Third stage of labor: analysis of duration and clinical practice

Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes

The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.

Severe maternal morbidity following stillbirth in Western Australia 2000-2015: a population-based study

PURPOSE

There is scant literature about the management of stillbirth and the subsequent risk of severe maternal morbidity (SMM). We aimed to assess the risk of SMM associated with stillbirths compared with live births and whether this differed by the presence of maternal comorbidities.

METHODS

In this retrospective cohort study, we used a population-based dataset of all stillbirths and live births ≥ 20 weeks' gestation in Western Australia between 2000 and 2015. SMM was identified using a published Australian composite for use with routinely collected hospital morbidity data. Maternal comorbidities were identified in the Hospital Morbidity Data Collection or the Midwives Notification System using a modified Australian chronic disease composite. Multivariable Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with SMM in analyses stratified by the presence of maternal comorbidities. Singleton and multiple pregnancies were examined separately.

RESULTS

This study included 458,639 singleton births (2319 stillbirths and 456,320 live births). The adjusted RRs for SMM among stillbirths were 2.30 (95% CI 1.77, 3.00) for those without comorbidities and 4.80 (95% CI 4.11, 5.59) (Interaction P value < 0.0001) for those with comorbidities compared to live births without and with comorbidities, respectively.

CONCLUSION

In Western Australia between 2000 and 2015, mothers of stillbirths both with and without any maternal comorbidities had an increased risk of SMM compared with live births. Further investigation into why women who have had a stillbirth without any existing conditions or pregnancy complications develop SMM is warranted.

Duration of third stage labour and postpartum blood loss: a secondary analysis of the WHO CHAMPION trial data

Background

Obstetric haemorrhage continues to be a leading cause of maternal mortality, contributing to more than a quarter of the 2,443,000 maternal deaths reported between 2003 and 2009. During this period, about 70% of the haemorrhagic deaths occurred postpartum. In addition to other identifiable risk factors for greater postpartum blood loss, the duration of the third stage of labour (TSL) seems to be important, as literature shows that a longer TSL can be associated with more blood loss. To better describe the association between the duration of TSL and postpartum blood loss in women receiving active management of third stage of labour (AMTSL), this secondary analysis of the WHO CHAMPION trial data has been conducted.

Methods

This was a secondary analysis of the WHO CHAMPION trial conducted in twenty-three sites in ten countries. We studied the association between the TSL duration and blood loss in the sub cohort of women from the CHAMPION trial (all of whom received AMTSL), with TSL upto 60 min and no interventions for postpartum haemorrhage. We used a general linear model to fit blood loss as a function of TSL duration on the log scale, arm and center, using a normal distribution and the log link function. We showed this association separately for oxytocin and for Heat stable (HS) carbetocin.

Results

For the 10,040 women analysed, blood loss rose steeply with third stage duration in the first 10 min, but more slowly after 10 min. This trend was observed for both Oxytocin and HS carbetocin and the difference in the trends for both drugs was not statistically significant (p-value = 0.2070).

Conclusions

There was a positive association between postpartum blood loss and TSL duration with either uterotonic. Blood loss rose steeply with TSL duration until 10 min, and more slowly after 10 min.

Study registration The main trial was registered with Australian New Zealand Clinical Trials Registry ACTRN12614000870651 and Clinical Trial Registry of India CTRI/2016/05/006969

The duration of the third stage of labour (TSL) seems to be an important risk factor for greater postpartum blood loss, as literature shows that a longer TSL can be associated with more blood loss. Active management of third stage of labour (AMTSL), included in the WHO guidelines for prevention of postpartum haemorrhage (PPH), is effective in reducing both the amount of postpartum blood loss and the duration of the third stage. To better describe the association between duration of TSL and postpartum blood loss in women receiving AMTSL, we conducted this secondary analysis of WHO CHAMPION trial data.

To assess the association between the duration of third stage of labour and postpartum blood loss, a subcohort of the CHAMPION modified ITT population was selected by excluding women with missing blood loss or missing TSL duration or TSL duration more than 60 min and women with interventions. Thus, the subcohort consisted of 10,040 women.

In women with vaginal birth and not receiving interventions for treating atonic PPH or other sources of bleeding, and with TSL duration up to 60 min, there was a positive association between duration of the TSL and postpartum blood loss. The blood loss rose steeply with duration in women with TSL of 10 min or less, while in women with longer TSL duration the slope was less steep.

There was no evidence of a difference between oxytocin and HS carbetocin in the pattern of association of duration of the TSL and blood loss.

Minimally invasive management of retained products of conception and the adherent placenta

PURPOSE OF REVIEW

Retained products of conception (POC) may occur independently or as a consequence of placenta accreta spectrum (PAS). Managing these conditions depends on the clinical scenario, and in some cases, can involve the use of minimally invasive techniques. This review presents the role of hysteroscopy and laparoscopy in the treatment of retained POC and the adherent placenta.

RECENT FINDINGS

Hysteroscopic resection of retained POC is reported to have favorable outcomes compared to blind dilation and curettage, including higher success rates and a lower risk of intrauterine adhesion formation. Hysteroscopic and laparoscopic techniques for managing PAS are limited to select cases where uterine preservation is desired, or a laparoscopic gravid or postpartum delayed hysterectomy is feasible. Data on these methods are limited to case reports.

