Knowledge and factors associated with active management of the third stage of labor in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality in sub-Saharan Africa. Implementing active management in the third stage of labor has significantly reduced the incidence of PPH. Thus, understanding the level of healthcare providers' knowledge of active management in the third stage of labor can inform guidelines, policies, and practices for effectively preventing PPH.

OBJECTIVE

This review aimed to assess the level of healthcare providers' knowledge and associated factors of active management in the third stage of labor in sub-Saharan Africa.

SEARCH STRATEGY

We conducted a search using PubMed, Scopus, Web of Science, Google Scholar, Cochrane Library, and the African Journals online international databases.

SELECTION CRITERIA

The inclusion criteria were determined before the review of the articles and adhere to the criteria of population, intervention, comparison, and outcome.

DATA COLLECTION AND ANALYSIS

Statistical analysis was performed using STATA data analysis software version 14, while Microsoft Excel was utilized for data abstraction. We checked publication bias using a funnel plot and Egger and Begg regression tests. A P value less than 0.05 was considered statistically significant, suggesting the presence of presence publication bias. The I2 statistic was used to assess heterogeneity between studies. The study's overall effect was evaluated using the random effects model.

MAIN RESULT

The study included 20 studies to conduct a pooled prevalence analysis. The overall prevalence of healthcare providers' knowledge of active management of third-stage labor in sub-Saharan Africa was 47.975% (95% CI: 32.585, 63.365). Having pre- and in-service training (AOR: 2.25, 95% CI: 1.00, 5.08), having a higher degree (AOR: 1.98, 95% CI: 1.39, 2.82), and having good practices (AOR: 8.91, 95% CI: 4.58, 17.40) were significantly associated with healthcare provider's knowledge regarding active management third stage of labor.

CONCLUSIONS

The overall healthcare providers' knowledge of active management of the third stage of labor (AMTSL) was low in sub-Saharan Africa. Obstetric healthcare providers should undertake comprehensive training covering all AMTSL components through pre- and in-service diploma training programs.

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

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

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Effect of umbilical cord drainage after spontaneous delivery in the third stage of labor

Umbilical cord drainage involves releasing the cord clam from the umbilical cord after separation of the newborn from the maternal end of the umbilical cord. Consequently, there is emptying of blood from the placenta. This procedure is part of the active management of the third stage of labor (TSL).

OBJECTIVE

This study is intended to provide knowledge about the duration of TSL and the risk of retention of the placenta using umbilical cord drainage and the no-drainage procedure.

MATERIALS AND METHODS

A prospective randomized study of the management of the third stage of labor in 600 patients. The patients were equally divided into two groups with umbilical cord drainage (300) and without umbilical cord drainage (300). TSL was actively managed by FIGO (the International Federation of Gynecology and Obstetrics) recommendations. We monitored the duration of TSL and retention of the placenta after a 30 min period.

RESULTS

The mean duration of TSLwas 6.8 ± 0.4 min in the drainage group and 11.6 ± 0.8 min in the control group. We conclude that umbilical cord drainage significantly shortens the duration of TSL (P = 0.026) as well as reduces the risk of placental retention. In a group where we use the drainage of the umbilical cord, placental retention 30 min after delivery of the fetus occurred in four cases while the second set occurred in 14 cases (RR 3.62; 95% CI 1.18-11.14).

CONCLUSION

We assume that during umbilical cord drainage, the collapse of thin-walled uteroplacental vessels occurs earlier causing bleeding from these vessels between the placenta and the uterine wall, and therefore, earlier separation of the placenta occurs. Of course, the drainage of the umbilical cord is only one step in the algorithm of active management at the third stage of labor according to FIGO.

