Intraumbilical Oxytocin for the Management of Retained Placenta: A Randomized Controlled Trial

Objective: To evaluate the ability of intraumbilical oxytocin injection as a treatment for retained placenta after vaginal delivery to reduce the incidence of manual removal and postpartum hemorrhage.Methods: A randomized controlled trial was set up in a university and a district general hospital. We recruited 81 women with singleton pregnancies who underwent vaginal delivery and who failed to deliver the placenta after 20 minutes of active management of the third stage of labor. Study subjects were randomized to receive either 1) an intraumbilical injection of oxytocin (20 IU in 20 mL of saline); 2) an intraumbilical injection of saline (20 mL); or 3) no treatment. Outcome measures were expulsion of the placenta within 45 minutes of delivery, need for manual removal of the placenta under anesthesia, and postpartum hemorrhage (defined as a blood loss greater than 500 mL).Results: Women given an intraumbilical injection of oxytocin had a significant increase in spontaneous expulsion of the placenta within 45 minutes of delivery and fewer manual removals of the placenta, compared with women without treatment (odds ratio [OR] 11.6, 99% confidence interval [CI] 1.4, 272.8; and OR 7.4, 99% CI 1.1, 86.5; respectively). When women given intraumbilical oxytocin were compared with women given only intraumbilical saline, the difference was not statistically significant (OR 6.6, 99% CI 0.9, 77.2 for spontaneous expulsion of the placenta; and OR 4.7, 99% CI 0.8, 39.5 for manual removal). There was no significant difference in the incidence of spontaneous expulsion and manual removal of the placenta between women given intraumbilical saline injection and women without treatment (OR 1.8, 99% CI 0.1, 53.9; and OR 1.6, 99% CI 0.1, 22.4; respectively).Conclusion: The results of our study suggest a clinically important beneficial effect of intraumbilical oxytocin injection in the management of retained placenta.     

Effect of intraumbilical prostaglandin F2 alpha injection on the third stage of labor.

The effect of an intraumbilical prostaglandin (PG) F2 alpha injection on the third stage of normal labor was studied in 54 normal, laboring women at term. Either 1 mg of PGF2 alpha diluted to 20 mL in normal saline (27 women) or 20 mL of normal saline alone (27 women) was injected into the umbilical vein immediately after delivery using a randomized, double-blind protocol. The mean (+/- SD) duration of the third stage was 7.31 +/- 6.37 minutes in the PGF2 alpha patients and 8.94 +/- 7.10 in the normal saline patients. Intraumbilical PGF2 alpha did not influence the third stage of normal labor.     

Oral misoprostol for third stage of labor: a randomized placebo-controlled trial.

OBJECTIVE: To investigate whether orally administered misoprostol during the third stage of labor is efficient in reducing postpartum blood loss. METHODS: In a double-masked trial, during vaginal delivery women were randomly assigned to receive a single oral dose of misoprostol (600 microg) or placebo in third stage of labor, immediately after cord clamping. The third stage of labor was managed routinely by early cord clamping and controlled cord traction; oxytocin was administered only if blood loss seemed more than usual. Blood loss was estimated by the delivering physician and differences in hematocrit were measured before and after delivery. RESULTS: Mean (+/- standard error of the mean) estimated blood loss (345 +/- 19.5 mL versus 417 +/- 25.9 mL, P = .031) and hematocrit difference (4.5 +/- 0.9% versus 7.9 +/- 1.2%, P = .014) were significantly lower in women who received misoprostol than those who received placebo. Fewer women in the misoprostol group had postpartum hemorrhage (blood loss of at least 500 mL), but that difference was not statistically significant (7% versus 15%, P = .43). Additional oxytocin before or after placental separation was used less often in the misoprostol group (16% versus 38%, P = .047). There were no differences in the length of third stage of labor (8 +/- 0.9 minutes versus 9 +/- 1 minutes, P = .947). There were no differences in pain during third stage of labor, postpartum fever, or diarrhea, but shivering was more frequent in the misoprostol group. CONCLUSION: Oral misoprostol administered in the third stage of labor reduced postpartum blood loss and might be effective in reducing incidence of postpartum hemorrhage.     

