The length of the third stage of labor and the risk of postpartum hemorrhage

Duration of the second and third stages of labor and risk of postpartum hemorrhage: a cohort study stratified by parity

BACKGROUND

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. It is therefore important to improve our understanding of the risk factors for PPH according to parity, in particular, those linked to modifiable obstetric practices. The aim of this study was to assess the risk of PPH by the duration of the second and third stages of labor, stratified by parity.

METHODS

This study was based on secondary analysis of data from participants in a randomized controlled trial. A sample of women from three university hospitals in France aged at least 18 years, with a singleton pregnancy, in the first stage of labor, at 36-42 weeks of gestation, with epidural anesthesia and a vaginal delivery were included. The main outcome was PPH rates, defined by blood loss > 500 mL within 2 h after delivery. Characteristics of mothers, newborns, labor, and delivery, and their relation to PPH were explored with multivariable regression models.

RESULTS

Of 1598 women included, 864 were nulliparous and 680 parous; their respective PPH rates were 9.1% (79/864) and 7.4% (54/680) (P = 0.2), and the overall rate 8.3% (133/1598). The multivariable analysis found that PPH was associated with the durations of both oxytocin exposure (aOR 1.10, 95%CI 1.01-1.20) and the third stage of labour (aOR 1.80, 95%CI 1.37-2.38) among nulliparous women, and the PPH risk increased with both duration of the third stage (aOR 2.10, 95%CI 1.56-2.83) and history of PPH (aOR 3.02, 95%CI 1.38-6.59) among parous women.

CONCLUSIONS

The duration of oxytocin exposure was found to be a risk factor for PPH among nulliparous women as was a history of PPH among parous women. Future studies should focus on duration of third stage of labor, especially when active management of the third stage of labor (AMTSL) is routinely used.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT01113229.

Time to redefine prolonged third stage of labor? A systematic review and meta-analysis of the length of the third stage of labor and adverse maternal outcome after vaginal birth

OBJECTIVE

This study aimed (1) to assess the association between the length of the third stage of labor and adverse maternal outcome after vaginal birth and (2) to evaluate whether earlier manual placenta removal reduces the risk of adverse outcome.

DATA SOURCES

PubMed, MEDLINE, Embase, ClinicalTrials.gov, the Cochrane Library, Journals@Ovid, and the World Health Organization International Clinical Trials Registry were searched from January 1, 2000, to June 13, 2023.

STUDY ELIGIBILITY CRITERIA

All studies that assessed adverse maternal outcome, defined as any maternal complication after vaginal birth, concerning the length of the third stage of labor and the timing of manual placenta removal were included.

METHODS

The included studies were evaluated using the Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology methodology. Pooled odds ratios with 95% confidence intervals were calculated. Heterogeneity (I2 test) was assessed, subgroup analyses were performed, and 95% prediction intervals were calculated.

RESULTS

To meet the first objective, 18 cohort studies were included. The assessed cutoff values for the length of the third stage of labor were 15, 30, and 60 minutes. Women with a third stage of labor of ≥15 minutes had an increased risk of postpartum hemorrhage compared with those with a third stage of labor of <15 minutes (odds ratio, 5.55; 95% confidence interval, 1.74-17.72). For women without risk factors for postpartum hemorrhage, the odds ratio was 2.20 (95% confidence interval, 0.75-6.49). Among women with a third stage of labor of ≥60 minutes vs women with a third stage of labor of <60 minutes, the odds ratio was 3.72 (95% confidence interval, 2.36-5.89). The incidence of red blood cell transfusion was higher for a third stage of labor of ≥30 minutes than for a third stage of labor of <30 minutes (odds ratio, 3.23; 95% confidence interval, 2.26-4.61). Of note, 3 studies assessed the timing of placenta removal and the risk of adverse maternal outcome. However, the results could not be pooled because of the different outcome measures. Moreover, 1 randomized controlled trial (RCT) reported a significantly higher incidence of hemodynamic compromise in women with manual placenta removal at 15 minutes than in women with manual placenta removal at 10 minutes (30/156 [19.2%] vs 10/156 [6.4%], respectively), whereas 2 observational studies reported a lower risk of bleeding among women without manual placenta removal.

CONCLUSION

Although the risk of adverse maternal outcome after vaginal birth increases when the third stage of labor exceeds 15 minutes, there is no convincing supporting evidence that reducing the length of the third stage of labor by earlier manual removal of the placenta can reduce the incidence of adverse maternal outcome.

Prevention of postpartum hemorrhage in vaginal deliveries

Identification of patients at risk for postpartum hemorrhage (PPH) may allow for prompt diagnosis and intervention. Individual risk factors, risk assessment tools and prediction models have been used for determining a patient's risk of PPH. Measures for the prevention of PPH include identification and management of iron deficiency anemia, unit readiness and preparedness through performing regular simulations and having a PPH cart or medication kit readily available, prophylactic uterotonic - carbetocin alone or dual agents such as oxytocin and misoprostol or oxytocin and methylergometrine or antifibrinolytic (oxytocin and tranexamic acid) use in the third stage of labor immediately after fetal head delivery, and controlled cord traction.

Obstetric Emergencies

Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.

Placental cord drainage and its outcomes at third stage of labor: a randomized controlled trial

BACKGROUND

The third stage of labor begins with the baby's birth and ends with the expulsion of the placenta and embryonic membranes. The prolongation of the third stage of labor, placental retention, subsequent issues such as postpartum hemorrhage, and manual removal of the placenta have adverse outcomes, which eventually affect the positive experience of delivery. The present study aimed to assess the effect of placental cord drainage on the duration of the third stage of labor and to clarify its effects on postpartum hemorrhage, retained placenta, and incidence of manual removal of placenta.