A Comparative Study of Sublingual Misoprostol Versus Intramuscular Oxytocin in the Active Management of Third Stage of Labor

Objective Misoprostol has attracted low-income low-resource countries for the active management of the third stage of labor. The objective of this study was to compare the efficacy of sublingual misoprostol and intramuscular oxytocin in the active management of the third stage of labor. Study design This was a prospective randomized controlled trial in which a total of 407 healthy pregnant women having singleton pregnancy, cephalic presentation, and normal vaginal delivery were divided into two groups. In the first group (n=203), women received 600 µg misoprostol tablet sublingually, and in the second group (n=204), women received 10 IU of intramuscular oxytocin, within 1 minute of the delivery of the baby during the third stage of labor. Three patients from the first group and four patients from the second group were excluded from the analysis due to traumatic postpartum hemorrhage (PPH). The primary outcome was an incidence of PPH. Secondary outcomes were the duration of the third stage of labor, amount of blood loss, fall in hemoglobin concentration after 48 hours of delivery, need for additional uterotonics, and side effects of the drugs. Data were compared using the chi-square and independent samples t-test. Results The incidence of PPH was 6.5% in the misoprostol group as compared to 2% in the oxytocin group (p=0.026). The misoprostol group also had significantly higher blood loss (293.75±125.8 mL) and a greater fall in hemoglobin level (0.58±0.25 g/dL) as compared to that in the oxytocin group (226.13±98.44 mL and 0.45±0.20 g/dL) (p<0.001). The mean duration of the third stage of labor was significantly higher in the misoprostol group (5.31±2.1 min) as compared to that in the oxytocin group (3.65±1.75 min) (p<0.001). The additional need for uterotonics was recorded in 15% of the study participants in the misoprostol group as compared to 8% in the oxytocin group (p=0.028). The incidence of side effects such as shivering and fever was significantly higher in the misoprostol group as compared to the oxytocin group. No significant difference between the two groups was observed concerning the incidence of nausea, vomiting, diarrhea, and headache. Conclusion Intramuscular oxytocin is a safe and useful alternative to sublingual misoprostol in facilitating the third stage of labor with minimal blood loss, fewer incidences of hemorrhage, and fewer adverse effects.

Reassessing the duration of each stage of labor and their relation to postpartum hemorrhage in the current Japanese population

AIM

To reassess the normal duration of each stage of labor in a contemporary Japanese cohort, and to determine whether prolongation of each stage of labor increases the rate of postpartum hemorrhage (PPH) in vaginal deliveries.

METHODS

Clinical data of women who delivered at term at 12 facilities between 2012 and 2018 were retrospectively collected. A total of 31 758 women were subdivided into three or four subgroups according to the duration of each stage of labor and parity. Univariate and multivariate logistic regression analyses were performed to estimate crude and adjusted odds ratios (ORs) of PPH (blood loss ≥ 1000 mL) in each subgroup, with women with the shortest durations in each subgroup used as the reference group.

RESULTS

The reference range of each stage of labor was found to be shorter than that previously reported. Women with prolonged second (primiparity, adjusted OR: 1.15-1.78; multiparity, adjusted OR: 1.14-1.74) and third (primiparity, adjusted OR: 1.39-4.95; multiparity, adjusted OR: 1.46-3.80) stages of labor showed an increased risk of PPH, whereas those with prolonged first stage did not. A significantly increased risk of PPH was found both in primiparous and multiparous women with third stages of labor ≥ 5 min.

CONCLUSIONS

The normal duration of each stage of labor in the Japanese population needs to be revised and well-recognized by obstetric care providers. A prolonged third stage of labor was a more important contributing factor to PPH than prolonged first or second stages.

Manual removal of the placenta and postpartum hemorrhage: A multicenter retrospective study

AIM

In postpartum women, retained placenta is diagnosed in the absence of signs of placental separation and expulsion, and requires manual removal of the placenta (MROP). MROP may lead to massive hemorrhage, hemodynamic instability, and the need for emergency interventions including blood transfusion, interventional radiology, and hysterectomy. In this study, we aimed to identify the risk factors for retained placenta requiring MROP after vaginal delivery and postpartum hemorrhage (PPH) following MROP.

METHODS

A multicenter retrospective study was performed using data from women who delivered at term between 2010 and 2018 at 13 facilities in Japan. Of 36 454 eligible women, 112 women who required MROP were identified. Multivariate logistic regression analyses were conducted to evaluate the risk factors for retained placenta and PPH following MROP.

RESULTS

A history of abortion, assisted reproductive technology (ART), instrumental delivery, and delivery of small-for-gestational-age infant were independent risk factors for MROP (adjusted odds ratios [95% confidence intervals]: 1.93 [1.28-2.92], 8.41 [5.43-13.05], 1.80 [1.14-2.82], and 4.32 [1.97-9.48], respectively). ART was identified as an independent risk factor for PPH (adjusted odds ratio [95% confidence interval]: 6.67 [2.42-18.36]) in patients who underwent MROP.

