Uterine massage to reduce postpartum hemorrhage after vaginal delivery

Objective

To determine the effectiveness of sustained uterine massage started before delivery of the placenta in reducing postpartum hemorrhage.

Methods

A randomized controlled trial conducted in Egypt and South Africa between September 2006 and February 2009. A total of 1964 pregnant women were randomly allocated to 1 of 3 treatment groups: intramuscular oxytocin, sustained uterine massage, or both treatments. Blood loss within 30 minutes of delivery was recorded.

Results

The incidence of blood loss of 300 mL or more within 30 minutes of delivery was significantly higher in the massage group than in the massage plus oxytocin (RR 1.88; 95% CI, 1.29-2.74 in Assiut, and RR 1.3; 95% CI, 1.00-1.68 in SA) and the oxytocin only group (RR 1.7; 95% CI, 1.11-2.61 in Assiut, and RR 2.24; 95% CI, 1.54-3.27 in SA). In both centers, use of additional uterotonics was significantly higher in the uterine massage group compared with the other 2 groups.

Conclusion

Uterine massage was less effective than oxytocin for reducing blood loss after delivery. When oxytocin was used, there was no additional benefit from uterine massage. The effectiveness of uterine massage in the absence of oxytocin was not studied. ACTRN: 12609000372280.     

Misoprostol versus oxytocin for the reduction of postpartum blood loss.

OBJECTIVE: To compare the effect of 400 mug of oral misoprostol with 5 U of intravenous oxytocin in the reduction of postpartum blood loss and prevention of postpartum hemorrhage. METHODS: In a prospective, double-blind, randomized controlled trial conducted in a tertiary maternity hospital 622 women received either 400 mug of oral misoprostol or 5 U of intravenous oxytocin after delivery of the anterior shoulder or within 1 min of delivery. The primary outcome was a hematocrit drop of 10% or greater 24 h postpartum. The secondary outcomes were a hemoglobin drop of 30 mg/L or greater, the use of additional oxytocin, an estimated blood loss greater than 1000 mL, manual removal of the placenta, a blood transfusion, and shivering and fever (>or=38 degrees C) as adverse effects of misoprostol. RESULTS: There was no difference between the 2 groups regarding the primary outcome (a >or=10% hematocrit drop occurred in 3.4% and 3.7% of the participants in the oxytocin and misoprostol groups, P=0.98). The rate of use of additional oxytocin was higher in the misoprostol group (51% versus 40.5%, P=0.01). Shivering was confined to the misoprostol group (6.8%), and fever occurred in 12.5% of the women in the misoprostol group and 0.3% of the women in the oxytocin group. CONCLUSION: The routine use of 400 microg of oral misoprostol was no less effective than 5 U of intravenous oxytocin in reducing blood loss after delivery, as assessed by change in postpartum hematocrit. The adverse effects of misoprostol were mild and self-limiting.     

A double-blind, randomized, placebo-controlled trial of misoprostol and routine uterotonics for the prevention of postpartum hemorrhage

Objective

To assess the effects of 400-μg sublingual misoprostol plus routine uterotonics on postpartum hemorrhage.

Methods

A double-blind, placebo-controlled, randomized study was performed. After delivery of the child, eligible women received routine uterotonics and were randomly allocated to receive 400-μg misoprostol or placebo sublingually. The primary outcome measure was blood loss of at least 500 mL within 1 hour of taking the trial tablets.

Results

In total, 672 women received misoprostol and 673 received placebo. The baseline data were similar for both groups. Misoprostol plus routine uterotonics reduced postpartum blood loss, but the effect was not significant for blood loss of at least 500 mL (relative risk [RR] 0.96; 95% confidence interval [CI], 0.63-1.45) or blood loss of at least 1000 mL (RR 0.50; 95% CI, 0.15-1.66). Misoprostol also reduced the need for non-routine oxytocin, manual removal of the placenta, and hysterectomy, but these differences were not significant either. Misoprostol was associated with pyrexia and moderate/severe shivering. There was no death in either group.