METHODS

This study was a parallel-group randomized trial. Four hundred women in the third stage of labor after vaginal delivery were randomized into the drainage (placenta drainage, n = 200) and the control groups (no placenta drainage, n = 200). In both groups, the third stage of labor was performed with the active method, and the placenta was removed using the Brandt-Andrews maneuver with maternal pushing. The duration of the third stage was compared between the two groups as the primary outcome. Also, the incidence of postpartum hemorrhage, retained placenta, and manual removal of placenta was compared.

RESULTS

In all, 175 women in the drainage group and 165 women in the control group were included in the analysis. The third stage of labor was significantly shorter after placental cord drainage. The mean duration of the third stage was 7.09 ± 1.01 minutes in the drainage group, and it was 10.43 ± 3.20 minutes in the control group (P < 0.001). Postpartum hemorrhage, retained placenta, and incidence of manual removal of placenta in the drainage group was significantly less than in the control group.

CONCLUSION

Placental cord drainage is a simple and non-invasive method of reducing the duration of the third stage of labor. This method does not increase postpartum complications.

TRIAL REGISTRATION

IRCT2014041917341N1 , retrospectively registered at 15. 10. 2017.

Evidence-based labor management: third stage of labor (part 5)

During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) immediately after delivery of the neonate are recommended. Single-dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations with continuous synthetic suture technique is recommended. No repair of first-degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third-degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth-degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single-dose second-generation cephalosporin at the time of third- or fourth-degree laceration repairs can be considered. Skin-to-skin contact after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.

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.

Retained Placenta and Postpartum Hemorrhage: A Case Report and Review of Literature

The third stage of labor (delivery of the placenta), per current definition, takes place within 30 minutes of fetal delivery in a nulliparous or multiparous woman. According to the American Pregnancy Association, a retained placenta is diagnosed if the placenta is not delivered within 30 minutes following delivery of the fetus. Retained placenta can be caused by placenta accreta, increta, or percreta. There are several complications of a retained placenta, including postpartum hemorrhage, which can lead to maternal death if not treated promptly. We report the case of a 32-year-old female, gravida 4 para 3, who was diagnosed with a retained placenta after delivering at term (39 weeks gestation). The retained placenta was complicated by postpartum hemorrhage and was treated within 15 minutes of fetal delivery with several uterotonics (misoprostol, oxytocin, carboprost, and tranexamic acid) and several passes of ultrasound-guided suction curettage. Sharp curettage was also used with ultrasound to confirm that the uterus was empty, followed by one more suction curettage to remove any products of conception that were scraped off with sharp curettage. Vaginal bleeding was significantly reduced; minor bleeding was noted from a first-degree vaginal laceration, which was repaired by suture. The patient recovered from surgery and was discharged on postpartum day 3 with her neonate in stable condition. In conclusion, this case highlights that retained placenta is a serious obstetric complication that can cause life-threatening postpartum hemorrhage. More data are needed to define the period of time correlating with the greatest chance of encountering a retained placenta in order to improve obstetric care and reduce maternal morbidity and mortality. Future research should consider challenging the current definition of retained placenta, defined as a placenta undelivered after 30 minutes, in favor of a shorter time period, 15 minutes undelivered, in order to mobilize the obstetric team, anesthesiologist, and blood bank to prevent catastrophic postpartum hemorrhage.

Development and Validation of Prognostic Nomogram for Postpartum Hemorrhage After Vaginal Delivery: A Retrospective Cohort Study in China

Background

Postpartum hemorrhage (PPH) is a common complication following vaginal delivery and in severe cases can lead to maternal death. A straightforward predictive model is required to enable prenatal evaluations by obstetricians to prevent PPH complications.

Methods

Data of patients who delivered vaginally after 37 weeks of gestation were retrospectively collected from the medical database at Shengjing Hospital of China Medical University for the period 2016 to 2020. PPH was defined as blood loss of 500 mL or more within 24 h of delivery, and important independent prognostic factors were determined using univariate and multivariate logistic regression analyses to construct nomograms regarding PPH.

Results

A total of 24,833 patients who delivered vaginally were included in this study. The training cohort included 22,302 patients who delivered between 2016 and 2019 and the external validation cohort included 2,531 patients who delivered during 2020. Nomogram was created using data such as age, race, occupation, parity, gestational weeks, labor time, neonatal weight, analgesic delivery, gestational diabetes mellitus, premature rupture of membranes, anemia, hypertension, adenomyosis, and placental adhesion. The nomogram has good predictive power and clinical practicality through the analysis of the area under the curve and decision curve analysis. Internal verification was performed on the nomogram for PPH, demonstrating consistency between the nomogram's predicted probability and actual probability.

Conclusions

The developed and validatable nomogram is a good predictor of PPH in vaginal delivery and can be used in clinical practice to guide obstetricians to administer preventive therapies before delivery.

Duration of third stage labour and postpartum blood loss: a secondary analysis of the WHO CHAMPION trial data

Background

Obstetric haemorrhage continues to be a leading cause of maternal mortality, contributing to more than a quarter of the 2,443,000 maternal deaths reported between 2003 and 2009. During this period, about 70% of the haemorrhagic deaths occurred postpartum. In addition to other identifiable risk factors for greater postpartum blood loss, the duration of the third stage of labour (TSL) seems to be important, as literature shows that a longer TSL can be associated with more blood loss. To better describe the association between the duration of TSL and postpartum blood loss in women receiving active management of third stage of labour (AMTSL), this secondary analysis of the WHO CHAMPION trial data has been conducted.

