The Bristol third stage trial: active versus physiological management of third stage of labour

Ascending dose tolerance study of intramuscular carbetocin administered after normal vaginal birth

OBJECTIVE

To determine the maximum tolerated dose (MTD) of carbetocin (a long-acting synthetic analogue of oxytocin), when administered immediately after vaginal delivery at term.

MATERIALS AND METHODS

Carbetocin was given as an intramuscular injection immediately after the birth of the infant in 45 healthy women with normal singleton pregnancies who delivered vaginally at term. Dosage groups of 15, 30, 50, 75, 100, 125, 150, 175 or 200 microg carbetocin were assigned to blocks of three women according to the continual reassessment method (CRM).

RESULTS

All dosage groups consisted of three women, except those with 100 microg (n=6) and 200 microg (n=18). Recorded were dose-limiting adverse events: hyper- or hypotension (three), severe abdominal pain (0), vomiting (0) and retained placenta (four). Serious adverse events occurred in seven women: six cases with blood loss > or = 1000 ml, four cases of manual placenta removal, five cases of additional oxytocics administration and five cases of blood transfusion. Maximum blood loss was greatest at the upper and lower dose levels, and lowest in the 70-125 microg dose range. Four out of six cases with blood loss > or = 1000 ml occurred in the 200 microg group. The majority of additional administration of oxytocics (4/5) and blood transfusion (3/5) occurred in the dose groups of 200 microg. All retained placentae were found in the group of 200 microg.

CONCLUSION

The MTD was calculated to be at 200 microg carbetocin.

Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial

BACKGROUND

This study tested the hypotheses that active management of the third stage of labour lowers the rates of primary postpartum haemorrhage (PPH) and longer-term consequences compared with expectant management, in a setting where both managements are commonly practised, and that this effect is not mediated by maternal posture.

BACKGROUND

1512 women judged to be at low risk of PPH (blood loss >500 mL) were randomly assigned active management of the third stage (prophylactic oxytocic within 2 min of baby's birth, immediate cutting and clamping of the cord, delivery of placenta by controlled cord traction or maternal effort) or expectant management (no prophylactic oxytocic, no cord clamping until pulsation ceased, delivery of placenta by maternal effort). Women were also randomly assigned upright or supine posture. Analyses were by intention to treat.

FINDINGS

The rate of PPH was significantly lower with active than with expectant management (51 [6.8%] of 748 vs 126 [16.5%] of 764; relative risk 2.42 [95% CI 1.78-3.30], p<0.0001). Posture had no effect on this risk (upright 92 [12%] of 755 vs supine 85 [11%] of 757). Objective measures of blood loss confirmed the results. There was more vomiting in the active group but no other important differences were detected.

INTERPRETATION

Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.

Intra-umbilical vein injection and retained placenta: evidence from a collaborative large randomised controlled trial. Grupo Argentino de Estudio de Placenta Retenida

OBJECTIVE

To determine whether intra-umbilical vein injection with saline solution, with or without oxytocin, reduces the need for manual removal of placenta compared with expectant management.

DESIGN

Multicenter, randomised controlled trial.

SETTING

Eleven hospitals in four cities of Argentina: Buenos Aires, Corrientes, Rosario, and Salta.

PARTICIPANTS

Two hundred and ninety-one women showing no evidence of placental separation thirty minutes after vaginal delivery.

INTERVENTIONS

Three different management strategies: 1. intra-umbilical vein injection of saline solution plus oxytocin; 2. intra-umbilical vein injection of saline solution alone; and 3. expectant management.

MAIN OUTCOME MEASURES

Primary: manual removal of the placenta. Secondary: blood loss after trial entry, haemoglobin level at 24 to 48 hours and at 40 to 45 days after delivery, blood transfusion, curettage, infection, and days of hospital stay.

