Active versus expectant management of the third stage of labor in rural Ghana

Inability to predict postpartum hemorrhage: insights from Egyptian intervention data

Background

Knowledge on how well we can predict primary postpartum hemorrhage (PPH) can help policy makers and health providers design current delivery protocols and PPH case management. The purpose of this paper is to identify risk factors and determine predictive probabilities of those risk factors for primary PPH among women expecting singleton vaginal deliveries in Egypt.

Methods

From a prospective cohort study, 2510 pregnant women were recruited over a six-month period in Egypt in 2004. PPH was defined as blood loss ≥ 500 ml. Measures of blood loss were made every 20 minutes for the first 4 hours after delivery using a calibrated under the buttocks drape. Using all variables available in the patients' charts, we divided them in ante-partum and intra-partum factors. We employed logistic regression to analyze socio-demographic, medical and past obstetric history, and labor and delivery outcomes as potential PPH risk factors. Post-model predicted probabilities were estimated using the identified risk factors.

Results

We found a total of 93 cases of primary PPH. In multivariate models, ante-partum hemoglobin, history of previous PPH, labor augmentation and prolonged labor were significantly associated with PPH. Post model probability estimates showed that even among women with three or more risk factors, PPH could only be predicted in 10% of the cases.

Conclusions

The predictive probability of ante-partum and intra-partum risk factors for PPH is very low. Prevention of PPH to all women is highly recommended.

CEU: Prevention and Treatment of Postpartum Hemorrhage: New Advances for Low-Resource Settings

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Cost-effectiveness analysis of active management of third-stage labour in Vietnam

Active management of the third stage of labour (AMTSL) using oxytocin substantially reduces postpartum haemorrhage (PPH), a leading cause of maternal mortality. An economic analysis of the use of AMTSL was conducted as part of an intervention study in Thanh Hoa Province, Vietnam. A spreadsheet was used to calculate various scenarios and estimate the costs and outcomes of the routine use of AMTSL with oxytocin in Uniject compared with oxytocin in ampoules, and AMTSL compared with no AMTSL. We estimated the health outcomes from probabilities that were generated from the effectiveness portion of the AMTSL intervention project. The study also estimates the costs of treating PPH and the net incremental costs of AMTSL (costs and savings); examines the impact of different scenarios of PPH rate and Uniject cost; and estimates the potential cost per PPH case and PPH death averted. The additional net cost per woman of providing AMTSL with ampoules was just US dollar 0.20 in the base case; using Uniject devices added only US dollar 0.08 more per woman to the ampoule cost. Varying the rate of PPH had the biggest effect; if the underlying PPH rate were 8%, the incremental cost of AMTSL drops to just US dollar 0.07 per woman with ampoules and the cost to avert a case of PPH is US dollar 2.10 with ampoules and US dollar 4.52 with Uniject. The low net incremental cost of AMTSL suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women's health without adding much to national health care costs.

Challenges in managing postpartum hemorrhage in resource-poor countries

Managing postpartum hemorrhage depends in part on having a prepared mind, a complement of trained coworkers, and full access to modern therapies. The last 2 components are rare in resource-poor areas and their absence may be accentuated by climatic instability and lack of basic transportation. Greater use of the active management of third stage of labor and administration of misoprostol by nontrained birth attendants will provide beneficial reductions in hemorrhage rates in resource-poor areas. Additional improvements depend on increasing public awareness, facilitating existing nongovernmental organizations in their community-related, upgrading training of traditional birth attendants, and providing cell phone communication to workers in remote areas, in addition to providing better access to blood.

Reducing postpartum hemorrhage in Vietnam: Assessing the effectiveness of active management of third-stage labor

AIM

The study was undertaken to meet the need of the Ministry of Health to have local evidence on the effectiveness of active management of third-stage labor (AMTSL) in reducing the incidence of postpartum hemorrhage (PPH) > or = 500 mL and the need for PPH treatment.

METHODS

Using a quasi-experimental design, AMTSL was introduced for all births attended by government midwives (at home, community, and district levels) in one district while standard practice without AMTSL was continued in three neighboring districts (with a 1:2 ratio of participants). Oxytocin (10 IU) was administered either by standard disposable syringe and needle or by a prefilled, single-use injection device. Postpartum blood loss was estimated using standard containers; other outcome measures included the duration of third stage, the need for additional treatments, and final maternal condition. A total of 3607 women participated (1236 in the intervention district and 2371 in the comparison districts). Multivariate logistic regression was used to control for age, parity, place of delivery, and first-stage oxytocin augmentation.

RESULTS

AMTSL was associated with reduced risks for prolonged third stage beyond 30 min (odds ratio [OR] = 0.20, 95%; confidence interval [CI]: 0.11, 0.35), supplemental oxytocin (OR = 0.68, 95% CI: 0.49, 0.94), and bimanual compression (OR = 0.63, 95%; CI: 0.41, 0.98). When cases with first-stage oxytocin augmentation were excluded, AMTSL was associated with a 34% reduction in PPH incidence (OR = 0.66, 95%; CI: 0.45, 0.98).

CONCLUSION

This study supports the value of AMTSL in reducing the incidence of PPH, shortening the third stage of labor, and reducing the need for additional treatments.

Postpartum hemorrhage in resource-poor settings

Despite the strong interest of international health agencies, worldwide maternal mortality has not declined substantially over the past 10 years. Postpartum hemorrhage (PPH) is the most common cause of maternal death across the world, responsible for more than 25% of deaths annually. Although effective tools for prevention and treatment of PPH are available, most are not feasible or practical for use in the developing world where many births still occur at home with untrained birth attendants. Application of many available clinical solutions in rural areas would necessitate substantial changes in government infrastructure and in local culture and customs surrounding pregnancy and childbirth. Before treatment can be administered, prompt and accurate diagnosis must be made, which requires training and appropriate blood measurement tools. After diagnosis, appropriate interventions that can be applied in remote settings are needed. Many uterotonics known to be effective in reducing PPH in tertiary care settings may not be useful in community settings because they require refrigeration and/or skilled administration. Moreover, rapid transfer to a higher level of care must be available, a challenge in many settings because of distance and lack of transportation. In light of these barriers, low-technological replacements for treatments commonly applied in the developed-world must be utilized. Community education, improvements to emergency care systems, training for birth attendants, misoprostol, and Uniject have shown promise as potential solutions. In the short term, it is expedient to capitalize on practical opportunities that utilize the existing strengths and resources in each community or region in order to implement appropriate solutions to save the lives of women during childbirth.

Postpartum hemorrhage: a prospective, comparative study in Angola using a new disposable device for oxytocin administration

BACKGROUND

Postpartum hemorrhage (PPH) is the single most common cause of maternal death in the world, and oxytocin is known to be effective for its prevention and treatment. The use of syringes can be problematic in areas affected by HIV. The aim of this study was to introduce Uniject (a new disposable device for administration of 10 IU oxytocin) as part of active management of the third stage of labor (AMTL) and try to reduce PPH.

METHODS

A prospective, comparative study was performed between March 1998 and May 2000 in Luanda. Seven hundred and eighty-two parturient women with physiological management were compared to 814 with AMTL. Postpartum lost blood was collected using a plastic sheet during labor and a bucket placed under a cholera bed for 2 h postpartum. Student's t-test and chi(2) test were used.

RESULT

PPH was reduced from 40.4 to 8.2% and severe PPH (> or =1000 ml) from 7.5 to 1% in the AMTL group (P < 0.001).

CONCLUSIONS

Uniject was well tolerated and offers an alternative for oxytocin administration. AMTL should be implemented also in resource-poor settings as a routine management to reduce PPH.