Comparison of the effect of breast pump stimulation and oxytocin administration on the length of the third stage of labor, postpartum hemorrhage, and anemia: a randomized controlled trial

Efficacy of skin-to-skin contact between mother and infant on maternal outcomes during the third stage of labour: A systematic review and meta-analysis

BACKGROUND

Postpartum haemorrhage is a preventable cause of maternal mortality that commonly occurs during the third stage of labour. Skin-to-skin contact is an intervention that can support the physiological processes of labour by increasing oxytocin levels, which can accelerate placental expulsion and enhance uterine contractions, thereby contributing to the prevention of postpartum haemorrhage.

OBJECTIVE

This systematic review aims to evaluate the impact of skin-to-skin contact on key maternal variables during the third stage of labour, including the duration of this stage, placental integrity, the need for manual placental extraction, the administration of therapeutic uterotonics, and the position of the uterine fundus.

METHODS

A systematic review with meta-analysis of randomised controlled trials and prospective quasi-experimental studies was conducted. Studies were searched in PubMed, Scopus, Cochrane, CINAHL, Google Scholar, and Web of Science. Statistical analysis was performed using STATA version 18. The results of the meta-analysis were reported using relative risk (RR) for dichotomous data and mean difference (MD) for continuous data, both with 95 % confidence intervals (CI). A random-effects model was employed due to the anticipated heterogeneity among the included studies. Sensitivity analyses were performed to assess the robustness of the findings, and a subgroup analysis was conducted based on the type of birth, study design, and country economic level.

RESULTS

Twenty-five trials were included. Skin-to-skin contact significantly reduced the duration of the third stage of labour (MD: -4.26; 95 %; CI: -5.70, -2.81), increased the likelihood of complete placental integrity (RR: 1.09; 95 % CI: 1.02, 1.16), and significantly reduced both the likelihood of a supraumbilical position of the uterine fundus (RR: 0.39; 95 % CI: 0.20, 0.76) and the need for uterotonic administration (RR: 0.24; 95 % CI: 0.12, 0.48).

CONCLUSIONS

Skin-to-skin contact is a simple practice that can favourably influence the physiological processes of labour and improve various maternal outcomes. These benefits include reducing the duration of the third stage of labour, ensuring complete birth of the placenta, decreasing the need for uterotonic administration, and increasing the likelihood of a proper uterine fundal position. Therefore, it is recommended to include this practice in labour care protocols.

Stimulation Therapy to Induce Mothers: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

More than 1 million women have their labor induced in the United States each year, and synthetic oxytocin infusion is the most common method used. However, compared to spontaneous labor, medical induction is resource intensive, has increased obstetric risks, and is associated with less successful breastfeeding. In contrast to the endogenous oxytocin hormone, which is released in a pulsatile fashion in the brain, synthetic oxytocin is continuously infused intravenously, resulting in important limitations related to efficacy, safety, and cost. Akin to spontaneous labor contractions, infant suckling of the breast nipple is known to stimulate the pulsatile release of endogenous oxytocin from the posterior pituitary gland. Nipple stimulation therapy via an electric breast pump similarly stimulates endogenous oxytocin release and may be a favorable inpatient method for patients undergoing labor induction.

OBJECTIVE

This study aims to examine whether inpatient nipple stimulation therapy is an efficacious labor induction method that increases the likelihood of spontaneous vaginal delivery and sustained breastfeeding and determine whether it is a cost-effective approach.

METHODS

This is a multicenter, pragmatic, open-label, parallel-group randomized controlled trial of nulliparous patients with singleton gestations ≥36 weeks undergoing labor induction. This trial compares inpatient nipple stimulation therapy via an electric breast pump versus immediate synthetic oxytocin infusion without nipple stimulation. This trial including 988 nulliparas will provide adequate statistical power to detect clinically meaningful differences in delivery mode and breast milk as the sole source of nutrition for newborns at hospital discharge or 72 hours after birth.

