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Kadirogullari P, Aslan Cetin B, Goksu M, Cetin Arslan H, Seckin KD. The effect of uterine massage after vaginal delivery on the duration of placental delivery and amount of postpartum hemorrhage. Arch Gynecol Obstet 2024; 309:2689-2695. [PMID: 37698604 DOI: 10.1007/s00404-023-07211-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the effects of uterine massage performed before placental delivery on the third stage of labor and postpartum hemorrhage after vaginal delivery. MATERIALS AND METHODS The study was designed as a prospective randomized controlled study. Between June 2018 and June 2019, 242 women who gave birth in Istanbul Kanuni Sultan Suleyman Training and Research Hospital were included in the study. The women were divided into two groups; group 1 received uterine massage after vaginal delivery before placental delivery (n: 128) and group 2 did not receive massage (n: 114). Demographic characteristics, delivery times of the baby and placenta, duration of uterine massage, amount of postpartum hemorrhage and postpartum hemoglobin values of both groups were recorded. RESULTS Baseline characteristics were similar in both groups. Placental output time after delivery was 8.3 ± 4.2 min in group 1 and 13.5 ± 6.3 min in group 2. The third stage of labor was significantly shorter in group 1 (p = 0.012). The amount of blood loss of 500 mL or more after delivery was higher in group 2 but not statistically different (p > 0.05). Hemoglobin value measured within 12-24 h after delivery was significantly lower in group 2 (hemoglobin < 8 g/dL after 12-24 h p = 0.003; hemoglobin < 10 g/dL after 12-24 h p = 0.001). Delta hb value was also significantly lower in group 2 (p = 0.03). With this result, it was determined that bleeding intense enough to require transfusion was more common in group 2. CONCLUSION In patients delivering vaginally, uterine massage before placental delivery shortens the placental delivery time and reduces postpartum hemorrhage. In addition to oxytocin and controlled cord traction to reduce postpartum blood loss, uterine massage should be routinely used in the active management of the third stage of labor. CLINICAL TRIALS NUMBER NCT03858569.
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Affiliation(s)
- Pinar Kadirogullari
- Department of Obstetrics and Gynecology, Acıbadem University Atakent Hospital, Istanbul, Turkey.
| | - Berna Aslan Cetin
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Mustafa Goksu
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Hale Cetin Arslan
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Kerem Doga Seckin
- Department of Obstetrics and Gynecology, Istinye University Liv Hospital Vadi Istanbul, Istanbul, Turkey
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Ghulmiyyah LM, El-Husheimi A, Usta IM, Colon-Aponte C, Ghazeeri G, Hobeika E, Mirza FG, Tamim H, Hamadeh C, Nassar AH. Effect of Sustained Uterine Compression versus Uterine Massage on Blood Loss after Vaginal Delivery: A Randomized Controlled Trial. Am J Perinatol 2023; 40:1644-1650. [PMID: 34775581 DOI: 10.1055/s-0041-1739409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery. STUDY DESIGN This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage. RESULTS A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin (p = 0.79). CONCLUSION There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery. KEY POINTS · Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference..
