Survey of prophylactic use of uterotonics in the third stage of labour in the Netherlands

Objective

aim of this study was to investigate current knowledge and practice regarding AMTSL in midwifery practices and obstetric departments in the Netherlands.

Design

web-based and postal questionnaire.

Setting

in August and September 2011 a questionnaire was sent to all midwifery practices and all obstetric departments in the Netherlands.

Participants

all midwifery practices (528) and all obstetric departments (91) in the Netherlands.

Measurements and findings

the response was 87.5%. Administering prophylactic uterotonics was seen as a component AMTSL by virtually all respondents; 96.1% of midwives and 98.8% of obstetricians. Cord clamping was found as a component of AMTSL by 87.4% of midwives and by 88.1% of obstetricians. Uterine massage was only seen as a component of AMTSL by 10% of the midwives and 20.2% of the obstetricians. Midwifery practices routinely administer oxytocin in 60.1% of births. Obstetric departments do so in 97.6% (p<0.01). Compared to 1995, the prophylactic use of oxytocin had increased in 2011 both by midwives (10–59.1%) and by obstetricians (55–96.4%) (p<0.01).

Key conclusions

prophylactic administration of uterotonics directly after childbirth is perceived as the essential part of AMTSL. The administration of uterotonics has significantly increased in the last decade, but is not standard practice in the low-risk population supervised by midwives.

Implications for practice

the evidence for prophylactic administration of uterotonics is convincing for women who are at high risk of PPH. Regarding the lack of evidence of AMTSL to prevent PPH in low risk (home) births, further research concerning low-risk (home) births, supervised by midwives in industrialised countries is indicated. A national guideline containing best practices concerning management of the third stage of labour supervised by midwives, should be composed and implemented.     

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.     

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.     

Management of the third stage of labor

Management of the third stage of labor has been an issue of discussion, concern, and continued debate for the past two decades. Despite the many strategies employed and the divergent approaches to care and philosophies espoused, there has not been a significant, consistent reduction in the postpartum hemorrhage rates reported in industrialized countries in recent times. This article explores the strategies that have been and are currently being used in an effort to reduce the risk of postpartum hemorrhage.     

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.     

Outcomes of physiological and active third stage labour care amongst women in New Zealand

Background

during the third stage of labour there are two approaches for care provision – active management or physiological (expectant) care. The aim of this research was to describe, analyse and compare the midwifery care pathway and outcomes provided to a selected cohort of New Zealand women during the third stage of labour between the years 2004 and 2008. These women received continuity of care from a midwife Lead Maternity Carer and gave birth in a variety of birth settings (home, primary, secondary and tertiary maternity units).

Methods

retrospective aggregated clinical information was extracted from the New Zealand College of Midwives research database. Factors such as type of third stage labour care provided; estimated blood loss; rate of treatment (separate to prophylaxis) with a uterotonic; and placental condition were compared amongst women who had a spontaneous onset of labour and no further assistance during the labour and birth. The results were adjusted for age, ethnicity, parity, place of birth, length of labour and weight of the baby.

Findings

the rates of physiological third stage care (expectant) and active management within the cohort were similar (48.1% vs. 51.9%). Women who had active management had a higher risk of a blood loss of more than 500 mL, the risk was 2.761 when a woman was actively managed (95% CI: 2.441–3.122) when compared to physiological management. Women giving birth at home and in a primary unit were more likely to have physiological management. A longer labour and higher parity increased the odds of having active management. Manual removal of the placenta was more likely with active management (0.7% active management – 0.2% physiological p<0.0001). For women who were given a uterotonic drug as a treatment rather than prophylaxis a postpartum haemorrhage of more than 500 mL was twice as likely in the actively managed group compared to the physiological managed group (6.9% vs. 3.7%, RR 0.54, CI: 0.5, 0.6).

Conclusions

the use of physiological care during the third stage of labour should be considered and supported for women who are healthy and have had a spontaneous labour and birth regardless of birth place setting. Further research should determine whether the use of a uterotonic as a treatment in the first instance may be more effective than as a treatment following initial exposure prophylactically.     