Routine oxytocin in the third stage of labour: a placebo controlled randomised trial

Objective To compare intravenous oxytocin administration (Partocon® 10 IU) with saline solution in the management of postpartum haemorrhage in the third stage of labour.
Design A double-blind, randomised controlled trial involving 1000 parturients with singleton fetuses in cephalic presentation and undergoing vaginal delivery, randomly allocated to treatment with oxytocin ( n =513) or 0.9% saline solution ( n =487).
Setting Labour ward at a central county hospital.
Main outcome measures Mean blood loss (total, and before and after placenta delivery); frequencies of blood loss > 800 mL, need of additional oxytocic treatment, postpartum haemoglobin < 10 g/dL; and duration of postpartum hospitalisation.
Results As compared with saline solution, oxytocin administration was associated with significant reduction in mean total blood loss (407 versus 527 mL), and in frequencies of postpartum haemorrhage > 800 mL (8.8% versus 15.2%), additional treatment with metylergometrine (7.8% versus 13.8%), and postpartum Hb < 10 g/dL (9.7% versus 15.2%), and a nonsignificant increase in the frequency of manual placenta removal (3.5% versus 2.3%). There was no group difference in the mean duration of postpartum hospitalisation (4.6 versus 4.5 days, respectively).
Conclusions Administration of intravenous oxytocin in the third stage of labour is associated with an approximately 22% reduction in mean blood loss, and approximately 40% reductions in frequencies of postpartum haemorrhage (> 500 mL or >800 mL) and of postpartum haemoglobin < 10 g/dL. Identification of risk groups for oxytocin treatment does not seem worthwhile. Oxytocin is a cheap atoxic drug and should be given routinely after vaginal delivery.     

A randomized comparison of umbilical vein and intravenous oxytocin during the puerperium

Oxytocin was administered in a randomized fashion via either the umbilical or maternal intravenous route. Women who received intraumbilical oxytocin had significantly greater calculated blood loss compared with those who received peripheral administration (P = .01). This greater blood loss was confirmed by a decrease in hematocrit and hemoglobin concentrations after delivery. There was no difference between the groups in the length of the third stage of labor. The incidence of fetomaternal transfusion was higher in the intraumbilical group (P = .07). We conclude that intraumbilical oxytocin is no more beneficial than peripheral administration.     

Influence of umbilical vein administration of oxytocin on the third stage of labor: a randomized, double-blind, placebo-controlled study

A randomized, double-blind, placebo-controlled study evaluated the influence of umbilical vein administration of oxytocin on the third stage of labor. Five minutes after delivery, 37 women received 10 units of oxytocin diluted in physiologic saline solution to a total volume of 20 ml; 41 women received 20 ml of saline solution alone. There was no significant difference between groups in mean (+/- SD) injection-placental expulsion interval (9 +/- 7 versus 10 +/- 8 minutes).     

Length of the third stage of labor at term pregnancies is shorter if placenta is located at fundus: prospective study

AIM: To investigate how the location of the placenta at term pregnancies affects the duration of the third stage of labor and to discuss the possible mechanisms affecting the duration of the third stage. We believe that this is the first prospective study comparing the duration of the third stage of labor according to placental location. METHODS: The placental implantation was determined as anterior (n = 78), posterior (n = 59), or fundal (n = 64) by ultrasound, in 201 women with singleton pregnancies. After delivery of the newborn, oxytocin infusion was routinely given. Duration of the third stage of labor was compared by anova. P < 0.05 was determined as significant. RESULTS: The duration of the third stage of labor was 10.36 +/- 5.94 min, 10.44 +/- 5.35 min, and 8.12 +/- 4.25 min with placentas located anteriorly, posteriorly, and fundal, respectively. The length of the third stage was significantly shorter in the fundal placenta group. CONCLUSION: In this study, the length of the third stage of labor was approximately 2 min shorter with placentas located at the fundus compared to the other two groups. The mechanism responsible for shorter duration may be the bipolar separation of fundal placentas in contrast to usual unipolar down-up separation of anterior or posterior placentas. Another contributing factor may be the use of oxytocin infusion for the management of the third stage, however this should be investigated by further studies by using real time ultrasonography.     