RESULTS

The project received pilot funding in 2021 and full funding in 2023. Enrollment for this study began in November 2021 at a single site, and as of May 2024, recruitment is underway at 3 study sites. It is anticipated that enrollment will be completed by late 2026.

CONCLUSIONS

Successful completion of this trial will provide rigorous data to determine whether inpatient nipple stimulation therapy with an electric breast pump can improve the way we induce labor and positively impact breastfeeding success and early infant nutrition through lactation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05079841; https://clinicaltrials.gov/study/NCT05079841.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63463.

The role of the oxytocin system in the resilience of patients with breast cancer

Breast cancer is a grave traumatic experience that can profoundly compromise patients' psychological resilience, impacting their overall quality of life. The oxytocin system represents one of the essential neurobiological bases of psychological resilience and plays a critical role in regulating resilience in response to social or traumatic events during adulthood. Oxytocin, through its direct interaction with peripheral or central oxytocin receptors, has been found to have a significant impact on regulating social behavior. However, the precise mechanism by which the activation of peripheral oxytocin receptors leads to improved social is still not completely comprehended and requires additional research. Its activation can modulate psychological resilience by influencing estrogen and its receptors, the hypothalamic-pituitary-adrenal axis, thyroid function, 5-hydroxytryptamine metabolism levels, and arginine pressure release in breast cancer patients. Various interventions, including psychotherapy and behavioral measures, have been employed to improve the psychological resilience of breast cancer patients. The potential effectiveness of such interventions may be underpinned by their ability to modulate oxytocin release levels. This review provides an overview of the oxytocin system and resilience in breast cancer patients and identifies possible future research directions and interventions.

Uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum

BACKGROUND

The reported success rate of uterine artery embolization (UAE) for postpartum hemorrhage (PPH) differs by the cause of bleeding; in some reports, UAE shows less successful results in patients with placenta accreta spectrum (PAS).

PURPOSE

To evaluate the outcome of UAE for treating PPH associated with PAS.

MATERIAL AND METHODS

From September 2011 to September 2021, 227 patients (mean age = 34.67±4.06 years; age range = 19-47 years) underwent UAE for managing intractable PPH. Patients were divided into two groups: those with PAS (n = 46) and those without PAS (n = 181). Delivery details, embolization details, and procedure-related outcomes were compared between the two groups. P values <0.05 were considered statistically significant.

RESULTS

The technical success rate was 96.9% (n = 222) and the clinical success rate was 93.8% (n = 215). There were no significant differences in outcome of UAE between the two patient groups. The technical success rate was 95.7% (n = 44) in patients with PAS and 98.3% (n = 178) in patients without PAS (P = 0.267). The clinical success rate was 91.3% (n = 42) in patients with PAS and 95.6% (n = 173) in patients without PAS (P = 0.269). There were 24 cases of immediate complications, including pelvic pain (n = 20), urticaria (n = 3), and puncture site hematoma (n = 1). No major complication was reported.

CONCLUSION

UAE is a safe and effective method to control intractable PPH for patients with or without PAS.

Skin-to-Skin Contact in the Third Stage of Labor and Postpartum Hemorrhage Prevention: A Scoping Review

INTRODUCTION

Literature supports numerous benefits of skin-to-skin contact for neonatal adaptation to extrauterine life and bonding/attachment, but few studies explore the effects of skin-to-skin contact on maternal outcomes. This review aims to map the evidence on skin-to-skin contact in the third stage of labor for postpartum hemorrhage prevention.

METHODS

Scoping review, which covered stages recommended by the Institute Joanna Briggs, including studies from the PubMed, EMBASE, CINAHL, LILACS, Web of Science, and Scopus databases, using the descriptors "Postpartum hemorrhage", "Labor stages, third", "Prevention" and "Kangaroo care/Skin-to-skin".