Methods

This was a secondary analysis of the WHO CHAMPION trial conducted in twenty-three sites in ten countries. We studied the association between the TSL duration and blood loss in the sub cohort of women from the CHAMPION trial (all of whom received AMTSL), with TSL upto 60 min and no interventions for postpartum haemorrhage. We used a general linear model to fit blood loss as a function of TSL duration on the log scale, arm and center, using a normal distribution and the log link function. We showed this association separately for oxytocin and for Heat stable (HS) carbetocin.

Results

For the 10,040 women analysed, blood loss rose steeply with third stage duration in the first 10 min, but more slowly after 10 min. This trend was observed for both Oxytocin and HS carbetocin and the difference in the trends for both drugs was not statistically significant (p-value = 0.2070).

Conclusions

There was a positive association between postpartum blood loss and TSL duration with either uterotonic. Blood loss rose steeply with TSL duration until 10 min, and more slowly after 10 min.

Study registration The main trial was registered with Australian New Zealand Clinical Trials Registry ACTRN12614000870651 and Clinical Trial Registry of India CTRI/2016/05/006969

The duration of the third stage of labour (TSL) seems to be an important risk factor for greater postpartum blood loss, as literature shows that a longer TSL can be associated with more blood loss. Active management of third stage of labour (AMTSL), included in the WHO guidelines for prevention of postpartum haemorrhage (PPH), is effective in reducing both the amount of postpartum blood loss and the duration of the third stage. To better describe the association between duration of TSL and postpartum blood loss in women receiving AMTSL, we conducted this secondary analysis of WHO CHAMPION trial data.

To assess the association between the duration of third stage of labour and postpartum blood loss, a subcohort of the CHAMPION modified ITT population was selected by excluding women with missing blood loss or missing TSL duration or TSL duration more than 60 min and women with interventions. Thus, the subcohort consisted of 10,040 women.

In women with vaginal birth and not receiving interventions for treating atonic PPH or other sources of bleeding, and with TSL duration up to 60 min, there was a positive association between duration of the TSL and postpartum blood loss. The blood loss rose steeply with duration in women with TSL of 10 min or less, while in women with longer TSL duration the slope was less steep.

There was no evidence of a difference between oxytocin and HS carbetocin in the pattern of association of duration of the TSL and blood loss.

Retained placenta and postpartum hemorrhage: time is not everything

PURPOSE

Postpartum hemorrhage is the major cause of maternal mortality worldwide. Retained placenta accounts for nearly 20% of severe cases. We investigated the influence of the time factor and retained placenta etiology on postpartum hemorrhage dynamics.

METHODS

Our retrospective study analyzed a single-center cohort of 296 women with retained placenta. Blood loss was measured using a validated and accurate technique based on calibrated blood collection bags, backed by the post- vs pre-partum decrease in hemoglobin. We evaluated the relationship between these two blood loss parameters and the duration of the third stage of labor using Spearman rank correlation, followed by subgroup analysis stratified by third stage duration and retained placenta etiology.

RESULTS

Correlation analysis revealed no association between third stage duration and measured blood loss or decrease in hemoglobin. A shorter third stage (< 60 min) was associated with significantly increased uterine atony (p = 0.001) and need for blood transfusion (p = 0.006). Uterine atony was significantly associated with greater decrease in hemoglobin (p < 0.001), higher measured blood loss (p < 0.001), postpartum hemorrhage (p = 0.048), and need for blood transfusion (p < 0.001).

CONCLUSION

Postpartum blood loss does not correlate with third stage duration in women with retained placenta. Our results suggest that there is neither a safe time window preceding postpartum hemorrhage, nor justification for an early cut-off for manual removal of the placenta. The prompt detection of uterine atony and immediate prerequisites for manual removal of the placenta are key factors in the management of postpartum hemorrhage.

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.

Anaesthesia/analgesia for manual removal of retained placenta

BACKGROUND

As a retained placenta is a potential life-threatening obstetrical complication, effective and timely management is important. The estimated mortality rates from a retained placenta in developing countries range from 3% to 9%. One possible factor contributing to the high mortality rates is a delay in initiating manual removal of the placenta. Effective anaesthesia or analgesia during this procedure will provide adequate uterine relaxation and pain control, enabling it to be carried out effectively.

OBJECTIVES

To assess the effectiveness and safety of general, regional, and local anaesthesia or analgesia during manual removal of a retained placenta.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform to 30 September 2019, and reference lists of retrieved studies.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), quasi-randomised controlled trials, and cluster-randomised trials that compared different methods of preoperative or intraoperative anaesthetic or analgesic, administered during the manual removal of a retained placenta.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the study reports for inclusion, and risk of bias, extracted data and checked them for accuracy. We followed standard Cochrane methodology.

MAIN RESULTS

We identified only one randomised controlled trial (N = 30 women) that evaluated the effect of paracervical block on women undergoing manual removal of a retained placenta compared with intravenous pethidine and diazepam. The study was conducted in a hospital in Papua New Guinea. The study was at high risk of bias of performance bias and detection bias, low risk of attrition bias, and an unclear risk of selection bias, reporting bias, and other bias. The included study did not measure this review's primary outcomes of pain intensity and adverse events. The study reported that there were no women, in either group, who experienced an estimated postpartum blood loss of more than 500 mL. We are uncertain about the providers' satisfaction with the procedure, defined as their perception of achieving good pain relief during the procedure (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.71 to 3.16, one study, 30 women; very low quality evidence). We are also uncertain about the women's satisfaction with the procedure, defined as their perception of achieving good pain relief during the procedure (RR 0.82, 95% CI 0.49 to 1.37; one study, 30 women; very low quality evidence). The included study did not report on any of our other outcomes of interest.

