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Zemouri C, Mestdagh E, Stiers M, Torfs K, Kuipers Y. Deferred cord clamping to improve neonatal blood values: A systematic review and meta-analysis. Int J Nurs Stud 2024; 153:104718. [PMID: 38417349 DOI: 10.1016/j.ijnurstu.2024.104718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/01/2024] [Accepted: 02/05/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Practices related to umbilical cord clamping at birth should be evidence-based. Deferred cord clamping, compared to immediate cord clamping, shows benefits for preterm neonates but this may also apply to healthy term neonates. Different blood sampling techniques are used to measure effect of deferred and immediate cord clamping. OBJECTIVE To assess the statistical and effect size differences between blood biomarkers from umbilical cord and capillary blood samples of healthy term neonates following either immediate or deferred cord clamping. DESIGN Systematic review and meta-analysis. METHODS The databases PubMed, Medline, CENTRAL, CINAHL and EMBASE were systematically searched. We included studies with a randomised clinical trial design comparing deferred and immediate cord clamping among healthy term neonates born by a spontaneous vaginal birth, reporting on blood biomarkers. Studies including caesarean births and premature births/neonates were excluded. Study attributes, sampling technique, blood biomarkers, mean differences, and standard deviations were extracted. The standardised mean differences (SMD) and sampling errors were calculated for effect size estimation. Meta-analyses were performed if ≥2 studies reported the same outcome using RevMan 5. Subgroup analyses distinguished effects from umbilical cord and capillary blood samples. Moderator tests and publication bias analyses were performed using JASP. RESULTS Fifteen studies were included for analysis. The biomarkers haematocrit, haemoglobin, and bilirubin were reported in ≥2 studies and thus eligible for pooling. No differences were found in haemoglobin (SMD -0.04, 95%CI -0.57 to 0.49) or bilirubin values (SMD 0.13, 95%CI -0.03 to 0.28) between umbilical cord blood samples collected after deferred or immediate cord clamping. Deferred cord clamping led to lower haematocrit values (SMD -0.3, 95%CI -0.53 to -0.07). Higher haematocrit (SMD 0.67, 95%CI 0.37 to 0.97) and haemoglobin values (SMD 0.76, 95%CI 0.56 to 0.97) from capillary blood samples, collected 2 to 72 h postpartum, showed when cord clamping was deferred. No effect was found on bilirubin values (SMD 0.13, 95%CI -0.03 to 0.28) irrespective of the sampling technique. CONCLUSIONS Blood collected after deferred umbilical cord clamping showed increased haemoglobin and haematocrit values up to 72 h after birth, opposed to bilirubin values. Clinical evaluation of blood biomarkers from the umbilical cord shows different values compared to capillary blood. Sampling time and technique therefore seem essential in estimating the effects of deferred cord clamping. TWEETABLE ABSTRACT This meta-analysis shows that sampling time and technique are essential in estimating the effects of deferred cord clamping on neonatal blood values.
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Affiliation(s)
- Charifa Zemouri
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Zemouri et al, Amsterdam, the Netherlands
| | - Eveline Mestdagh
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Centre for Research and Innovation in Care, University Antwerp, Antwerp, Belgium
| | - Mieke Stiers
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium
| | - Kimberly Torfs
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium
| | - Yvonne Kuipers
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Centre for Research and Innovation in Care, University Antwerp, Antwerp, Belgium; School of Health and Social Care, Edinburgh Napier University, Edinburgh, Scotland, UK.
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Deniau B, Ricbourg A, Weiss E, Paugam-Burtz C, Bonnet MP, Goffinet F, Mignon A, Morel O, Le Guen M, Binczak M, Carbonnel M, Michelet D, Dahmani S, Pili-Floury S, Ducloy Bouthors AS, Mebazaa A, Gayat E. Association of severe postpartum hemorrhage and development of psychological disorders: Results from the prospective and multicentre HELP MOM study. Anaesth Crit Care Pain Med 2024; 43:101340. [PMID: 38128731 DOI: 10.1016/j.accpm.2023.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/10/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Post-partum hemorrhage (PPH) is the leading preventable cause of worldwide maternal morbidity and mortality. Risk factors for psychological disorders following PPH are currently unknown. HELP-MOM study aimed to determine the incidence and identify risk factors for psychological disorders following PPH. METHODS HELP-MOM study was a prospective, observational, national, and multicentre study including patients who experienced severe PPH requiring sulprostone. The primary endpoint was the occurrence of psychological disorders (anxiety and/or post-traumatic disorder and/or depression) following PPH, assessed at 1, 3, and 6 months after delivery using HADS, IES-R, and EPDS scales. RESULTS Between November 2014 and November 2016, 332 patients experienced a severe PPH and 236 (72%) answered self-questionnaires at 1, 3, and 6 months. A total of 161 (68%) patients declared a psychological disorder following severe PPH (146 (90.1%) were screened positive for anxiety, 96 (58.9%) were screened positive for post-traumatic stress disorder, and 94 (57.7%) were screened positive for post-partum depression). In multivariable analysis, the use of intra-uterine tamponnement balloon was associated with a lower risk to be screened positive for psychological disorder after severe PPH (OR = 0.33 [IC95% 0.15-0.69], p = 0.004, and after propensity score matching (OR=0.34 [IC95% 0.12-0.94], p = 0.04)). Low hemoglobin values during severe PPH management were associated with a higher risk of being screened positive for psychological disorders. Finally, we did not find differences in desire or pregnancy between patients without or with psychological disorders occurring in the year after severe PPH. DISCUSSION Severe PPH was associated with significant psychosocial morbidity including anxiety, post-traumatic disorder, and depression. This should engage a psychological follow-up. Large cohorts are urgently needed to confirm our results. REGISTRATION ClinicalTrials.gov under number NCT02118038.
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Affiliation(s)
- Benjamin Deniau
- Département d'Anesthésie-Réanimation et Centre de Traitement des Brûlés, Hôpitaux Universitaires Saint-Louis - Lariboisière, AP-HP, Paris, France; UMR-S 942, INSERM, MASCOT, Paris University, Paris, France; Université de Paris Cité, Paris, France; FHU PROMICE, France; Réseau INI-CRCT, France
| | - Aude Ricbourg
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Emmanuel Weiss
- Université de Paris Cité, Paris, France; Département d'Anesthésie-Réanimation, Hôpital Beaujon, APHP, Clichy, France
| | - Catherine Paugam-Burtz
- Université de Paris Cité, Paris, France; Département d'Anesthésie-Réanimation, Hôpital Beaujon, APHP, Clichy, France
| | - Marie-Pierre Bonnet
- Université de Paris Cité, Paris, France; Département d'Anesthésie Réanimation, Hôpital Armand Trousseau, DMU DREAM, APHP, Paris, France
| | - François Goffinet
- Université de Paris Cité, Paris, France; Maternité Cochin-Port Royal, APHP, Paris, France
| | - Alexandre Mignon
- Université de Paris Cité, Paris, France; Département d'Anesthésie-Réanimation, Hôpital Cochin-Port Royal, APHP, Paris, France; Maternité Cochin-Port Royal, APHP, Paris, France
| | - Olivier Morel
- Service de Gynécologie et Obstétrique, Centre Hospitalier Universitaire de Nancy, Nancy France
| | - Morgan Le Guen
- Université de Versailles Saint-Quentin, France; Département d'Anesthésie, Hôpital Foch, Suresnes, France
| | - Marie Binczak
- Service de Gynécologie et Obstétrique, Hôpital Foch, Suresnes, France
| | - Marie Carbonnel
- Service de Gynécologie et Obstétrique, Hôpital Foch, Suresnes, France
| | - Daphné Michelet
- Département d'Anesthésie et Réanimation, CHU de Reims, France; Université de Reins Champagne Ardenne, Reims, France
| | - Souhayl Dahmani
- Université de Paris Cité, Paris, France; Service d'Anesthésie, Hôpital Robert Debré, APHP, Paris, France; Service d'Anesthésie et Réanimation, Hôpital Robert Ballanger, Aulnay-sous-Bois, France
| | | | | | - Alexandre Mebazaa
- Département d'Anesthésie-Réanimation et Centre de Traitement des Brûlés, Hôpitaux Universitaires Saint-Louis - Lariboisière, AP-HP, Paris, France; UMR-S 942, INSERM, MASCOT, Paris University, Paris, France; Université de Paris Cité, Paris, France; FHU PROMICE, France; Réseau INI-CRCT, France
| | - Etienne Gayat
- Département d'Anesthésie-Réanimation et Centre de Traitement des Brûlés, Hôpitaux Universitaires Saint-Louis - Lariboisière, AP-HP, Paris, France; UMR-S 942, INSERM, MASCOT, Paris University, Paris, France; Université de Paris Cité, Paris, France; FHU PROMICE, France.
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Peberdy L, Young J, Massey D, Kearney L. Integrated review of the knowledge, attitudes, and practices of maternity health care professionals concerning umbilical cord clamping. Birth 2022; 49:595-615. [PMID: 35582849 PMCID: PMC9790596 DOI: 10.1111/birt.12647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Umbilical cord clamp timing has implications for newborn health, which include increased iron stores up to 6 months of age. National and International cord clamping guidelines differ as do health professionals' practices. The rationale for differences in cord clamping practice is unclear. AIMS AND OBJECTIVE Studies on the knowledge, attitudes, and practices of maternity health care professionals about cord clamp timing were synthesized. Similarities and differences between professional groups and understanding of the optimal timing of cord clamp timing for term newborns were compared. METHODS An integrative review was undertaken. PubMed, Scopus, MIDIRS, CINAHL, and Google Scholar were searched. Publication date limits were set between January 2007 and December 2020. Quality appraisal was undertaken using the Critical Appraisal Skills Program (CASP) tools. RESULTS Eighteen studies met inclusion criteria, as they included primary research studies that investigated maternity health care professionals' knowledge, attitudes, and practices about umbilical cord clamping, and were written in English. Four main subject areas were identified: a) knowledge of optimal cord clamp timing; b) attitudes and perceptions of early vs deferred cord clamping; c) cord clamping practice; and d) rationale for cord clamping practice. CONCLUSIONS Different attitudes and practices were identified between midwifery and medical professionals in relation to cord clamp timing together with health professional knowledge and practice gaps pertaining to optimal cord clamp timing. Contemporary evidence should inform guidelines for clinical practice and be embedded into maternity health professional curricula and professional development programs.