Conclusion

Misoprostol plus routine uterotonics resulted in modest reductions of blood loss in the third stage of labor, but the effects did not reach statistical significance. Larger studies are recommended.     

Prospective randomized trial of oxytocin administration for active management of the third stage of labor

Objective

To determine the most efficient route and timing of oxytocin administration for active management of the third stage of labor.

Methods

A prospective randomized study was done at one center in Ankara, Turkey, between January and October 2010. Women with a singleton pregnancy (> 37 weeks) who had a live vaginal birth were randomly allocated to four groups: iv-A (intravenous oxytocin after delivery of the fetus), iv-B (when anterior shoulder seen), im-A (intramuscular oxytocin after delivery), and im-B (when anterior shoulder seen). Postpartum blood loss within the first hour, hemoglobin, hematocrit, and duration of the third stage were compared.

Results

A total of 600 eligible women were recruited; 150 were assigned to each group. Postpartum blood loss, prepartum and postpartum hemoglobin and hematocrit, and need for additional uterotonics were similar among groups (P > 0.05). The duration of the third stage of labor and changes in hemoglobin and hematocrit were significantly reduced in group iv-B (P < 0.05). Among women not exposed to oxytocin before delivery, postpartum blood loss was significantly lower in group iv-B (P = 0.019). Labor augmentation was related to significantly increased postpartum blood loss in all groups except iv-A.

Conclusion

Although postpartum blood loss was similar in all groups, early intravenous administration seemed to have beneficial effects.ClinicalTrials.gov: NCT01954186.     

Using Uniject to increase the use of prophylactic oxytocin for management of the third stage of labor in Latin America

Objective

To evaluate a multifaceted intervention for effectiveness in increasing the use of prophylactic oxytocin by birth attendants (obstetricians, midwives, and nurses) working in small maternity hospitals in Argentina.

Methods

A before-and-after quasi-experimental study was conducted in 5 small maternity hospitals. The study intervention consisted of training birth attendants in the active management of the third stage of labor, distributing oxytocin in Uniject (Hipofisina BIOL Uniject; Laboratorios BIOL, Buenos Aires, Argentina), and using posters as reminders. The primary outcome was the rate of prophylactic oxytocin use in the 6 months before and the 6 months of the intervention period. Secondary outcomes included use of controlled cord traction and uterine massage, and birth attendants' acceptance of the use of oxytocin in Uniject.

Results

The use of prophylactic oxytocin showed a median rate of 14.6% at baseline and 85.6% during the intervention period. 96% of birth attendants reported that the Uniject device facilitated oxytocin 1administration.

Discussion

Prophylactic oxytocin in the third stage of labor is a beneficial intervention with current low use, particularly in low- and middle-income countries. If the results shown in the present study were further replicated, this strategy could be an effective method for improving prophylactic oxytocin use in other similar Latin American hospitals.     

Reducing postpartum hemorrhage in Africa.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in sub-Saharan Africa. This is being addressed by leading professional organizations, which point to the importance of a skilled attendant at birth. But they also emphasize that the active management of the third stage of labor is proven to reduce the incidence of PPH. In low-income settings, the prostaglandin misoprostol should be considered as it is low-cost, stable at room temperature and easy to administer.     

Misoprostol and active management of the third stage of labor.

OBJECTIVE: To compare current practices for the active management of the third stage of labor (AMTSL) with the use of 600 mug of oral misoprostol. METHODS: An operations research study was designed to compare blood loss with current AMTSL practices and misoprostol use. RESULTS: Women in the misoprostol group were less likely to bleed 500 ml or more (adjusted odds ratio, 0.30; 95% confidence interval, 0.16-0.56) compared with those in the current practices group. In the current practices group 73% women required interventions because of postpartum hemorrhage, compared with 11% in the misoprostol group. CONCLUSION: In situations where oxytocin and or ergometrine are not consistently and appropriately used during third stage of labor, misoprostol should be considered for inclusion in the AMTSL protocol.     

Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study

Objective: The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH).

Methods: This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ² tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000?cc), retained placenta over 30?min and manual removal of the placenta.

Results: A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p?=?0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR?=?0.69 (95% CI 0.50–0.97; p?=?0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta.

Conclusions: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.     

Rectal misoprostol versus intravenous oxytocin for prevention of postpartum hemorrhage

Objective

To assess the effectiveness of 800 μg of rectal misoprostol compared with an intravenous infusion of 5 IU of oxytocin as prophylaxis against postpartum hemorrhage (PPH).

Methods

A total of 514 women in labor were randomized into two groups (257 women in each). Within 1 minute of delivery of the anterior shoulder participants in group 1 received 800 μg of rectal misoprostol and 1 ampoule of normal saline in 5 mL lactated Ringer solution intravenously; group 2 received a rectal placebo tablet and 5 IU of oxytocin in 5 mL lactated Ringer solution intravenously.

Results

Both groups were comparable regarding the need for uterotonics, blood transfusion, and hematocrit drop of 10% or greater, 24 hours post partum (P = 0.54, P = 0.25, and P = 0.85, respectively). Fever was significantly higher among misoprostol patients (18.7% vs 0.8%, P < 0.001).

Conclusions

Routine use of 800 μg of rectal misoprostol was effective in reducing blood loss after delivery. We recommend the regimen for low-resource, busy obstetric settings.     

Postpartum hemorrhage today: ICM/FIGO initiative 2004-2006.

Postpartum hemorrhage (PPH) is the main cause of maternal mortality. Yet, even though solutions have been identified, governments and donor countries have been slow to implement programs to contain the problem. While poverty and low educational level remain the underlying cause of PPH, the current literature suggests that active management of the third stage of labor can prevent it. The International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) are attempting to address the chronic PPH crisis by educating their members on best practices and on troubleshooting where resources are inadequate. Some studies found oxytocin to be preferable to misoprostol in settings where active management is the norm. However, secondary clinical effects may prove more troublesome with oxytocin than with misoprostol, and misoprostol may prove to be more practical and equally effective in low-resource settings. Two new interventions are also proposed, the anti-shock garment and the balloon tamponade.     

刺激乳头对产后出血的影响：（附300例分析）

本文对1992年8月至1992年12月在辽宁省彰武县正常分娩、非高危妊娠的300例产妇进行产后出血的前瞻性研究。其中200例为实验组,当胎儿前肩娩出后刺激双侧乳头以增强子宫收缩;另选条件相似的100例产妇为对照,不作任何干预,对比第三产程时间及产后2小时和产后24小时的出血量。结果证明:胎儿前肩娩出后刺激乳头能减少产后出血发生率,对照组产后出血发生率为20％,刺激乳头组产后出血发生率仅为10.51％,二组差异显著,P<0.05。此方法简便易行,适于推广应用。     

Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial

Background

Postpartum haemorrhage is one of the most important causes of maternal death.

Objectives

To evaluate the effect of active management of the third stage of labour on the amount of blood loss in the third and fourth stages of labour, and the duration of the third stage of labour.

Methods

A randomised controlled trial was completed on 200 women who gave birth at a maternity unit in Iran. In the intervention group (n=100), 10 IU of oxytocin was injected intramuscularly into the mother following birth of the anterior shoulder of the baby. After clamping and cutting the umbilical cord, the uterus was pushed upwards and posterior, while the cord was pulled down with constant and intermittent traction until the placenta was delivered. In the control group (n=100), on observing signs of placental separation, the placenta was expulsed by maternal force. In both groups of women, blood loss was measured at birth using collecting devices, and drapes and sheets were weighed to estimate blood loss.