AUTHORS' CONCLUSIONS

There is insufficient evidence from one small study to evaluate the effectiveness and safety of anaesthesia or analgesia during the manual removal of a retained placenta. The quality of the available evidence was very low. We downgraded based on issues of limitations in study design (risk of bias) and imprecision (single study with small sample size, few or no events, and wide confidence intervals). There is a need for well-designed, multi-centre, randomised, controlled trials to evaluate the effectiveness and safety of different types of anaesthesia and analgesia during manual removal of a retained placenta. These studies could report on the important outcomes outlined in this review.

Do Breathing Techniques Enhance the Effect of Massage Therapy in Reducing the Length of Labor or not? a Randomized Clinical Trial

Introduction: Prolonged labor is a common birth complication that is associated with some negative maternal and fetal effects. The aims of this study were 1) to evaluate the effect of effleurage abdominal massage and 2) to assess the effects size of breathing techniques with massage on the length of labor.

Methods: This study was a randomized trial with concealed allocation, assessor blinding for some outcomes and intent-to-treat analysis. Primiparous women (n=117) age 18-35 years who were randomly assigned to three groups; abdominal massage (n=37), abdominal massage with breathing technique (n=38) and control (n=42). Although it was randomized block design with the allocation ratio 1:1:1 but soon after the sample was withdrawn in labor, another was replaced. Experimental groups’ participants received a 30-min effleurage abdominal massage during the active and transitional phases of labor. Particular breathing techniques in each stage of labor were done. Data were analyzed using SPSS ver.13.

Results: Duration of the active phase was 244.89(83.30) min in the massage, 254(68.55) min in massage with breathing and 312.07(67.17) min in control group, which was significantly different between the massage and control groups (P<0.001, Min Diff; -67.18), as well as massage with breathing and control groups (P=0.003, Min Diff; -9.63). The Scheffe test showed no significant difference between the two experimental groups.

Conclusion: Effleurage abdominal massages decrease length of active phase on labor, but the learning of breathing techniques in labor couldn’t enhance this effect of massage, so it is likely that breathing exercises may be considered during pregnancy.

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.

Retained placenta after vaginal delivery: risk factors and management

Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18–60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.

The increasing role of a retained placenta in postpartum blood loss: a cohort study

PURPOSE

To describe the association between quantity of blood loss, duration of the third stage of labour, retained placenta and other risk factors, and to describe the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage.

METHODS

Cohort study of all vaginal deliveries at two Danish maternity units between 1 January 2009 and 31 December 2013 (n = 43,357), univariate and multivariate linear regression statistical analyses.

RESULTS

A retained placenta was shown to be a strong predictor of quantity of blood loss and duration of the third stage of labour a weak predictor of quantity of blood loss. The predictive power of the third stage of labour was further reduced in the multivariate analysis when including retained placenta in the model. There was an increase in the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage, increasing from 12% in cases of blood loss ≥ 500 ml to 53% in cases of blood loss ≥ 2000 ml CONCLUSION: The predictive power of duration of the third stage of labour in regard to postpartum blood loss was diminished by the influence of a retained placenta. A retained placenta was, furthermore, present in the majority of most severe cases.

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.

The Third Stage of Labour in the Extremely Obese Parturient

BACKGROUND

Maternal obesity has been associated with an increased risk for an abnormal progression of labour; however, less is known about the length of the third stage of labour and its relation to maternal obesity.

OBJECTIVE

To determine if the length of the third stage of labour is increased in extremely obese women and its possible correlation with an increased risk for postpartum hemorrhage.

STUDY DESIGN

This was a retrospective cohort study of deliveries from January 2008 to December 2015 at our university hospital. Women with a BMI ≥40 and a vaginal delivery were compared with the next vaginal delivery of a woman with a BMI <30. There were 147 women with a BMI ≥40 compared with 157 with a BMI <30. Outcomes evaluated the length of the third stage of labour and the risk for postpartum hemorrhage and included antepartum, intrapartum, and perinatal complications.

RESULTS

Subjects in the extreme obese group were more likely to be African American, older, diabetic (pregestational and gestational), hypertensive, pre-eclamptic, had a preterm delivery, and underwent an induction of labour. The overall length of the third stage of labour was significantly longer in the extreme obese group, 5 minutes (3, 8 [25th and 75th percentiles]) compared with 4 minutes (3,7) (P = 0.0374) in the non-obese group. Postpartum hemorrhage occurred more often in the extreme obese group (N = 16/147; 11%) compared with the non-obese group (N = 5/157; 3%) (P = 0.01). There were no differences between groups in respect to the following: gravidity, parity, length of the second stage of labour, birth weight, GA at delivery, Apgar score, cord blood gases, hematocrit change, need for postpartum transfusion, operative delivery, and development of chorioamnionitis. After an adjustment for ethnicity, maternal age, diabetes, preeclampsia, preterm labour, hypertension, and induction/augmentation, the analysis failed to show a significant difference in estimated blood loss and postpartum hemorrhage between the groups.

CONCLUSIONS

The length of the third stage of labour is longer in the extreme obese parturient. Postpartum hemorrhage also occurs more often, but after adjustments for confounding variables, it is no longer significant.