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Affiliation(s)
- Labib M Ghulmiyyah
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida
| | - Alaa El-Husheimi
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ihab M Usta
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Cristina Colon-Aponte
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida
| | - Ghina Ghazeeri
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Hobeika
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi G Mirza
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Caroline Hamadeh
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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Erkaya R, Karabulutlu Ö, Çalik KY. Uterine massage to reduce blood loss after vaginal delivery. Health Care Women Int 2023; 44:1346-1362. [PMID: 34369853 DOI: 10.1080/07399332.2021.1940184] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 06/03/2021] [Indexed: 10/20/2022]
Abstract
Postpartum hemorrhage (PPH) is a major cause of maternal mortality and disability. A need for simple, inexpensive techniques to prevent PPH and provide treatment exists, particularly in cases where uterotonics cannot be accessed. Uterine massage is recommended as part of the routine active management of the third stage of labor. This study was conducted to determine the effectiveness of uterine massage after delivery of the placenta in reducing postpartum blood loss. Thus, a randomized controlled trial was conducted in Turkey between March 2018 and September 2018. A total of 176 pregnant women (88 in the control and 88 in the uterine massage groups) were randomly allocated to the two groups: one group receiving sustained uterine massage, while the other comprising the control group. The uterine massage group was administered transabdominal uterine massage, starting immediately after delivery of the placenta and continuing every 15 min for a duration of 2 h until the uterus hardened. The blood loss within 2 h of delivery was recorded. Level of significance was taken as p < 0.05, and the chi-square, t, and Mann-Whitney U tests as well as Spearman's correlation and linear regression were employed in the analysis of the data. The average amount blood loss within 2 h of the delivery was significantly higher in the control group than in the massage group (X = 170.49 ± 61.46 and X = 186.20 ± 47.59, p < 0.05). A statistically significant difference was present between the uterine massage and control groups in terms of hemoglobin, hematocrit, WBC, and RCB pre-delivery and pre-discharge (first 24 h) values and in the use of additional uterotonics and the amount of blood loss (p < 0.05). The results of the analysis show that postpartum uterine massage has a reducing effect on the amount of PPH.
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Affiliation(s)
- Reyhan Erkaya
- Faculty of Health Science, Obstetrics and Gynaecology Nursing Department, Karadeniz Technical University, Trabzon, Turkey
| | - Özlem Karabulutlu
- Faculty of Health Sciences, Department of Midwifery, Kafkas University, Kars, Turkey
| | - Kıymet Yeşilçiçek Çalik
- Faculty of HealthScience, Obstetrics and Gynaecology Nursing Department, Karadeniz Technical University, Trabzon, Turkey
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Zhang S, Fu X. Uterine Massage to Reduce Blood Loss Before Delivery of the Placenta in Caesarean Section: A Retrospective Cohort Study. Z Geburtshilfe Neonatol 2021; 225:428-431. [PMID: 33694148 DOI: 10.1055/a-1386-6155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND/OBJECTIVE To estimate the effectiveness of uterine massage UM in reducing blood loss before delivery of placenta in CS. METHODS This was a retrospective cohort study of 1393 women who delivered with CS. Patients who underwent UM (671women) were compared with those who underwent controlled cord traction (722 women). According to risk assessment of PPH, 2 groups were both divided to low risk group and high risk group. Outcomes included blood loss amount within 2 h after delivery, incidence of PPH and intractable PPH. RESULTS Blood loss amount within 2 h was lower in UM group than CCT group(516.6±196.5 ml compared with 674.1±272.2 ml, P<0.01). The incidence of PPH and intractable PPH didn't differ significantly between the 2 groups (6.7% compared with 9.1%, P=0.09 and 3.9% compared with 5.3%, P=0.22,respectively).In high risk group, the amount of blood loss within 2 h and the incidence of PPH were both lower in UM group (n=382) than CCT group (n=407) (576.8±228.1 ml compared with 854.9±346.1 ml, P<0.01 and 7.1% compared with 11.3%,P=0.04 ,respectively). The incidence of intractable PPH didn't differ significantly between the 2 groups (4.7% compared with 6.9%,P=0.19). In low risk group, the 3 outcomes didn't differ significantly between the 2 groups(n=289 vs. 315) (428.5±172.6 ml compared with 447.9±180.5 ml; 6.2% compared with 6.3%; 2.8% compared with 3.2%; P=0.56, 0.95 and 0.77,respectively). CONCLUSION In high risk patients of PPH, UM before delivery of placenta contributed to reduce blood loss in CS.
