Literature Review: Physiological Management for Preventing Postpartum Hemorrhage

Efficacy of skin-to-skin contact between mother and newborn during the third stage of labour in reducing postpartum haemorrhage risk

OBJECTIVE

To evaluate the efficacy of skin-to-skin contact (SSC) in reducing the risk of postpartum haemorrhage and blood loss after childbirth.

BACKGROUND

Postpartum haemorrhage is a leading cause of preventable mortality, particularly in developing countries. Although various strategies exist for its prevention, the effect of SSC remains unclear.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Searches were conducted in PubMed, Scopus, Cochrane Library, CINAHL, Google Scholar, and Web of Science up to May 2024.

REVIEW METHODS

The PRISMA guidelines were followed. Prospective clinical trials were included and assessed using the revised Cochrane RoB 2 tool for randomized controlled trials and ROBINS-I for non-randomized studies. The meta-analysis was performed using STATA 18.

RESULTS

The analysis of 18 prospective clinical trials showed that SSC during the third stage of labour was associated with a reduction in the incidence of uterine atony and a lower likelihood of blood loss greater than or equal to 500 mL. Additionally, SSC was linked to a decrease in mean blood loss during the third stage of labour, the first two hours postpartum, and at 24 h postpartum. No significant differences were found in the incidence of severe postpartum haemorrhage.

CONCLUSIONS

SSC during the third stage of labour appears to be effective in reducing the risk of uterine atony, blood loss of 500 mL or more, and mean postpartum blood loss. This suggests significant potential for improving obstetric outcomes. However, given the high risk of bias in the studies analysed, caution is required in interpreting these results. Further high-quality research is needed to confirm these benefits, particularly in caesarean sections.

IMPACT

Postpartum haemorrhage is one of the leading causes of maternal mortality, particularly in developing countries. This meta-analysis suggests that SSC during the third stage of labour could be a key intervention in reducing the risk of uterine atony, blood loss of 500 mL or more, and mean postpartum blood loss. These findings are especially relevant in countries where access to uterotonic drugs is limited, highlighting the need for cost-effective, evidence-based alternatives to improve maternal health.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. TRIAL REGISTRATION : PROSPERO registration number CRD 42024543192.

Transforming Postpartum Care: The Efficacy of Simulation Training in Hemorrhage Management Among Nurses

Background/Objectives: Postpartum hemorrhage (PPH) is the most prevalent complication of childbirth and the most preventable cause of maternal mortality worldwide. Maternity nurses and midwives are often the first-line providers responding to PPH. As a result, maternity nurses have the potential to save the lives of women who are clinically deteriorating because of PPH. Simulation-based training is an effective way to develop maternity nurses' knowledge, skills, and experience to save a woman's life after PPH. Aim: to investigate the effect of simulation-based training on nurses' knowledge and performance about primary postpartum hemorrhage management. Design: an experimental design (pre-test/post-test control group). Setting: the study was conducted in the labor and delivery room at KAUH in Jeddah, Saudi Arabia. Sample: A convenient sample of 54 nurses and midwives who were working in the labor and delivery room and the postnatal unit was randomly divided into two equal groups, the control group and study group. Tools: A structured tool was used for data collection and consisted of four parts: I-sociodemographic data, II-assessment of nurse's/midwives' knowledge about prevention and management of primary PPH, III-nurse's/midwives' performance observational checklist for primary PPH management, and IV-nurse's/midwife's satisfaction of the simulation-based training session. Results: The study group had a significantly higher knowledge level immediately after training (X2 = 9.39, p = 0.002) and one month after training (X2 = 5.51, p = 0.02). Regarding the performance level and total practice level immediately after the intervention, the study group had statistically significantly better practices (X2 = 50.143, p = 0.000 *) and this continued one month later (X2 = 50.143, p = 0.000 *). Conclusions: The nurses' knowledge and performance skills related to primary postpartum hemorrhage care improved after receiving simulation-based training. We recommend that all the maternity nurses and midwives participate in an ongoing in-service simulation training program to enable nurses to demonstrate an active role in PPH prevention and management.

