Uterine massage for preventing postpartum hemorrhage at cesarean delivery: Which evidence?

Evidence-based cesarean delivery: intraoperative management from skin incision until placental delivery (Part 8)

The goal of standardizing the technique of the routine, uncomplicated cesarean delivery (CD) is to decrease maternal morbidity while optimizing neonatal outcomes. During the procedure, a family-oriented CD is recommended. The low transverse cesarean skin incision (created with either scalpel or diathermy) is preferred with either the Joel-Cohen or Pfannenstiel methods being acceptable. For patients with obesity (BMI > 35kg/m2), surgeons may also elect either the Cohen (including supraumbilical) or Pfannenstiel (infraumbilical or infrapannus) technique as there are similar outcomes, however the Cohen approach has been associated with lower Apgar scores and decreased surgeon satisfaction related to the feasibility of the incision. Diathermy may be preferred for subcutaneous tissue opening as compared to sharp dissection. Though postoperative recovery outcomes may be improved with an extraperitoneal approach to CD, a transperitoneal technique is the current standard of care. The initial fascial incision is made sharply, further extension can be carried out either sharply or bluntly. Inferior dissection of the rectus muscle can be omitted and routine cutting of the muscles is not needed. If necessary, a Maylard modification is acceptable. Though based on limited data, blunt peritoneal entry and extension should be considered. With regards to uterine entry and delivery: bladder flap creation should be omitted, a low transverse hysterotomy is recommended with blunt cephalo-caudad expansion, and manual delivery of the fetal head should be performed. If the fetal head is impacted, then reverse breech extraction may be preferred for maternal benefit. Delayed cord clamping is recommended for at least 30 seconds and up to 120 seconds (recommended for preterm deliveries) with either routine or selected umbilical cord gas collection being considered. In areas where available, carbetocin is more effective in prevention of postpartum hemorrhage (PPH). Otherwise, the combination of oxytocin plus either misoprostol or methergine should be utilized. There is insufficient evidence regarding the effectiveness of uterine massage for PPH prevention. Spontaneous removal of the placenta with gentle cord traction is recommended.

WITHDRAWN: The Effect of Preoperative Intravenous Tranexamic Acid Versus Rectal Misoprostol in Reducing Blood Loss During and After Elective Cesarean Delivery in Primigravida: A Double-Blinded, Randomized, Comparative-Placebo Trial

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Effect of delayed versus immediate umbilical cord clamping in vaginal delivery at term: A randomized clinical trial

OBJECTIVE

To compare maternal blood loss with immediate cord clamping versus delayed cord clamping in women undergoing spontaneous vaginal delivery at term.

METHODS

Parallel group non-blinded randomized trial conducted at a single center in Italy. Women with singleton gestations who underwent spontaneous vaginal delivery at term were eligible and were randomized in a 1:1 ratio to either immediate or delayed cord clamping. In the immediate cord clamping group, cord clamping was within 15 s after birth. In the delayed cord clamping group, cord clamping was after more than 60 s, or when the cord had stopped pulsing. The primary outcome was change in maternal hemoglobin level from the day of delivery to day one after delivery.

RESULTS

A total of 122 participants were enrolled in the trial. There were no significant differences in maternal blood loss as assessed by comparing the decrease in maternal hemoglobin level (mean difference - 0.10 g/dl, 95% confidence interval - 0.28 to 0.08) between the two groups. The mean hemoglobin level at postdelivery day 1 was 11.0 ± 1.5 g/dl in the delayed group and 11.3 ± 1.6 g/dl in the immediate group.

CONCLUSIONS

Delayed umbilical cord clamping, compared with immediate umbilical cord clamping, resulted in no significant change in maternal hemoglobin level 1 day after delivery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04353544.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

Comparison of the Effect of Intravenous Tranexamic Acid and Sublingual Misoprostol on Reducing Bleeding After Cesarean Section: A Double-Blind Randomized Clinical Trial

Purpose

To evaluate the effects of intravenous tranexamic acid (TA) and sublingual misoprostol on reducing bleeding after cesarean section.

Materials

One hundred and fifty-eight participants with term pregnancies scheduled for cesarean section were randomly divided into two groups. In M group, two sublingual misoprostol pills (400 mg) were administrated, immediately after the delivery. In TA group, ten minutes before skin incision, TA ampoule (1 g) was injected. In both groups, immediately after the delivery, 20 units of oxytocin in 1 L ringer lactate with speed of 1000 CC/h was injected. At the end of the operation, the amount of bleeding was measured based on the number of small and large gauzes, the blood in the suction container and the difference of patient's hemoglobin before and 24 h after surgery.