CONCLUSION

ART pregnancies significantly increased the risk of retained placenta requiring MROP and PPH. Our results suggest that clinicians need consider patient transfer to a higher-level facility and preparation of sufficient blood products before initiating MROP in cases of ART pregnancies. Our study may assist in identifying high-risk women for PPH before MROP and in guiding treatment decisions, especially in facilities without a blood bank.

Prospective evaluation of clinical characteristics and maternal outcomes of women with pathologically confirmed postpartum retained placental fragments

OBJECTIVE

To determine the incidence, risk factors, and short-term maternal outcomes of women with pathologically confirmed retained products of conception (RPOC) following vaginal delivery.

METHODS

Prospective cohort study of women with suspicion of RPOC following vaginal delivery, from March 2018 to April 2019. Women were followed for eight weeks postpartum. Women with complete retained placenta were excluded. Women with pathologically confirmed RPOC were compared to those without. Univariate analysis was conducted (ORs; [95% CI]) and was followed by multivariate analysis (aOR; [95% CI]).

RESULTS

During the study period, there were 16,583 vaginal deliveries. A total of 96 women (0.58%) with a suspicion of RPOC were enrolled, of these, 53 women (55%) had pathologically confirmed RPOC. The most significant risk factors for pathologically confirmed RPOC were placental abruption (aOR 5.0 [2.29-11.13]) and Oxytocin augmentation of labor (aOR 1.7 [1.07-2.63]). Pathologically confirmed RPOC were associated with higher rates of prolonged hospitalization (OR 9.2 [2.83-30.05]), postpartum hemorrhage (PPH) (OR 6.6 [3.60-11.98]), hemoglobin drop > 3 g/dl (OR 11.4 [5.49-23.49]), and blood transfusion (OR 8.6 [2.07-38.18]). Women who had exploration of uterine cavity without pathological confirmation of RPOC, still had higher rates of perineal laceration (OR 17.6 [4.93-63.08]), PPH (OR 6.1 [3.05-12.21]), and a hemoglobin drop > 3 g/dl (OR 6.0 [2.13-16.95]).

CONCLUSIONS

Pathologically confirmed RPOC following vaginal delivery has unique characteristics and is associated with significantly higher rates of PPH and blood transfusions. These findings may assist in the development of better criteria for selecting women for manual exploration and for preventive measures to reduce PPH and complications.

Does Delayed Cord Clamping Improve Long-Term (≥4 Months) Neurodevelopment in Term Babies? A Systematic Review and a Meta-Analysis of Randomized Clinical Trials

Background: Recently, the literature suggested that placental transfusion facilitated by delayed cord clamping (DCC), besides having benefits on hematological parameters, might improve the infants' brain development. Objective: The present review primarily evaluates the Ages and Stages Questionnaire (ASQ) total score mean difference (MD) at long-term follow-up (≥4 months) comparing DCC (>90 or >180 s) to early cord clamping (ECC). Secondary aims consisted of evaluating the ASQ domains' MD and the results obtained from other methods adopted to evaluate the infants' neurodevelopment. Methods: MEDLINE, Scopus, Cochrane, and ClinicalTrials.gov databases were searched (up to 2nd November 2020) for systematic review and meta-analysis. All randomized controlled trials (RCTs) of term singleton gestations received DCC or ECC. Multiple pregnancies, pre-term delivery, non-randomized studies, and articles in languages other than English were excluded. The included studies were assessed for bias and quality. ASQ data were pooled stratified by time to follow up. Results: This meta-analysis of 4 articles from 3 RCTs includes 765 infants with four-month follow-up and 672 with 12 months follow-up. Primary aim (ASQ total score) pooled analysis was possible only for 12 months follow-up, and no differences were found between DCC and ECC (MD 1.1; CI 95: -5.1; 7.3). DCC approach significantly improves infants' communication domains (MD 0.6; CI 95: 0.1; 1.1) and personal-social assessed (MD 1.0; CI 95: 0.3; 1.6) through ASQ at 12 months follow-up. Surprisingly, the four-month ASQ personal social domain (MD -1.6; CI 95: -2.8; -0.4) seems to be significantly lower in the DCC group than in the ECC group. Conclusions: DCC, a simple, non-interventional, and cost-effective approach, might improve the long-term infants' neurological outcome. Single-blinding and limited studies number were the main limitations. Further research should be performed to confirm these observations, ideally with RCTs adopting standard methods to assess infants' neurodevelopment. Trial registration: NCT01245296, NCT01581489, NCT02222805, NCT01620008, IRCT201702066807N19, and NCT02727517.