Management of CHAOS by intact cord resuscitation: case report and literature review

Background: Congenital high airway obstruction syndrome (CHAOS) is a near fatal condition, except when the ex utero intrapartum treatment (EXIT) procedure is performed as rescue. After antenatal diagnosis of the condition, counseling regarding prognosis and outcome needs to be provided.Case: We describe here a case with CHAOS due to isolated fetal laryngeal atresia, presented at our center at 33-week gestation. After counseling regarding the uncertain outcome, consent for elective caesarean was not given. Intact cord resuscitation (ICR) was done as a rescue by a well-coordinated team during delivery. Tracheostomy was performed successfully under local anesthesia within five minutes, while the cord was still attached to the placenta. The baby had supraglottic stenosis on CT scan. Reconstructive surgery is planned after 8 months. The literature review showed 24 reports of 28 cases with intrinsic airway obstruction managed by EXIT, laryngeal atresia was the most common cause (18/28). The outcome was poor in tracheal agenesis (1/4 survived) whereas those having laryngeal web or small communication (4/4 survived) had better outcome. Tracheal reconstruction was done in 3/28 cases only.Conclusions: The case emphasizes that ICR and tracheostomy during vaginal delivery can rescue the baby. The literature reviewed provided insight into the outcome of CHAOS cases in world literature.

Association of the Length of the Third Stage of Labor and Blood Loss Following Vaginal Delivery

OBJECTIVES

The length of the third stage of labor is correlated with blood loss following a vaginal delivery. We aimed to accurately measure blood loss following a vaginal delivery and examine the relation between blood loss and length of the third stage of labor.

METHODS

This was a prospective observational study of singleton pregnancies ≥24 weeks undergoing a vaginal delivery. Blood loss was meticulously measured and the length of the third stage of labor was recorded.

RESULTS

The median blood loss of the 600 women was 125 mL (interquartile range 175) and the median length of the third stage of labor was 5 minutes (interquartile range 4). Total blood loss (P = 0.0263) and length of the third stage of labor (P = 0.0120) were greater in pregnancies ≥37 weeks versus <37 weeks. Women with a third stage of labor ≥15 minutes had a significantly greater risk of blood loss >500 mL (relative risk 5.8, 95% confidence interval 8.36-29.88).

CONCLUSIONS

The median blood loss following a vaginal delivery is 125 mL and the median length of the third stage of labor is 5 minutes. Total blood loss and the length of the third stage of labor are greater in pregnancies >37 weeks. Women with a third stage of labor >15 minutes are 15.8 times more likely to have total blood loss ≥500 mL. As such, it is prudent to consider manual extraction of the placenta at 15 minutes rather than 30 minutes to minimize the risk of excessive blood loss.

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.

How Long Is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study

OBJECTIVE

The aim of our study was to determine the optimal time for manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion. Risk factors for postpartum blood transfusions were studied.

METHODS

Computerized data of all vaginal deliveries at our labor and delivery unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation up to 60 minutes into the third stage of labor were extracted for analysis. Patient demographics, obstetrical history, delivery course, and outcome were assessed as well as blood product requirements during the postpartum period. Receiver-operating curves (ROC) for prediction of blood transfusion during the third stage were calculated and risk factors were assessed.

RESULTS

31,226 vaginal deliveries occurred during the study period and 28,586 deliveries culminated with complete and spontaneous placental separation, 25,160 of which met inclusion criteria. Independent risk factors for blood transfusions were primiparity, longer second and third stage length, labor induction, and maternal intrapartum fever. ROC curves showed that the optimal cutoff for the prediction of blood transfusions was 17 minutes into the third stage of labor. Waiting more than 30 minutes for placental separation increases the risk for blood transfusion more than threefold.

CONCLUSIONS

A third stage longer than 17 minutes is associated with an increased risk for blood transfusion postpartum. After more than 30 minutes, the risk for blood transfusions increases more than threefold.

Retained placenta: will medical treatment ever be possible?

The standard treatment for retained placenta is manual removal whatever its subtype (adherens, trapped or partial accreta). Although medical treatment should reduce the risk of anesthetic and surgical complications, they have not been found to be effective. This may be due to the contrasting uterotonic needs of the different underlying pathologies. In placenta adherens, oxytocics have been used to contract the retro‐placental myometrium. However, if injected locally through the umbilical vein, they bypass the myometrium and perfuse directly into the venous system. Intravenous injection is an alternative but exacerbates a trapped placenta. Conversely, for trapped placentas, a relaxant could help by resolving cervical constriction, but would worsen the situation for placenta adherens. This confusion over medical treatment will continue unless we can find a way to diagnose the underlying pathology. This will allow us to stop treating the retained placenta as a single entity and to deliver targeted treatments.

Carbetocin versus intra-umbilical oxytocin in the management of retained placenta: a randomized clinical study

AIM

This study aimed to compare the hemodynamic profile and efficacy of carbetocin versus intra-umbilical oxytocin in the management of retained placenta following vaginal delivery.

MATERIAL AND METHODS

In this randomized clinical study, women with retained placenta for more than 30 min were assigned to receive either an i.v. bolus of 100-µg carbetocin (n = 38) or an intra-umbilical vein injection of 50 IU oxytocin in 30 mL saline (n = 40). The main parameters evaluated were the success rate for expulsion of the placenta and the effects of these drugs on maternal blood pressure.

RESULTS

The success rate in the carbetocin group was 86.84% compared to 77.5% in the intra-umbilical oxytocin group. Notably, 57.7% of the participants had prior induction of labor or augmentation during labor. There were no significant differences between the two groups regarding the estimated blood loss, drop of hemoglobin within the first 48 h, additional uterotonic injection or the need for manual removal of the placenta. Systolic blood pressure was significantly lower in the intra-umbilical oxytocin group at 30 and 60 min after injection (P = 0.008, 0.026, respectively). Nonetheless, diastolic blood pressure was significantly lower in the intra-umbilical oxytocin group than in the carbetocin group at 30 min (P = 0.036).