SUMMARY

A hysteroscopic approach is preferred over dilation and curettage for retained POC. Minimally invasive surgery may have a role in unique cases of PAS.

Risk factors for non-adherent retained placenta after vaginal delivery: a systematic review

Background

Retained placenta represents a cause of maternal morbidity and mortality affecting 0.5–3% of all vaginal deliveries. The unpredictability of this condition makes difficult to develop predictive and preventive strategies to apply in clinical practice. This analysis collected and analyzed all known risk factors related to this obstetric complication.

Methods

A systematic literature review for all original research articles published between 1990 and 2020 was performed. Observational studies about retained placenta risk factors published in English language were considered eligible. Conference abstracts, untraceable articles and studies focused on morbidly adherent placenta were excluded. The included articles were screened to identify study design, number of enrolled patients and retained placenta risk factors investigated. All stages of the revision followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.

Results

Thirty-five studies met the inclusion criteria. The reported retained placenta prevalence ranged from 0.5 to 4.8%. Maternal age, previous cesarean sections, previous dilation and curettage, previous retained placenta, labor induction, resulted as the most recurrent, independent risk factors for retained placenta. Previous estro-progestins therapy, morphological placental features (weight, shape, insertion of umbilical cord, implantation site), endometriosis, Assisted Reproductive Technologies, Apgar score are fascinating new proposal risk factors.

Conclusions

Old and new data are not enough robust to draw firm conclusions. Prospective and well-designed studies, based on a well agreed internationally retained placenta definition, are needed in order to clarify this potential dramatic and life-threatening condition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03721-9.

Retained placenta and postpartum hemorrhage: time is not everything

PURPOSE

Postpartum hemorrhage is the major cause of maternal mortality worldwide. Retained placenta accounts for nearly 20% of severe cases. We investigated the influence of the time factor and retained placenta etiology on postpartum hemorrhage dynamics.

METHODS

Our retrospective study analyzed a single-center cohort of 296 women with retained placenta. Blood loss was measured using a validated and accurate technique based on calibrated blood collection bags, backed by the post- vs pre-partum decrease in hemoglobin. We evaluated the relationship between these two blood loss parameters and the duration of the third stage of labor using Spearman rank correlation, followed by subgroup analysis stratified by third stage duration and retained placenta etiology.

RESULTS

Correlation analysis revealed no association between third stage duration and measured blood loss or decrease in hemoglobin. A shorter third stage (< 60 min) was associated with significantly increased uterine atony (p = 0.001) and need for blood transfusion (p = 0.006). Uterine atony was significantly associated with greater decrease in hemoglobin (p < 0.001), higher measured blood loss (p < 0.001), postpartum hemorrhage (p = 0.048), and need for blood transfusion (p < 0.001).

CONCLUSION

Postpartum blood loss does not correlate with third stage duration in women with retained placenta. Our results suggest that there is neither a safe time window preceding postpartum hemorrhage, nor justification for an early cut-off for manual removal of the placenta. The prompt detection of uterine atony and immediate prerequisites for manual removal of the placenta are key factors in the management of postpartum hemorrhage.

Criteria for low von Willebrand factor diagnosis and risk score to predict future bleeding

BACKGROUND

Important diagnostic and clinical aspects of moderately reduced von Willebrand factor (VWF) levels are still unknown. There is no clear evidence which cutoff value (0.50 vs 0.60 IU/ml) should be used to diagnose "low VWF." Also, the incidence of bleeding after the diagnosis has been made, and risk factors for bleeding are unknown yet.

OBJECTIVES

To investigate the incidence of postsurgical bleeding, postpartum hemorrhage (PPH), and traumatic and spontaneous bleeding after low VWF diagnosis, and to develop a risk score to predict future bleeding.

METHODS

We performed a cohort study in patients with historically lowest VWF levels of 0.31 to 0.60 IU/ml. Clinical data of patients were retrospectively collected.

RESULTS

We included 439 patients with low VWF. During a follow-up of 6.3 ± 3.7 years, 259 surgical procedures, 81 deliveries, and 109 spontaneous and traumatic bleeding episodes were reported. The incidence of postsurgical bleeding was 2.7%, whereas 10% of deliveries was complicated by PPH. Overall, 65 patients (14.8%) had bleeding requiring treatment, which was not different between patients with historically lowest VWF levels of 0.31-0.50 and 0.51-0.60 IU/ml (p = .154). Age <18 years, abnormal bleeding score at diagnosis, and being referred for bleeding symptoms at the time of diagnosis were independent risk factors for bleeding during follow-up, and therefore included in the risk score.

CONCLUSIONS

The cutoff value of low VWF diagnosis should be set at 0.60 IU/ml. Furthermore, a risk score is developed to identify individuals with a high risk for bleeding after low VWF diagnosis.