Complications of the third stage of labor in in vitro fertilization pregnancies: an additional expression of abnormal placentation?

OBJECTIVE

To assess the correlation between in vitro fertilization (IVF) and complications of the third stage of labor.

DESIGN

Retrospective cohort of vaginal deliveries from November 2008 to January 2020. Maternal and obstetric outcomes of singleton deliveries were compared between IVF and non-IVF pregnancies.

SETTING

University hospital.

PATIENT(S)

Women with live singleton vaginal deliveries at >24 weeks of gestation.

INTERVENTION(S)

In vitro fertilization-attained pregnancies (compared with spontaneous ones).

MAIN OUTCOME MEASURE(S)

Complications of the third stage of labor, defined as manual placental removal (either entire removal due to nonseparation or exploration of the uterine cavity due to suspected retained products of conception).

RESULT(S)

Overall, 1,264 IVF pregnancies and 34,166 non-IVF pregnancies were included. Deliveries in the IVF group were characterized by an older maternal age, lower parity, higher rate of diabetes and hypertensive disorders, higher rate of placental abnormalities, earlier gestational age, higher rate of labor induction, chorioamnionitis, and instrumental delivery. Complications of the third stage of labor occurred in 5.9% of IVF deliveries and in 2.8% of controls, and blood transfusion was more prevalent in IVF deliveries. The rate of complications of the third stage were higher in both fresh and frozen transfer cycles as compared with spontaneous pregnancies (5.8%, 8.8%, and 2.8%, respectively), although no difference was noted between fresh and frozen transfers. In vitro fertilization was associated independently with complications of the third stage of labor after adjustment for potential confounders.

CONCLUSION(S)

In vitro fertilization is associated independently with an increased risk of complications of the third stage of labor.

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

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

Complications of the third stage of labor are more prevalent in IVF pregnancies

Background: Pregnancies conceived by in vitro fertilization (IVF) are associated with a higher prevalence of perinatal complications than pregnancies conceived spontaneously, even after correction of confounding factors. Little is known about the prevalence of complications of the third stage of labor in IVF pregnancies.Objective: To compare the prevalence and types of complications of the third stage of labor following vaginal delivery of singleton infants born to matched groups of women who conceived through IVF or spontaneously.Study design: A retrospective case-control study design was used. The electronic delivery files of a tertiary medical center were reviewed for all women with a singleton IVF pregnancy who gave birth by vaginal delivery from August 2011 to March 2014. The women were matched 1:2 for age, gravidity, parity, and week of delivery to women with a singleton spontaneously conceived pregnancy who gave birth by vaginal delivery during the same period at the same hospital. The impact of mode of conception on the length and complications of the third stage of labor was evaluated.Results: The study group consisted of 242 women with IVF pregnancies (cases), and 484 matched controls with spontaneously conceived pregnancies (controls). The length of the third stage was similar in the cases and controls (14.23 ± 8.89 and 13.69 ± 9.19 min, respectively). IVF pregnancy was associated with a significantly higher rate of postpartum hemorrhage (PPH) (5.79 versus 1.45%, p = .001), manual removal of retained placenta (11.98 versus 7.02%, p = .025), and blood transfusion (2.07 versus 0.41%, p = .032). On multivariate analysis, pregnancy conceived by IVF was an independent risk factor for an adverse outcome of the third stage of labor (OR 2.86, 95% CI 1.53-5.33).Conclusion: After correction for confounders, IVF conception proved to be a significant independent risk factor for PPH, manual removal of the placenta, and blood transfusion in the third stage of labor. Therefore, the management of women who give birth vaginally following IVF pregnancy should be designed to anticipate complications in the third stage even in the absence of other risk factors.