CONCLUSION

A single i.v. bolus of carbetocin and umbilical vein injection of 50 IU oxytocin are similarly effective in reducing the need for manual removal of the placenta. Carbetocin seems to have an acceptable hemodynamic safety profile and can be used as an alternative choice to the conventional oxytocic agents in the management of retained placenta.

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.

Dynamic Changes in the Myometrium during the Third Stage of Labor, Evaluated Using Two-Dimensional Ultrasound, in Women with Normal and Abnormal Third Stage of Labor and in Women with Obstetric Complications

OBJECTIVE

To investigate dynamic changes in myometrial thickness during the third stage of labor.

METHODS

Myometrial thickness was measured using ultrasound at one-minute time intervals during the third stage of labor in the mid-region of the upper and lower uterine segments in 151 patients including: women with a long third stage of labor (n = 30), postpartum hemorrhage (n = 4), preterm delivery (n = 7) and clinical chorioamnionitis (n = 4). Differences between myometrial thickness of the uterine segments and as a function of time were evaluated.

RESULTS

There was a significant linear increase in the mean myometrial thickness of the upper uterine segments, as well as a significant linear decrease in the mean myometrial thickness of the lower uterine segments until the expulsion of the placenta (p < 0.001). The ratio of the measurements of the upper to the lower uterine segments increased significantly as a function of time (p < 0.0001). In women with postpartum hemorrhage, preterm delivery, and clinical chorioamnionitis, an uncoordinated pattern among the uterine segments was observed.

CONCLUSION

A well-coordinated activity between the upper and lower uterine segments is demonstrated in normal placental delivery. In some clinical conditions this pattern is not observed, increasing the time for placental delivery and the risk of postpartum hemorrhage.

[Clinical and pharmacological procedures for the prevention of postpartum haemorrhage in the third stage of labor]

OBJECTIVES

To describe the clinical and pharmacological procedures for the prevention of Postpartum Haemorrhage (PPH).

MATERIALS AND METHODS

We searched the Medline and the Cochrane Library (1st December 2004 to 1st March 2014) and we checked the international guidelines.

RESULTS

Vaginal birth: only the use of uterotonics reduces the incidence of PPH. Oxytocin is the treatment of choice if it is readily available (grade A). Oxytocin can be used either after the shoulders expulsion or rapidly after the placental delivery (grade B). A dose of 5 or 10IU must be administrated IV over at least 1minute or directly by an intramuscular injection (professional agreement) except in women with documented cardiovascular disease in which the duration of the IV perfusion should be over at least 5minutes (professional agreement). Mechanical procedures have no significant impact on PPH. The decision to use a collector bag is left to the medical team (professional agreement). A systematic complementary oxytocin perfusion is not recommended (professional agreement). Caesarean delivery: There is no evidence to recommend a particular type of caesarean technique to prevent PPH (professional agreement) but a lower uterine section is recommended (grade B). All types of incision expansion may be used (professional agreement). A controlled cord traction is associated with lower blood losses than manual removal of the placenta (grade B). A dose of 5 or 10IU can be injected (IV) over 1minute, and over 5minutes in women with cardiovascular disease (professional agreement). Carbetocin reduces the incidence of PPH but there is presently no inferiority study comparing oxytocin and carbetocin so that oxytocin remains the gold standard therapy to prevent PPH in C-section (professional agreement).

Retained placenta: Do we have any option?

Retained placenta is a known cause of post-partum haemorrhage and maternal mortality. A recent systemic review has confirmed that the incidence of retained placenta had increased all over the world, which is more common in developed countries. Failure of retro-placental myometrium contraction is the main cause of retained placenta. Maternal age greater than 35 years, grandmultipara, preterm labor, history of previous retained placenta, and caesarean section were the risk factors for retained placenta. Manual removal of the placenta has been the treatment of choice. Attempts had been made by clinician and researchers to find a safe, effective and reliable method to avoid the need for surgical intervention. The efficacy and safety of prostaglandin, nitroglycerin or acupuncture in the management of retained placenta are yet to be further evaluated. Nonetheless, till date only intra-umbilical vein oxytocin has been studied extensively but with varied success. More randomized clinical trials are needed to address this issue. However, if immediate manual placenta removal service is unavailable, a trial of intra-umbilical vein oxytocin 100 IU at a total volume of at least 40 mL while preparing for transfer to a tertiary center or theatre may result in spontaneous expulsion of the placenta.

Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study

OBJECTIVE

To quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (≥500 ml) and progression to severe PPH (≥1500 ml).

DESIGN

Prospective observational study.

SETTING

Two UK maternity services.

POPULATION

Women giving birth between 1 August 2008 and 31 July 2009 (n = 10 213).

METHODS

Weighted sampling with sequential adjustment by multivariate analysis.

MAIN OUTCOME MEASURES

Incidence and risk factors for PPH and progression to severe PPH.

RESULTS

Errors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH ≥500, ≥1500 and ≥2500 ml were 33.7% (95% CI 31.2-36.2), 3.9% (95% CI 3.3-4.6) and 0.8% (95% CI 0.6-1.0). New independent risk factors predicting PPH ≥ 500 ml included Black African ethnicity (adjusted odds ratio [aOR] 1.77, 95% CI 1.31-2.39) and assisted conception (aOR 2.93, 95% CI 1.30-6.59). Modelling demonstrated how prepregnancy- and pregnancy-acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53-108.00) or emergency (aOR 40.5, 95% CI 16.30-101.00), and retained placenta (aOR 21.3, 95% CI 8.31-54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11-2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20-2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24-3.22).

CONCLUSIONS

Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.