The Effect of Immediate Kangaroo Mother Care During Third Stage of Labor on Postpartum Blood Loss and Uterine Involution: A Quasi-Experimental Comparative Study

BACKGROUND

Obstetric hemorrhage is the leading cause of maternal death worldwide. Obstetric hemorrhage accounts for 27.1% of all maternal death worldwide. Of all obstetric hemorrhages, postpartum hemorrhage (PPH) accounts for 72%. The physiological management of the third stage of labor is a growing area as a preventive measure to control postpartum blood loss. Immediate kangaroo mother care (KMC) is suggested as one of the physiological management methods of the third stage of labor to reduce postpartum blood loss. The duration of the third stage of labor, uterine involution, and amount of postpartum blood loss are the physiological parameters of effective management of the third stage of labor. Examining the absolute effects of immediate KMC on maternal physiological parameters is needed in different populations with different settings. Thus, this study aimed to examine the effects of immediate KMC on uterine involution and postpartum blood loss.

METHODS

A quasi-experimental comparative design was conducted in the labor and delivery room at Maternity and Children Hospital, Makkah, Saudi Arabia. A sample of 80 women was divided into two equal groups: a treatment group that underwent immediate KMC and a control group that received routine care.

INSTRUMENT

A questionnaire developed by the researchers was used to collect the data.

RESULTS

The effects of immediate KMC were significant concerning uterine involution and regarding the uterine position immediately after placenta separation (70% at umbilicus, χ2 = 8.5, p < 0.01), postpartum blood loss (χ2 = 76.098, p < 0.00), the heaviness of lochia (χ2 = 44.679, p = 0.00), and the number of pads used in the first 24 h (p < 0.001).

Comparative study between the roles of intrauterine misoprostol versus the sublingual route for prevention of postpartum blood loss in elective cesarean sections: a randomized controlled trial

BACKGROUND

The prostaglandin E1 analog "misoprostol" is a drug that has powerful ecbolic effects and can be beneficial in the prevention and treatment of postpartum hemorrhage, which is the leading cause of maternal mortality worldwide.

OBJECTIVES

To assess the value of adding intrauterine misoprostol together with intravenous oxytocin injection compared with sublingual misoprostol together with intravenous oxytocin injection during elective cesarean section to reduce blood loss intraoperatively and prevent postpartum hemorrhage.

METHODS

A total of 192 pregnant women were counseled and recruited from the labor and delivery unit at Kasr Al Aini Hospital, Cairo University, and equally randomized into two groups. Group (A) included 96 women who received intrauterine misoprostol (400 mg) + oxytocin. Group (B) included 96 women who received sublingual misoprostol (400 mg) + oxytocin. The primary outcome of our study was estimation of the amount of blood loss during and after cesarean delivery. The secondary outcomes were the incidence of PPH within the first 6 h after labor, the need for blood transfusion, the need for any supplementary ecbolic drugs, the need for additional surgical intervention for PPH, changes in hematocrit and hemoglobin in both groups after delivery, and the incidence of side effects of the study medications.

RESULTS

We observed a significant discrepancy between the two groups in terms of postoperative Hb and Hct, postoperative differences (pre- and post-Hb and post-Hct) and EBL favoring the intrauterine group. However, no significant difference was observed between the groups with respect to excessive blood loss > 1000 ml in the 1st six hours, the need for supplementary ecbolics, the necessity for blood or blood prod, the need for additional surgical intervention (for PPH) or side effects.

CONCLUSION

Intrauterine misoprostol combined with oxytocin intravenous infusion is more effective than sublingual misoprostol combined with oxytocin intravenous infusion in lowering intraoperative blood loss and preventing postpartum hemorrhage in elective cesarean section.

TRIAL REGISTRATION

This trial was retrospectively registered with the ClinicalTrials.gov Registry on 12-April-2024 (registration number: NCT06364098).

The Association of Longer Breastfeeding Duration and Socioeconomic, Pregnancy, Childbirth and Postpartum Characteristics

Background and Objectives: Breastmilk is the safest and most suitable food for an infant, playing the role of their first vaccine and containing all the essential nutrients for the first months of life. The World Health Organisation recommends exclusive breastfeeding for the first 6 months of life and continued breastfeeding while introducing a child to complementary foods until 2 years and beyond. According to Latvian statistics from 2022, only 27.4% of babies were breastfed for 12 months. The aim of this study was to determine the socio-economic factors and factors related to pregnancy, childbirth and postpartum that influence breastfeeding for more than 6 months in Latvia. Materials and Methods: Data were used from the cross-sectional survey "Research on factors and behaviours affecting the sexual and reproductive health of the population of Latvia", which was conducted in 2023. A study sample was randomised and stratified by gender and five age groups. The analyses in this study are based on a sample of women who had given birth at least once (n = 1407), and the dependent variable was the duration of breastfeeding their last child. Binary logistic regression was conducted to identify the associated factors. Results: The point prevalence of longer duration of breastfeeding for the last child was 47.9% (n = 674). The odds of longer breastfeeding duration were higher among mothers who did not smoke during pregnancy (vs. smokers, aOR 2.1, p < 0.001), of Latvian nationality (vs. Russian, aOR 1.3, p = 0.03), who had two childbirth (vs. one, aOR 1.5, p = 0.003), who had the highest level of education (vs. primary education, aOR 2.0, p = 0.03), started breastfeeding immediately after the birth (vs. later than the first day, aOR 1.7, p = 0.01) or on the first day (vs. later, aOR 1.6, p = 0.01). Conclusions: We documented socio-demographic pregnancy and childbirth factors associated with longer breastfeeding durations. Efforts to promote breastfeeding practices should target mothers from the most vulnerable groups.