RESULTS

Rates of subsequent manual removal were similar: intra-umbilical vein injection of saline solution plus oxytocin (58%; RR 0.92; 95% CI 0.73-1.15), or saline alone (63%; RR 1.00; 95% CI 0.80-1.24), compared with expectant management (63%). There were also no detectable effects of the active managements on any of the secondary measures of outcome.

CONCLUSIONS

Based on evidence available from randomised controlled trials, including this trial, it is unlikely that intra-umbilical injection with or without oxytocin, is clinically useful. We recommend that this intervention should not be used in third stage management of labour.

Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial

OBJECTIVES

Our purpose was to compare the controlled cord traction technique with the minimal intervention technique for delivery of the placenta. The primary outcome was the incidence of postpartum hemorrhage. Secondary outcomes included duration of third stage of labor, frequency of retained placenta, hemorrhagic shock, the need for blood transfusion, and the need for uterotonic agents to control postpartum hemorrhage.

STUDY DESIGN

A total of 1648 women who were delivered vaginally were randomly allocated during labor to the controlled cord traction group (n = 827) or the minimal intervention group (n = 821). In the controlled cord traction group women received oxytocin, 10 units intramuscularly, with delivery of the baby's anterior shoulder, after which the placenta was delivered actively by controlled cord traction (Brandt-Andrews method). In the minimal intervention group the placenta was delivered by maternal pushing. Continuous intravenous oxytocin was given after delivery of the placenta. Odds ratios with 95% confidence intervals were calculated for each variable.

RESULTS

The overall incidence of postpartum hemorrhage was significantly lower in the controlled cord traction group (5.8% vs 11%; odds ratio 0.50, 95% confidence interval 0.34 to 0.73). The incidence of retained placenta (> or = 30 minutes) was 1.6% in the controlled cord traction group and 4.5% in the minimal intervention group (odds ratio 0.31, 95% confidence interval 0.15 to 0.63). Significantly more patients in the minimal intervention group required additional uterotonic agents to control hemorrhage (5.1% vs 2.3%; odds ratio 0.44, 95% confidence interval 0.24 to 0.78).

CONCLUSION

The controlled cord traction technique for delivery of the placenta results in a significantly lower incidence of postpartum hemorrhage and retained placenta, as well as less need for uterotonic agents, compared with the minimal intervention technique.

A randomized controlled study of birth center care versus standard maternity care: effects on women's health

BACKGROUND

The safety of birth center care for low-risk women is an important issue, but it has not yet been studied in randomized controlled trials. Our purpose was to evaluate the effect of birth center care on women's health during pregnancy, birth, and 2 months postpartum by comparing the outcomes with those of women experiencing standard maternity care in the greater Stockholm area.

METHODS

Of 1860 women, 928 were randomly allocated to birth center care and 932 to standard antenatal, intrapartum, and postpartum care. Information about medical procedures and health outcomes was collected from clinical records, and a questionnaire was mailed to women 2 months after the birth. Analysis was by "intention to treat;" that is, all antenatal, intrapartum, and postpartum transfers were included in the birth center group.

RESULTS

During pregnancy, birth center women made fewer visits to midwives and doctors, experienced fewer tests, and reported fewer health problems. No statistical difference occurred in hospital admissions (4.8%) compared with the control group (4.7%). During labor, birth center women used more alternative birth positions, had longer labors, and did not differ in perineal lacerations. In both groups 1.7 percent of women developed complications, requiring more than 7 days of hospital care after the birth. During the first 2 postpartum months, about 20 percent of women in both groups saw a doctor for similar types of health problems, and no statistical difference occurred in hospital readmissions, 1.4 and 0.8 percent in the birth center and control groups, respectively.

CONCLUSION

The results suggest that birth center care is effective in identifying significant maternal complications and as safe for women as standard maternity care.

Use of oral misoprostol in the prevention of postpartum haemorrhage

OBJECTIVE

To investigate the use of the oral prostaglandin E1 analogue, misoprostol in the prevention of postpartum haemorrhage.