First trimester serum PAPP-A is associated with placenta accreta: a retrospective study

PURPOSE

Our objective of this study was to investigate whether first trimester serum pregnancy-associated plasma protein-A (PAPP-A) differed amongst pregnancies with placenta previa-accreta and non-adherent placenta previa and healthy pregnancies by a retrospective cohort analysis.

METHODS

A total of 177 pregnant females were included in the study, as follows: 35 cases of placenta previa-accreta, 30 cases of non-adherent placenta previa, and 112 cases of BMI and age matched, healthy pregnant controls. PAPP-A multiples of the median (MoM) were acquired from laboratory data files in 1 January 2017-30 September 2019. The probable maternal serum biochemical predictor of placenta accreta was analyzed by using multiple logistic regression analysis.

RESULTS

PAPP-A MoM of placenta previa-accreta group was significantly higher than those of the non-adherent placenta previa group and control group (p = 0.009 < 0.05, p < 0.001). Serum PAPP-A was found to be significantly positively associated with placenta accreta after adjusted gestational week at time of blood sampling, BMI, age, smoking, and previous cesarean section history (OR: 3.51; 95% CI: 1.77-6.94; p = 0.0003 < 0.05). In addition, smoking (OR: 9.17; 95% CI: 1.69-49.62; p = 0.010 < 0.05) and previous cesarean section history (OR: 2.75; 95% CI: 1.23-6.17; p = 0.014 < 0.05) were also significantly associated with placenta accreta.

CONCLUSION

Increased first trimester serum PAPP-A was significantly positively associated with placenta accreta, suggesting that the potential role of PAPP-A in identifying pregnancies at high risk for placenta accreta. Smoking and previous cesarean section history may be the risk factors for accreta in placenta previa patients.

First trimester serum PIGF is associated with placenta accreta

OBJECTIVES

In this retrospective study, we investigated whether first trimester serum placental growth factor (PIGF) differed amongst pregnancies with placenta previa-accreta and non-adherent placenta previa and healthy pregnancies.

METHODS

In 1 January 2017-30 September 2019, a total of 177 pregnant females were included in the study, as follows: 35 cases of placenta previa-accreta, 30 cases of non-adherent placenta previa, and 112 cases of age and BMI-matched, healthy pregnant controls. PIGF multiples of the median (MoM) were acquired from laboratory data files. The predictor of placenta accreta was analyzed by using multiple logistic regression analysis.

RESULTS

PIGF MoM of placenta previa-accreta group was significantly higher than those of the non-adherent placenta previa group and control group (p = 0.0098 < 0.01, p = 0.0002 < 0.01). Serum PIGF was found to be significantly positively associated with placenta accreta after adjusted gestational week at time of blood sampling, BMI, and age (OR: 4.83; 95% CI: 1.91-12.24；p = 0.0009 < 0.01). In addition, previous cesarean section history (OR: 2.75; 95% CI: 1.23-6.17; p = 0.014 < 0.05) and smoking (OR: 9.17; 95% CI: 1.69-49.62; p = 0.010 < 0.05) were also significantly associated with placenta accreta.

CONCLUSION

Increased first trimester serum PIGF was significantly positively associated with placenta accreta, suggesting that the potential role of PIGF in identifying pregnancies at high risk for placenta accreta. Previous cesarean section history and smoking may be the risk factors for accreta in placenta previa patients.

Duration of the Third Stage of Labor and Estimated Blood Loss in Twin Vaginal Deliveries

Objective  The main aim of this study was to characterize the duration of the third stage of labor and estimated blood loss in twin vaginal deliveries. Study Design  This was a retrospective case-control study. The data was collected from deliveries at the University of Arkansas for Medical Sciences in Little Rock, Arkansas, from January 2013 to June 2017. Women were identified who had twin gestation, were delivered vaginally, and whose maternal age was greater than 18 years old. Women were excluded if they had an intrauterine fetal demise, delivered either/both fetuses via cesarean, history of a previous cesarean or a fetus with a congenital anomaly. If a subject met criteria to be included in the study, the next normal singleton vaginal delivery was used as the control subject. Results  There were 132 singleton vaginal deliveries and 133 twin vaginal deliveries analyzed. There was no significant difference in the length of the third stage of labor between twin and singleton vaginal deliveries except in the 95th percentile of the distribution. Mothers delivering twins had an increase in third-stage duration by 7.618 minutes (95% confidence interval [CI]: 0.73, 14.50; p  = 0.03) compared with those who delivered singletons. The twin group had a higher estimated blood loss than singleton deliveries. The increase in blood loss in the twin group was 149.02 mL (95% CI: 100.2, 197.8), 257.01 mL (95% CI: 117.9, 396.1), and 381.53 mL (95% CI: 201.1, 562.1) at the 50th, 90th, and 95th percentiles, respectively. When the third stage of labor was at the 90th percentile or less in twin pregnancy (14 minutes), estimated blood loss was less than 1000 mL. Conclusion  Twin pregnancy is a known risk factor for postpartum hemorrhage. As the duration of the third stage prolongs, the risk for hemorrhage also increases. We recommend delivery of the placenta in twin pregnancies by 15 minutes to reduce this risk. Key Points The third stage is longer in twin pregnancy at extremes.Twin placentas should be delivered by 15 minutes.Manually extract the placenta when third stage is prolonged.