Material properties of nonpregnant and pregnant human uterine layers

The uterus has critical biomechanical functions in pregnancy and undergoes dramatic material growth and remodeling from implantation to parturition. The intrinsic material properties of the human uterus and how they evolve in pregnancy are poorly understood. To address this knowledge gap and assess the heterogeneity of these tissues, the time-dependent material properties of all human uterine layers were measured with nanoindentation. The endometrium-decidua layer was found to be the least stiff, most viscous, and least permeable layer of the human uterus in nonpregnant and third-trimester pregnant tissues. In pregnancy, the endometrium-decidua becomes stiffer and less viscous with no material property changes observed in the myometrium or perimetrium. Additionally, uterine material properties did not significantly differ between third-trimester pregnant tissues with and without placenta accreta. The foundational data generated by this study will facilitate the development of physiologically accurate models of the human uterus to investigate gynecologic and obstetric disorders.

Material Properties of Nonpregnant and Pregnant Human Uterine Layers

The uterus has critical biomechanical functions in pregnancy and undergoes dramatic material growth and remodeling from implantation to parturition. The intrinsic material properties of the human uterus and how they evolve in pregnancy are poorly understood. To address this knowledge gap and assess the heterogeneity of these tissues, the time-dependent material properties of all human uterine layers were measured with nanoindentation. The endometrium-decidua layer was found to be the least stiff, most viscous, and least permeable layer of the human uterus in nonpregnant and third-trimester pregnant tissues. In pregnancy, endometrium-decidua becomes stiffer and less viscous with no material property changes observed in the myometrium or perimetrium. Additionally, uterine material properties did not significantly differ between third-trimester pregnant tissues with and without placenta accreta. The foundational data generated by this study will facilitate the development of physiologically accurate models of the human uterus to investigate gynecologic and obstetric disorders.

Prevalence of maternal mortality causes based on ICD-MM: a systematic review and meta-analysis

BACKGROUND

Maternal mortality is a universal public health challenge. ICD-Maternal Mortality (ICD-MM) was introduced in 2012 to facilitate the gathering, analysis, and interpretation of data on maternal deaths worldwide. The present study aimed to estimate the global prevalence of maternal death causes through a systematic review and meta-analysis.

METHODS

A systematic literature search was conducted using various databases, including Web of Science, PubMed, Scopus, ScienceDirect, Cochrane Library, as well as Persian databases such as MagIran and Scientific Information Database (SID). The search encompassed articles published until August 21, 2022. Thirty-four eligible articles were included in the final analysis. Analysis was performed using a meta-analysis approach. The exact Clopper-Pearson confidence intervals, heterogeneity assessment, and random effects models with Mantel-Haenszel methods were employed using the STATA software version 14.2.

RESULTS

The most prevalent causes of maternal deaths, listed in descending order from highest to lowest prevalence, were non-obstetric complications (48.32%), obstetric hemorrhage (17.63%), hypertensive disorders of pregnancy, childbirth, and the puerperium (14.01%), other obstetric complications (7.11%), pregnancy with abortive outcome (5.41%), pregnancy-related infection (5.26%), unanticipated complications of management (2.25%), unknown/undetermined causes (2.01%), and coincidental causes (1.59%), respectively.

CONCLUSION

Non-obstetric complications, obstetric hemorrhage, and hypertensive disorders of pregnancy, childbirth, and puerperium were the most common causes of maternal deaths. To reduce the burden of maternal mortality causes, increasing awareness and promoting self-care management among women of reproductive age, and implementing effective screening mechanisms for high-risk mothers during pregnancy, childbirth, and the puerperium can play a significant role. ICD-MM enables the uniform collection and comparison of maternal death information at different levels (local, national, and international) by facilitating the consistent collection, analysis, and interpretation of data on maternal deaths. Our findings can be utilized by policymakers and managers at various levels to facilitate necessary planning aimed at reducing the burden of maternal mortality causes.