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Affiliation(s)
- Shitong Zhang
- Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, China
| | - Xianhu Fu
- Obstetrics and Gynecology, Ningbo Women and Children's Hospital, Ningbo, China
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Sharifi N, Bahri N, Hadizadeh-Talasaz F, Azizi H, Nezami H. The effect of foot reflexology in the fourth stage of labor on postpartum hemorrhage and after pain: Study protocol for a randomized controlled trial. ADVANCES IN INTEGRATIVE MEDICINE 2021. [DOI: 10.1016/j.aimed.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Uterine massage for preventing postpartum hemorrhage at cesarean delivery: Which evidence? Eur J Obstet Gynecol Reprod Biol 2018; 223:64-67. [DOI: 10.1016/j.ejogrb.2018.02.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/22/2018] [Indexed: 11/20/2022]
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Saccone G, Caissutti C, Ciardulli A, Abdel‐Aleem H, Hofmeyr GJ, Berghella V. Uterine massage as part of active management of the third stage of labour for preventing postpartum haemorrhage during vaginal delivery: a systematic review and meta‐analysis of randomised trials. BJOG 2017; 125:778-781. [DOI: 10.1111/1471-0528.14923] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 11/29/2022]
Affiliation(s)
- G Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry School of Medicine University of Naples Federico II Naples Italy
| | - C Caissutti
- Department of Experimental Clinical and Medical Science DISM Clinic of Obstetrics and Gynaecology University of Udine Udine Italy
| | - A Ciardulli
- Department of Obstetrics and Gynaecology Catholic University of Sacred Heart Rome Italy
| | - H Abdel‐Aleem
- Department of Obstetrics and Gynaecology Women's Health Hospital Assiut University Hospital Assiut Egypt
| | - GJ Hofmeyr
- Effective Care Research Unit Eastern Cape Department of Health Fort Hare and Walter Sisulu Universities and University of the Witwatersrand Johannesburg South Africa
| | - V Berghella
- Division of Maternal–Fetal Medicine Department of Obstetrics and Gynecology Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia PA USA
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Uterine massage to reduce postpartum hemorrhage after vaginal delivery. Int J Gynaecol Obstet 2016; 111:32-6. [DOI: 10.1016/j.ijgo.2010.04.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 04/17/2010] [Accepted: 05/28/2010] [Indexed: 11/20/2022]
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Şentürk Ş, Kağıtçı M, Balık G, Arslan H, Kır Şahin F. The Effect of the Combined Use of Methylergonovine and Oxytocin during Caesarean Section in the Prevention of Post-partum Haemorrhage. Basic Clin Pharmacol Toxicol 2015; 118:338-43. [PMID: 26449959 DOI: 10.1111/bcpt.12500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/30/2015] [Indexed: 11/29/2022]
Abstract
We aimed to show to patients the benefit of post-partum haemorrhage prophylaxis treatment and the effectiveness as a uterotonic agent of the combined use of methylergonovine and oxytocin infusion in the prevention of haemorrhage during and after Caesarean section, by comparison with a control group which received oxytocin infusion only. Two groups of patients undergoing Caesarean section at the same clinic were included in the study. A combination of methylergonovine and oxytocin was administered to the first group during the intra-operative and post-operative periods. The second group did not receive methylergonovine and was administered only with oxytocin infusion in the intra-operative and post-operative periods. Pre-operative and post-operative haemogram readings were taken for all patients in each of the groups for comparison. No difference was found between the two groups with regard to mean ages and pre-operative haemogram values. The decrease in post-operative haemoglobin values for the group administered with methylergonovine maleate and oxytocin was found to be significantly greater than for the group administered with oxytocin only. Results indicated that prophylactic methylergonovine treatment was clearly successful for the patients and no adverse side effects were found. The routine use of methylergonovine and oxytocin infusion in combination during the intra-operative period of Caesarean section reduced the level of post-partum haemorrhage considerably. We believe that this procedure will also reduce the risk of uterine atony, but clearly, prospective studies will be necessary in future to confirm this assumption.