The duration of the third stage in relation to postpartum hemorrhage

INTRODUCTION

In this study, we describe the distribution of placenta delivery and the incidence of postpartum hemorrhage in both spontaneous placental delivery and manual removal of the placenta.

METHODS

A retrospective study was performed of 7603 singleton vaginal deliveries of a gestational age over 32 weeks, registered between September 2011 and 2016. We calculated the incidence of postpartum hemorrhage (≥1000 mL blood loss) per 10-minute duration of the third stage. The odds ratio for developing postpartum hemorrhage was assessed, adjusted for risk factors. The incidence of postpartum hemorrhage was compared between women that did and did not receive manual removal of placenta.

RESULTS

The median duration of the third stage was 10 minutes (interquartile range 7-16 minutes). The median amount of blood loss was 300 mL (200-400 mL). The overall incidence of postpartum hemorrhage was 8.5%. With every additional 10 minutes of third-stage duration, the risk of developing postpartum hemorrhage significantly increased. In a third stage longer than 60 minutes, the incidence of postpartum hemorrhage was 21.2% without manual removal of the placenta and 70.3% with manual removal.

CONCLUSIONS

The incidence of postpartum hemorrhage increases significantly from 10 to 19 minutes into the third stage. Women with the removal of the placenta had a significantly higher percentage of postpartum hemorrhage. The optimal timing for manual removal of the placenta should be investigated in a carefully designed randomized controlled trial to examine whether earlier manual removal of placenta lowers the incidence and limits the severity of postpartum hemorrhage.

Third stage of labor placental complications and placenta-associated syndromes

OBJECTIVE

To evaluate the association between third stage placental complications and placental insufficiency associated disorders, also known as, placenta associated syndromes.

STUDY DESIGN

A population-based retrospective cohort study comparing placental-related perinatal outcomes of parturient with (study group) and without third stage placental complications, defined as a composite of retained placenta, adherent placenta, placenta accrete, need for manual removal of the placenta, postpartum curettage and revision of the uterine cavity. A univariate analysis was followed by a multivariable logistic regression model.

RESULTS

During the study period, 263,023 deliveries met inclusion criteria, of which, 10,281 (3.9%) experienced placental complications during the third stage of labor. Parturient in the study group had significantly higher rates of placental insufficiency associated disorders which included among others: hypertensive disorders of pregnancy (6.5 versus 5.6%, p < .001), stillbirth (1.9 versus 0.7%, p < .001) and preterm delivery (9.9 versus 7.7%, p < .001). Using a multivariable regression model, while controlling for confounders such as maternal age and induction of labor, third stage placental complications were independently associated with placental insufficiency associated disorders.

CONCLUSION

Our findings suggest that placental associated adverse pregnancy outcomes and third stage placental complications may represent different manifestations of a common pathological or inadequate placentation process.

Retained placenta after vaginal delivery: risk factors and management

Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18–60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.

Manual removal of placenta in women having unpredictable adherent placenta

AIM

Our aim is to provide expected outcomes for undergoing manual removal of placenta (MROP) following vaginal delivery in women having an unpredictable adherent placenta (AP).

METHODS

The data were obtained from four hospitals in Miyazaki Prefecture, Japan. We used propensity score-matched (1:1) analysis to match women who underwent MROP with women who did not undergo MROP (control). Total blood loss and hemorrhagic rate used as a ratio of women who reached a certain amount of blood loss were compared. Subgroup analysis was undertaken and was dependent on the presence of AP. We found the cut-off value of blood loss for detecting AP.

RESULTS

Thirty-seven MROP cases were identified. Total blood loss and hemorrhagic rate differed significantly between MROP cases and controls; 95% of controls had blood loss of 1000 mL or less, whereas for the MROP cases, it was 14%. Fourteen MROP cases were diagnosed with AP. The hemorrhagic rate differed significantly between MROP cases with and without AP (n = 19); 79% of MROP cases without AP had blood loss of 2000 mL or less, whereas for the MROP cases with AP, it was 7%. There were seven incidents of hysterectomy and two of arterial embolization in MROP cases with AP. Through receiver operating characteristic curve analysis, 2035 mL of blood loss was determined to be the optimal cut-off value for detecting AP.

CONCLUSION

The incidence of unpredictable AP in MROP cases was as high as 38%. The morbidity of MROP cases with unpredictable AP was severe. MROP should be prohibited in the absence of appropriate hemostatic preparations.

Does fetal sex affect placental delivery times? A prospective observational study

Objective: The aim of this study was to determine the potential effect of fetal sex on placental delivery times.Study design: This was a prospective observational study of term, singleton, and primiparous pregnant women who underwent vaginal delivery and subsequently delivered a phenotypically normal live infant. Women with labor or pregnancy complications and comorbid diseases were excluded. Women with factors who could lengthen the placental delivery time were also excluded. The cohort was divided into two groups according to fetal sex. A total of 299 vaginal deliveries were included, and placental delivery times were analyzed in both groups.Results: There were 3938 vaginal deliveries during the study period. Of these, 150 male-bearing pregnant women and 149 female-bearing pregnant women who met the inclusion criteria were included in the analysis. The mean placental delivery time was significantly longer in the male-bearing group than the female-bearing group (12.20 versus 8.21 min, p = .01). Birth weight was significantly greater in the male-bearing group than the female-bearing group (3194 versus 3059 g, p = .004). There was no significant between-group difference in maternal age, gestational age, and preconception body mass index (BMI).Conclusion: Fetal sex had a significant effect on the placental delivery time in the present study. Fetal sex should be considered in future clinical trials of placental delivery times.

Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.

Timing of manual placenta removal to prevent postpartum hemorrhage: is it time to act?

OBJECTIVE

The length of the third stage of labor is an important risk factor for postpartum hemorrhage (PPH). Current practice recommends manual placenta removal, if not delivered spontaneously, within 30 min. The review reexamines the evidence to determine the optimal length of the third stage of labor.

METHODS

A MEDLINE search that associated the length of the third stage of labor with the risk of PPH was undertaken.

RESULTS

A retrospective cohort study revealed the risk of a PPH became significant at 10 min (odds ratio = 2.1, 95% confidence interval: 1.6-2.6), and had doubled by 20 min (odds ratio = 4.3, 95% confidence interval: 3.3-5.5). A receiver operator curve determined the optimal length of the third stage of labor to prevent PPH was 18 min. A follow up randomized controlled trial showed that hemodynamic compromise secondary to a PPH can be reduced with manual placenta removal at 10 compared to 15 min (6.4 versus 19.2%, p = 0.001).

CONCLUSION

The time interval of 15 min may be a more appropriate time interval to recommend placental removal to prevent PPH.

How Long Is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study

OBJECTIVE

The aim of our study was to determine the optimal time for manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion. Risk factors for postpartum blood transfusions were studied.

METHODS

Computerized data of all vaginal deliveries at our labor and delivery unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation up to 60 minutes into the third stage of labor were extracted for analysis. Patient demographics, obstetrical history, delivery course, and outcome were assessed as well as blood product requirements during the postpartum period. Receiver-operating curves (ROC) for prediction of blood transfusion during the third stage were calculated and risk factors were assessed.

RESULTS

31,226 vaginal deliveries occurred during the study period and 28,586 deliveries culminated with complete and spontaneous placental separation, 25,160 of which met inclusion criteria. Independent risk factors for blood transfusions were primiparity, longer second and third stage length, labor induction, and maternal intrapartum fever. ROC curves showed that the optimal cutoff for the prediction of blood transfusions was 17 minutes into the third stage of labor. Waiting more than 30 minutes for placental separation increases the risk for blood transfusion more than threefold.

CONCLUSIONS

A third stage longer than 17 minutes is associated with an increased risk for blood transfusion postpartum. After more than 30 minutes, the risk for blood transfusions increases more than threefold.

Dynamic Changes in the Myometrium during the Third Stage of Labor, Evaluated Using Two-Dimensional Ultrasound, in Women with Normal and Abnormal Third Stage of Labor and in Women with Obstetric Complications

OBJECTIVE

To investigate dynamic changes in myometrial thickness during the third stage of labor.

METHODS

Myometrial thickness was measured using ultrasound at one-minute time intervals during the third stage of labor in the mid-region of the upper and lower uterine segments in 151 patients including: women with a long third stage of labor (n = 30), postpartum hemorrhage (n = 4), preterm delivery (n = 7) and clinical chorioamnionitis (n = 4). Differences between myometrial thickness of the uterine segments and as a function of time were evaluated.

RESULTS

There was a significant linear increase in the mean myometrial thickness of the upper uterine segments, as well as a significant linear decrease in the mean myometrial thickness of the lower uterine segments until the expulsion of the placenta (p < 0.001). The ratio of the measurements of the upper to the lower uterine segments increased significantly as a function of time (p < 0.0001). In women with postpartum hemorrhage, preterm delivery, and clinical chorioamnionitis, an uncoordinated pattern among the uterine segments was observed.

CONCLUSION

A well-coordinated activity between the upper and lower uterine segments is demonstrated in normal placental delivery. In some clinical conditions this pattern is not observed, increasing the time for placental delivery and the risk of postpartum hemorrhage.

Ultrasound-guided instrumental removal of the retained placenta after vaginal delivery

The standard treatment for retained placenta is manual extraction, in which a hand is introduced inside the uterus to cleave a plane between the placenta and the uterine wall. For women without an epidural, the procedure is extremely uncomfortable and may require additional measures such as intravenous narcotics or regional anesthesia. Although ultrasound-guided instrumental removal of the placenta is standard practice as part of second-trimester abortion by dilation and evacuation and may be done at many institutions, especially after failed manual extraction, it has not yet been described in the literature as a technique following vaginal birth. Our experience with this technique is that it causes less discomfort to the patient than a traditional manual extraction, because the instrument entering the uterus is much narrower than a hand. With the patient in dorsal lithotomy, we locate the cervix and stabilize it either with fingers or a ring forceps on the anterior lip. We introduce Bierer ovum forceps into the uterus under direct ultrasound guidance. The Bierer forceps are preferred because of their long length, large head, and serrated teeth that allow for a firm, secure grip on the placenta. We grasp the placental tissue with the forceps and apply slow, gentle traction in short strokes, regrasping increasingly more distal areas of placenta as necessary to tease out the placenta. After 1-2 minutes, the placenta separates and can be pulled out of the uterus, usually intact. Our experience suggests that this technique is a well-tolerated option for women without an epidural who have a retained placenta. Further study is needed to quantify the amount of discomfort and anesthesia that can be avoided with this technique, as well as whether there is any change in the frequency of infectious complications or the necessity of postremoval curettage.