Acupressure application to relieve postpartum uterus pain during breastfeeding: A randomized controlled study

OBJECTIVE

Postpartum uterus pain while breastfeeding is a situation that can affect mother-infant bonding negatively and is a matter of concern for women. The purpose of this study is to investigate the effectiveness of acupressure application in reducing postpartum uterus pain during breastfeeding.

METHODS

This prospective randomized controlled trial was carried out at a maternity hospital in northwestern Turkey between March and August 2022. The sample of the study included 125 multiparous women who were in the 6th to 24th hours after vaginal delivery. The participants were randomly divided into acupressure and control groups. Visual Analog Scale (VAS) was used to evaluate postpartum uterine pain.

RESULTS

While the VAS scores of the acupressure and control groups were similar before breastfeeding, the scores of the acupressure group at the 10th and 20th minutes of breastfeeding were lower (respectively, p = 0.038 and p = 0.011). In the intragroup comparisons, compared to their values before breastfeeding, the pain score of the acupressure group decreased at a statistically highly significant degree at the 20th minute of breastfeeding (p<0.001), whereas the score of the control group increased at a statistically highly significant degree at the 10th and 20th minutes (p<0.001).

CONCLUSION

It was concluded that acupressure can be an effective nonpharmacological method in reducing uterus pain while breastfeeding in the postpartum period.

Association of duration of skin-to-skin contact after cesarean delivery in China: a superiority, multicentric randomized controlled trial

BACKGROUND

In China, the rates of early initiation and exclusive breastfeeding are low. The high cesarean delivery rates further contribute to low breastfeeding outcomes. Skin-to-skin contact, a key component of early essential newborn care, is known to be associated with improved breastfeeding initiation and exclusivity; however, the necessary duration has not been subjected to a randomized control trial.

OBJECTIVE

This study aimed to determine the association of the duration of skin-to-skin contact after cesarean delivery with breastfeeding outcomes and maternal and neonatal health outcomes in China.

STUDY DESIGN

This was a multicentric randomized controlled trial that was conducted at 4 hospitals in China. A total of 720 participants at ≥37 gestational weeks with a singleton pregnancy and who received an elective cesarean delivery with epidural anesthesia or spinal anesthesia or combined spinal-epidural anesthesia were randomly divided into 4 groups at a ratio of 1:1:1:1. The control group received routine care. Intervention group 1 (G1), 2 (G2), and 3 (G3) received 30, 60, and 90 minutes of skin-to-skin contact immediately after the cesarean delivery, respectively.

RESULTS

Between January 3 and October 14, 2021, 659 participants were recruited, including 173 in the control group, 176 in G1, 146 in G2, and 164 in G3. Among G1, G2, and G3, the rate of early initiation of breastfeeding within 60 minutes of birth was 56%, 71%, and 72%, respectively, compared with 22% in the control group (P<.001). The exclusive breastfeeding rate at discharge was 69%, 62%, and 71%, respectively, compared with 57% in the control group (P=.003). Early essential newborn care practices were associated with a reduction in postpartum blood loss and neonatal intensive care unit or neonatal ward admission (P<.001; P=.022) .

CONCLUSION

Our findings highlight that prolonged skin-to-skin contact after a cesarean delivery was associated with higher initiation and exclusive breastfeeding at discharge rates. It also found associations with reduced postpartum blood loss and neonatal intensive care unit or neonatal ward admission.

Intrapartum care policies in high-income countries with a universal health system: A scoping review

Evidence-based and sustainable intrapartum care policies are essential for safer, effective, and positive birth experiences. This scoping review aimed to map intrapartum care policies for pregnant women at low-risk of complications, in high-income countries with a universal health system. The study followed Joanna Briggs Institute methodology for scoping reviews and PRISMA-ScR. Search was conducted on CINAHL-EBSCO, Scopus, MEDLINE-Pubmed, Cochrane Central Register of Controlled Trials-EBSCO, and, Academic Search Complete-EBSCO. Grey literature was searched, references screened and experts contacted for additional studies/policies. Data were extracted/analysed by two independent reviewers and results were presented in tabular and narrative format. The concept was governmental intrapartum care policies, the context were OECD high-income countries with a health-financing system founded on the Beveridge Model and the participants were low-risk pregnant women From the 561 records screened, 22 were selected, concerning intrapartum care policies from Australia, Denmark, Spain, Finland, Portugal, and the United Kingdom. All the included records were retrieved in the grey literature. No intrapartum care governmental policies were found for Greece, Iceland, Italy, New Zealand, Norway, and Sweden. Some countries do not refer to all the analysed care aspects and there are differences in detail, depth, range, and scientific. The policies show general similarities but differ in the timing and the content of the recommended intrapartum care. Not all of the analysed countries have intrapartum care policies and those who have shown differences between recommendations. These results can be used to create/revise intrapartum care policies.