Manual removal of the placenta after vaginal delivery: an unsolved problem in obstetrics

The third stage of labor is associated with considerable maternal morbidity and mortality. The major complication is postpartum hemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. Whereas in the event of PPH due to atony of the uterus there exist numerous treatment guidelines; for the management of retained placenta the general consensus is more difficult to establish. Active management of the third stage of labour is generally accepted as standard of care as already its duration is contributing to the risk of PPH. Despite scant evidence it is commonly advised that if the placenta has not been expelled 30 minutes after delivery, manual removal of the placenta should be carried out under anaesthesia. Pathologic adhesion of the placenta in the low risk situation usually is diagnosed at the time of delivery; therefore a pre- or intrapartum screening opportunity for placenta accreta would be desirable. But diagnosis of abnormalities of placentation other than placenta previa remains a challenge. Nevertheless the use of ultrasound and doppler sonography might be helpful in the third stage of labor. An improvement might be the implementation of standardized operating procedures for retained placenta which could contribute to a reduction of maternal morbidity.

Risk factors for a prolonged third stage of labor and postpartum hemorrhage

OBJECTIVES

To determine the effect of a third stage of labor ≥15 minutes on bleeding after delivery and other risk factors for a postpartum hemorrhage (PPH).

METHODS

This was a case-control study of women undergoing vaginal delivery with placental delivery ≥15 minutes matched by gestational age to the next delivery with placental delivery <15 minutes. Multiple risk factors were evaluated for association with delayed placenta and with PPH.

RESULTS

There were 226 pregnancies ≥15 minutes (cases) versus 226 whose placental time was <15 minutes (controls). The best-fit model identified placental delivery ≥15 minutes, history of retained placenta, nulliparity, and increased length of first stage of labor as significant factors for PPH.

CONCLUSIONS

The best risk model for PPH includes placental delivery ≥15 minutes, history of retained placenta, nulliparity, and longer first stage of labor.

Combined early fluid resuscitation and hydrogen inhalation attenuates lung and intestine injury

AIM: To study the effects of combined early fluid resuscitation and hydrogen inhalation on septic shock-induced lung and intestine injuries.

METHODS: Wistar male rats were randomly divided into four groups: control group (Group A, n = 15); septic shock group (Group B, n = 15); early fluid resuscitation-treated septic shock group (Group C, n = 15); and early fluid resuscitation and inhalation of 2% hydrogen-treated septic shock group (Group D, n = 15). The activity of hydroxyl radicals, myeloperoxidase (MPO), superoxide dismutase (SOD), diamine oxidase (DAO), and the concentration of malonaldehyde (MDA) in the lung and intestinal tissue were assessed according to the corresponding kits. Hematoxylin and eosin staining was carried out to detect the pathology of the lung and intestine. The expression levels of interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-α in lung and intestine tissue were detected by enzyme-linked immunosorbent assay method. The expression levels of Fas and Bcl2 in lung tissues were determined by immunohistochemistry and Western blotting.

RESULTS: Septic shock elicited a significant increase in the levels of MDA (10.17 ± 1.12 nmol/mg protein vs 2.98 ± 0.64 nmol/mg protein) and MPO (6.79 ± 1.02 U/g wet tissue vs 1.69 ± 0.14 U/g wet tissue) in lung tissues. These effects were not significantly decreased by Group C pretreatment, but were significantly reduced by Group D pretreatment (MDA: 4.45 ± 1.13 nmol/mg protein vs 9.56 ± 1.37 nmol/mg protein; MPO: 2.58 ± 0.21 U/g wet tissue vs 6.02 ± 1.16 U/g wet tissue). The activity of SOD (250.32 ± 8.56 U/mg protein vs 365.78 ± 10.26 U/mg protein) in lung tissues was decreased after septic shock, and was not significantly increased by Group C pretreatment, but was significantly enhanced by Group D pretreatment (331.15 ± 9.64 U/mg protein vs 262.98 ± 5.47 U/mg protein). Histological evidence of lung hemorrhage, neutrophil infiltration and overexpression of IL-6, IL-8, and TNF-α was observed in lung tissues, all of which were attenuated by Group C and further alleviated by Group D pretreatment. Septic shock also elicited a significant increase in the levels of MDA, MPO and DAO (6.54 ± 0.68 kU/L vs 4.32 ± 0.33 kU/L) in intestinal tissues, all of which were further increased by Group C, but significantly reduced by Group D pretreatment. Increased Chiu scoring and overexpression of IL-6, IL-8 and TNF-α were observed in intestinal tissues, all of which were attenuated by Group C and further attenuated by Group D pretreatment.

CONCLUSION: Combined early fluid resuscitation and hydrogen inhalation may protect the lung and intestine of the septic shock rats from the damage induced by oxidative stress and the inflammatory reaction.

Delays in the delivery room of a primary maternity unit: a retrospective analysis of obstetric outcomes

OBJECTIVE

To compare obstetric outcomes in women undergoing vaginal delivery with or without delay in the 2nd and 3rd stage of labour (SOL).

METHODS

This is an observational retrospective study including 10,416 full-term vaginal deliveries occurred at a primary obstetric unit. Our sample was divided according to the length of 2nd and 3rd SOL: >2 h vs. ≤2 h; and >1 h vs. ≤1 h, respectively. Obstetric outcomes were compared using univariate and multivariate analysis.

RESULTS

A prolonged 2nd SOL was associated with severe perineal tears (odds ratio (OR) = 3.53), episiotomy (OR = 3.25), major post-partum hemorrhage (PPH) (OR = 2.35), operative delivery (OR = 3.54), and Asian ethnicity (OR = 12.12). Likewise, a prolonged 3rd SOL was associated with operative deliveries (OR = 10.49), labor induction (OR = 3.24), non-use of oxytocin after delivery (OR = 12.39), major PPH (OR = 46.95), retained placenta (OR = 3.57) and female fetal gender (OR = 4.07).