A randomised trial of carbetocin versus syntometrine in the management of the third stage of labour

OBJECTIVE: Syntometrine is an effective uterotonic agent used in preventing primary postpartum haemorrhage but has adverse effects including nausea, vomiting, hypertension and coronary artery spasm. Carbetocin is a newly developed long-acting oxytocin analogue that might be used as an uterotonic agent. We compare the efficacy and safety of intramuscular (IM) carbetocin with IM syntometrine in preventing primary postpartum haemorrhage. DESIGN: Prospective, double-blinded, randomised controlled trial. SETTING: Delivery suite of a university-based obstetrics unit. POPULATION: Women with singleton pregnancy achieving vaginal delivery after and throughout 34 weeks. METHODS: Three hundred and twenty-nine eligible women were randomised to receive either a single dose of 100 microgram IM carbetocin or 1 ml IM syntometrine (a mixture of 5 iu oxytocin and 0.5 mg ergometrine) at the end of second stage of labour. MAIN OUTCOME MEASURES: Difference in haemoglobin drop measured 2 days after delivery between the two groups. RESULTS: There was no difference in the drop of haemoglobin concentration within the first 48 hours between the two groups. The incidence of additional oxytocic injections, postpartum haemorrhage (blood loss > or = 500 ml) and retained placenta were also similar. The use of carbetocin was associated with significant lower incidence of nausea (relative risk [RR] 0.18, 95% confidence interval [CI] 0.04-0.78), vomiting (RR 0.1, 95% CI 0.01-0.74), hypertension 30 minutes (0 versus 8 cases, P < 0.01) and 60 minutes (0 versus 6 cases, P < 0.05) after delivery but a higher incidence of maternal tachycardia (RR 1.68, 95% CI 1.03-3.57). CONCLUSIONS: IM carbetocin is as effective as IM syntometrine in preventing primary postpartum haemorrhage after vaginal delivery. It is less likely to induce hypertension and has a low incidence of adverse effect. It should be considered as a good alternative to conventional uterotonic agents used in managing the third stage of labour.     

Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe

Background  The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.
Objectives  The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth.
Design  Survey of policies.
Setting  The project was a European collaboration, with participants in 14 European countries.
Sample  All maternity units in 12 countries and in selected regions of two countries in Europe.
Methods  A postal questionnaire was sent to all or a defined sample of maternity units in each participating country.
Main outcome measures  Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage.
Results  Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable.
Conclusions  Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.     

A randomized comparative study of prophylactic oxytocin versus ergometrine in the third stage of labor.

OBJECTIVE: To compare the effect of prophylactic use of oxytocin and ergometrine in management of the third stage of labor. METHODS: A prospective randomized study of 600 women assigned to receive either oxytocin or ergometrine in the third stage of labor. Outcome measures were the predelivery and 48-hour postdelivery hematocrit, duration of the third stage, specific side effects, and incidence of postpartum hemorrhage. Statistical analyses were done using the t test for continuous variables and chi2 test for categorical variables. The level of significance was set at P<0.05. RESULTS: There were no significant differences between the 2 groups in maternal age, gestational age, duration of third stage, birth weights, risk for retained placenta, manual removal of placenta, or need for additional oxytocics. Patients in the ergometrine group were at significant risk for nausea, vomiting, headaches, and elevated blood pressure (P=0.0001). CONCLUSION: Oxytocin is as effective as ergometrine at reducing the incidence of postpartum hemorrhage, but without the undesirable side effects of nausea, vomiting, and elevated blood pressure associated with ergometrine.     

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.     

Comparison of sublingual misoprostol, intravenous oxytocin, and intravenous methylergometrine in active management of the third stage of labor

Objective

To compare the efficacy and adverse effects of sublingual misoprostol, intravenous oxytocin, and intravenous methylergometrine in active management of the third stage of labor (AMTSL).

Methods

A double-blind randomized trial of 300 women with a healthy singleton pregnancy allocated into 4 groups to receive either: 400 µg or 600 µg of sublingual misoprostol, 5 IU of intravenous oxytocin, or 200 µg of intravenous methylergometrine. The primary outcome measure was blood loss in the third and fourth stage of labor; secondary measures were duration of the third stage of labor, changes in hemoglobin levels, and adverse effects.

Results

Patients who received 600 µg of misoprostol had the lowest blood loss (96.05 ± 21.1 mL), followed by 400 µg of misoprostol (126.24 ± 49.3 mL), oxytocin (154.7 ± 45.7 mL), and methylergometrine (223.4 ± 73.7 mL) (P < 0.01). Shortest mean duration of the third stage of labor (5.74 minutes) was with 600 µg of misoprostol, while methylergometrine had the longest (6.83 minutes) (P < 0.05). Pyrexia was observed in the misoprostol groups, and raised blood pressure in the methylergometrine group (P < 0.001). The 24-hour postpartum hemoglobin level was similar among the groups (P > 0.05).

Conclusion

Administration of 600 µg of sublingual misoprostol was more effective than 400 µg of misoprostol, intravenous oxytocin, and intravenous methylergometrine for AMTSL.     

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.     

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.     

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.     

Afterpains: A Comparison Between Active and Expectant Management of the Third Stage of Labor

Abstract: Background: Management of the third stage of labor, the period following the birth 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, that oxytocin 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. (BIRTH 38:4 December 2011)     

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.