The duration of the third stage in relation to postpartum hemorrhage

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Isolated single umbilical artery and the risk of adverse perinatal outcome and third stage of labor complications: A population-based study

INTRODUCTION

Isolated single umbilical artery (iSUA) refers to single umbilical artery cords with no other fetal malformations. The association of iSUA to adverse outcome of pregnancy has not been consistently reported, and whether iSUA carries increased risk of third stage of labor complications has not been studied. We aimed to investigate the risk of adverse perinatal outcome, third stage of labor complications, and associated placental and cord characteristics in pregnancies with iSUA. A further aim was to assess the risk of recurrence of iSUA and anomalous cord or placenta characteristics in Norway.

MATERIAL AND METHODS

This was a population-based study of all singleton pregnancies with gestational age >16 weeks at birth using data from the Medical Birth Registry of Norway from 1999 to 2014 (n = 918 933). Odds ratios (OR) with 95% confidence intervals were calculated for adverse perinatal outcome (preterm birth, perinatal and intrauterine death, low Apgar score, transferral to neonatal intensive care ward, placental and cord characteristics [placental weight, cord length and knots, anomalous cord insertion, placental abruption and previa]), and third stage of labor complications (postpartum hemorrhage and the need for manual placental removal or curettage) in pregnancies with iSUA, and recurrence of iSUA using generalized estimating equations and logistic regression.

RESULTS

Pregnancies with iSUA carried increased risk of adverse perinatal outcome (OR 5.06, 95% confidence interval [CI] 4.26-6.02) and perinatal and intrauterine death (OR 5.62, 95% CI 4.69-6.73), and a 73% and 55% increased risk of preterm birth and small-for-gestational-age neonate, respectively. The presence of iSUA also carried increased risk of a small placenta, placenta previa and abruption, anomalous cord insertion, long cord, cord knot and third stage of labor complications. Women with iSUA, long cord or anomalous cord insertion in one pregnancy carried increased risk of iSUA in the subsequent pregnancy.

CONCLUSIONS

The presence of ISUA was associated with a more than five times increased risk of intrauterine and perinatal death and with placental and cord complications. The high associated risk of adverse outcome justifies follow up with assessment of fetal wellbeing in the third trimester, intrapartum surveillance and preparedness for third stage of labor complications.

Recurrence of retained placenta in multiple consecutive deliveries

Objective: Retained placenta is a leading cause of maternal hemorrhage. A history of retained placenta is a well-recognized risk factor for recurrence; however, recurrence risk pattern has not been previously described. We aimed to evaluate the longitudinal recurrence pattern of retained placenta in multiple consecutive deliveries.Methods: This is a retrospective computerized base study conducted at Shaare Zedek Medical Center, a university-affiliated hospital, between 2005 and 2018. Medical records of parturient who had at least one coded diagnosis of either retained partial or complete placenta were retrieved. The first delivery with retained placenta diagnosis was chosen as the index delivery. In order to account for dependency between deliveries of the same individual parturient, we used a multivariate binary logistic regression with generalized estimating equation (GEE) to calculate the individual recurrence risk, adjusted odds ratios (95% confidence interval).Results: During the study period, we identified 2177 parturient diagnosed with retained placenta in the index delivery and that had at least one subsequent delivery; overall 300 (13.8%) parturient had at least one subsequent event of retained placenta: 9.3% for the subsequent delivery and 6% in later deliveries. Induction of labor and epidural analgesia either in the index or in the subsequent delivery were found to be independently associated with recurrence 1.61 (1.16-2.24), 1.45 (1.10-1.90) and 1.46 (1.11-1.93), 1.82 (1.45-2.28), respectively. Complete and not partial retained placenta in the index delivery was also found to be independently associated with recurrence 4.90 (3.90-6.32).Conclusion: For the individual parturient, an event of retained placenta is a sentinel of the subsequent deliveries and has modifiable recurrence risks.

The relationship between attitude toward labor pain and length of the first, second, and third stages in primigravida women

INTRODUCTION

Factors affecting labor pain include physiological, psychological, and social factors, among which psychological factors refer to attitudes and beliefs about labor pain. Hence, the present study was conducted to determine the relationship between attitude toward labor pain and length of the first, second, and third stages in primigravida women.