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Affiliation(s)
- Lisa Peberdy
- University of the Sunshine CoastSunshine CoastQueenslandAustralia
| | - Jeanine Young
- University of the Sunshine CoastSunshine CoastQueenslandAustralia
| | - Debbie Massey
- Southern Cross UniversityLismoreNew South WalesAustralia
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Voillequin S, Rozenberg P, Letutour K, Rousseau A. Comparative satisfaction and effectiveness of virtual simulation and usual supervised work for postpartum hemorrhage management: a crossover randomized controlled trial. BMC MEDICAL EDUCATION 2022; 22:709. [PMID: 36203183 PMCID: PMC9540154 DOI: 10.1186/s12909-022-03761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Because virtual simulation promotes learning and cognitive skill development, it may be useful for teaching students to manage postpartum hemorrhage (PPH) and its complex decision algorithm. OBJECTIVE This study aimed to compare the satisfaction and effectiveness of virtual simulation with usual supervised work in producing knowledge and satisfaction. METHODS This two-center two-stage crossover randomized controlled trial included student midwives. One group underwent the virtual simulation intervention in the first period (January 2018) and the usual supervised classroom work in the second (May 2018); the other group followed the reverse chronology. Satisfaction was the primary outcome. The secondary outcome was knowledge of the PPH management algorithm, assessed by responses to a case vignette after each intervention session. RESULTS The virtual simulation -supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47; Satisfaction was significantly higher for the virtual simulation for its overall grade (6.8 vs. 6.1, P = 0.009), engagingness (very good 82.1% vs. 24.3%, P < 0.001), and ease of use (very good 77.9% vs. 46.1%, P < 0.001). Knowledge did not differ between the two groups (respectively, 89.5% versus 83.5%, P = 0.3). CONCLUSION Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. This could lead to an increase in students' motivation to learn.
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Affiliation(s)
| | - P Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, 78300, Poissy, France
- Clinical Epidemiology, Paris Saclay University, CESP, UVSQ, Inserm, Team U1018, 78180, Montigny- le-Bretonneux, France
| | - K Letutour
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, 78300, Poissy, France
- Midwifery Department, UVSQ, 78180, Montigny-le-Bretonneux, France
| | - A Rousseau
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, 78300, Poissy, France
- Clinical Epidemiology, Paris Saclay University, CESP, UVSQ, Inserm, Team U1018, 78180, Montigny- le-Bretonneux, France
- Midwifery Department, UVSQ, 78180, Montigny-le-Bretonneux, France
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Historical liver subcapsular hematoma revealed by a severe postpartum hemorrhage: About a case. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Isacson M, Thies-Lagergren L, Oras P, Hellström-Westas L, Andersson O. Umbilical cord clamping and management of the third stage of labor: A telephone-survey describing Swedish midwives’ clinical practice. Eur J Midwifery 2022; 6:6. [PMID: 35274089 PMCID: PMC8832505 DOI: 10.18332/ejm/145697] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/29/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The timing of cord clamping impacts children’s short- and long-term well-being. When making clinical decisions, midwives incorporate their tacit and professional knowledge, experience and current evidence. There appears to be a lack of knowledge regarding Swedish midwives’ management of the third stage of labor and cord clamping practice. The aim of this study was to explore Swedish midwives’ clinical practice concerning umbilical cord clamping and the third stage of labor in spontaneous vaginal births. METHODS The study was designed as a cross-sectional telephone survey including 13 questions. Midwives were randomly selected from 48 births units in Sweden. Two midwives from each unit were interviewed. The primary outcome was timing of umbilical cord clamping practice in full-term infants. Secondary outcomes were the management of the third stage of labor including prophylactic use of synthetic oxytocin, the timing of cord clamping in preterm infants, controlled cord traction, uterine massage, and cord milking. RESULTS Altogether, 95 midwives were interviewed. In full-term infants, all midwives preferred late cord clamping. Considerable heterogeneity was seen regarding the practices of synthetic oxytocin administration postpartum, controlled cord traction, uterine massage or cord milking, and cord clamping in preterm infants. CONCLUSIONS Midwives in Sweden modify recommendations regarding delayed cord clamping in a way they might perceive as more natural and practical in their daily, clinical work. The study revealed a reluctance toward the administration of prophylactic oxytocin due to fear that the drug could pass to the infant. An overall large variation of the management of the third stage of labor was seen.
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Affiliation(s)
- Manuela Isacson
- Neonatology research group, Section of Pediatrics, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Li Thies-Lagergren
- Midwifery research, reproductive, perinatal and sexual health, Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Obstetrics and Gynaecology, Helsingborg Hospital, Helsingborg, Sweden
| | - Paola Oras
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | | | - Ola Andersson
- Neonatology research group, Section of Pediatrics, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Richardson J, Hollier-Hann G, Kelly K, Chiara Alvisi M, Winter C, Cetin I, Draycott T, Harvey T, Visser GHA, Yip Sonderegger YL, Perroud J. A study of the healthcare resource use for the management of postpartum haemorrhage in France, Italy, the Netherlands, and the UK. Eur J Obstet Gynecol Reprod Biol 2021; 268:92-99. [PMID: 34894537 DOI: 10.1016/j.ejogrb.2021.11.432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Postpartum haemorrhage (PPH) complicates approximately 5% of births worldwide and is a leading direct cause of maternal death. Rates of PPH are increasing in many developed countries, particularly PPH related to uterine atony. There is a lack of published up-to-date information about healthcare resource use associated with management of PPH following vaginal birth. The objective of this study was to describe healthcare resource use for the management of minor PPH (blood loss 500-1,000 ml) and major PPH (blood loss > 1,000 ml) compared to uncomplicated birth (no PPH) following hospital vaginal birth in France, Italy, the Netherlands, and the UK. STUDY DESIGN In-depth interviews with two midwives from each participating country were conducted to establish differences in resource use for the management of minor PPH, major PPH, and uncomplicated birth. A web-survey was then developed and one obstetrician per participating country reviewed the survey. In total, 100 midwives (25 per country) completed the survey. Results were discussed at a multi-professional consensus meeting of midwives and obstetricians/gynaecologists (n = 6). RESULTS AND CONCLUSIONS Midwives participating in the survey estimated that 80% of women receive Active Management of the Third Stage of Labour (AMTSL) and 93% of participants specified that uterotonics would routinely be used during AMTSL. Most participants (84%) reported that blood loss is routinely measured in their hospital, using a combination of methods. PPH is associated with increased healthcare resource use, including administration of additional uterotonics and use of additional medical interventions, such as urinary catheter, intravenous fluids, and possible requirement for surgery. The number of nurses, obstetricians/gynaecologists, and anaesthetists involved in the management of PPH increases with the occurrence and severity of PPH, as well as the proportion of healthcare personnel providing continuous care. Women may spend an additional 24 h in hospital following major PPH compared to uncomplicated birth. The results of this study highlight the burden of PPH management on healthcare resources. To reduce costs associated with PPH, prevention is the most effective strategy and can be enhanced with the use of an effective uterotonic as part of the active management of the third stage of labour.
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Affiliation(s)
- Jessica Richardson
- GENESIS Research, West One, Forth Banks, Newcastle Upon Tyne, United Kingdom
| | | | - Kathryn Kelly
- GENESIS Research, West One, Forth Banks, Newcastle Upon Tyne, United Kingdom
| | | | - Cathy Winter
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Irene Cetin
- Vittore Buzzi Children's Hospital, Milan, Italy
| | | | | | | | | | - Julie Perroud
- Ferring Pharmaceuticals, 1162 Saint-Prex, Switzerland
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Iron deficiency during the first 1000 days of life: are we doing enough to protect the developing brain? Proc Nutr Soc 2021; 81:108-118. [PMID: 34548120 DOI: 10.1017/s0029665121002858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Iron is essential for the functioning of all cells and organs, most critically for the developing brain in the fundamental neuronal processes of myelination, energy and neurotransmitter metabolism. Iron deficiency, especially in the first 1000 days of life, can result in long-lasting, irreversible deficits in cognition, motor function and behaviour. Pregnant women, infants and young children are most vulnerable to iron deficiency, due to their high requirements to support growth and development, coupled with a frequently inadequate dietary supply. An unrecognised problem is that even if iron intake is adequate, common pregnancy-related and lifestyle factors can affect maternal-fetal iron supply in utero, resulting in an increased risk of deficiency for the mother and her fetus. Although preterm birth, gestational diabetes mellitus and intrauterine growth restriction are known risk factors, more recent evidence suggests that maternal obesity and delivery by caesarean section further increase the risk of iron deficiency in the newborn infant, which can persist into early childhood. Despite the considerable threat that early-life iron deficiency poses to long-term neurological development, life chances and a country's overall social and economic progress, strategies to tackle the issue are non-existent, too limited or totally inappropriate. Prevention strategies, focused on improving the health and nutritional status of women of reproductive age are required. Delayed cord clamping should be considered a priority. Better screening strategies to enable the early detection of iron deficiency during pregnancy and early-life should be prioritised, with intervention strategies to protect maternal health and the developing brain.