Perinatal management of congenital oropharyngeal tumors: the ex utero intrapartum treatment (EXIT) approach

PURPOSE

To present our experience in the perinatal management of fetuses with large oropharyngeal tumors by ex utero intrapartum treatment (EXIT).

METHODS

We performed a retrospective chart review of all patients with congenital oropharyngeal tumor who underwent an EXIT procedure between May 2006 and June 2012.

RESULTS

Four patients were included in the series, three females and one male. The diagnoses were epignathus (n=2) and congenital epulis (n=2). Three EXITs were done at term and one at late preterm due to premature rupture of membranes. Median maternal time under anesthesia was 185 min (range: 166-281) and median maternal operative time was 99 min (range: 85-153). Median maternal blood loss was 550 ml (range: 350-2000); one mother required a blood transfusion. Mean maternal hospital stay was 4 days. Median hysterotomy-to-cord clamp time was 24 min (range: 18-66). Mean fetal birth weight was 2.7 kg (range: 2.4-3). The airway was successfully accessed and secured under placental circulation in all cases. In the two patients with congenital epulis the tumors were resected at the base of their pedicles and the airway accessed via direct laryngoscopy before the umbilical cord was clamped. One patient with epignathus underwent a retrograde tracheal intubation under placental circulation and had the tumor resected thereafter. The second patient with epignathus had a tracheostomy done under placental circulation and then had tumor debulking immediately after the EXIT. The maternal morbidity was minimal and there were no mortalities.

CONCLUSIONS

We conclude that the EXIT procedure is the ideal delivery strategy for fetuses with prenatally diagnosed oropharyngeal tumors and potential airway obstruction at birth. Patients with prenatally diagnosed oropharyngeal tumors should be promptly referred to a fetal treatment center with a dedicated multidisciplinary team and EXIT capabilities.

Risk factors for a prolonged third stage of labor and postpartum hemorrhage

OBJECTIVES

To determine the effect of a third stage of labor ≥15 minutes on bleeding after delivery and other risk factors for a postpartum hemorrhage (PPH).

METHODS

This was a case-control study of women undergoing vaginal delivery with placental delivery ≥15 minutes matched by gestational age to the next delivery with placental delivery <15 minutes. Multiple risk factors were evaluated for association with delayed placenta and with PPH.

RESULTS

There were 226 pregnancies ≥15 minutes (cases) versus 226 whose placental time was <15 minutes (controls). The best-fit model identified placental delivery ≥15 minutes, history of retained placenta, nulliparity, and increased length of first stage of labor as significant factors for PPH.

CONCLUSIONS

The best risk model for PPH includes placental delivery ≥15 minutes, history of retained placenta, nulliparity, and longer first stage of labor.

Delays in the delivery room of a primary maternity unit: a retrospective analysis of obstetric outcomes

OBJECTIVE

To compare obstetric outcomes in women undergoing vaginal delivery with or without delay in the 2nd and 3rd stage of labour (SOL).

METHODS

This is an observational retrospective study including 10,416 full-term vaginal deliveries occurred at a primary obstetric unit. Our sample was divided according to the length of 2nd and 3rd SOL: >2 h vs. ≤2 h; and >1 h vs. ≤1 h, respectively. Obstetric outcomes were compared using univariate and multivariate analysis.

RESULTS

A prolonged 2nd SOL was associated with severe perineal tears (odds ratio (OR) = 3.53), episiotomy (OR = 3.25), major post-partum hemorrhage (PPH) (OR = 2.35), operative delivery (OR = 3.54), and Asian ethnicity (OR = 12.12). Likewise, a prolonged 3rd SOL was associated with operative deliveries (OR = 10.49), labor induction (OR = 3.24), non-use of oxytocin after delivery (OR = 12.39), major PPH (OR = 46.95), retained placenta (OR = 3.57) and female fetal gender (OR = 4.07).

CONCLUSIONS

even at a primary care setting, where there are mostly low-risk pregnancies, a prolonged 2nd and 3rd SOL may occur and lead to poor obstetric outcomes. Our findings raise a very controversial issue about the meaning of "low obstetrics risk", given the unpredictability of any labor, and the management of complications in the delivery room of primary maternity units.