MATERIALS AND METHODS

This cross-sectional study was performed on 230 pregnant women who were referred to hospitals affiliated to Isfahan University of Medical Sciences in a two-stage sampling in 2018. In the beginning, the participants completed the questionnaire of demographic/fertility characteristics and attitude to labor pain (25Q), and at the next stage, the researcher completed the form of labor information including length of the labor stages. Data were analyzed by SPSS software version 22 and Pearson correlation coefficient, Student's t-test, one-way ANOVA, and general linear regression.

RESULTS

The mean (standard deviation) of the attitude to labor pain was 53.96 (1.9), and the length of the first stage was 10.01 (0.3) (h), the second stage was 1.6 (0.4) (h), and the third stage was 15.9 (1.7) (min). One hundred and eighty-three (79.6%) had negative attitude and 47 (20.4%) had positive attitude toward labor pain. There was a significant positive correlation between attitude toward labor pain and length of the first (P = 0.001, r = 0.37) and second stages of labor (P = 0.001, r = 0.24). There was no significant between length of third stage of labor and attitude toward labor pain (P = 714).

CONCLUSION

The results showed that the majority of primiparous women had a higher (negative) attitude toward labor pain, which was associated with longe the first and second stages of labor.

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

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

Variables That Influence US Midwife and Physician Management of the Third Stage of Labor

INTRODUCTION

Midwives and physicians incorporate their knowledge, experiences, and other variables in making clinical decisions. Variations in the management of the third stage of labor may be a result of variables that influence providers' decision making. The purpose of this study was to describe variables that influence US midwives' and physicians' management of the third stage of labor.

METHODS

A randomly selected national sample of certified nurse-midwives and certified midwives, certified professional midwives, obstetricians, and family physicians was surveyed about the extent to which maternal characteristics, maternal history, and current birth characteristics influence their third-stage management. The extent of influence was defined in terms of always to never altering management. Descriptive summaries, group comparisons, and partial correlations were used to determine differences in influences between midwives and physicians. One free-text question was analyzed using qualitative methods.

RESULTS

A total of 1243 clinicians responded. There was considerable variability in the response patterns in that the same variable was reported to always alter management during the third stage of labor for some participants yet did not influence the management practices of others at all. Differences between responses from midwives and physicians were explored as a possible explanation for some of the variability. In response to the free-text inquiry about variables that most influenced changes in participants' usual management of the third stage, the participants most often included active bleeding, current recommendations or guidelines, and maternal or family preferences.

DISCUSSION

This study identifies variables reported as influencing clinical decision making during the third stage of labor. Therefore, these variables are important to consider when evaluating interventions and outcomes related to management of the third stage of labor and any attempts to design new interventions. The findings are descriptive of practice; they are not intended to guide changes in practice.

The clinical research into the application of multifunctional airbag abdominal pressure belt in midwifery and in the prevention of postpartum hemorrhage

OBJECTIVE

Explore the effect of the multifunctional airbag abdominal pressure belt on midwifery and on the prevention of postpartum hemorrhage.

METHODS

Select 363 natural delivery cases of hospitalized primiparae and divide them randomly into two groups. In the observation group, 182 primiparae used the multifunctional airbag abdominal pressure belt during the second and third stages of labor, whereas the control group of 181 did not use the belt. Delivery outcomes of the primiparae and their fetus were then observed.

RESULTS

The average duration for the second stage of labor, from head emergence to delivery, placenta delivery and postpartum hemorrhage were all shorter in the observation group (p < 0.01). There was no statistical difference in episiotomy rate, maternal signs 2 h postpartum, neonatal Apgar score and neonatal cord blood gas analysis (p > 0.05). No statistical difference was found in primipara signs and no fetal heart rate change of the primiparae under different internal pressures of the belt during the second stage of labor in the observation group (p > 0.05).

CONCLUSION

By closely monitoring and appropriately adjusting the internal pressure of the belt, the multifunctional airbag abdominal pressure belt can speed up the second and third stages of labor, prevent postpartum hemorrhage and promote natural delivery.

Comparison of active vs. expectant management of the third stage of labor in women with low risk of postpartum hemorrhage: a randomized controlled trial

OBJECTIVES

To compare the 'strictly' active management protocol in women with low risk of postpartum hemorrhage using the expectant management protocol with respect to changes in hematologic parameters, uterotonics, blood transfusions, or additional interventions.