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Celen S, Horn-Oudshoorn EJJ, Knol R, van der Wilk EC, Reiss IKM, DeKoninck PLJ. Implementation of Delayed Cord Clamping for 3 Min During Term Cesarean Sections Does Not Influence Maternal Blood Loss. Front Pediatr 2021; 9:662538. [PMID: 34239848 PMCID: PMC8257925 DOI: 10.3389/fped.2021.662538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To assess maternal safety outcomes after a local protocol adjustment to change the interval of cord clamping to 3 min after term cesarean section. Design, Setting, and Patients: A retrospective cohort study in a tertiary referral hospital (Erasmus MC, Rotterdam). We included pregnant women who gave birth at term after cesarean section. A cohort (Nov 2016-Oct 2017) prior to the protocol implementation was compared to a cohort after its implementation (Nov 2017-Nov 2018). The study population covered 789 women (n = 376 pre-cohort; n = 413 post-cohort). Interventions: Implementation of a local protocol changing the interval of cord clamping to 3 min in all term births. Main outcome measures: Primary outcomes were the estimated maternal blood loss and the occurrence of postpartum hemorrhage (blood loss >1,000 ml). Secondary outcomes included both maternal as well as neonatal outcomes. Results: Estimated maternal blood loss was not significantly different between the pre-cohort and post-cohort (400 mL [300-600] vs. 400 mL [300-600], p = 0.52). The incidence of postpartum hemorrhage (26 [6.9%] vs. 35 (8.5%), OR 1.24, 95% CI 0.73-2.11) and maternal blood transfusion (9 [2%] vs. 13 (3%), OR 1.33, 95% CI 0.56-3.14) were not different. Hemoglobin change was significantly higher in the post-cohort (-0.8 mmol/L [-1.3 to -0.5] vs. -0.9 mmol/L [-1.4 to -0.6], p = 0.01). In the post-cohort, neonatal hematocrit levels were higher (51 vs. 55%, p = 0.004) and need for phototherapy was increased (OR 1.95, 95% CI 0.99-3.84). Conclusion: Implementation of delayed cord clamping for 3 min in term cesarean sections was not associated with increased maternal bleeding complications.
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Affiliation(s)
- Stefanie Celen
- Department of Pediatrics, University Hospital Gent, Ghent, Belgium.,Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Eline C van der Wilk
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
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McCarthy EK, Kiely ME. The neonatal period: A missed opportunity for the prevention of iron deficiency and its associated neurological consequences? NUTR BULL 2019. [DOI: 10.1111/nbu.12407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E. K. McCarthy
- Cork Centre for Vitamin D and Nutrition Research School of Food and Nutritional Sciences University College Cork and INFANT Research Centre Cork Ireland
| | - M. E. Kiely
- Cork Centre for Vitamin D and Nutrition Research School of Food and Nutritional Sciences University College Cork and INFANT Research Centre Cork Ireland
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Ortiz-Esquinas I, Gómez-Salgado J, Pascual-Pedreño AI, Rodríguez-Almagro J, Martínez-Galiano JM, Hernández-Martínez A. Variability of Clinical Practice in the Third Stage of Labour in Spain. J Clin Med 2019; 8:E637. [PMID: 31075863 PMCID: PMC6571899 DOI: 10.3390/jcm8050637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/17/2022] Open
Abstract
Clinical practice guidelines recommend the active management of the third stage of labour, but it is currently unknown what practices professionals actually perform. Therefore, the aim of this study was to determine the variability of professional practices in the management of the third stage of labour and to identify any associated professional and work environment factors. A nationwide cross-sectional study was performed with 1054 obstetrics professionals between September and November 2018 in Spain. A self-designed questionnaire was administered online. The crude odds ratios (OR) and adjusted odds ratios (ORa) were estimated using binary logistic regression. The main outcome measures were included in the clinical management of the third stage of labour and they were: type of management, drugs, doses, routes of administration, and waiting times used. The results showed that 75.3% (783) of the professionals used uterotonic agents for delivery. Oxytocin was the most commonly administered drug. Professionals who attend home births were less likely to use uterotonics (ORa: 0.23; 95% confidence interval (CI): 0.12-0.47), while those who completed their training after 2007 (ORa: 1.57 (95% CI: 1.13-2.18) and worked in a hospital that attended >4000 births per year (ORa: 7.95 CI: 4.02-15.72) were more likely to use them. Statistically significant differences were also observed between midwives and gynaecologists as for the clinical management of this stage of labour (p < 0.005). These findings could suggest that there is clinical variability among obstetrics professionals regarding the management of delivery. Part of this variability can be attributed to professional and work environment factors.
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Affiliation(s)
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, University of Huelva, 21071 Huelva, Spain.
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil 091650, Ecuador.
| | - Ana I Pascual-Pedreño
- Department of Obstetrics & Gynaecology, Alcázar de San Juan, 13600 Ciudad Real, Spain.
| | - Julián Rodríguez-Almagro
- Department of Nursing, Ciudad Real Nursing School. University of Castilla-La Mancha, 13071 Ciudad Real, Spain.
| | - Juan Miguel Martínez-Galiano
- Department of Nursing, University of Jaen, 23071 Jaen, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain.
| | - Antonio Hernández-Martínez
- Department of Obstetrics & Gynaecology, Alcázar de San Juan, 13600 Ciudad Real, Spain.
- Department of Nursing, Ciudad Real Nursing School. University of Castilla-La Mancha, 13071 Ciudad Real, Spain.
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Begley CM, Gyte GML, Devane D, McGuire W, Weeks A, Biesty LM. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2019; 2:CD007412. [PMID: 30754073 PMCID: PMC6372362 DOI: 10.1002/14651858.cd007412.pub5] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. This is an update of a review last published in 2015. OBJECTIVES To compare the effects of active versus expectant management of the third stage of labour on severe primary postpartum haemorrhage (PPH) and other maternal and infant outcomes.To compare the effects of variations in the packages of active and expectant management of the third stage of labour on severe primary PPH and other maternal and infant outcomes. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World health Organization International Clinical Trials Registry Platform (ICTRP), on 22 January 2018, and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. Cluster-randomised trials were eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, carried out data extraction and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included eight studies, involving analysis of data from 8892 women. The studies were all undertaken in hospitals, seven in higher-income countries and one in a lower-income country. Four studies compared active versus expectant management, and four compared active versus a mixture of managements. We used a random-effects model in the analyses because of clinical heterogeneity. Of the eight studies included, we considered three studies as having low risk of bias in the main aspects of sequence generation, allocation concealment and completeness of data collection. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes, which is reflected in the cautious language below.The evidence suggested that, for women at mixed levels of risk of bleeding, it is uncertain whether active management reduces the average risk of maternal severe primary PPH (more than 1000 mL) at time of birth (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, 3 studies, 4636 women, I2 = 60%; GRADE: very low quality). For incidence of maternal haemoglobin (Hb) less than 9 g/dL following birth, active management of the third stage may reduce the number of women with anaemia after birth (average RR 0.50, 95% CI 0.30 to 0.83, 2 studies, 1572 women; GRADE: low quality). We also found that active management of the third stage may make little or no difference to the number of babies admitted to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, 2 studies, 3207 infants; GRADE: low quality). It is uncertain whether active management of the third stage reduces the number of babies with jaundice requiring treatment (RR 0.96, 95% CI 0.55 to 1.68, 2 studies, 3142 infants, I2 = 66%; GRADE: very low quality). There were no data on our other primary outcomes of very severe PPH at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management reduces mean maternal blood loss at birth and probably reduces the rate of primary blood loss greater than 500 mL, and the use of therapeutic uterotonics. Active management also probably reduces the mean birthweight of the baby, reflecting the lower blood volume from interference with placental transfusion. In addition, it may reduce the need for maternal blood transfusion. However, active management may increase maternal diastolic blood pressure, vomiting after birth, afterpains, use of analgesia from birth up to discharge from the labour ward, and more women returning to hospital with bleeding (outcome not pre-specified).In the comparison of women at low risk of excessive bleeding, there were similar findings, except it was uncertain whether there was a difference identified between groups for severe primary PPH (average RR 0.31, 95% CI 0.05 to 2.17; 2 studies, 2941 women, I2 = 71%), maternal Hb less than 9 g/dL at 24 to 72 hours (average RR 0.17, 95% CI 0.02 to 1.47; 1 study, 193 women) or the need for neonatal admission (average RR 1.02, 95% CI 0.55 to 1.88; 1 study, 1512 women). In this group, active management may make little difference to the rate of neonatal jaundice requiring phototherapy (average RR 1.31, 95% CI 0.78 to 2.18; 1 study, 1447 women).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, for example, omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours). Women could be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.It must be emphasised that this review includes only a small number of studies with relatively small numbers of participants, and the quality of evidence for primary outcomes is low or very low.