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Affiliation(s)
- Şenol Şentürk
- Departments of Obstetrics and Gynecology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Mehmet Kağıtçı
- Departments of Obstetrics and Gynecology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Gülşah Balık
- Departments of Obstetrics and Gynecology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Halit Arslan
- Departments of Obstetrics and Gynecology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Figen Kır Şahin
- Departments of Obstetrics and Gynecology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
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Dupont C, Ducloy-Bouthors AS, Huissoud C. [Clinical and pharmacological procedures for the prevention of postpartum haemorrhage in the third stage of labor]. ACTA ACUST UNITED AC 2014; 43:966-97. [PMID: 25447388 DOI: 10.1016/j.jgyn.2014.09.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the clinical and pharmacological procedures for the prevention of Postpartum Haemorrhage (PPH). MATERIALS AND METHODS We searched the Medline and the Cochrane Library (1st December 2004 to 1st March 2014) and we checked the international guidelines. RESULTS Vaginal birth: only the use of uterotonics reduces the incidence of PPH. Oxytocin is the treatment of choice if it is readily available (grade A). Oxytocin can be used either after the shoulders expulsion or rapidly after the placental delivery (grade B). A dose of 5 or 10IU must be administrated IV over at least 1minute or directly by an intramuscular injection (professional agreement) except in women with documented cardiovascular disease in which the duration of the IV perfusion should be over at least 5minutes (professional agreement). Mechanical procedures have no significant impact on PPH. The decision to use a collector bag is left to the medical team (professional agreement). A systematic complementary oxytocin perfusion is not recommended (professional agreement). Caesarean delivery: There is no evidence to recommend a particular type of caesarean technique to prevent PPH (professional agreement) but a lower uterine section is recommended (grade B). All types of incision expansion may be used (professional agreement). A controlled cord traction is associated with lower blood losses than manual removal of the placenta (grade B). A dose of 5 or 10IU can be injected (IV) over 1minute, and over 5minutes in women with cardiovascular disease (professional agreement). Carbetocin reduces the incidence of PPH but there is presently no inferiority study comparing oxytocin and carbetocin so that oxytocin remains the gold standard therapy to prevent PPH in C-section (professional agreement).
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Affiliation(s)
- C Dupont
- Réseau périnatal Aurore, université Lyon-1, hôpital de la Croix-Rousse, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; EA 4129, laboratoire « santé, individu, société », faculté de médecine Laennec, 7, rue Guillaume-Paradin, 69372 Lyon cedex 08, France.
| | - A-S Ducloy-Bouthors
- Pôle d'anesthésie-réanimation, maternité Jeanne de Flandre, CHRU de Lille, 59037 Lille cedex, France
| | - C Huissoud
- Réseau périnatal Aurore, université Lyon-1, hôpital de la Croix-Rousse, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; Inserm U846, Stem Cell and Brain Research Institute, 18, avenue Doyen-Lépine, 69675 Bron cedex, France
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Delesalle C, Dolley P, Beucher G, Dreyfus M, Benoist G. [Uterine artery pseudoaneurysm: an unusual cause of postpartum hemorrhage]. ACTA ACUST UNITED AC 2014; 44:88-92. [PMID: 24656739 DOI: 10.1016/j.jgyn.2014.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 11/28/2013] [Accepted: 02/06/2014] [Indexed: 11/25/2022]
Abstract
Uterine artery pseudoaneurysm is a rare complication of cesarean section. It can lead to severe postpartum hemorrhage. We report three cases of pseudoaneurysm diagnosed late after cesarean delivery, one followed by hemorrhagic shock. Ultrasound may point to the diagnosis, but arteriography of uterine arteries is decisive for the diagnosis. Selective artery embolization is recommended for treatment. Main advantages are complete occlusion of the pseudoaneurysm and fertility preservation.
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Affiliation(s)
- C Delesalle
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, pôle Femme-Enfant, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France; Université de Caen Basse-Normandie, esplanade de La-Paix, 14032 Caen cedex 5, France
| | - P Dolley
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, pôle Femme-Enfant, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France; Université de Caen Basse-Normandie, esplanade de La-Paix, 14032 Caen cedex 5, France
| | - G Beucher
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, pôle Femme-Enfant, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France
| | - M Dreyfus
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, pôle Femme-Enfant, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France; Université de Caen Basse-Normandie, esplanade de La-Paix, 14032 Caen cedex 5, France
| | - G Benoist
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, pôle Femme-Enfant, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France; Université de Caen Basse-Normandie, esplanade de La-Paix, 14032 Caen cedex 5, France.