CONCLUSIONS

even at a primary care setting, where there are mostly low-risk pregnancies, a prolonged 2nd and 3rd SOL may occur and lead to poor obstetric outcomes. Our findings raise a very controversial issue about the meaning of "low obstetrics risk", given the unpredictability of any labor, and the management of complications in the delivery room of primary maternity units.

Umbilical vein injection for the routine management of third stage of labour

BACKGROUND

Postpartum haemorrhage is among the biggest contributor to maternal mortality worldwide. Prevention of this condition includes routine use of uterotonic in the third stage of labour, which has been recommended throughout the world. Use of umbilical route to deliver this uterotonic after delivery of the baby has been proposed. Therapeutic use of this has been assessed, although routine (prophylactic) use of this has not been evaluated.

OBJECTIVES

To compare, from the best available evidence, the effects of umbilical vein injection of a saline solution alone or with any uterotonic drug versus an alternative solution with or without any other uterotonic agent or expectant management or any other method for routine management of the third stage of labour, on maternal and perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised controlled trials comparing the effects of umbilical vein injection of a saline solution alone or with any uterotonic drug versus any other alternative methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and trial quality. Two review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

We included nine studies involving 1118 women.We identified four comparisons. One comparison included six studies (which randomised 394 women) comparing umbilical vein injection of normal saline plus oxytocin versus that of normal saline, as well as three other comparisons, each of which includes one study. Comparing intraumbilical injection of normal saline plus oxytocin with intraumbilical injection of saline only, there was no evidence of difference in any of the relevant outcomes reported namely the number of women who required blood transfusion, the incidence of manual removal of placenta, blood loss, and length of the third stage of labour. Subgroup analyses by both total amount of solution administered and dose of oxytocin showed no evidence of difference. Other comparisons included only one study for each, and there was no relevant information available.

AUTHORS' CONCLUSIONS

Routine use of oxytocin or any other uterotonics with normal saline via umbilical vein injection is not recommended until new evidence is available. Further research should be conducted to show effectiveness of oxytocin with normal saline via umbilical vein injection.

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.

The retained placenta: historical and geographical rate variations

In this study, we sought to explore the variation in reported rates of retained placenta around the world and over time in the UK. A systematic review of observational studies was performed to obtain retained placenta rates from around the world and annual hospital reports from the Royal College of Obstetricians and Gynaecologists archives were examined to obtain historical retained placenta rates. The data show that the median rate of retained placenta at 30 minutes was higher in developed countries (2.67% vs 1.46%, p < 0.02), as was the median manual removal rate (2.24% vs 0.45%, p < 0.001). In addition to this, there appears to have been a rise in rate of manual removal in the UK from a mean of 0.66% in the 1920s to 2.34% in the 1980s (p < 0.0001).

A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial

OBJECTIVE

to compare blood loss in women actively and expectantly managed in the third stage of labour.

DESIGN

randomised controlled trial (RCT).

SETTING

two delivery units at a Swedish university hospital.

POPULATION

healthy women with normal pregnancies, at gestational age 34-43 weeks, with singleton cephalic presentation and expected vaginal delivery.

METHODS

the women were randomly allocated to either active (n = 903) or expectant (n = 899) management of the third stage of labour.

MAIN OUTCOME MEASURES

the primary outcome was blood loss > 1000 ml, and secondary outcomes were mean blood loss, duration of third stage, retained placenta, haemoglobin level and blood transfusion.

RESULTS

blood loss > 1000 ml occurred in 10% of the actively managed group and 16.8% of the expectantly managed group (P < 0.001). Mean blood loss was 535 ml in the actively managed group and 680 ml in the expectantly managed group (P < 0.001). A prolonged duration of the third stage was associated with increased blood loss. Increased placenta weight was associated with increased blood loss. The haemoglobin level was 118 g/dl in actively managed women and 115/dl in expectantly managed women (P < 0.001) the day after childbirth. The occurrence of retained placenta and the number of blood transfusions did not differ between the groups.

CONCLUSIONS

active management of the third stage of labour was associated with less blood loss compared with expectant management. It is reasonable to advocate this regime, especially in primiparous women.

Umbilical vein oxytocin in the management of retained placenta: an alternative to manual removal of placenta?

PURPOSE

Retained placenta is potentially life threatening due to possible complications associated with manual removal. Our aim was to determine whether umbilical vein injection of oxytocin in saline reduces the need for manual removal of placenta.

METHODS

This was a randomised controlled trial conducted at a tertiary hospital from December 2002 to March 2004. A total of 61 women delivering singletons, who had no sign of placental separation 20 min after vaginal delivery, were randomised to receive either intra-umbilical oxytocin 100 IU diluted in 30 ml of saline or controlled cord traction only. Manual removal was done if the placenta was not expelled in another 30 min in both arms.

RESULTS

There was a significant reduction in the rate of subsequent manual removal of placenta (30 vs. 67.7%, p < 0.05), incidence of uterine atony (3.3 vs. 25.8%, p < 0.05) and the need for uterotonic agents (33.3 vs. 64.5%, p < 0.05) in the oxytocin group when compared with the control group. No significant differences were found in the need for blood transfusion, uterine curettage, incidence of postpartum haemorrhage and haemoglobin level reduction.

CONCLUSION

Intra-umbilical vein oxytocin injection is clinically effective for the management of a retained placenta.