Effect of intraumbilical vein oxytocin injection on third stage of labor

ObjectiveManual removal of placenta is performed in 1–3% of cases, and although it is a well-established and relatively safe procedure, it is not without complications. We carried out this study to determine whether intraumbilical vein oxytocin injection reduces the need for manual removal of placenta and shortens the third stage of labor, in comparison with placebo.Materials and MethodsIn this randomized clinical trial, 178 women with singleton pregnancy and normal delivery were studied in 1 year. Immediately after fetus delivery, oxytocin infusion (20 IU/L) was started in both groups. Moreover, 10 IU oxytocin and 1 mL normal saline were injected into the umbilical vein of women in the experimental and control groups, respectively. The duration of third-stage labor, need for manual delivery of placenta, and drug side effects were evaluated in both groups. With regard to the mean level of hemoglobin before and after delivery, the two groups were compared using the Levene test and independent t test, and other qualitative variables of the two groups were compared using the χ² test.ResultsThe women who received intraumbilical vein oxytocin had a shorter third stage of labor as compared with the placebo group (4.24 ± 3.27 min vs. 10.66 ± 7.41) (p < 0.001) and there was less need for manual delivery of placenta in the experiment group (1.1% vs. 5.1%) (p = 0.024).ConclusionIt was concluded that intraumbilical vein administration of 10 IU (1 mL) oxytocin immediately after fetus delivery was clinically effective in shortening the third stage of labor.     

Treatment of a retained placenta with intraumbilical oxytocin injection

The aim of the study was to assess the effect of intraumbilical administration of oxytocin in the management of retained placenta. This prospective double-blinded clinical study included 31 mothers with retained placenta. The women were divided into three groups: group 1 (n = 19) was given 20 IU syntocinon in 20 ml 0.9% NaCl saline intraumbilically into the vein (IUV); group 2 (n = 8) received 20 ml 0.9% NaCl saline; and group 3 (n = 4) received 0.2 mg ergometrine IUV in 20 ml 0.9% NaCl saline. Intraumbilical injection was used 30-45 min after delivery, and the distal cord segment was clamped to the umbilical vein.--In group 1, placental expulsion within 60 min of IUV oxytocin injection occurred in 13 (68.4%) women; in group 2, placental expulsion was recorded in one (12.5%) woman, whereas no placental expulsion occurred in group 3 women (p < 0.001). Complications in terms of major hemorrhage were not observed in group 1, whereas a hemorrhage of > 500 ml was recorded in one group 2 and 3 woman each. Febrility developed in one woman, and abdominal pain in two women from each group. Manual lysis of the placenta was performed in seven group 1, seven group 2, and all four group 3 women. IUV oxytocin injection provides a useful and inexpensive non-surgical, non-aggressive, cheap and pharmacological method which should be included in the treatment protocol for retained placenta before turning to the procedure of manual lysis of the placenta.     

Effects of different doses of intraumbilical oxytocin on the third stage of labor

ObjectiveTo determine the optimal dose of oxytocin to be injected intraumbilically after fetal delivery for active management of the third stage of labor.MethodsA prospective randomized study was carried out with 125 primigravidas to compare the duration of the third stage of labor following the intraumbilical administration of 50 mL of a normal saline solution alone (in a control group), or with 10 IU, 20 IU, or 30 IU of oxytocin. The volumes of blood lost were also compared.ResultsCompared with the control group, the duration of the third stage of labor was significantly reduced in the 3 study groups (P < 0.001), and the maximum reduction was in the group that received 30 IU of oxytocin. Blood loss and hematocrit values followed the same pattern.ConclusionAdministering 30 IU of oxytocin intraumbilically in 50 mL of a normal saline solution after fetal delivery is a simple, noninvasive, and effective method for active management of the third stage of labor.     

Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor

The use of umbilical vein injection of oxytocin was compared with traditional management of the third stage of labor. Pregnant women were randomized to receive intravenous oxytocin after the delivery of the placenta (n = 25) or oxytocin via the umbilical vein immediately after cord clamping (n = 25). Those who received umbilical vein oxytocin had a shorter third stage of labor (4.1 versus 9.4 minutes), less measured blood loss (135 versus 373 ml), and a lower drop in hematocrit (3.9% versus 6.2%). Intraumbilical vein oxytocin appears to be a useful alternative to traditional management of the third stage of labor.     

Misoprostol for prevention of postpartum hemorrhage.