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Affiliation(s)
- Cecily M Begley
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland
| | - Gillian ML Gyte
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
| | - William McGuire
- University of YorkCentre for Reviews and DisseminationYorkY010 5DDUK
| | - Andrew Weeks
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Linda M Biesty
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
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Rousseau A, Rozenberg P, Perrodeau E, Ravaud P. Variation in severe postpartum hemorrhage management: A national vignette-based study. PLoS One 2018; 13:e0209074. [PMID: 30543683 PMCID: PMC6292622 DOI: 10.1371/journal.pone.0209074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 11/29/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To assess variations in management of severe postpartum hemorrhage: 1) between obstetricians in the same situation 2) by the same obstetrician in different situations. STUDY DESIGN A link to a vignette-based survey was emailed to obstetricians of 215 maternity units; the questionnaire asked them to report how they would manage the PPH described in 2 previously validated case-vignettes of different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH. They were constructed in 3 successive steps and included multiple-choice questions proposing several types of clinical practice options at each step. Variations in PPH were assessed in a descriptive analysis; agreement about management and its timing between vignette 1 and vignette 2 was assessed with the Kappa coefficient. RESULTS Analysis of complete responses from 119 (43.4%) obstetricians from 53 (24.6%) maternity units showed delayed or inadequate management in both vignettes. While 82.3% and 83.2% of obstetricians (in vignettes 1 and 2, respectively) would administer oxytocin 15 minutes after PPH diagnosis, only 52.9% and 29.4% would alert other team members. Management by obstetricians of the two vignette situations was inconsistent in terms of choice of treatment and timing of almost all treatments. CONCLUSION Case vignettes demonstrated inadequate management as well as variations in management between obstetricians and in different PPH situations. Protocols or procedures are necessary in all maternity units to reduce the variations in practices that may explain a part of the delay in management that leads to PPH-related maternal mortality and morbidity.
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Affiliation(s)
- Anne Rousseau
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- INSERM U1153, METHODS (Méthodes en Évaluation Thérapeutique des Maladies Chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- Research Unit EA 7285, Versailles-St Quentin University, Saint Quentin en Yvelines, France
| | - Elodie Perrodeau
- INSERM U1153, METHODS (Méthodes en Évaluation Thérapeutique des Maladies Chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
| | - Philippe Ravaud
- INSERM U1153, METHODS (Méthodes en Évaluation Thérapeutique des Maladies Chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
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Weeks A, Bewley S. Improbable, but plausible, research study: a randomised controlled trial of premature cord clamping vs. neonatal venesection to achieve routine prophylactic neonatal red cell reduction. J R Soc Med 2018; 111:270-275. [PMID: 29985087 DOI: 10.1177/0141076818781406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Andrew Weeks
- 1 Sanyu Research Unit, Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Liverpool L8 7SS, UK
| | - Susan Bewley
- 2 Department of Women and Children's Health, Faculty of Life Sciences and Medicine, Kings College London, St Thomas' Hospital, London SE1 7EH, UK
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Askelöf U, Andersson O, Domellöf M, Fasth A, Hallberg B, Hellström-Westas L, Pettersson K, Westgren M, Wiklund IE, Götherström C. Wait a minute? An observational cohort study comparing iron stores in healthy Swedish infants at 4 months of age after 10-, 60- and 180-second umbilical cord clamping. BMJ Open 2017; 7:e017215. [PMID: 29289934 PMCID: PMC5778270 DOI: 10.1136/bmjopen-2017-017215] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Umbilical cord blood (UCB) is a valuable stem cell source used for transplantation. Immediate umbilical cord (UC) clamping is widely practised, but delayed UC clamping is increasingly advocated to reduce possible infant anaemia. The aim of this study was to investigate an intermediate UC clamping time point and to evaluate iron status at the age of 4 months in infants who had the UC clamped after 60 s and compare the results with immediate and late UC clamping. DESIGN Prospective observational study with two historical controls. SETTING A university hospital in Stockholm, Sweden, and a county hospital in Halland, Sweden. METHODS Iron status was assessed at 4 months in 200 prospectively recruited term infants whose UC was clamped 60 s after birth. The newborn baby was held below the uterine level for the first 30 s before placing the infant on the mother's abdomen for additional 30 s. The results were compared with data from a previously conducted randomised controlled trial including infants subjected to UC clamping at ≤10 s (n=200) or ≥180 s (n=200) after delivery. RESULTS After adjustment for age differences at the time of follow-up, serum ferritin concentrations were 77, 103 and 114 µg/L in the 10, 60 and 180 s groups, respectively. The adjusted ferritin concentration was significantly higher in the 60 s group compared with the 10 s group (P=0.002), while the difference between the 60 and 180 s groups was not significant (P=0.29). CONCLUSION In this study of healthy term infants, 60 s UC clamping with 30 s lowering of the baby below the uterine level resulted in higher serum ferritin concentrations at 4 months compared with 10 s UC clamping. The results suggest that delaying the UC clamping for 60 s reduces the risk for iron deficiency. TRIAL REGISTRATION NUMBER NCT01245296.
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Affiliation(s)
- Ulrica Askelöf
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
- The Swedish National Umbilical Cord Blood Bank, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ola Andersson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Unit for Pediatrics, Umeå University, Umeå, Sweden
| | - Anders Fasth
- The Swedish National Umbilical Cord Blood Bank, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatrics, Institution of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Boubou Hallberg
- Department of Neonatology, CLINTEC, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | | | - Karin Pettersson
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
- The Swedish National Umbilical Cord Blood Bank, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
- The Swedish National Umbilical Cord Blood Bank, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ingela E Wiklund
- Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
- The Swedish National Umbilical Cord Blood Bank, Sahlgrenska University Hospital, Gothenburg, Sweden
- Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
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Schorn MN, Dietrich MS, Donaghey B, Minnick AF. US Physician and Midwife Adherence to Active Management of the Third Stage of Labor International Recommendations. J Midwifery Womens Health 2017; 62:58-67. [DOI: 10.1111/jmwh.12586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 10/10/2016] [Accepted: 10/19/2016] [Indexed: 11/26/2022]
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Elbohoty AE, Mohammed WE, Sweed M, Bahaa Eldin AM, Nabhan A, Abd-El-Maeboud KH. Randomized controlled trial comparing carbetocin, misoprostol, and oxytocin for the prevention of postpartum hemorrhage following an elective cesarean delivery. Int J Gynaecol Obstet 2016; 134:324-8. [DOI: 10.1016/j.ijgo.2016.01.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/04/2016] [Accepted: 05/17/2016] [Indexed: 11/24/2022]
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Policies for management of postpartum haemorrhage: the HERA cross-sectional study in France. Eur J Obstet Gynecol Reprod Biol 2016; 205:21-6. [DOI: 10.1016/j.ejogrb.2016.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/29/2016] [Accepted: 08/01/2016] [Indexed: 11/23/2022]
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Rousseau A, Rozenberg P, Perrodeau E, Deneux-Tharaux C, Ravaud P. Variations in Postpartum Hemorrhage Management among Midwives: A National Vignette-Based Study. PLoS One 2016; 11:e0152863. [PMID: 27043439 PMCID: PMC4820253 DOI: 10.1371/journal.pone.0152863] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 03/21/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess variations in adherence to guidelines for management of postpartum hemorrhage (PPH) among midwives. METHODS A multicentre vignette-based study was e-mailed to a random sample of midwives from 145 maternity units in France. They were asked to describe how they would manage the PPH described in 2 case-vignettes. These previously validated case-vignettes described 2 different scenarios for severe PPH. Vignette 1 described a typical immediate, severe PPH and vignette 2 a less typical case of severe but gradual PPH. They were constructed in 3 successive steps and included multiple-choice questions proposing several types of clinical practice options at each step. An expert consensus defined 14 criteria for assessing adherence to guidelines issued by the French College of Obstetricians and Gynecologists in 2004 in the midwives' responses. We analyzed the number of errors among the 14 criteria to quantify the level of adherence. RESULTS We obtained 450 complete responses from midwives from 87 maternity units. The rate of complete adherence (no error for any of the 14 criteria) was low: 25.1% in vignette 1 and 4.2% in vignette 2. The error rate was higher for pharmacological management, especially oxytocin use, than for non-pharmacological management and communication-monitoring-investigation. Adherence to guidelines varied substantially between and within maternity units, as well as between the vignettes for the same midwives. CONCLUSION Reponses to case-vignettes demonstrated substantial variations in PPH management and especially individual variations in adherence to guidelines. Midwives should participate in continuous and individualized training.
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Affiliation(s)
- A. Rousseau
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - P. Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- Research unit EA 7285, Versailles-St Quentin University, Saint Quentin en Yvelines, France
| | - E. Perrodeau
- INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
| | - C. Deneux-Tharaux
- INSERM U1153, EPOPé (Epidémiologie Obstétricale, Périnatale et Pédiatrique) Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - P. Ravaud
- INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
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Rousseau A, Rozenberg P, Perrodeau E, Deneux-Tharaux C, Ravaud P. Staff and Institutional Factors Associated with Substandard Care in the Management of Postpartum Hemorrhage. PLoS One 2016; 11:e0151998. [PMID: 27010407 PMCID: PMC4806984 DOI: 10.1371/journal.pone.0151998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/06/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE to identify staff and institutional factors associated with substandard care by midwives managing postpartum hemorrhage (PPH). METHODS A multicenter vignette-based study was e-mailed to a random sample of midwives at 145 French maternity units that belonged to 15 randomly selected perinatal networks. Midwives were asked to describe how they would manage two case-vignettes about PPH and to complete a short questionnaire about their individual (e.g., age, experience, and full- vs. part-time practice) and institutional (private or public status and level of care) characteristics. These previously validated case-vignettes described two different scenarios: vignette 1, a typical immediate, severe PPH, and vignette 2, a severe but gradual hemorrhage. Experts consensually defined 14 criteria to judge adherence to guidelines. The number of errors (possible range: 0 to 14) for the 14 criteria quantified PPH guideline adherence, separately for each vignette. RESULTS 450 midwives from 87 maternity units provided complete responses. Perfect adherence (no error for any of the 14 criteria) was low: 25.1% for vignette 1 and 4.2% for vignette 2. After multivariate analysis, midwives' age remained significantly associated with a greater risk of error in guideline adherence in both vignettes (IRR 1.19 [1.09; 1.29] for vignette 1, and IRR 1.11 [1.05; 1.18] for vignette 2), and the practice of mortality and morbidity reviews in the unit with a lower risk (IRR 0.80 [0.64; 0.99], IRR 0.78 [0.66; 0.93] respectively). Risk-taking scores (IRR 1.41 [1.19; 1.67]) and full-time practice (IRR 0.83 [0.71; 0.97]) were significantly associated with adherence only in vignette 1. CONCLUSIONS Both staff and institutional factors may be associated with substandard care in midwives' PPH management.