Nitroglycerin for management of retained placenta: a multicenter study

The primary aim was to determine if sequential administration of oxytocin and nitroglycerin is effective for management of retained placenta when performed by obstetricians with no experience of the method. Secondary aims were to examine possible adverse effects of nitroglycerin. One hundred and five women with retained placenta were randomly selected to receive either 1 mg nitroglycerin or placebo tablets sublingually if intravenous oxytocin had failed to expel the placenta. At two of the hospitals some of the midwives were familiar with the use of nitroglycerin. The other midwives and all the participating obstetricians had no clinical experience of the method. In the treatment group, detachment of placenta following nitroglycerin occurred in 37.3% of the women compared to 20.4% in the placebo group (P = 0.056). In the two hospitals with some experience of the method, placenta was removed in 9 of 19 (47.4%) women in the nitroglycerin group compared to 3 of 17 (15.0%) women in the placebo group. No adverse effects of clinical importance were registered. Although the difference between the two groups did not reach statistical significance, the higher success rate in the two hospitals with some experience could indicate that clinical experience is of importance in order to achieve placental detachment.

Umbilical vein injection for the routine management of third stage of labour

BACKGROUND

Postpartum haemorrhage is among the biggest contributor to maternal mortality worldwide. Prevention of this condition includes routine use of uterotonic in the third stage of labour, which has been recommended throughout the world. Use of umbilical route to deliver this uterotonic after delivery of the baby has been proposed. Therapeutic use of this has been assessed, although routine (prophylactic) use of this has not been evaluated.

OBJECTIVES

To compare, from the best available evidence, the effects of umbilical vein injection of a saline solution alone or with any uterotonic drug versus an alternative solution with or without any other uterotonic agent or expectant management or any other method for routine management of the third stage of labour, on maternal and perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised controlled trials comparing the effects of umbilical vein injection of a saline solution alone or with any uterotonic drug versus any other alternative methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and trial quality. Two review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

We included nine studies involving 1118 women.We identified four comparisons. One comparison included six studies (which randomised 394 women) comparing umbilical vein injection of normal saline plus oxytocin versus that of normal saline, as well as three other comparisons, each of which includes one study. Comparing intraumbilical injection of normal saline plus oxytocin with intraumbilical injection of saline only, there was no evidence of difference in any of the relevant outcomes reported namely the number of women who required blood transfusion, the incidence of manual removal of placenta, blood loss, and length of the third stage of labour. Subgroup analyses by both total amount of solution administered and dose of oxytocin showed no evidence of difference. Other comparisons included only one study for each, and there was no relevant information available.

AUTHORS' CONCLUSIONS

Routine use of oxytocin or any other uterotonics with normal saline via umbilical vein injection is not recommended until new evidence is available. Further research should be conducted to show effectiveness of oxytocin with normal saline via umbilical vein injection.

Invasive placentation and uterus preserving treatment modalities: a systematic review

Purpose

We present a systematic review to evaluate failure rates (secondary hysterectomy or maternal mortality) and success rates (subsequent menstruation or pregnancy) after different uterus preserving treatment modalities in women with invasive placentation.

Methods

A review of English, German or Dutch language-published research, using Medline and Embase databases, was performed. Studies of any design were included.

Results

Ten cohort studies and 50 case series or case reports were included. Expectant management reported a secondary hysterectomy in 55/287 (19%), maternal mortality in 1/295 (0.3%), a subsequent menstruation in 44/49 (90%) and a subsequent pregnancy in 24/36 (67%). Embolization of the uterine arteries described a secondary hysterectomy in 8/45 (18%), a subsequent menstruation in 8/13 (62%) and a subsequent pregnancy in 5/33 (15%). Methotrexate therapy presented a secondary hysterectomy in 1/16 (6%), a subsequent menstruation in 4/5 (80%) and a subsequent pregnancy in 1/2 (50%). Uterus preserving surgery showed a secondary hysterectomy in 24/77 (31%), maternal mortality in 2/55 (4%), a subsequent menstruation in 28/34 (82%) and a subsequent pregnancy in 19/26 (73%).

Conclusions

This review indicates that different uterus preserving treatment modalities may be effective in managing invasive placentation. Despite the extensive review of the literature, no conclusions about the superiority of any modality can be drawn.

The retained placenta: historical and geographical rate variations

In this study, we sought to explore the variation in reported rates of retained placenta around the world and over time in the UK. A systematic review of observational studies was performed to obtain retained placenta rates from around the world and annual hospital reports from the Royal College of Obstetricians and Gynaecologists archives were examined to obtain historical retained placenta rates. The data show that the median rate of retained placenta at 30 minutes was higher in developed countries (2.67% vs 1.46%, p < 0.02), as was the median manual removal rate (2.24% vs 0.45%, p < 0.001). In addition to this, there appears to have been a rise in rate of manual removal in the UK from a mean of 0.66% in the 1920s to 2.34% in the 1980s (p < 0.0001).

Intravenous nitroglycerin for controlled cord traction in the management of retained placenta

OBJECTIVE

To determine the effect of 200 μg of intravenous nitroglycerin in the release of retained placenta by controlled cord traction.

METHODS

In this randomized controlled study, 40 women with a placenta retained for 30 minutes received intravenously 200 μg of nitroglycerin or a normal saline solution before umbilical cord traction was initiated. The rates of successful removal of the retained placenta in the study (n=20) and control (n=20) groups were compared, as were blood pressure, pulse rate, blood loss, and adverse effects.