Findings

Mean blood loss during the third stage of labour was 216.93±165.16 ml and 232.12±150.35 ml in the intervention and control groups, respectively; the difference was not significant (p=0.49). In contrast, mean blood loss during the fourth stage of labour differed significantly (422.62±324.7 ml and 327.27±255.99 ml in the intervention and control groups, respectively; p=0.02). The mean duration of the third stage of labour was less in the intervention group than in the control group (4.69±5.51 mins and 6.34±5.03 mins; p=0.028).

Conclusions

Active management did not decrease blood loss during the third stage of labour, but did decrease the duration of this stage. Active management was associated with increased blood loss during the fourth stage of labour. Due to conflicting results between studies, further research should be undertaken to determine the optimal method by which to manage the third stage of labour.     

Misoprostol in preventing postpartum hemorrhage: a meta-analysis.

OBJECTIVE: To assess misoprostol's ability to prevent postpartum hemorrhage (PPH) where no alternatives exist. Comparison to oxytocics demonstrates how similarly misoprostol achieves a level of effectiveness-obtainable only in hospitals-in remote locations around the world. METHOD: Using the Mantel-Haenszel fixed-effects model and the DerSirmonian and Laird random-effects model, summary statistics indicated that misoprostol's excess risk of PPH was only 4% when compared to oxytocics. RESULT: This risk difference was well within the range of expected results for all uterotonic agents and does not warrant branding misoprostol as an inferior drug. CONCLUSION: Conventional uterotonic drugs should not be used to set the lowest-accepted level of effectiveness in settings where they are entirely unsuitable. Continuing to weigh the benefits of one effective drug against another only delays the distribution of misoprostol in countries where it is the only feasible choice and must be measured against no treatment at all.     

A multifaceted intervention to increase prophylactic oxytocin use during the third stage of labor and to reduce routine episiotomies in Nicaragua

Objective

To assess the effect of a multifaceted intervention among skilled birth attendants on the use of oxytocin during the third stage of labor, the active management of the third stage of labor (AMTSL), and the rate of routine episiotomy during vaginal births in two health districts in Nicaragua.

Methods

An uncontrolled before-and-after study design was used. The rates of oxytocin use in the third stage of labor, AMTSL, and episiotomy were measured for vaginal births occurring in eight hospitals and health centers during 2011–2012, before and after implementation of a multifaceted facility-based intervention. The intervention involved the use of opinion leaders, interactive workshops to develop and implement evidence-based guidelines, academic detailing, the use of reminders, and feedback on the rates of oxytocin use and episiotomy.

Results

Oxytocin use during the third stage of labor increased significantly from 95.3% to 97.4% (P = 0.003). The episiotomy rate dropped significantly from 31.2% to 21.2% overall, and from 59.6% to 40.5% in primiparous women (P < 0.001 for both comparisons).

Conclusion

The multifaceted intervention improved the targeted care practices during childbirth. However, a further decrease in the routine use of episiotomy would be desirable.     

Management of the third stage of labor in an Egyptian teaching hospital.

OBJECTIVES: The study describes normal labor practices in an Egyptian teaching hospital for the first time, where postpartum hemorrhage is the leading cause of maternal mortality. Third-stage management patterns are described and compared to evidence-based medicine. Reasons for third-stage practices observed are explored. STUDY DESIGN: 176 normal births were directly observed. Women were interviewed postpartum and study findings were shared with providers. RESULTS: Third-stage active management was correctly done for 15% of women observed. Most common deviations for the remaining 85% were: giving uterotonic drugs after placental delivery (65%) and without cord traction (49%). Passive management was not done for any observed delivery. CONCLUSIONS: The preventive role actively managing the third stage can provide against postpartum hemorrhage was lost to the majority of the deliveries observed. Obstacles to adopting protocols shown to reduce hemorrhage should be explored, given the contribution of postpartum hemorrhage to maternal deaths in Egypt.