DESIGN

A prospective observational study.

SETTING

A university teaching hospital.

PARTICIPANTS

Two hundred and thirty-seven consecutive women undergoing vaginal delivery.

METHODS

All the women were given 600 micrograms oral misoprostol just after delivery.

MAIN OUTCOME MEASURES

Rates of postpartum haemorrhage; need for therapeutic oxytocic drugs; retained placenta and length of the third stage of labour.

RESULTS

Postpartum haemorrhage occurred in 6% of the women; the need for therapeutic oxytocics in 5%, retained placenta in 2% and the median length of the third stage was 5 min. Vomiting and diarrhoea in the first hour after delivery occurred in 8% and 3% respectively and shivering in 60%.

CONCLUSIONS

Misoprostol may be effective in the prevention of postpartum haemorrhage, and has few side effects. A double blind randomised trial is required.

The prevention of post partum haemorrhage: optimising routine management of the third stage of labour

This paper concerns itself with the use of oxytocic therapy as part of the routine management of the third stage of labour. It attempts to answer three different questions: (1) do oxytocics reduce the risk of post partum haemorrhage (PPH) when used during the routine management of the third stage of labour? (2) does the clinical package of active management reduce the risk of PPH (3) which is the best oxytocic to use during routine active management of the third stage? It attempts to answer these questions by presenting the evidence from formal meta-analytical reviews of the randomised controlled trials of the pertinent intervention and by presenting the results of the two trials that were undertaken as a result of the hypotheses which were generated from the formal reviews.

The effect of intraumbilical oxytocin on the third stage of labour

The umbilical vein administration of oxytocin in saline was compared with umbilical vein saline alone and the traditional management of the third stage of labour. Seventy-two women were randomized to 3 groups. Group 1 received intraumbilical 20 IU of oxytocin diluted to 40 mL with saline. Group 2 received intraumbilical vein 40 mL of saline while subjects in group 3 were managed according to the standard protocol without any intraumbilical injection. No significant differences were found in terms of the length of the third stage, the blood loss in the third stage and postpartum haematocrit differences among the 3 groups. The administration of diluted oxytocin or saline do not seem to have any superiority to the traditional management of the third stage of labour.

Prevention of postpartum haemorrhage

Primary prevention of PPH is advocated at all levels of obstetric care. This implies active management of the third stage of labour also at the first and most peripheral levels of obstetric care. Active management includes the use of an oxytocic, early cord clamping and active delivery of the placenta. The oxytocic drug of choice at this moment is oxytocin 5 IU given intramuscularly. Women with high-risk factors for PPH (polyhydramnios, previous complications in third stage, APH or multiple pregnancies) should be delivered in hospital. Timely antepartum referral is necessary. In these women, prevention and anticipatory management includes the availability of intravenous treatment, as well as active management with an oxytocic. Evidence for the effectiveness of active management of the third stage of labour in women at low risk of PPH is not yet available. Whether women delivering at home with easy accessibility to hospital, or those at low risk delivering in hospital, should be actively managed remains controversial, and such an approach is not supported by us until a clinical trial in this particular group of women has shown the effectiveness of the active management.

Bioavailability and pharmacokinetics of sublingual oxytocin in male volunteers

The aim of this investigation was to assess the bioavailability and pharmacokinetics of oxytocin in six male subjects after a sublingual dose of 400 int. units (684 micrograms) and after an intravenous dose of 1 int. unit (1.71 micrograms). After intravenous administration, the pharmacokinetic profile could be described with a two-compartment model. The distribution half-life was 0.049 +/- 0.106 h, the elimination half-life was 0.33 +/- 0.23 h, the total body clearance was 67.1 +/- 13.4 L h-1 and the volume of distribution was 33.2 +/- 28.1 L. After sublingual administration, a poor bioavailability with a 10-fold variation between 0.007 and 0.07% was observed. The pharmacokinetic profile could be described with a one-compartment model. The lag time was subject-dependent and ranged between 0.12 and 0.30 h (40% CV). The absorption half-life was 0.45 +/- 0.29 h, and the apparent elimination half-life 0.69 +/ - 0.26 h. This study showed a very poor and interindividual variability in bioavailability. The sublingual route of administration with its 'long' lag time and 'long' absorption half-life would not seem a reliable route for accurate high dosing for immediate prevention of post-partum haemorrhage.