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Abstract
BACKGROUND Postpartum haemorrhage (PPH) (bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under-resourced areas. In these settings, uterotonics are often not accessible. There is a need for simple, inexpensive techniques which can be applied in low-resourced settings to prevent and treat PPH. Uterine massage is recommended as part of the routine active management of the third stage of labour. However, it is not known whether it is effective. If shown to be effective, uterine massage would represent a simple intervention with the potential to have a major effect on PPH and maternal mortality in under-resourced settings. OBJECTIVES To determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013). SELECTION CRITERIA All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or in addition to uterotonics before or after delivery of the placenta, or both, with non-massage. DATA COLLECTION AND ANALYSIS Two researchers independently considered trials for eligibility, assessed risk of bias and extracted the data using the agreed form. Data were checked for accuracy. The effect of uterine massage commenced before or after placental delivery were first assessed separately, and then the combined for an overall result. MAIN RESULTS This review included two randomised controlled trials. The first trial included 200 women who were randomised to receive uterine massage or no massage following delivery of the placenta, after active management of the third stage of labour including use of oxytocin. The numbers of women with blood loss more than 500 mL was small, with no statistically significant difference (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.16 to 1.67). There were no cases of retained placenta in either group. The mean blood loss was significantly less in the uterine massage group at 30 minutes (mean difference (MD) -41.60 mL, 95% CI -75.16 to -8.04) and 60 minutes after trial entry (MD -77.40 mL, 95% CI -118.71 to -36.09). The need for additional uterotonics was significantly reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50).For use of uterine massage before and after delivery of the placenta, one trial recruited 1964 women in Egypt and South Africa. Women were assigned to receive oxytocin, uterine massage or both after delivery of the baby but before delivery of the placenta. There was no added benefit for uterine massage plus oxytocin over oxytocin alone as regards blood loss greater than or equal to 500 mL (average RR 1.56, 95% CI 0.44, 5.49; random-effects) or need for additional use of uterotonics (RR 1.02, 95% CI 0.56 to 1.85).The two trials were combined to examine the effect of uterine massage commenced either before or after delivery of the placenta. There was substantial heterogeneity with respect to the blood loss 500 mL or more after trial entry. The average effect using a random-effects model found no statistically significant differences between groups (average RR 1.14, 95% CI 0.39 to 3.32; random-effects). AUTHORS' CONCLUSIONS The results of this review are inconclusive, and should not be interpreted as a reason to change current practice. Due to the limitations of the included trials, more trials with sufficient numbers of women are needed in order to estimate the effects of sustained uterine massage. All the women compared in this review received oxytocin as part of the active management of labour. Recent research suggests that once an oxytocic has been given, there is limited scope for further reduction in postpartum blood loss. Trials of uterine massage in settings where uterotonics are not available, and which measure women's experience of the procedure, are needed.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex,University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa.
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Sheldon WR, Durocher J, Winikoff B, Blum J, Trussell J. How effective are the components of active management of the third stage of labor? BMC Pregnancy Childbirth 2013; 13:46. [PMID: 23433172 PMCID: PMC3607929 DOI: 10.1186/1471-2393-13-46] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 02/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Active management of the third stage of labor is recommended for the prevention of post-partum hemorrhage and commonly entails prophylactic administration of a uterotonic agent, controlled cord traction, and uterine massage. While oxytocin is the first-choice uterotonic, it is not known whether its effectiveness varies by route of administration. There is also insufficient evidence regarding the value of controlled cord traction or uterine massage. This analysis assessed the independent and combined effectiveness of all three interventions, and the effect of route of oxytocin administration on post-partum blood loss. METHODS Secondary data were analyzed from 39202 hospital-based births in four countries and two clinical regimens: one in which oxytocin was administered following delivery of the baby; the other in which it was not. We used logistic regression to examine associations between clinical and demographic variables and post-partum blood loss ≥ 700 mL. RESULTS Among those with no oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by nearly 50% as compared with expectant management (P < 0.001). Among those with oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by 66% when oxytocin was intramuscular (P < 0.001), but conferred no benefit when oxytocin was intravenous. Route of administration was important when oxytocin was the only intervention provided: intravenous administration reduced hemorrhage risk by 76% as compared with intramuscular administration (P < 0.001); when combined with other interventions, route of administration had no effect. In both clinical regimens, uterine massage was associated with increased hemorrhage risk. CONCLUSIONS Recommendations for active management of the third stage of labor should account for setting-related differences such as the availability of oxytocin and its route of administration. The optimal combination of interventions will vary accordingly.