MATERIAL AND METHODS

A randomized controlled prospective trial in which 934 singleton parturients enrolled; 654 were randomly assigned to the active and mixed management groups. The primary outcome parameter was the reduction in hemoglobin concentrations due to delivery, and the secondary outcome parameters were changes in hemoglobin of more than 3 g/dL (ΔHb ≥ 3 g/dL), durations of the third stage of labor, need for additional uterotonic agents, blood transfusions, manual removal of the placenta, and surgical evacuation of retained products of conception.

RESULTS

The mean postpartum hemoglobin concentration was significantly higher (P = 0.04) in the active management group with a significantly lower reduction (P = 0.03). Falls of hemoglobin levels of more than 3 g/dL (ΔHb ≥ 3g/dL) were less common in the active management group though not significantly (P = 0.32). The mean duration of the third stage of labor was significantly (P < 0.001) shorter in the active management group. There was no significant difference between the two groups with regard to the need for additional uterotonic agents, uterine atony, blood transfusion, manual removal of the placenta, surgical evacuation of retained products of conception, and prolonged third stage of labor.

CONCLUSIONS

Although active management of the third stage of labor was associated with higher postpartum hemoglobin levels, it did not influence the risk of 'severe postpartum hemorrhage' in women with low risk of postpartum hemorrhage.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of sequential use of oxytocin and sublingual nitroglycerin in the cases of retained placenta

OBJECTIVES

To evaluate the effects of adding sublingual nitroglycerin to oxytocin, for delivery of retained placenta after vaginal delivery.

METHOD

The study was performed as a placebo controlled clinical trial on women who did not finish delivering placenta after 30 min of active management of the third stage of labor. In case group, 1 mg nitroglycerin and in the control group, placebo was prescribed sublingually.

RESULTS

In total, 80 women finished the study. The number of manual removal of placenta did not show significant difference between the two groups [25 women (62.5%) in the case and 30 women (75%) in the control group, p = 0.335]. There was no significant difference between the two groups according to duration of the third stage of labor, hemoglobin index, decline in HB index >30% and maternal vital signs after treatment. There was no significant difference between the two groups according to adverse effects [eight women (20%) in the case group and four (10%) in the control group (p = 0.348)].

CONCLUSION

The sequential use of oxytocin and sublingual nitroglycerin could not lead to delivery of more placentas and did not reduce the necessity of manual removal of placenta in comparison with placebo.

Third stage of labor risks in velamentous and marginal cord insertion: a population-based study

OBJECTIVE

To assess whether anomalous cord insertion is associated with risk of complications in the third stage of labor.

DESIGN

A population-based study.

SETTING

Norwegian Medical Birth Register.

POPULATION

All singleton births (gestational age >16 weeks and <45 weeks) during the period 1999-2011 (n = 738,443 singletons). Deliveries by cesarean were excluded, leaving 628,680 vaginal singleton deliveries for the analyses.

METHODS

Calculation of odds ratios for complications in the third stage of labor (postpartum hemorrhage, manual delivery of the placenta, curettage) in velamentous and marginal cord insertion by logistic regression with adjustment for confounders.

MAIN OUTCOME MEASURES

Complications in the third stage of labor, postpartum hemorrhage, manual placental removal and curettage.

RESULTS

Anomalous cord insertion was associated with an increased risk of complications in the third stage of labor, the risk being higher for velamentous than for marginal insertion. The risks persisted after adjusting for possible confounding factors. Velamentous cord insertion carried a 5.6% risk of a need for manual removal of the placenta, compared with the risk of 1.1% for nonvelamentous insertion (odds ratio = 5.21, 95% confidence interval 4.71-5.76) in vaginal delivery, and we found increased risks of curettage (odds ratio = 3.29, 95% confidence interval 2.87-3.77) and postpartum hemorrhage (odds ratio = 2.06, 95% confidence interval 1.77-2.39).

CONCLUSIONS

Marginal and especially velamentous cord insertion is associated with an increased risk of hemorrhage in the third stage of labor, need for manual removal of the placenta and curettage. Anomalous cord insertion can be identified prenatally and so possibly influence obstetric management.