History of ergot alkaloids from ergotism to ergometrine

Epidemics of ergotism occurred frequently in the Middle Ages. They were a source of inspiration for artists and were popularly known as 'St. Anthony's Fire', resulting in gangrene, neurological diseases and death. It was caused by eating rye bread contaminated with the fungus claviceps purpurea. In 1582 it was described that a delivery could be hastened by administering a few spurs of the secale cornutum. The dosage was, however, very inaccurate resulting in frequent uterine ruptures. The nickname of the preparation of 'pulvis ad partum' was changed to 'pulvis ad mortem'. Therefore, after 1828 the ergot alkaloids were no longer used during delivery but only as a measure to prevent postpartum haemorrhage. From 1875 onwards many derivatives of ergot alkaloids were found. Dudley and Moir isolated ergometrine in 1932. It proved to have a very specific uterotonic action. However, because of severe and unpredictable side effects and the instability of the drug, ergometrine is not the drug of choice for either the prevention or the treatment of postpartum haemorrhage.

Third stage of labor: analysis of duration and clinical practice

OBJECTIVES

Our purpose was to record gestational age-specific data for third-stage duration of labor, frequencies of retained placentas (undelivered at 30 minutes), manual removal of the placenta, and hemorrhage.

STUDY DESIGN

Included were 45,852 singleton deliveries > or = 20 weeks' gestation from 1984 to 1992. Odds ratios, 95% confidence intervals, and actuarial life analysis with censoring of cases with manual placenta removal were performed.

RESULTS

The frequency of retained placentas (2.0% overall) was markedly increased among gestations < or = 26 weeks (odds ratio 20.8, 95% confidence interval 17.1 to 25.4) and < 37 weeks (odds ratio 3.0, 95% confidence interval 2.6 to 3.5) compared with term. The frequency of manual removal (3.0% overall) was increased among gestations < or = 26 weeks (odds ratio 9.2, 95% confidence interval 7.5 to 11.4) and < 37 weeks (odds ratio 2.8, 95% confidence interval 2.4 to 3.1) compared with term. Hemorrhage (3.5% overall) was increased among subjects with manual placenta removal (odds ratio 10.4, 95% confidence interval 9.1 to 11.9); hemorrhage was also increased among gestations < or = 26 weeks (odds ratio 3.0, 95% confidence interval 2.3 to 4.0) and < 37 weeks (odds ratio 1.2, 95% confidence interval 1.01 to 1.3) compared with term. The frequency of hemorrhage peaked by 40 minutes regardless of gestational age. Life-table analysis predicted 90% of placentas would spontaneously deliver by 180 minutes for gestations at 20 weeks, 21 minutes at 30 weeks, and 14 minutes at 40 weeks; the predicted frequency of retained placentas was 42% higher than the recorded incidence.

CONCLUSIONS

The duration of the third stage decreases and the frequencies of hemorrhage and manual removal decrease with increasing gestational age. Hemorrhage was associated with manual placental removal. Life-table analysis indicated that manual removal of placentas shortened the duration of the third stage of labor, especially among preterm deliveries. A prospective trial is needed to determine whether manual placental removal can reduce hemorrhage among prolonged third stages.