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Affiliation(s)
- Wendy R Sheldon
- Office of Population Research, Princeton University, Princeton, NJ, USA
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - Jennifer Blum
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - James Trussell
- Office of Population Research, Princeton University, Princeton, NJ, USA
- The Hull York Medical School, Hull, England
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Stephens LC, Bruessel T. Systematic Review of Oxytocin Dosing at Caesarean Section. Anaesth Intensive Care 2012; 40:247-52. [DOI: 10.1177/0310057x1204000206] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We undertook a systematic review to determine the optimal dose of oxytocin after elective caesarean section or caesarean section in labouring women. We identified seven trials. These trials raise questions about the use of high dose (10 international units; IU) or moderate dose (5 IU) oxytocin in both settings and provide evidence that lower doses are equally effective but associated with significantly fewer side-effects. For elective caesarean section, a slow 0.3 to 1 IU bolus of oxytocin over one minute, followed by an infusion of 5 to 10 IU.h−1 for four hours represents an evidence-based approach to dosing for women at low risk of postpartum haemorrhage. For the labouring parturient a slow 3 IU bolus of oxytocin, followed by an infusion of 5 to 10 IU.h−1 for four hours is supported by limited evidence. These doses represent a starting point in the control of postpartum haemorrhage after caesarean section and do not reduce the need for mandatory active observation of the clinical situation, to detect situations that require additional doses of oxytocin or other uterotonic drugs. These doses of oxytocin minimise the risk of adverse haemodynamic changes as well as the unpleasant side-effect of nausea.
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Affiliation(s)
- L. C. Stephens
- Department of Anaesthesia, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - T. Bruessel
- Department of Anaesthesia, Canberra Hospital, Garran, Australian Capital Territory, Australia
- Chair of Anaesthesia, Australian National University and Director of Anaesthesia, Canberra Hospital
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Integration of the practice of active management of the third stage of labor within training and service implementation programming in Zambia. J Midwifery Womens Health 2010; 55:447-54. [PMID: 20732666 DOI: 10.1016/j.jmwh.2010.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 02/22/2010] [Accepted: 02/22/2010] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is the leading cause of pregnancy-related mortality (cited at 591 per 100,000 Zambian women), and is responsible for up to 60% of maternal deaths in developing countries. Active management of the third stage of labor (AMTSL) has been endorsed as a means of reducing the risk of PPH. The Ministry of Health/Zambia has incorporated the use of AMTSL into its reproductive health guidelines. METHODS Midwives employed in five public hospitals and eight health centers were interviewed (N = 62), and 82 observations were conducted during the second through fourth stages of labor. RESULTS Data from facilities in which oxytocin was available (62 births in 11 settings) indicated that a uterotonic was used in 53 of the births (85.5%); however, AMTSL was conducted in strict accord with the currently recommended protocol (a time-specific use of the uterotonic, controlled cord traction, and fundal massage) in only 25 (40.4%) of births. DISCUSSION Midwives have concerns about risks of maternal to newborn HIV blood transfusion; it is doubtful that they will adopt the currently recommended practice of delayed cord clamping and cutting. Infrastructure issues and supply shortages challenged the ability to correctly and safely implement the AMTSL protocol; nevertheless, facilities were generally ready to support it.