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Affiliation(s)
- A. Rousseau
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - P. Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- Research unit EA 7285, Versailles-St Quentin University, Saint Quentin en Yvelines, France
| | - E. Perrodeau
- INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
| | - C. Deneux-Tharaux
- INSERM U1153, EPOPé (Epidémiologie Obstétricale, Périnatale et Pédiatrique) Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - P. Ravaud
- INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
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The LENTE Study: The Effectiveness of Prophylactic Intramuscular Oxytocin in the Third Stage of Labor Among Low-Risk Women in Primary Care Midwifery Practice: A Randomized Controlled Trial. INTERNATIONAL JOURNAL OF CHILDBIRTH 2016. [DOI: 10.1891/2156-5287.6.3.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE:To test third stage management of labor for low-risk women comparing routine prophylactic intramuscular oxytocin management versus modified expectant management.STUDY DESIGN:Randomized controlled multicenter trial in primary care midwifery practice.MAJOR FINDINGS:32.4% of women in the prophylactic intramuscular oxytocin management group had blood loss of 500 mL or more versus 44.2% in the modified expectant management group, relative risk (RR) 0.61, 95% confidence interval (CI) [0.50, 0.74]. The percentage of women experiencing postpartum hemorrhage (PPH) defined as more than 1,000 mL blood loss was 6.3% in the prophylactic intramuscular oxytocin management group versus 11.9% in the modified expectant management group (RR 0.50, 95% CI [0.36, 0.71]). The type of management showed no significant differences between the two groups in clinically relevant indicators of women’s short-term health such as the number of referrals, treatment given, hemoglobin level 36 hours postpartum, and breastfeeding rates after 1 week. Medium-term health such as hemoglobin level at 6 weeks postpartum, women’s perceptions of tiredness, and breastfeeding rates at 3 months after birth also showed no differences between the two groups.CONCLUSION:Third stage management by means of routine prophylactic intramuscular oxytocin reduced the risk of postpartum hemorrhage in a group of childbearing women at low risk of complications in primary midwifery care compared to modified expectant third stage management, but there was no evidence this was associated with a reduction in clinically relevant adverse health outcomes.
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Rousseau A, Rozenberg P, Ravaud P. Assessing Complex Emergency Management with Clinical Case-Vignettes: A Validation Study. PLoS One 2015; 10:e0138663. [PMID: 26383261 PMCID: PMC4575125 DOI: 10.1371/journal.pone.0138663] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 09/02/2015] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate whether responses to dynamic case-vignettes accurately reflect actual practices in complex emergency situations. We hypothesized that when obstetricians were faced with vignette of emergency situation identical to one they previously managed, they would report the management strategy they actually used. On the other hand, there is no reason to suppose that their response to a vignette based on a source case managed by another obstetrician would be the same as the actual management. Methods A multicenter vignette-based study was used in 7 French maternity units. We chose the example of severe postpartum hemorrhage (PPH) to study the use of case-vignettes for assessing the management of complex situations. We developed dynamic case-vignettes describing incidents of PPH in several steps, using documentation in patient files. Vignettes described the postpartum course and included multiple-choice questions detailing proposed clinical care. Each participating obstetrician was asked to evaluate 4 case-vignettes: 2 directly derived from cases they previously managed and 2 derived from other obstetricians’ cases. We compared the final treatment decision in vignette responses to those documented in the source-case by the overall agreement and the Kappa coefficient, both for the cases the obstetricians previously managed and the cases of others. Results Thirty obstetricians participated. Overall agreement between final treatment decisions in case-vignettes and documented care for cases obstetricians previously managed was 82% (Kappa coefficient: 0.75, 95% CI [0.62–0.88]). Overall agreement between final treatment decisions in case-vignettes and documented care in vignettes derived from other obstetricians’ cases was only 48% (Kappa coefficient: 0.30, 95% CI [0.12–0.48]). Final agreement with documented care was significantly better for cases based on their own previous cases than for others (p<0.001). Conclusions Dynamic case-vignettes accurately reflect actual practices in complex emergency situations. Therefore, they can be used to assess the quality of management in these situations.
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Affiliation(s)
- Anne Rousseau
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- INSERM U1153 Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- * E-mail:
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
- Research unit EA 7285, Versailles-St Quentin University, Saint Quentin en Yvelines, France
| | - Philippe Ravaud
- INSERM U1153 Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France
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Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2015:CD007412. [PMID: 25730178 DOI: 10.1002/14651858.cd007412.pub4] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. OBJECTIVES To compare the effectiveness of active versus expectant management of the third stage of labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2014) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women, GRADE:very low quality) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women, GRADE:low quality). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 infants, GRADE:low quality) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 infants, GRADE:very low quality). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both, and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS Although there is a lack of high-quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.
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Affiliation(s)
- Cecily M Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24, D'Olier Street, Dublin, Ireland, Dublin 2
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Egenberg S, Øian P, Bru LE, Sautter M, Kristoffersen G, Eggebø TM. Can inter-professional simulation training influence the frequency of blood transfusions after birth? Acta Obstet Gynecol Scand 2015; 94:316-23. [PMID: 25545119 PMCID: PMC4674974 DOI: 10.1111/aogs.12569] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/16/2014] [Indexed: 10/30/2022]
Abstract
OBJECTIVE To investigate whether inter-professional simulation training influenced the rate of red blood cell (RBC) transfusions after birth. DESIGN Two cohorts were compared retrospectively using a pre-post design. SETTING Norwegian university hospital with 4800 deliveries annually. POPULATION Women with estimated blood loss >500 mL within 24 h after birth in 2009 and 2011. METHODS In 2010, all maternity staff attended a 6-h, scenario-based training on emergency obstetrics including postpartum hemorrhage, using a birthing simulator. The simulation focused on prevention, identification, and treatment of postpartum hemorrhage and on communication and leadership. Debrief immediately after the scenarios involved reflection and self-assessment. MAIN OUTCOME MEASURES The frequency of women receiving RBC transfusions as a marker for blood loss. Secondary outcome was the frequency of surgical procedures in the management of postpartum hemorrhage. RESULTS In 2009, 111/534 (20.8%) women with estimated blood loss >500 mL after birth received RBC transfusions vs. 67/546 (12.3%) in 2011 (p < 0.01). The adjusted odds ratio for women receiving RBC transfusions in 2011 vs. 2009 was 0.53 (95% CI 0.38-0.74). Parity, oxytocin augmentation, duration of second stage, episiotomy, operative vaginal delivery, and sphincter injury were included in the final model. The odds ratio was stable in all combinations of possible confounders. We observed a significant reduction in the frequencies of curettage (p < 0.01) and uterine artery embolizations (p = 0.01). CONCLUSION We found a significant reduction in RBC transfusions after birth, which might be associated with mandatory simulation training. A causal link cannot be documented because of complex interactions of several variables.