RESULTS

The placenta was released in only 15% and 20% of the participants in the study and control group, respectively. The remainder of the participants required general anesthesia and manual removal of the retained placenta regardless of group assignation. Blood pressure fell in significantly more women in the study group, but there were no differences in estimated blood loss or minor adverse effects.

CONCLUSION

Intravenously administered nitroglycerin did not facilitate the release of retained placenta by umbilical cord traction. However, cord traction may be performed longer than 30 minutes to attempt releasing the placenta before operative manual removal is initiated.

Active versus expectant management of the third stage of labor and implementation of a protocol

Although the focus at delivery may naturally shift to infant transition, continued maternal vigilance during stage 3 is imperative to accomplish a safe outcome for the mother and her newborn. The third stage of labor is a normal physiological progression of birth that may be compounded by serious complications. The most common complication is postpartum hemorrhage due to uterine atony. Clinicians choose either active management or expectant management for stage 3 to prevent excessive maternal blood loss. Rapid identification and response to a postpartum hemorrhage are critical. A multidisciplinary perinatal team at a large Midwest tertiary center led the transition from an expectant to an active-management protocol within the obstetric service. Outcomes included a decrease in the postpartum hemorrhage rate and decreased usage of additional uterotonic medications during the immediate recovery period.

Introducing maternal morbidity audit in the Netherlands

OBJECTIVE

To describe the panel audit process and to identify substandard care in selected women from a nationwide prospective cohort study into severe acute maternal morbidity (SAMM) in the Netherlands.

DESIGN

Prospective audit of selected women with SAMM.

SETTING

Eight audit meetings held throughout the Netherlands.

POPULATION

All pregnant women in the Netherlands.

METHODS

Before each meeting, SAMM details of selected women were sent to all panel members for individual assessment by completing an audit form. During a subsequent plenary meeting, findings were discussed and substandard care factors as judged by the majority of assessors were scored.

MAIN OUTCOME MEASURES

Incidence of substandard care and recommendations for improving the quality of care.

RESULTS

Substandard care was identified in 53 of 67 women (79%). Specific recommendations were formulated concerning the procedure of audit and concerning local as well as national management guidelines.

CONCLUSION

Our findings reflect SAMM in the Netherlands and substandard care is present in four out of five women. Ongoing audit of women with SAMM is promoted both at local and national level.

Treatment of retained placenta with misoprostol: a randomised controlled trial in a low-resource setting (Tanzania)

BACKGROUND

Retained placenta is one of the common causes of maternal mortality in developing countries where access to appropriate obstetrical care is limited. Current treatment of retained placenta is manual removal of the placenta under anaesthesia, which can only take place in larger health care facilities. Medical treatment of retained placenta with prostaglandins E1 (misoprostol) could be cost-effective and easy-to-use and could be a life-saving option in many low-resource settings. The aim of this study is to assess the efficacy and safety of sublingually administered misoprostol in women with retained placenta in a low resource setting.

METHODS

DESIGN

Multicentered randomised, double-blind, placebo-controlled trial, to be conducted in 5 hospitals in Tanzania, Africa.

INCLUSION CRITERIA

Women with retained placenta, at a gestational age of 28 weeks or more and blood loss less than 750 ml, 30 minutes after delivery of the newborn despite active management of third stage of labour. Trial Entry & Randomisation & Study Medication: After obtaining informed consent, eligible women will be allocated randomly to the treatment groups using numbered envelopes that will be randomized in variable blocks containing identical capsules with either 800 microgram of misoprostol or placebo. The drugs will be given sublingually. The women, maternal care providers and researchers will be blinded to treatment allocation.

SAMPLE SIZE

117 women, to show a 40% reduction in manual removals of the placenta (p = 0.05, 80% power). The randomization will be misoprostol: placebo = 2:1. PRIMARY STUDY OUTCOME: Expulsion of the placenta without manual removal. Secondary outcome is the number of blood transfusions.

DISCUSSION

This is a protocol for a randomized trial in a low resource setting to assess if medical treatment of women with retained placenta with misoprostol reduces the incidence of manual removal of the placenta.

CLINICAL TRIAL REGISTRATION

Current Controlled Trials ISRCTN16104753.

The retained placenta

The incidence and importance of retained placenta (RP) varies greatly around the world. In less developed countries, it affects about 0.1% of deliveries but has up to 10% case fatality rate. In more developed countries, it is more common (about 3% of vaginal deliveries) but very rarely associated with mortality. There are three main types of retained placenta following the vagina delivery: placenta adherens (when there is failed contraction of the myometrium behind the placenta), trapped placenta (a detached placenta trapped behind a closed cervix) and partial accreta (when there is a small area of accreta preventing detachment). All can be treated by manual removal of placenta, which should be carried out at 30-60 minutes postpartum. Medical management is also an option for placenta adherens and trapped placenta. The need for manual removal can be reduced by 20% by the use of intraumbilical oxytocin (30 i.u. in 30 mL saline). A trapped placenta may respond to glyceryl trinitrate (500 mcg sublingually) or gentle, persistent, controlled cord traction.

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.