OBJECTIVE: To compare the effectiveness of 400 microg rectal misoprostol in 5 cm(3) of saline with oxytocin 10 IU, i.m., in reducing bleeding during the third stage of labor. DESIGN: A double blind, randomized, clinical trial including 663 women with uncomplicated vaginal delivery who received misoprostol (n=324) or oxytocin (n=339). MAIN OUTCOME MEASURES: Changes in hemoglobin and hematocrit from before to 72 h postpartum; blood loss during the third stage; duration of the third stage of labor; need for additional oxytocic drug; frequency of requisition and of administration of blood; changes in blood pressure; and occurrence of side effects. RESULTS: No significant differences were observed between groups, before and 72 h postpartum, in mean hemoglobin and hematocrit, on volume of blood loss and duration of third stage of labor. The incidence of shivering and mean temperature (P<0.01) was significantly greater among women receiving misoprostol than oxytocin. CONCLUSIONS: Misoprostol administered as a micro-enema, 400 microg in 5 ml of saline during the third stage of labor, appears to be as effective as oxytocin 10 IU, i.m., but misoprostol produced more side effects than oxytocin.     

A randomized comparison of oxytocin, sulprostone and placebo in the management of the third stage of labour

OBJECTIVE--To compare the effect on post partum bloodloss of the postpartum prophylactic administration of oxytocin or sulprostone in low risk women having an expectant management of the third stage. DESIGN--Randomized, placebo controlled, double-blind trial. SETTING--Radboud University Hospital, Nijmegen (67 women) and Lievensberg Hospital, Bergen op Zoom (10 women). PARTICIPANTS--77 women entered the trial (three were excluded). INTERVENTIONS--The intramuscular injection, immediately after the birth of the baby, of either oxytocin 5 IU, sulprostone 500 micrograms or 0.9% saline. MAIN OUTCOME MEASURES--Quantitative postpartum blood loss and length of third stage. RESULTS--Postpartum blood loss was reduced almost equally, by about 35%, by oxytocin (P = 0.02), or sulprostone (P = 0.05). The mean length of the third stage was shorter in both groups receiving the active treatment, this effect was significant in the sulprostone group (P = 0.01). CONCLUSION--Prophylactic administration of oxytocin or sulprostone directly after delivery followed by expectant management of the third stage reduces post partum blood loss and shortens the third stage.     

Oxytocin or saline injected intra-umbilically did not influence the third stage of labor.

The injection of varying volumes of normal saline solution, alone or with oxytocin, into the umbilical vein immediately after delivery was studied in 125 normal women delivered at term. Thirty seconds after cord clamping, either 20 ml (group 1, n = 25 women), 30 ml (group 2, n = 25) or 40 ml (group 3, n = 25) of normal saline solution alone, or oxytocin 10 units in 20 ml saline solution (group 4, n = 25) or oxytocin 10 units in 40 ml saline solution (group 5, n = 25) were injected into the umbilical vein 1 cm from the introitus just proximal to the umbilical clamp. The mean (+/- SD) duration of placental expulsion was similar in the five study groups. We conclude that neither the volume of the solution nor the oxytocin injected intra-umbilically has any effect on the duration of the third stage of normal labor.     

Maternal hemodynamics after oxytocin bolus compared with infusion in the third stage of labor: a randomized controlled trial

OBJECTIVE: To assess the effects of oxytocin bolus or infusion on maternal hemodynamics in the third stage of labor. METHODS: In a randomized, double-blind, double-dummy fashion, 99 women received an intravenous oxytocin bolus (10 IU push) and 102 women received an infusion (10 IU in 500 mL saline at 125 mL/h) at delivery of the anterior shoulder. Mean arterial pressure and heart rate were measured every minute for 10 minutes, then every 5 minutes for the next 20 minutes. These serial measurements were analyzed using a 2-factor analysis of variance for repeated measures. RESULTS: Serial mean arterial pressure measures varied significantly between groups (interaction effect, P = .002). Mean arterial pressure (+/- standard deviation) nadirs were reached after 10 minutes, 80.9 (+/- 11.0) mm Hg in the bolus group compared with 77.0 (+/- 12.1) mm Hg in the dilute infusion group. The mean difference (95% confidence interval) between groups was 4.0 (0.7-7.2) mm Hg. Serial heart rate measures also varied between groups (interaction effect, P < .001). Mean heart rate (+/- standard deviation) peaked 1 minute after the oxytocin infusion, 115 (+/- 27) beats per minute (bpm) in the bolus group compared with 109 (+/- 21) bpm in the dilute infusion group. The mean difference (95% confidence interval) between groups was 6.6 bpm (-0.1 to 13.3). The dilute oxytocin infusion group experienced a greater mean estimated blood loss (423.7 mL compared with 358.1 mL, P = .029, t test), increased use of additional oxytocics (35.3% compared with 22.2%, P = .044, Fisher exact test) and a greater drop in hemoglobin (admission minus postpartum) (17.4g/L compared with 11.4g/L, P = .002, t test) compared with the oxytocin bolus group. CONCLUSION: Bolus oxytocin of 10 IU is not associated with adverse hemodynamic responses and can safely be administered to women with intravenous access in the third stage of labor for postpartum hemorrhage prophylaxis. LEVEL OF EVIDENCE: I.     