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Affiliation(s)
- Signe Egenberg
- Department of Obstetrics and Gynecology, Stavanger University HospitalStavanger, Norway
| | - Pål Øian
- Department of Obstetrics and Gynecology, University Hospital of North NorwayTromsø, Norway
| | - Lars Edvin Bru
- Center for Behavioral Research, University of StavangerStavanger, Norway
| | | | - Gunn Kristoffersen
- Department of Immunology and Transfusion Medicine, Stavanger University HospitalStavanger, Norway
| | - Torbjørn Moe Eggebø
- Department of Obstetrics and Gynecology, Stavanger University HospitalStavanger, Norway
- National Center for Fetal Medicine, Trondheim University HospitalTrondheim, Norway
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Abstract
BACKGROUND Active management of the third stage of labour (AMTSL) consists of a group of interventions, including administration of a prophylactic uterotonic (at at or after delivery of the baby), baby, cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage. Recent recommendations are to delay cord clamping until the caregiver is ready to initiate CCT. The package of AMTSL reduces the risk of postpartum haemorrhage, (PPH), as does one component, routine use of uterotonics. The contribution, if any, of CCT needs to be quantified, as it is uncomfortable, and women may prefer a 'hands-off' approach. In addition its implementation has resource implications in terms of training of healthcare providers. OBJECTIVES To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 January 2014), PubMed (1966 to 29 January 2014), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data using a standard data extraction form. MAIN RESULTS We included three methodologically sound trials with data on 199, 4058 and 23,616 women respectively. Blinding was not possible, but bias could be limited by the fact that blood loss was measured objectively.There was no difference in the risk of blood loss ≥ 1000 mL (three trials, 27,454 women; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.77 to 1.08). Manual removal of the placenta was reduced with CCT (two trials, 27,665 women; RR 0.69, 95% CI 0.57 to 0.83). In the World Health Organization (WHO) trial the reduction in manual removal occurred mainly in sites where ergometrine was used routinely in the third stage of labour. The non-prespecified analysis excluding sites routinely using ergometrine for management of the third stage of labour found no difference in the risk of manual removal of the placenta in the WHO trial (one trial, 23,010 women; RR 1.03, 95% CI 0.73 to 1.46). The policy of restricting the third stage of labour to 30 minutes (4057 women; RR 0.69, 95% CI 0.53 to 0.90) may have had an effect in the French study.Among the secondary outcomes, there were reductions in blood loss ≥ 500 mL (three trials, 27,454 women; RR 0.93, 95% CI 0.88 to 0.99), mean blood loss (two trials, 27,255 women; mean difference (MD) -10.85 mL, 95% CI -16.73 to -4.98), and duration of the third stage of labour (two trials, 27,360 women; standardised MD -0.57, -0.59 to -0.54). There were no clear differences in use of additional uterotonics (three trials, 27,829 women; average RR 0.95, 95% CI 0.88 to 1.02), blood transfusion, maternal death/severe morbidity, operative procedures nor maternal satisfaction. Maternal pain (non-prespecified) was reduced in one trial (3760 women; RR 0.78, 95% CI 0.61 to 0.99).The following secondary outcomes were not reported upon in any of the trials: retained placenta for more than 60 minutes or as defined by trial author; maternal haemoglobin less than 9 g/dL at 24 to 48 hours post-delivery or blood transfusion; organ failure; intensive care unit admission; caregiver satisfaction; cost-effectiveness; evacuation of retained products; or infection. AUTHORS' CONCLUSIONS CCT has the advantage of reducing the risk of manual removal of the placenta in some circumstances, and evidence suggests that CCT can be routinely offered during the third stage of labour, provided the birth attendant has the necessary skills. CCT should remain a core competence of skilled birth attendants. However, the limited benefits of CCT in terms of severe PPH would not justify the major investment which would be needed to provide training in CCT skills for birth attendants who do not have formal training. Women who prefer a less interventional approach to management of the third stage of labour can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without increased risk of severe PPH, but that the risk of manual removal of the placenta may be increased.Research gaps include the use of CCT in the absence of a uterotonic, and the place of uterine massage in the management of the third stage of labour.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Nolundi T Mshweshwe
- Effective Care Research UnitDepartment of Obstetrics and GynaecologyFrere Maternity HospitalAmalinda DriveEast LondonEastern CapeSouth Africa5200
| | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Schorn MN, Minnick A, Donaghey B. An exploration of how midwives and physicians manage the third stage of labor in the United States. J Midwifery Womens Health 2015; 60:187-98. [PMID: 25643921 DOI: 10.1111/jmwh.12217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Care of the woman during the third stage of labor is a critical component of good patient outcomes. The type and extent of activities used in the United States, including those suggested for active management of the third stage of labor, are unknown. This study obtained preliminary data for the development of a national study of interventions used by US birth attendants during the third stage of labor, work that will ultimately lead to a study examining links between activities and outcomes. The specific aims were to identify provider-reported assessments and interventions used during the third stage of labor and to examine which management steps or interventions providers believe should always be used during the third stage of labor. METHODS Four provider-specific focus groups (certified nurse-midwives, certified professional midwives, obstetricians, and family practice physicians) were held using a nominal group technique. Two researchers analyzed audio-recorded transcriptions independently. RESULTS More than 100 assessments, 110 interventions, and 65 "always used" activities were identified. There was variation within and across groups. Midwife groups were more likely to specify maternal preference activities, and physician groups were more likely to specify drug-related actions. DISCUSSION Surveys of third-stage labor practices must include large numbers of actions to represent what may be the state of US practices. Survey design may need to include a multiple-forms approach to avoid participant burden. Designs should include the exploration of differences by provider type as well as within provider variation.
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Brown A, Jordan S. Active management of the third stage of labor may reduce breastfeeding duration due to pain and physical complications. Breastfeed Med 2014; 9:494-502. [PMID: 25347567 DOI: 10.1089/bfm.2014.0048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Evidence is growing that active management of the third stage of labor using prophylactic uterotonics may be associated with lower breastfeeding rates. The reasons underlying this relationship are incompletely understood. The aim of this article is to examine the experiences of mothers who stopped breastfeeding in relation to administration of parenteral uterotonics for postpartum hemorrhage prophylaxis. SUBJECTS AND METHODS Two hundred eighty-eight mothers with an infant 0-6 months of age who had a vaginal birth completed a self-report questionnaire examining injections of uterotonics during the third stage of labor, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological. RESULTS No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty. CONCLUSIONS These findings suggest that injection of prophylactic uteronics may reduce breastfeeding duration, but not initiation. This may be attributable to the effects of oxytocin or ergometrine on the physiology of lactation, leading to difficulties with infant latch and milk supply. If breastfeeding rates are to be optimized, this hypothesis needs to be explored in randomized controlled trials of third-stage management. Meanwhile, mothers who receive parenteral uterotonics may need additional support to establish breastfeeding.
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Affiliation(s)
- Amy Brown
- College of Human and Health Sciences, Swansea University , Swansea, United Kingdom
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Guillaume A, Sananès N, Poirier V, Gaudineau A, Fritz G, Boudier E, Viville B, Aissi G, Favre R, Nisand I, Langer B. Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study. J Matern Fetal Neonatal Med 2014; 28:2111-4. [PMID: 25341670 DOI: 10.3109/14767058.2014.979401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH). METHODS This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ(2) tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000 cc), retained placenta over 30 min and manual removal of the placenta. RESULTS A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50-0.97; p = 0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta. CONCLUSIONS In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.
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Affiliation(s)
- Anne Guillaume
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and.,b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Nicolas Sananès
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and.,b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Valérie Poirier
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and
| | - Adrien Gaudineau
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and.,b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Gabrielle Fritz
- b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Eric Boudier
- b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Brigitte Viville
- b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Germain Aissi
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and
| | - Romain Favre
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and
| | - Israel Nisand
- a Department of Gynaecology & Obstetrics , CMCO Schiltigheim and.,b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
| | - Bruno Langer
- b Department of Gynaecology & Obstetrics , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg , Strasbourg Cedex , France
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Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG 2014; 122:202-10. [PMID: 25289730 DOI: 10.1111/1471-0528.13098] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 11/26/2022]
Abstract
Postpartum haemorrhage (PPH) remains a major cause of maternal deaths worldwide, and is estimated to cause the death of a woman every 10 minutes. This review presents the latest clinical advice, including new evidence on controlled cord traction, misoprostol, and oxytocin. The controversy around the diagnosis of PPH, the limitations of universal prophylaxis, and novel ways to provide obstetric first aid are also presented. It ends with a call to develop high-quality front-line obstetric services that can deal rapidly with unexpected haemorrhages as well as minimising blood loss at critical times: major abruption, placenta praevia, and caesarean for prolonged labour.
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Affiliation(s)
- A Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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Lim PS, Ismail NAM, Ghani NAA, Kampan NC, Sulaiman AS, Ng BK, Chew KT, Karim AKA, Yassin MAJM. Retained placenta: Do we have any option? World J Obstet Gynecol 2014; 3:124-129. [DOI: 10.5317/wjog.v3.i3.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/06/2014] [Accepted: 07/14/2014] [Indexed: 02/05/2023] Open
Abstract
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.
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McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. ACTA ACUST UNITED AC 2014; 9:303-97. [DOI: 10.1002/ebch.1971] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Briley A, Seed PT, Tydeman G, Ballard H, Waterstone M, Sandall J, Poston L, Tribe RM, Bewley S. Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study. BJOG 2014; 121:876-88. [PMID: 24517180 PMCID: PMC4282054 DOI: 10.1111/1471-0528.12588] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- A Briley
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
| | - PT Seed
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
| | - G Tydeman
- NHS Fife, Royal Victoria HospitalKirkcaldy, Fife, UK
| | - H Ballard
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
| | - M Waterstone
- Dartford and Gravesham NHS Trust, Darent Valley HospitalDartford, Kent, UK
| | - J Sandall
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
| | - L Poston
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
| | - RM Tribe
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
| | - S Bewley
- Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, St Thomas' Hospital CampusLondon, UK
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Engjom HM, Morken NH, Norheim OF, Klungsøyr K. Availability and access in modern obstetric care: a retrospective population-based study. BJOG 2014. [PMID: 24283373 PMCID: PMC4253080 DOI: 10.1111/bjo.12510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the availability of obstetric institutions, the risk of unplanned delivery outside an institution and maternal morbidity in a national setting in which the number of institutions declined from 95 to 51 during 30 years. DESIGN Retrospective population-based, three cohorts and two cross-sectional analyses. SETTING Census data, Statistics Norway. The Medical Birth Registry of Norway from 1979 to 2009. POPULATION Women (15-49 years), 2000 (n = 1,050,269) and 2010 (n = 1,127,665). Women who delivered during the period 1979-2009 (n = 1,807,714). METHODS Geographic Information Systems software for travel zone calculations. Cross-table and multiple logistic regression analysis of change over time and regional differences. World Health Organization Emergency Obstetric and Newborn Care (EmOC) indicators. MAIN OUTCOME MEASURES Proportion of women living outside the 1-hour travel zone to obstetric institutions. Risk of unplanned delivery outside obstetric institutions. Maternal morbidity. RESULTS The proportion of women living outside the 1-hour zone for all obstetric institutions increased from 7.9% to 8.8% from 2000 to 2010 (relative risk, 1.1; 95% confidence interval, 1.11-1.12), and for emergency obstetric care from 11.0% to 12.1% (relative risk, 1.1; 95% confidence interval, 1.09-1.11). The risk of unplanned delivery outside institutions increased from 0.4% in 1979-83 to 0.7% in 2004-09 (adjusted odds ratio, 2.0; 95% confidence interval, 1.9-2.2). Maternal morbidity increased from 1.7% in 2000 to 2.2% in 2009 (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.5) and the regional differences increased. CONCLUSIONS The availability of and access to obstetric institutions was reduced and we did not observe the expected decrease in maternal morbidity following the centralisation.