Influence of acupuncture on the third stage of labor: a randomized controlled trial

INTRODUCTION

A prolonged third stage of labor is considered to be a risk factor for postpartum hemorrhage. The objective of this study was to determine the ability of acupuncture to reduce the length of the third stage of labor.

METHODS

Seventy-six puerperal women who had a normal spontaneous birth at the Hospital Universitario Principe de Asturias, Alcalá de Henares, Spain, were included in a single-blind randomized trial and evaluated by a third party. Women were randomly assigned to receive true acupuncture or placebo acupuncture (also known as sham acupuncture). In the first group, a sterilized steel needle was inserted at the Ren Mai 6 point, which is located on the anterior midline between the umbilicus and the upper part of the pubic symphysis. In the second group, the insertion site was located at the same horizontal level as the Ren Mai 6 point but shifted slightly to the left of the anterior midline. The management of the third stage of labor was the same in both groups.

RESULTS

Statistically significant differences were found, with an average time to placental expulsion of 15.2 minutes in the placebo group and 5.2 minutes in the acupuncture group. No major complications occurred in either group.

DISCUSSION

These results confirm that acupuncture at the Ren Mai 6 point can decrease the time to placental expulsion. This treatment represents a simple, safe, and inexpensive way of decreasing the duration of the third stage of labor.

An exploration of how midwives and physicians manage the third stage of labor in the United States

INTRODUCTION

Care of the woman during the third stage of labor is a critical component of good patient outcomes. The type and extent of activities used in the United States, including those suggested for active management of the third stage of labor, are unknown. This study obtained preliminary data for the development of a national study of interventions used by US birth attendants during the third stage of labor, work that will ultimately lead to a study examining links between activities and outcomes. The specific aims were to identify provider-reported assessments and interventions used during the third stage of labor and to examine which management steps or interventions providers believe should always be used during the third stage of labor.

METHODS

Four provider-specific focus groups (certified nurse-midwives, certified professional midwives, obstetricians, and family practice physicians) were held using a nominal group technique. Two researchers analyzed audio-recorded transcriptions independently.

RESULTS

More than 100 assessments, 110 interventions, and 65 "always used" activities were identified. There was variation within and across groups. Midwife groups were more likely to specify maternal preference activities, and physician groups were more likely to specify drug-related actions.

DISCUSSION

Surveys of third-stage labor practices must include large numbers of actions to represent what may be the state of US practices. Survey design may need to include a multiple-forms approach to avoid participant burden. Designs should include the exploration of differences by provider type as well as within provider variation.

Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study

OBJECTIVE

The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH).

METHODS

This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ(2) tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000 cc), retained placenta over 30 min and manual removal of the placenta.

RESULTS

A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50-0.97; p = 0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta.

CONCLUSIONS

In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.

A comparison of oxytocin and carboprost tromethamine in the prevention of postpartum hemorrhage in high-risk patients undergoing cesarean delivery

The aim of this study was to compare carboprost with oxytocin for the prevention of postpartum hemorrhage (PPH) in females with a high risk of PPH undergoing cesarean delivery. Patients were randomly divided into three groups that received different uterotonics (oxytocin, carboprost and oxytocin plus carboprost) during cesarean section, following the delivery of the infant. A total of 117 females (age range, 19–40 years) at 35–40 weeks gestation who delivered by cesarean between December, 2010 and May, 2012 were included in this study. There were 29 cases of twins, 12 cases of polyhydramnios, 23 cases of placenta previa and 53 cases of fetal macrosomia. There were 37 patients in the oxytocin group, 36 in the carboprost group and 44 in the oxytocin plus carboprost group. No significant differences were identified in maternal age, gravidity/parity, gestational age and reason for cesarean delivery between the three groups. The median blood loss in the oxytocin, carboprost and oxytocin plus carboprost groups was 610, 438 and 520 ml, respectively. The blood loss in the carboprost group was significantly lower than that in the oxytocin and oxytocin plus carboprost groups (both P<0.05). Vomiting occurred in eight patients from the carboprost group, two from the oxytocin group and two from the oxytocin plus carboprost group (P=0.036). Carboprost was more effective than oxytocin in preventing PPH in high-risk patients undergoing cesarean delivery.

A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood loss

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.