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Active versus expectant management of the third stage of labor and implementation of a protocol. J Perinat Neonatal Nurs 2010; 24:215-28; quiz 229-30. [PMID: 20697238 DOI: 10.1097/jpn.0b013e3181e8ce90] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Gao Y, Barclay L. Availability and quality of emergency obstetric care in Shanxi Province, China. Int J Gynaecol Obstet 2010; 110:181-5. [PMID: 20570261 DOI: 10.1016/j.ijgo.2010.05.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sloan NL, Durocher J, Aldrich T, Blum J, Winikoff B. What measured blood loss tells us about postpartum bleeding: a systematic review. BJOG 2010; 117:788-800. [PMID: 20406227 PMCID: PMC2878601 DOI: 10.1111/j.1471-0528.2010.02567.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Meta-analyses of postpartum blood loss and the effect of uterotonics are biased by visually estimated blood loss. OBJECTIVES To conduct a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage (PPH). SEARCH STRATEGY We searched Medline and PubMed terms (labour stage, third) AND (ergonovine, ergonovine tartrate, methylergonovine, oxytocin, oxytocics or misoprostol) AND (postpartum haemorrhage or haemorrhage) and Cochrane reviews without any language restriction. SELECTION CRITERIA Refereed publications in the period 1988-2007 reporting mean postpartum blood loss, PPH (> or =500 ml) or severe PPH (> or =1000 ml) following vaginal births. DATA COLLECTION AND ANALYSIS Raw data were abstracted into Excel by one author and then reviewed by a co-author. Data were transferred to SPSS 17.0, and copied into RevMan 5.0 to perform random effects meta-analysis. MAIN RESULTS The distribution of average blood loss (29 studies) is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with no uterotonic, oxytocin and misoprostol have lower PPH (OR 0.43, 95% CI 0.23-0.81; OR 0.73, 95% CI 0.50-1.08, respectively) and severe PPH rates (OR 0.61, 95% CI 0.29-1.29; OR 0.74, 95% CI 0.52-1.04, respectively). Oxytocin has lower PPH (OR 0.65, 95% CI 0.60-0.70) and severe PPH (OR 0.71, 95% CI 0.56-0.91) rates than misoprostol, but not in developing countries. CONCLUSION Oxytocin is superior to misoprostol in hospitals. Misoprostol substantially lowers PPH and severe PPH. A sound assessment of the relative merits of the two drugs is needed in rural areas of developing countries, where most PPH deaths occur.
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Affiliation(s)
- N L Sloan
- Gynuity Health Projects, New York, NY, USA.
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21
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Postpartum Hemorrhage: Evidence-based Medical Interventions for Prevention and Treatment. Clin Obstet Gynecol 2010; 53:165-81. [DOI: 10.1097/grf.0b013e3181ce0965] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Butwick A, Coleman L, Cohen S, Riley E, Carvalho B. Minimum effective bolus dose of oxytocin during elective Caesarean delivery. Br J Anaesth 2010; 104:338-43. [DOI: 10.1093/bja/aeq004] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Althabe F, Alemán A, Tomasso G, Gibbons L, Vitureira G, Belizán JM, Buekens P. A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood loss. Int J Gynaecol Obstet 2009; 107:4-7. [PMID: 19541304 PMCID: PMC2771375 DOI: 10.1016/j.ijgo.2009.05.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 04/06/2009] [Accepted: 05/19/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate whether controlled cord traction (CCT) for management of the third stage of labor reduced postpartum blood loss compared with a "hands-off" management protocol. METHODS Women with imminent vaginal delivery were randomly assigned to either a CCT group or a hands-off group. The women received prophylactic oxytocin. The primary outcome was blood loss during the third stage of labor. RESULTS In total, 103 women were allocated to the CCT group and 101 were allocated to the hands-off group. Median blood loss in the CCT group and the hands-off group was 282.0 mL and 310.2 mL, respectively. The difference in blood loss (-28.2 mL) was not significant (95% confidence interval, -92.3 to 35.9; P=0.126). Blood collection in the hands-off group took 1.2 minutes longer than in the CCT group, which may have contributed to this difference. CONCLUSION CCT may reduce postpartum blood loss. The present findings support conducting a large trial to determine whether CCT can prevent postpartum hemorrhage.