Results

Hemoglobin level reduction in the TA group was higher than the M group (- 2.45 ± 0.84 vs - 2.14 ± 1.38 g/dL) (P < 0.001). Furthermore, number of used gauze and blood suction in the TA group was significantly higher compared to sublingual misoprostol (4.67 ± 1.34 vs 3.25 ± 1.31 and 260.25 ± 79.06 vs 193.94 ± 104.79 cc, respectively) (P < 0.001). Mean blood pressure during the entire duration of surgery in the TA group decreased significantly as compared to the M group (P < 0.001).

Conclusion

Total bleeding was significantly lower in sublingual misoprostol as compared to the tranexamic acid group. Furthermore, in misoprostol group hemodynamic variables were stabilized greater than tranexamic acid group.

Registration Number

IRCT201708308611N6.

Intrapartum cardiotocography with and without computer analysis: a systematic review and meta-analysis of randomized controlled trials

Objective: To evaluate whether intrapartum cardiotocography with computer analysis decreases the incidence of newborn metabolic acidosis or obstetric intervention when compared with visual analysis through a systematic review with meta-analysis of randomized controlled trials.Methods: The research was conducted using Medline, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid and Cochrane Library as electronic databases from the inception of each database to May 2018. Selection criteria included randomized trial evaluating women with cephalic presentation at term or late preterm term during labor who were randomized to electronic fetal heart rate monitoring with either computer analysis (i.e. intervention group) or standard visual analysis (i.e. control group). Trials evaluating antenatal fetal heart rate monitoring in women not in labor were excluded. The primary outcome was incidence of newborn metabolic acidosis, defined as pH less than 7.05 and base deficit greater than 12 mmol/L. Secondary outcomes were mode of delivery, admission to neonatal intensive care unit, hypoxic-ischemic encephalopathy, and perinatal death. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI).Results: Three randomized controlled trials (RCTs), including 54,492 participants, which met inclusion criteria for this meta-analysis, were analyzed. All the included trials enrolled women with cephalic presentation at term or late preterm. Women were randomized in the active first stage of labor and all of them received continuous cardiotocography (CTG) from randomization until delivery. Women who received continuous CTG during labor with computerized analysis had similar risk of newborn metabolic acidosis. No between group differences were found in the secondary outcomes.Conclusions: Compared with visual analysis, use of computer analysis of fetal monitoring signals during labor did not significantly reduce the rate of metabolic acidosis or obstetric intervention.

Use of lubricant gel to shorten the second stage of labor during vaginal delivery

Background: Vaginal application of lubricant during labor has been studied to shorten the length of the second stage of labor.Objective: To evaluate whether vaginal application of lubricant shortens the second stage of labor.Data sources: Electronic databases were searched from their inception until February 2018. No restrictions for language or geographic location were applied.Study eligibility criteria: Randomized controlled trials (RCTs) comparing the use of lubricant of the vaginal canal (i.e. intervention group) with a control group (i.e. no lubricant) in pregnant women with singleton gestation and cephalic presentation undergoing spontaneous vaginal delivery at term. Trials on other interventions that might impact second stage of labor (pushing methods, perineal massage, Ritgen's maneuver, etc.) were not included.Study appraisal and synthesis methods: All analyses were done using an intention-to-treat approach. The primary outcome was the length of the second stage of labor. Pooled analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of mean difference (MD) with 95% confidence interval (CI).Tabulation, integration, and results: Three RCTs including 512 women evaluating the effect of lubricant application during labor were included in the meta-analysis. All trials included pregnant women with singleton gestations in cephalic presentation at term undergoing spontaneous vaginal delivery. One trial included only nulliparous women, while the other two included both nulliparous and multiparous women. Lubricant application started in the first stage before the active phase of labor, and was done intermittently by the midwife or the physician. A sterile gel was applied into the vaginal canal manually or with an applicator. All trials used water-soluble gel. The quantity of gel used was about 2-5 ml for each vaginal examination. There were no statistically significant differences, comparing women who received lubricant gel during labor with those who did not, in the lengths of second stage of labor (MD -7.11 min, 95% CI -15.60 to 1.38), of the first stage of labor, or of the active phase of the first stage of labor. No between-group differences were noticed in the risk of perineal lacerations, mode of delivery, and in the neonatal outcomes.Conclusion: Vaginal application of lubricant during labor does not reduce the length of the second stage of labor in pregnant women with singleton gestations undergoing an attempt at spontaneous vaginal delivery at term.