Evaluation of the meta-analyses on the effects, on both mother and baby, of the various components of 'active' management of the third stage of labour

In their comprehensive review of controlled trials, Prendiville and Elbourne (1989) used the technique of meta-analysis to study the effects, on both mother and baby, of various aspects of third stage management, acknowledging some of the shortcomings of the trials used. This paper questions some of the conclusions which these authors drew and, drawing on other evidence (some of which has been published since the review), puts forward alternative interpretations of some of the meta-analyses. Reference is also made to the updated meta-analyses in the Cochrane Pregnancy and Childbirth Database (Elbourne, 1994a-h). In addition, this paper examines the extent to which the findings of the Bristol and Dublin third stage trials (Prendiville et al, 1988; Begley, 1990) add to our understanding of what is effective care during the third stage of labour.

A matched cohort study of planned home and hospital births in Western Australia 1981-1987

OBJECTIVE

to evaluate practice comparing planned home birth with planned hospital birth

DESIGN

a retrospective analysis of a cohort who had planned to have a home birth compared with a matched hospital birth group

SETTING

Western Australia (WA) PARTICIPANTS: all women (N = 976) who 'booked' to have a home birth 1981-1987 and 2928 matched women who had a planned hospital birth (singleton births only).

MEASUREMENTS AND FINDINGS

women in the home birth group had a longer labour, were less likely to have had labour induced or to have had any sort of operative delivery. They were less likely overall to have had complications of labour, but more likely to have had a postpartum haemorrhage and more likely to have had a retained placenta. Babies in the home birth group were heavier and more likely to be post-term. They were less likely to have had an Apgar score below 8 at 5 minutes, to have taken more than 1 minute to establish respiration or to have received resuscitation. The crude odds ratio for planned home births for perinatal mortality was 1.25 (95% CI 0.44-3.55). Postneonatal mortality was more common in the hospital group. Planned home births were generally associated with less intervention than hospital births and with less maternal and neonatal morbidity, with the exception of third stage complications. Although not significant, the increase in perinatal mortality has been observed in other Australian studies of home births and requires continuing evaluation.

KEY CONCLUSIONS

Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births.

IMPLICATIONS FOR PRACTICE

whether these observed differences in intervention and morbidity have any relationship to the small, non-significant increase in perinatal mortality could not be determined in this study. Continuing evaluation of home birth practice and outcome is essential.

A simple alternative to parenteral oxytocics for the third stage of labor

OBJECTIVE

To determine the effect of nipple stimulation on uterine activity during the third stage of labor.

METHODS

Randomized controlled study comparing; (i) 15 min of nipple stimulation (n = 6), (ii) routine syntometrine injection (n = 3), (iii) no action/control (N = 5). Uterine activity was continuously measured using the placenta as an in-situ hydrostatic bag connected to a pressure transducer.

RESULTS

Compared to controls uterine pressure was higher during nipple stimulation (103 mmHg vs. 70.8 mmHg, P = 0.04). The duration of the third stage and blood loss tended to be reduced with nipple stimulation compared to controls (20.3 vs. 12.3 min) and (257 vs. 166 ml) respectively but was not significant. Similar differences were observed between syntometrine and control groups.

CONCLUSIONS

For women in developing countries where parenteral oxytocics are not available, nipple stimulation might reduce the incidence of postpartum hemorrhage. A larger trial now seems warranted.

Pharmacokinetics and bioavailability of oral ergometrine in male volunteers

The aim of this investigation was to assess the pharmacokinetics and bioavailability of ergometrine in six human male subjects after an oral dose of 0.200 mg and after an intravenous dose of 0.075 mg of ergometrine maleate. A large variation in bioavailability of between 34% and 117% in the six volunteers was observed. The lag time was also subject dependent and ranged between 0.0073 h (0.4 min) and 0.47 h (28 min). After intravenous administration, the pharmacokinetic profile can be described by a two-compartment model. The distribution half-life t1/2 alpha is 0.18 +/- 0.20 h, the elimination half-life t1/2 beta is 2.06 +/- 0.90 h, the total body clearance (CL) amounts to 35.9 +/- 13.4 l h-1 and the steady-state volume (Vss) of distribution is 73.4 +/- 22.01. After oral administration, the pharmacokinetic profile can be described by a one-compartment model. The absorption half-life t1/2 abs is 0.19 +/- 0.22 h, and the elimination half-life t1/2 beta 1.90 +/- 0.16 h. This study with oral ergometrine shows such a large interindividual variability in bioavailability that the oral route of administration does not seem not to be the most reliable means of accurate dosing in preventing post-partum haemorrhage.

