, including preterm birth

AHRQ Priority Populations

• Women

Federal Health Care Program

None

Importance

Describe why this topic is important.

Best practice for birth attendants during the third stage of labor is not clearly identified. Postpartum hemorrhage, which occurs most commonly during or immediately following the third stage of labor, continues to be a significant issue in obstetrics. It is a common reason for maternal mortality worldwide with it being the leading cause of death related to childbirth in developing countries.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

I am interested specifically in this issues because of several reasons:

1. Women are still affected by postpartum hemorrhage. Our academic center had 27 cases in one month. In an attempt to standardize care, there does not seem to be a "best practice" to recommend for our providers.
2. I teach in this field. I present all the various interventions providers use - including active management - but it is very difficult to provide any recommendations regarding how students should manage this aspect of childbirth.
3. When overseeing ob resident births, I notice a great deal of manipulation during the third stage - in addition to active management. The data do not guide what I should teach in this regard.
4. Patients request not to have intervention unless it is medically necessary - which is counter to the active management guidelines.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

There is large variation in clinical care and controversy in what is considered appropriate care. More research is needed in this area, but it would be helpful for this body to evaluate the current state of third stage of labor management and provide recommendations. It would be helpful to include the difference between active, physiologic, and expectant management so that future studies evaluate specific components.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

It will provide direction for future research. It will provide guidance for systematic care of women during the third stage for outcome evaluation.

Describe the timeframe in which an answer to your question is needed.

It is an important issue that affects millions of women giving birth. Becauce the impact is great and the population is large, this is an urgent question to be answered.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Since pregnant women are considered a vulnerable population, this question addresses a vulnerable population. The continued mortality rate related to third stage management is not acceptable for any population.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

It will provide direction for future research. It will provide guidance for systematic care of women during the third stage for outcome evaluation.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program