Skin-to-Skin Contact in the Third Stage of Labor and Postpartum Hemorrhage Prevention: A Scoping Review

INTRODUCTION

Literature supports numerous benefits of skin-to-skin contact for neonatal adaptation to extrauterine life and bonding/attachment, but few studies explore the effects of skin-to-skin contact on maternal outcomes. This review aims to map the evidence on skin-to-skin contact in the third stage of labor for postpartum hemorrhage prevention.

METHODS

Scoping review, which covered stages recommended by the Institute Joanna Briggs, including studies from the PubMed, EMBASE, CINAHL, LILACS, Web of Science, and Scopus databases, using the descriptors "Postpartum hemorrhage", "Labor stages, third", "Prevention" and "Kangaroo care/Skin-to-skin".

RESULTS

100 publications on the subject found, 13 articles met the inclusion criteria, with 10,169 dyads were assessed in all studies. Publications from 2008 to 2021 were mostly written in English and designed as a randomized controlled trial. Skin-to-skin contact was effective and significant in: reducing the duration of the third stage of labor; placenta delivery; uterine contractility and physiological involution; absence of atony, decreasing blood loss with lower rates of erythrocyte and hemoglobin drop; reducing the need for synthetic oxytocin and/or ergometrine to control bleeding; and reducing changing pads per period and length of stay.

DISCUSSION

Skin-to-skin contact was considered an effective, low-cost, and safe strategy, with positive effects already established in the literature for infants and extremely favorable results in postpartum hemorrhage prevention cases, being highly recommended in assistance for the dyad. Open Science Framework Registry ( https://osf.io/n3685 ).

The role of fibrinogen in postpartum hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide (WHO), with almost 60000 deaths annually. Pregnancy is a prothrombotic state with increased levels of several coagulation factors to protect the parturient from bleeding problems during delivery. Fibrinogen has a significant role in coagulation and bleeding. Studies have pointed out that lower fibrinogen levels before delivery, but also at the initiation of PPH, are predictive of major hemorrhage. Early, the goal-directed fibrinogen concentrate therapy might be very useful in a subgroup of patients with serious PPH. This review aims to summarize the current literature on fibrinogen during PPH.

Ethical Considerations for Hospital-Based Infant Feeding Support

I applied a systematic ethical decision-making approach to evaluate how health care professionals in hospital settings should provide infant feeding support after childbirth. Human milk is recommended as the optimal source of nutrition for infants because of the health benefits it provides for infants and their lactating parents. However, health consequences of insufficient oral intake in infants and psychological distress in the lactating parent may occur when infant feeding does not go according to plan. Infant feeding support should be provided in a way that is objective, sensitive, individualized, equitable, and supportive of autonomy and avoids harm. I provide recommendations for ethical infant feeding support that can be applied by individual health care professionals and on postpartum units in hospitals.

Estimating blood loss during cesarean delivery: A comparison of methods

Objectives

Obstetrical hemorrhage contributes significantly to maternal morbidity and mortality. Assessment of blood loss while undergoing cesarean sections (CS) is essential in lowering the morbidity and mortality, however this amount is commonly underestimated by the surgeon and probably the anesthetist too.

Methods

This study addresses this issue by comparing three separate ways of assessing blood loss during cesarean sections. For each of 97 full-term pregnant women undergoing elective CS, blood loss was measured by the following: visual estimation by both the obstetrician and the anesthetist, weighing surgical pads pre operatively and post operatively and by calculations (multiplying the difference of pre-operative and postoperative hemoglobin values by the patient's estimated blood volume).

Results

The results of this study indicated that the lowest estimated value for blood loss came from visual estimation, while the highest value came from the mathematical formula. Anesthetists were more accurate in their visual estimation of blood loss than were obstetricians.

Conclusion

This study found the amount of blood loss during CS to be overestimated by the mathematical calculation and underestimated by obstetricians. However, the estimate given by anesthetists was close to that obtained by weighing pads. This underscores the need for more accurate methods of blood loss estimation in cesarean sections to be adopted.