Randomised controlled trial of oxytocin alone versus oxytocin and ergometrine in active management of third stage of labour

OBJECTIVE

To compare intramuscular oxytocin alone and intramuscular oxytocin with ergometrine (Syntometrine) for their effect in reducing the risk of postpartum haemorrhage when both are used as part of the active management of the third stage of labour.

DESIGN

Double blind, randomised controlled trial.

SETTING

Two metropolitan teaching hospitals in Perth, Western Australia.

SUBJECTS

All women who expected a vaginal birth during the period of the trial. Informed consent was obtained.

MAIN OUTCOME MEASURES

Postpartum haemorrhage, nausea, vomiting, and increased blood pressure.

RESULTS

3497 women were randomly allocated to receive oxytocin-ergometrine (n = 1730) or oxytocin (n = 1753). Rates of postpartum haemorrhage (> or = 500 ml or > or = 1000 ml) were similar in both arms (odds ratio 0.90 (0.82); 95% confidence interval 0.75 to 1.07 (0.59 to 1.14) at 500 ml (1000 ml) threshold). The use of oxytocin-ergometrine was associated with nausea, vomiting, and increased blood pressure.

CONCLUSIONS

There are few advantages but several disadvantages for the routine use of oxytoxinergometrine when prophylactic active management of the third stage of labour is practised. Further investigation of dose-response for oxytocin may be warranted.

Management of the third stage of labour in women at low risk of postpartum haemorrhage

OBJECTIVE

To compare active management with physiological management of the third stage of labour in women at low risk of postpartum haemorrhage.

DESIGN

Randomised allocation of women in labour at low risk of postpartum haemorrhage to either physiological or active management of the third stage.

SETTING

Labour ward in a district general hospital.

PATIENTS

193 Women with spontaneous vaginal delivery at term completed the study. Exclusion criteria were induction or augmentation of labour, antepartum or previous postpartum haemorrhage, premature rupture of membranes, previous caesarean section, raised blood pressure, cervical lacerations and third degree tears.

INTERVENTIONS

Active management with syntometrine and controlled cord traction; or physiological management, where the cord was not clamped and the placenta was delivered by maternal effort.

MEASUREMENTS

Blood loss was measured subjectively at delivery and estimated objectively by comparing the haemoglobin in labour with that on the third postpartum day. The duration of the third stage was also measured as was the incidence of retained placenta and blood transfusion.

RESULTS

There was no significant difference in the estimated blood loss or haemoglobin drop between the two groups (P > 0.5). In addition the duration of the third stage was significantly longer in the physiological group (P < 0.001). Out of 90 women having physiological management, 7 received oxytocics for presumed postpartum haemorrhage. Only one case in the active group required further oxytocics and one other case in this group required a manual removal of placenta.

CONCLUSIONS

This preliminary study confirms that active management results in a reduction in the length of the third stage of labour. However, it suggests that active management does not reduce blood loss when compared to physiological management in the woman at low risk of postpartum haemorrhage.

Research and the practice of midwifery

During the past decade, the professional journals have contained numerous papers authored by nurses and nurse-researchers describing the gap which persists between research and clinical practice. Problems have been highlighted and challenges explored in the quest to discover ways of encouraging practitioners to become more aware of research evidence as a knowledge base for practice. Many of the identified issues may be transposed into a midwifery setting but other factors may be recognized which are specific to the practice of midwifery. This paper considers both conceptual and pragmatic issues in an attempt to explore the complexity of the influences which may affect the integration of research into midwifery practice.