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Affiliation(s)
- Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Alicia Alemán
- Clinical and Epidemiological Research Unit Montevideo (UNICEM), Montevideo, Uruguay
| | - Giselle Tomasso
- Clinical and Epidemiological Research Unit Montevideo (UNICEM), Montevideo, Uruguay
| | - Luz Gibbons
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | | | - José M. Belizán
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Pierre Buekens
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
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Tsu VD, Coffey PS. New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003? BJOG 2009; 116:247-56. [PMID: 19076957 DOI: 10.1111/j.1471-0528.2008.02046.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.
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Affiliation(s)
- V D Tsu
- PATH, Seattle, WA 98107, USA.
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Gülmezoglu AM, Widmer M, Merialdi M, Qureshi Z, Piaggio G, Elbourne D, Abdel-Aleem H, Carroli G, Hofmeyr GJ, Lumbiganon P, Derman R, Okong P, Goudar S, Festin M, Althabe F, Armbruster D. Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial. Reprod Health 2009; 6:2. [PMID: 19154621 PMCID: PMC2647525 DOI: 10.1186/1742-4755-6-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 01/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60-70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care. OBJECTIVE The primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package. METHODS A hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period. MANAGEMENT Overall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field. EXPECTED OUTCOMES The main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field. TRIAL REGISTRATION ACTRN12608000434392.
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Affiliation(s)
- A Metin Gülmezoglu
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Mariana Widmer
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Mario Merialdi
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Zahida Qureshi
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Gilda Piaggio
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Diana Elbourne
- London School of Hygiene and Tropical Medicine, London University, London, UK
| | - Hany Abdel-Aleem
- Department Obstetrics and Gynaecology, Assiut University Hospital, Assiut, Egypt
| | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of Witwatersrand, University of Fort Hare, East London, South Africa
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Khon Kaen University, Khon Kaen, Thailand
| | | | - Pius Okong
- Department Obstetrics and Gynaecology, San Raphael of St. Francis Hospital Nsambya, Kampala, Uganda
| | - Shivaprasad Goudar
- Department of Medical Education, K L E Society's J N Medical College, Belgaum, India
| | - Mario Festin
- Philippine General Hospital, Manila, Philippines
| | - Fernando Althabe
- Department of Mother and Child's Health Research, Buenos Aires, Argentina
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Abstract
BACKGROUND Postpartum haemorrhage (PPH) (bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under-resourced areas. In these settings, poor nutrition, malaria and anaemia may aggravate the effects of PPH. In addition to the standard known strategies to prevent and treat PPH, there is a need for simple, non-expensive techniques which can be applied in low-resourced settings to prevent or treat PPH. OBJECTIVES To determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2) and PubMed (1966 to June 2007). SELECTION CRITERIA All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or in addition to uterotonics before or after delivery of the placenta, or both, to non-massage. DATA COLLECTION AND ANALYSIS Both authors extracted the data independently using the agreed form. MAIN RESULTS One randomised controlled trial in which 200 women were randomised to receive uterine massage or no massage after active management of the third stage of labour. The numbers of women with blood loss more than 500 ml was small, with wide confidence intervals and no statistically significant difference (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.16 to 1.67). There were no cases of retained placenta in either group. The mean blood loss was less in the uterine massage group at 30 minutes (mean difference (MD) -41.60, 95% CI -75.16 to -8.04) and 60 minutes after enrolment (MD -77.40, 95% CI -118.71 to -36.09 ml) . The need for additional uterotonics was reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50). Two blood transfusions were administered in the control group. AUTHORS' CONCLUSIONS The present review adds support to the 2004 joint statement of the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians on the management of the third stage of labour, that uterine massage after delivery of the placenta is advised to prevent PPH. However, due to the limitations of the one trial reviewed, trials with sufficient numbers to estimate the effects of sustained uterine massage with great precision, both with and in the absence of uterotonics, are needed.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa.
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Prevention of postpartum hemorrhage in the absence of uterotonics. Int J Gynaecol Obstet 2006; 94 Suppl 2:S124-S125. [DOI: 10.1016/s0020-7292(06)60005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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