Prevention of postpartum hemorrhage by uterotonic agents: comparison of oxytocin and methylergometrine in the management of the third stage of labor

OBJECTIVES: To determine the efficacy of intravenous oxytocin administration compared with intravenous methylergometrine administration for the prevention of postpartum hemorrhage (PPH), and the significance of administration at the end of the second stage of labor compared with that after the third stage. METHODS: A prospective study was undertaken: two major groups (oxytocin group and methylergometrine group) of 438 women with singleton pregnancy and vaginal delivery were studied during a 15-month period. These two groups were subdivided into three subgroups: 1. intravenous injection (two minutes) group immediately after the delivery of the fetal anterior shoulder, 2. intravenous injection (two minutes) group immediately after the delivery of the placenta, and 3. drip infusion (20 min) group immediately after the delivery of the fetal head. In each group, quantitative postpartum blood loss, frequencies of blood loss >500 ml, and need of additional uterotonic treatment were evaluated. RESULTS: As compared with methylergometrine, oxytocin administration was associated with a significant reduction in postpartum blood loss and in frequency of blood loss >500 ml. The risk of PPH was significantly reduced with intravenous injection of oxytocin after delivery of the fetal anterior shoulder, compared with intravenous injection of oxytocin after expulsion of the placenta (OR 0.33, 95%CI 0.11-0.98) and intravenous injection of methylergometrine after delivery of the fetal anterior shoulder (OR 0.31, 95%CI 0.11-0.85). CONCLUSIONS: Intravenous injection of 5 IU oxytocin immediately after delivery of fetal anterior shoulder is the treatment of choice for prevention of PPH in patients with natural course of labor.     

Intra-amniotic injection of oxytetracycline hydrochloride for termination of mid-trimester pregnancy

Seventy-eight women underwent induced mid-trimester abortion. Fifty-two women aborted after an intra-amniotic injection of 1 g oxytetracycline hydrochloride. The control group comprised 16 women who received an intra-amniotic injection of hypertonic saline and 9 women with prostaglandin F2 alpha. All but 2 women aborted after one injection. Thirty-five women of the oxytetracycline hydrochloride group received intravenous oxytocin after the appearance of uterine contractions, 17 did not. The mean injection abortion interval in the women who received intravenous oxytocin was 38.6 +/- 2.7 h, whereas in the group without oxytocin it was 31.3 +/- 2.3 h. There is no statistically significant difference between these two groups (p less than 0.2). The mean injection abortion interval in the hypertonic saline group was 18.4 +/- 2.2 h. In the F2 alpha group it was 13.2 +/- 1.3 h. There is no statistically significant difference between hypertonic saline and prostaglandins (p less than 0.2). The mean injection abortion interval is significantly shorter in the F2 alpha and hypertonic saline groups as compared to the oxytetracycline hydrochloride group (p less than 0.001). It is advisable therefore to use oxytetracycline hydrochloride only in cases when the use of F2 alpha or hypertonic saline is contraindicated.     