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Affiliation(s)
- HM Engjom
- Department of Global Public Health and Primary Care, University of BergenBergen, Norway
| | - N-H Morken
- Department of Global Public Health and Primary Care, University of BergenBergen, Norway,Department of Obstetrics and Gynecology, Haukeland University HospitalBergen, Norway
| | - OF Norheim
- Department of Global Public Health and Primary Care, University of BergenBergen, Norway,Department of Research and Development, Haukeland University HospitalBergen, Norway
| | - K Klungsøyr
- Department of Global Public Health and Primary Care, University of BergenBergen, Norway,Medical Birth Registry of Norway, Norwegian Institute of Public HealthBergen, Norway
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Afshari P, Medforth J, Aarabi M, Abedi P, Soltani H. Management of third stage labour following vaginal birth in Iran: A survey of current policies. Midwifery 2014; 30:65-71. [DOI: 10.1016/j.midw.2013.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/22/2013] [Accepted: 02/04/2013] [Indexed: 11/30/2022]
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Abstract
Iron deficiency (ID) is the most common micronutrient deficiency worldwide and young children are a special risk group because their rapid growth leads to high iron requirements. Risk factors associated with a higher prevalence of ID anemia (IDA) include low birth weight, high cow's-milk intake, low intake of iron-rich complementary foods, low socioeconomic status, and immigrant status. The aim of this position paper was to review the field and provide recommendations regarding iron requirements in infants and toddlers, including those of moderately or marginally low birth weight. There is no evidence that iron supplementation of pregnant women improves iron status in their offspring in a European setting. Delayed cord clamping reduces the risk of ID. There is insufficient evidence to support general iron supplementation of healthy European infants and toddlers of normal birth weight. Formula-fed infants up to 6 months of age should receive iron-fortified infant formula, with an iron content of 4 to 8 mg/L (0.6-1.2 mg(-1) · kg(-1) · day(-1)). Marginally low-birth-weight infants (2000-2500 g) should receive iron supplements of 1-2 mg(-1) · kg(-1) · day(-1). Follow-on formulas should be iron-fortified; however, there is not enough evidence to determine the optimal iron concentration in follow-on formula. From the age of 6 months, all infants and toddlers should receive iron-rich (complementary) foods, including meat products and/or iron-fortified foods. Unmodified cow's milk should not be fed as the main milk drink to infants before the age of 12 months and intake should be limited to <500 mL/day in toddlers. It is important to ensure that this dietary advice reaches high-risk groups such as socioeconomically disadvantaged families and immigrant families.
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Hutchon DJR, Wepster B. The Estimated Cost of Early Cord Clamping at Birth Within Europe. INTERNATIONAL JOURNAL OF CHILDBIRTH 2014. [DOI: 10.1891/2156-5287.4.4.250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early cord clamping has been a common although variable practice at all births throughout Europe for the past 40 years. It is known to result in a variable degree of hypovolemia, reduced cardiac output, reduced cerebral circulation, and an immediate loss of placental oxygenated blood. Hypoxic ischemia of the brain at birth is recognized to be a major underlying cause of cerebral palsy. Using very conservative estimates of the adverse effects of early cord clamping in a proportion of births according to the survey of its use in Europe and an estimate of the cost of care for an individual with cerebral palsy, we have calculated a possible cost for the intervention which is unnecessary and continued practice is largely the result of habit and poor understanding of the physiology of transition.
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Engjom HM, Morken N, Norheim OF, Klungsøyr K. Availability and access in modern obstetric care: a retrospective population‐based study. BJOG 2013; 121:290-9. [DOI: 10.1111/1471-0528.12510] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 11/28/2022]
Affiliation(s)
- HM Engjom
- Department of Global Public Health and Primary Care University of Bergen Bergen Norway
| | - N‐H Morken
- Department of Global Public Health and Primary Care University of Bergen Bergen Norway
- Department of Obstetrics and Gynecology Haukeland University Hospital Bergen Norway
| | - OF Norheim
- Department of Global Public Health and Primary Care University of Bergen Bergen Norway
- Department of Research and Development Haukeland University Hospital Bergen Norway
| | - K Klungsøyr
- Department of Global Public Health and Primary Care University of Bergen Bergen Norway
- Medical Birth Registry of Norway Norwegian Institute of Public Health Bergen Norway
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Abstract
Deferring cord clamping allows blood flow between baby and placenta to continue for a few moments. This often leads to increased neonatal blood volume at birth. It also allows for longer transition to the neonatal circulation. Optimal timing for clamping the cord remains uncertain. This paper discusses the physiology of placental transfusion and presents the evidence from systematic reviews of randomised trials comparing alternative strategies for cord clamping for both term and preterm births. For healthy term infants, deferring cord clamping increases iron stores in infancy. Therefore, a more liberal approach to deferring cord clamping appears to be warranted, provided screening and treatment for jaundice requiring phototherapy is available. For preterm births, although there are few data on the main clinical outcomes, the evidence is promising that deferred cord clamping may be beneficial. For both term and preterm infants there is little information about long term development.
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Affiliation(s)
- Lelia Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, South Block, C floor, Queen's Medical Centre, NG7 2UH, United Kingdom.
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Prick BW, Vos AA, Hop WCJ, Bremer HA, Steegers EAP, Duvekot JJ. The current state of active third stage management to prevent postpartum hemorrhage: a cross-sectional study. Acta Obstet Gynecol Scand 2013; 92:1277-83. [PMID: 23962221 DOI: 10.1111/aogs.12238] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the implementation of the International Confederation of Midwives/International Federation of Gynecology and Obstetrics (ICM/FIGO) guideline on active third stage management in vaginal deliveries in daily clinical practice. DESIGN Observational, cross-sectional study. SETTING One tertiary and one teaching hospital in the Netherlands. POPULATION Women undergoing vaginal deliveries. METHODS A case record form was completed after every vaginal delivery. Primary outcome was adequate guideline adherence, defined as initial administration of 10 IU oxytocin, performance of controlled cord traction and uterine massage. Adequate guideline adherence was a priori estimated to be 10%. With a sample size of 600, i.e. 300 women per hospital, the standard error of the resulting percentage would be less than 2% for each hospital. RESULTS Six hundred and twenty six women were included. Guideline adherence was adequately performed in 48% of vaginal deliveries. Oxytocin was administered after birth in 98% of deliveries and in 80% the correct dose was used. Controlled cord traction was performed in 63% and uterine massage in 93%; however, the latter was performed as advised (at least eight times) in only 8%. The amount of blood loss was not associated with the use of either 5 or 10 IU oxytocin (p = 0.818). Controlled cord traction and uterine massage were more frequently performed when blood loss exceeded 500 mL (p < 0.001). CONCLUSIONS Active third stage management according to the ICM/FIGO guideline is adequately performed in only 48% of all vaginal deliveries. Results of this study call for training programs to increase adherence to the ICM/FIGO guideline.
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Affiliation(s)
- Babette W Prick
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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40
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Abstract
Over the past 40 years, there have been a number of review articles attempting to rationalise cord clamping practice. Early cord clamping was originally thought to be important in active management of the third stage of labour, but this was never evidence based. Without an evidence base to justify it, early cord clamping in clinical practice has remained very variable. There is good evidence that early cord clamping leads to hypovolaemia, anaemia and low iron stores in the neonate. We review all the evidence and discuss possible reasons why some obstetricians and midwives persevere with early clamping. We explain how a variable definition, defective education, deferred responsibility between obstetrician and paediatrician, variable guidelines and a lack of appreciation for the potential harm of the intervention, have all contributed. This study describes how the need for early cord clamping can be avoided in practically all clinical complications of birth.
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Medical prevention and treatment of postpartum hemorrhage: a comparison of different guidelines. Arch Gynecol Obstet 2013; 289:555-67. [DOI: 10.1007/s00404-013-3016-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
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de Castro Parreira MVB, Gomes NCF. Preventing postpartum haemorrhage: active management of the third stage of labour. J Clin Nurs 2013; 22:3372-87. [PMID: 23875752 DOI: 10.1111/jocn.12361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2013] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To review scientific publications on health to identify the main practices used for the active management of the third stage of vaginal labour and to assess their effectiveness in preventing postpartum haemorrhage. BACKGROUND According to the World Health Organization (WHO Recommendations for the Prevention of Postpartum Haemorrhage, 2007. WHO Document Production Services, Geneva), postpartum haemorrhage is considered to be the cause of a quarter of maternal morbidity and mortality rates worldwide. In an attempt to reduce the risk of haemorrhage, a group of interventions have been introduced into clinical practice that constitute active management conduct during the third stage of labour and are recommended by the international organisations. DESIGN AND METHODS An integrative literature review of studies on the subject in question, indexed in databases of health between the years 2006-2012, was conducted. The analysis included 13 articles, six of which were original articles and seven of which were literature reviews. RESULTS Based on our data analysis, we found that most studies supported the effectiveness of active management in reducing the risk of haemorrhage, in the immediate postpartum period. Despite the fact that active management practices for the third stage of labour differ in their specific elements, in the majority of the selected studies, the interventions followed those recommended by the international organisations. CONCLUSIONS The results of this review of management practices supported active management of the third stage of labour to prevent postpartum haemorrhage, with five main forms of intervention: administration of oxytocin, delayed clamping of umbilical cord, draining of placental blood, controlled cord traction and uterine massage. RELEVANCE TO CLINICAL PRACTICE There is a need to determine gaps in the clinical practices of midwives in regard to the active management of third stage of labour, to update knowledge and practices with the latest scientific evidence.