For a systematic policy of i.v. oxytocin inducted placenta deliveries in a unit where a fairly active management of third stage of labour is yet applied: results of a controlled trial

The authors analysed the effect of the i.v. oxytocin induced third stage of labour in a controlled trial concerning 1000 patients. The appliance of such an policy in a unit that already had a fairly active management of delivery was very encouraging. The incidence of post-partum haemorrhage (greater than 500 ml) is significantly (P less than 0.001) less than in the control group; and the same for severe haemorrhage. The third stage is significantly (P less than 0.001) shorter in the oxytocin-injected group than in the control group. Moreover, there is no significant difference between the two groups for retained placenta. The economy of blood transfusion, which is a major concern nowadays, could be the real interest of this active management of the third stage of labour.

Oxytocics for the prevention of post-partum haemorrhages. A review

Secale alkaloids, oxytocin and prostaglandins are used to prevent post-partum haemorrhage (post-partum haemorrhage defined as blood loss greater than or equal to 500 ml). Any oxytocic drug administered in the third stage of labour reduces the blood loss with approximately 40% and hence the incidence of post-partum haemorrhage from 10 to 6%. Therefore, routine active management of the third stage with an oxytocic drug is strongly advocated. Because of the fewest side-effects oxytocin is regarded as the best drug available at this moment.

Intractable postpartum haemorrhage managed by angiographic embolization: case report and review

A case of intractable postpartum haemorrhage successfully managed by angiographic embolization is presented. The literature concerning angiographic embolization and internal iliac artery ligation is reviewed. Angiographic embolization is a superior method to internal iliac artery ligation in appropriately selected cases of obstetric haemorrhage, and may also be used successfully in cases where internal iliac ligation and/or hysterectomy has failed to control pelvic haemorrhage. Angiographic embolization is a potentially life- and fertility-saving procedure.

A randomized comparison of oxytocin, sulprostone and placebo in the management of the third stage of labour

OBJECTIVE

To compare the effect on post partum bloodloss of the postpartum prophylactic administration of oxytocin or sulprostone in low risk women having an expectant management of the third stage.

DESIGN

Randomized, placebo controlled, double-blind trial.

SETTING

Radboud University Hospital, Nijmegen (67 women) and Lievensberg Hospital, Bergen op Zoom (10 women).

PARTICIPANTS

77 women entered the trial (three were excluded).

INTERVENTIONS

The intramuscular injection, immediately after the birth of the baby, of either oxytocin 5 IU, sulprostone 500 micrograms or 0.9% saline.

MAIN OUTCOME MEASURES

Quantitative postpartum blood loss and length of third stage.

RESULTS

Postpartum blood loss was reduced almost equally, by about 35%, by oxytocin (P = 0.02), or sulprostone (P = 0.05). The mean length of the third stage was shorter in both groups receiving the active treatment, this effect was significant in the sulprostone group (P = 0.01).

CONCLUSION

Prophylactic administration of oxytocin or sulprostone directly after delivery followed by expectant management of the third stage reduces post partum blood loss and shortens the third stage.

Primitive Delivery Positions in Modern Obstetrics: Were the wise women wiser wiser than we?

Fifty patients of an academic family medicine unit tried standing and squalting in second stage. Almost all (84.0%) of the women were able to deliver in an upright posture. They rated the upright position as safer, more comfortable, and more effective than the recumbent position. When compared with 136 similar deliveries from the same population, the study group had significantly fewer episiotomies and showed a trend toward more spontaneous deliveries.

The work of the National Perinatal Epidemiology Unit. One example of technology assessment in perinatal care

This article describes one approach to assessing the effects of perinatal care--that adopted by the National Perinatal Epidemiology Unit in Oxford, England. The unit's research has been based primarily on a combination of simple, descriptive analyses of observational data and statistically robust analyses of evidence derived from randomized controlled trials.