Rectal Misoprostol Versus Oxytocin in the Management of the Third Stage of Labour

ObjectiveTo compare the effect of rectal misoprostol with intramuscular oxytocin in the routine management of the third stage in a rural developing country.MethodsA randomized controlled trial was performed at two district hospitals in Ghana, West Africa. Four hundred fifty women in advanced labour were enrolled. The only exclusion criterion was a known medical contraindication to prostaglandin administration. Women were randomized to receive rectal misoprostol 800 μg or intramuscular oxytocin 10 IU with delivery of the anterior shoulder. The main outcome measure was change in hemoglobin concentration from before to after delivery. Secondary outcomes included the need for additional uterotonics, estimated blood loss, transfusion, and medication side effects.ResultsDemographic characteristics were similar in each treatment group. There was no significant difference between treatment groups in change in hemoglobin (misoprostol 1.19 g/dL and oxytocin 1.16 g/dL; relative difference 2.6%; 95% confidence intervals [CI]-16.8% to 19.4%; P = 0.80). The only significant secondary outcome was shivering, which was more common in the misoprostol group (misoprostol 7.5% vs. oxytocin 0.9%; relative risk 8.0; 95% CI 1.86—34.36; P = 0.001).ConclusionRectal misoprostol 800 μg is as effective as 10 IU intramuscular oxytocin in minimizing blood loss in the third stage of labour. Rectal misoprostol has a lower incidence of side effects than the equivalent oral dose. This confirms the utility of misoprostol as a safe and effective uterotonic for use in the rural and remote areas of developing nations where other pharmacologic agents may be less feasible.     

Uterine electric activity during the third stage of labor; a look into the physiology of a deserted stage

Abstract

Objective: To evaluate uterine activity during the third stage of labor and compare it to that observed in the second stage of labor.

Study design: Uterine electric activity was prospectively measured using electrical uterine myography (EUM) in 44 women with singleton pregnancy at term during the final 30?min of the second stage and throughout the third stage of labor. Results are reported using a scoring index of 1–5?mWS (micro-Watt-Second). Patients were stratified into two groups based on the duration of the third stage (<15?min and >=15?min)

Results: The mean durations of the second and third stages were 51.9?±?63.5 and 15.4?±?7.5?minutes, respectively. During the third stage, uterine activity (contractions peaks) was similar to that observed during the second stage of labor (3.43?±?0.64?mWS versus 3.42?±?0.57?mWS, p?=?0.8). No correlation was found between the duration of the third stage and EUM measurements during the third (p?=?0.9) or the second (p?=?0.2) stages of labor. No association was found between EUM measurements during the third stage and parity, maternal age, fetal weight, duration of labor, gestational age, gravity or BMI. The rate of oxytocin use during the second stage and EUM measurements during the second or third stage did not differ among women with short versus long duration of the third stage.

Conclusion: Uterine activity during the third stage is comparable and as intense as that occurring during the second stage. Third stage length cannot be predicted by contraction intensity during the second or third stage of labor.     

Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor

AIM: To assess the effectiveness of oral misoprostol compared with methylergometrine in the prevention of primary post-partum hemorrhage during the third stage of labor. METHODS: This was a randomized controlled trial of 864 singleton low-risk pregnant women. The outcomes were total blood loss, duration of the third stage of labor and peripartal change in hematocrit. Comparisons were by the chi2-test and Student t-test. Relative risks were calculated for side-effects profile. A P-value of less than 0.05 was statistically significant. RESULTS: The biodata of all the participants were similar. The mean blood loss for the misoprostol and methylergometrine groups was 191.6 +/- 134.5 mL and 246.0 +/- 175.5 mL, respectively (95% CI: -79.3 to -39.5 mL). The mean duration of the third stage of labor was 19.6 +/- 2.4 min and 9.4 +/- 3.3 min in the misoprostol and methylergometrine groups, respectively (95% CI: 9.82-10.58 min). More subjects had blood loss >500 mL, 42 (9.7%) versus 6 (1.4%), and peripartal hematocrit change greater than 10%, 38 (8.8%) versus 5 (1.2%), in the methylergometrine group than in the misoprostol group, respectively. Also, more subjects received additional oxytocic in the methylergometrine group, compared to the misoprostol group (80 [18.5%] versus 33 [7.6%] patients, respectively). CONCLUSIONS: Orally administered misoprostol was more effective in reducing blood loss during the third stage of labor than intramuscular methylergometrine. However, there were more subjects in the misoprostol group in whom duration of the third stage of labor was greater than 15 min and who also had manual placental removal than in the methylergometrine group.