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McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2013; 2013:CD004074. [PMID: 23843134 PMCID: PMC6544813 DOI: 10.1002/14651858.cd004074.pub3] [Citation(s) in RCA: 194] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord more than one minute after the birth or when cord pulsation has ceased. The benefits and potential harms of each policy are debated. OBJECTIVES To determine the effects of early cord clamping compared with late cord clamping after birth on maternal and neonatal outcomes SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013). SELECTION CRITERIA Randomised controlled trials comparing early and late cord clamping. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and quality and extracted data. MAIN RESULTS We included 15 trials involving a total of 3911 women and infant pairs. We judged the trials to have an overall moderate risk of bias. Maternal outcomes: No studies in this review reported on maternal death or on severe maternal morbidity. There were no significant differences between early versus late cord clamping groups for the primary outcome of severe postpartum haemorrhage (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.65 to 1.65; five trials with data for 2066 women with a late clamping event rate (LCER) of ~3.5%, I(2) 0%) or for postpartum haemorrhage of 500 mL or more (RR 1.17 95% CI 0.94 to 1.44; five trials, 2260 women with a LCER of ~12%, I(2) 0%). There were no significant differences between subgroups depending on the use of uterotonic drugs. Mean blood loss was reported in only two trials with data for 1345 women, with no significant differences seen between groups; or for maternal haemoglobin values (mean difference (MD) -0.12 g/dL; 95% CI -0.30 to 0.06, I(2) 0%) at 24 to 72 hours after the birth in three trials. Neonatal outcomes: There were no significant differences between early and late clamping for the primary outcome of neonatal mortality (RR 0.37, 95% CI 0.04 to 3.41, two trials, 381 infants with a LCER of ~1%), or for most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late, compared with early, cord clamping (101 g increase 95% CI 45 to 157, random-effects model, 12 trials, 3139 infants, I(2) 62%). Fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62, 95% CI 0.41 to 0.96, data from seven trials, 2324 infants with a LCER of 4.36%, I(2) 0%). Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord clamping group (MD -1.49 g/dL, 95% CI -1.78 to -1.21; 884 infants, I(2) 59%). This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed (RR 2.65 95% CI 1.04 to 6.73, five trials, 1152 infants, I(2) 82%). In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were seen for Ages and Stages Questionnaire scores. AUTHORS' CONCLUSIONS A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.
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Affiliation(s)
- Susan J McDonald
- Midwifery Professorial Unit, La Trobe University/Mercy Hospital for Women, Melbourne, Australia.
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Holleboom CAG, van Eyck J, Koenen SV, Kreuwel IAM, Bergwerff F, Creutzberg EC, Bruinse HW. Carbetocin in comparison with oxytocin in several dosing regimens for the prevention of uterine atony after elective caesarean section in the Netherlands. Arch Gynecol Obstet 2013; 287:1111-7. [PMID: 23329341 PMCID: PMC3655222 DOI: 10.1007/s00404-012-2693-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The aim of the study was to compare the prophylactic effects of carbetocin with those of oxytocin for the prevention of uterine atony in patients undergoing elective caesarean section (CS) in the Netherlands. The primary endpoint was the need for additional uterotonic medication. METHODS Each of the five participating Dutch hospitals treated 50-100 term patients with 100 μg of intravenous carbetocin on prescription. Each centre retrieved charts of 250 patients treated with oxytocin according to the hospital's policy for the prevention of uterine atony (oxytocin bolus 5 IU, bolus 10 IU or bolus 5 IU followed by 10 IU in 2 h). RESULTS In the carbetocin group 462 subjects were included and in the oxytocin group 1,122. The proportion of subjects needing additional uterotonic treatment was 3.1 % (95 % CI 1.7-5.1 %) after carbetocin and 7.2 % (5.8-8.9 %) after oxytocin; relative risk 0.41 (0.19-0.85); p = 0.0110. Carbetocin was most effective compared with the oxytocin 5 IU bolus subgroup with less need for additional uterotonic medication (3.1 vs. 9.3 %, p = 0.0067) and blood transfusions (2.2 vs. 3.6 %, p = 0.0357). CONCLUSIONS Compared with oxytocin, prophylaxis of uterine atony with carbetocin after an elective CS diminished the need for additional uterotonics by more than 50 %.
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Affiliation(s)
- C. A. G. Holleboom
- Departments of Gynaecology, Bronovo Hospital, The Hague, The Netherlands
| | - J. van Eyck
- Departments of Gynaecology, Isala Clinics, Zwolle, The Netherlands
| | - S. V. Koenen
- Departments of Gynaecology, University Medical Centre, Utrecht, The Netherlands
| | - I. A. M. Kreuwel
- Departments of Gynaecology, Medical Spectrum Twente, Enschede, The Netherlands
| | - F. Bergwerff
- Departments of Gynaecology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E. C. Creutzberg
- Departments of Gynaecology, Ferring B.V. Hoofddorp, P.O. Box 184, 2130 AD Hoofddorp, The Netherlands
| | - H. W. Bruinse
- Departments of Gynaecology, University Medical Centre, Utrecht, The Netherlands
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Deneux-Tharaux C, Sentilhes L, Maillard F, Closset E, Vardon D, Lepercq J, Goffinet F. Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR). BMJ 2013; 346:f1541. [PMID: 23538918 PMCID: PMC3610557 DOI: 10.1136/bmj.f1541] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2013] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting. DESIGN Randomised controlled trial. SETTING Five university hospital maternity units in France. PARTICIPANTS Women aged 18 or more with a singleton fetus at 35 or more weeks' gestation and planned vaginal delivery. INTERVENTIONS Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth. MAIN OUTCOME MEASURE Incidence of postpartum haemorrhage ≥ 500 mL as measured in a collector bag. RESULTS The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm. CONCLUSIONS In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking. TRIAL REGISTRATION ClinicalTrials.gov NCT01044082.
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Affiliation(s)
- Catherine Deneux-Tharaux
- INSERM U953, Epidemiologic Research in Perinatal, Women's, and Children's Health, Pierre et Marie Curie University, Paris, France.
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Miranda JE, Rojas-Suarez J, Paternina A, Mendoza R, Bello C, Tolosa JE. The effect of guideline variations on the implementation of active management of the third stage of labor. Int J Gynaecol Obstet 2013; 121:266-9. [DOI: 10.1016/j.ijgo.2012.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 12/19/2012] [Accepted: 02/15/2013] [Indexed: 11/30/2022]
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Zanardo V, Gabrieli C, de Luca F, Trevisanuto D, De Santis M, Scambia G, Straface G. Head-to-body delivery by “two-step” approach: effect on cord blood hematocrit. J Matern Fetal Neonatal Med 2013; 26:1234-8. [DOI: 10.3109/14767058.2013.776534] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sheldon WR, Durocher J, Winikoff B, Blum J, Trussell J. How effective are the components of active management of the third stage of labor? BMC Pregnancy Childbirth 2013; 13:46. [PMID: 23433172 PMCID: PMC3607929 DOI: 10.1186/1471-2393-13-46] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 02/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Active management of the third stage of labor is recommended for the prevention of post-partum hemorrhage and commonly entails prophylactic administration of a uterotonic agent, controlled cord traction, and uterine massage. While oxytocin is the first-choice uterotonic, it is not known whether its effectiveness varies by route of administration. There is also insufficient evidence regarding the value of controlled cord traction or uterine massage. This analysis assessed the independent and combined effectiveness of all three interventions, and the effect of route of oxytocin administration on post-partum blood loss. METHODS Secondary data were analyzed from 39202 hospital-based births in four countries and two clinical regimens: one in which oxytocin was administered following delivery of the baby; the other in which it was not. We used logistic regression to examine associations between clinical and demographic variables and post-partum blood loss ≥ 700 mL. RESULTS Among those with no oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by nearly 50% as compared with expectant management (P < 0.001). Among those with oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by 66% when oxytocin was intramuscular (P < 0.001), but conferred no benefit when oxytocin was intravenous. Route of administration was important when oxytocin was the only intervention provided: intravenous administration reduced hemorrhage risk by 76% as compared with intramuscular administration (P < 0.001); when combined with other interventions, route of administration had no effect. In both clinical regimens, uterine massage was associated with increased hemorrhage risk. CONCLUSIONS Recommendations for active management of the third stage of labor should account for setting-related differences such as the availability of oxytocin and its route of administration. The optimal combination of interventions will vary accordingly.
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Affiliation(s)
- Wendy R Sheldon
- Office of Population Research, Princeton University, Princeton, NJ, USA
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - Jill Durocher
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - Jennifer Blum
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, USA
| | - James Trussell
- Office of Population Research, Princeton University, Princeton, NJ, USA
- The Hull York Medical School, Hull, England
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49
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Outcomes of physiological and active third stage labour care amongst women in New Zealand. Midwifery 2013; 29:67-74. [DOI: 10.1016/j.midw.2011.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 09/29/2011] [Accepted: 11/06/2011] [Indexed: 11/18/2022]
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50
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Brown N. Contradictions of value: between use and exchange in cord blood bioeconomy. SOCIOLOGY OF HEALTH & ILLNESS 2013; 35:97-112. [PMID: 22497249 DOI: 10.1111/j.1467-9566.2012.01474.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Umbilical cord blood (CB) has become established as an increasingly viable clinical alternative to bone marrow in the treatment of leukaemia leading to the construction of a global network of CB banks promoted through a moral ethos of gift. Additionally, some banks offer the opportunity to retain stem cells privately. CB is discursively presented as clinical 'waste', a 'by-product' of birthing. In this way CB units are made available to a global exchange-based bioeconomy. Crucially, CB collection has developed in parallel with several necessary obstetric practices, especially the immediate clamping of the cord following delivery, essential to high volume collection. However, this article strongly suggests the promotional basis of CB banking (such as by gift, waste or donation) is in tension with the growing preference of new parents to delay cord clamping. Based on focus groups with expectant parents, the promotion of CB banking can in fact be seen to feed into critical reflection on the value of CB for newborn infants, potentially reinvigorating a tradition of delayed umbilical cord clamping. Theoretically, these contradictory systems of valuing are conceptualised through recent literature on bioeconomy and Marx's writings on the contrasting tensions between use and exchange value.
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Affiliation(s)
- Nik Brown
- Department of Sociology, University of York, Heslington, York Y01 5DD.
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