Planned homebirths in South Australia 1976-1987

Homebirths booked with a group of general practitioners and midwives in South Australia in 1976-1987 are described using data obtained from midwives' and hospital records. The births represented 84.7% of all births occurring at home in South Australia in 1984-1987, as assessed by official birth registrations. Of the 799 women intending to deliver at home, 136 (17.0%) required transfer to hospital before or during labour. A further 38 mothers or babies (4.8%) required transfer after delivery. The women tended to be of a relatively high socioeconomic status and older age distribution when compared with women who had hospital births as identified from the State perinatal data collection. Some had recognised pregnancy risk factors. They had lower frequencies of ultrasound examination, induced labour, epidural analgesia, episiotomy, forceps delivery and caesarean section, and a low frequency of use of oxytocics for the third stage. Their rates of postpartum haemorrhage and, in particular, perinatal mortality were higher. Potential sources of risk and difficulty in homebirth care and evaluation of this care are identified and an approach to providing an effective homebirth service is proposed.

Does cord drainage of placental blood facilitate delivery of the placenta?

A series of 1,908 women delivering vaginally, and actively managed in stage 3 of labour, were randomly assigned to 2 groups to study if cord drainage of placental blood facilitated delivery of the placenta. Prophylactic oxytocics were given with the birth of the anterior shoulder. In both groups, early cord clamping was practised, timing being at the midwives' discretion. In the control group the cord remained clamped; in the drainage group the cord was unclamped and the volume of placental blood measured. Controlled cord traction completed active management at evidence of separation/descent of the placenta. Rates for retained placenta, postpartum haemorrhage and transfusion were similar. It was concluded that when the third stage of labour is actively managed, placental drainage of cord blood confers no extra benefits. Pre- and post-delivery Kleihauer tests were performed on blood from 20 women in each group. All tests were negative. Contrary to previous work, this does not suggest that cord drainage reduces the fetomaternal transfusion rate. The well known association of prolonged duration of stage 3 of labour and the risk of haemorrhage was strongly confirmed.

Intrapartum hemorrhage

Intrapartum hemorrhage complicates about 5% of all deliveries. Cases can be classified according to the time bleeding begins: before or after delivery of the infant. The author outlines the causes, clinical presentation, and methods of management.

Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants

A randomised, controlled trial was carried out to determine whether suckling immediately after birth reduces the frequency of post-partum haemorrhage (PPH), the mean blood loss, and the frequency of retained placenta. The trial subjects were attended by traditional birth attendants (TBAs), and randomisation was by TBA and not by mother. 68 TBAs attended a course on third stage management and data collection; 19 had to be excluded from the trial. 23 TBAs in the early suckling group and 26 in the control group recorded blood loss in 2104 and 2123 deliveries of liveborn singletons, respectively. The frequency of PPH (loss greater than 500 ml) was 7.9% in the suckling group and 8.4% in the control group and the mean blood loss 258 ml and 256 ml, respectively. Neither of these results differed significantly between the groups. Analysis of the results by individual TBA showed no significant difference between the groups. The frequency of PPH in women of higher parity and in those with multiple pregnancies and stillbirths was high, as expected, which seems to validate the results. The frequency of retained placenta was too low to be analysed.

Views of mothers and midwives participating in the Bristol randomized, controlled trial of active management of the third stage of labor

Mothers and midwives who had participated in the Bristol randomized controlled trial of active versus physiologic management of the Third Stage of Labor were asked for their views. One hundred ninety-one mothers (11% of the total randomized) and 49 midwives completed self-administered questionnaires. Both mothers and midwives commented adversely about the length of the third stage under physiologic management. In general, their views were in accord with the conclusions of the main trial (based on clinical data, including maternal blood loss, length of third stage, need for therapeutic oxytocic agents, and specified neonatal morbidity) in favor of continuing with the current practice of active management.