RESULTS

100 publications on the subject found, 13 articles met the inclusion criteria, with 10,169 dyads were assessed in all studies. Publications from 2008 to 2021 were mostly written in English and designed as a randomized controlled trial. Skin-to-skin contact was effective and significant in: reducing the duration of the third stage of labor; placenta delivery; uterine contractility and physiological involution; absence of atony, decreasing blood loss with lower rates of erythrocyte and hemoglobin drop; reducing the need for synthetic oxytocin and/or ergometrine to control bleeding; and reducing changing pads per period and length of stay.

DISCUSSION

Skin-to-skin contact was considered an effective, low-cost, and safe strategy, with positive effects already established in the literature for infants and extremely favorable results in postpartum hemorrhage prevention cases, being highly recommended in assistance for the dyad. Open Science Framework Registry ( https://osf.io/n3685 ).

Prevention of postpartum hemorrhage in vaginal deliveries

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

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

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

The Role of Early Initiation of Breastfeeding in the Duration of the Third Stage of Delivery and the Amount of Blood Loss in the Fourth Stage in Spontaneous Vaginal Delivery

Aims: To determine the effect of Early Initiation of Breastfeeding (EIBF) in the third stage of labor and the amount of blood loss in the forth stage of delivery. Methods: An experimental study comparing the duration of 3rd stage and the amount of blood loss in 4th stage in Early Initiation of Breastfeeding (EIBF), oxytocin administration, and Early Initiation of Breastfeeding (IBF) given oxytocin at spontaneous vaginal delivery in delivery room of H. Adam Malik General Hospital, Dr. Pirngadi Hospital, Sundari Hospital and Universitas Sumatera Utara Hospital starting from March 2019 until the minimum sample was met. Results: The data analysis results of the comparison of duration demonstrated p-value of 0.001The comparison among groups with post hoc analysis showed a meaningful comparison in this analysis with p value of 0.001, while duration of the3rd stage in group B compared to group C statistically did not show any significant difference with  p value of 1.00. The mean of amount of blood loss among groups A, B, and C respectively were 139 ± 11.8, 141.8 ± 12.4 and 132.1 ± 14.4 with p value 0.048. Conclusions: It is concluded that the amount of blood loss in the fourth stage among the groups was not significantly different in each group. Comparisons of the amount of bleeding in group A vs. B, A vs. C and B vs. C are indicated by the p value of each group i.e. 1.0; 0184 and 0.059.

A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization

This study aimed to review the obstetric complications during subsequent pregnancies after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) by exploring the relationship between prior UAE and obstetric complications through a meta-analysis. We conducted a systematic literature review through March 31, 2021, using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in compliance with the PRISMA guidelines and determined the effect of prior UAE for PPH on the rate of placenta accreta spectrum (PAS), PPH, placenta previa, hysterectomy, fetal growth restriction (FGR), and preterm birth (PTB). Twenty-three retrospective studies (2003–2021) met the inclusion criteria. They included 483 pregnancies with prior UAE and 320,703 pregnancies without prior UAE. The cumulative results of all women with prior UAE indicated that the rates of obstetric complications PAS, hysterectomy, and PPH were 16.3% (34/208), 6.5% (28/432), and 24.0% (115/480), respectively. According to the patient background-matched analysis based on the presence of prior PPH, women with prior UAE were associated with higher rates of PAS (odds ratio [OR] 20.82; 95% confidence interval [CI] 3.27–132.41) and PPH (OR 5.32, 95% CI 1.40–20.16) but not with higher rates of hysterectomy (OR 8.93, 95% CI 0.43–187.06), placenta previa (OR 2.31, 95% CI 0.35–15.22), FGR (OR 7.22, 95% CI 0.28–188.69), or PTB (OR 3.00, 95% CI 0.74–12.14), compared with those who did not undergo prior UAE. Prior UAE for PPH may be a significant risk factor for PAS and PPH during subsequent pregnancies. Therefore, at the time of delivery, clinicians should be more attentive to PAS and PPH when women have undergone prior UAE. Since the number of women included in the patient background-matched study was limited, further investigations are warranted to confirm the results of this study.

Obstetric Outcomes of Pregnancy After Uterine Artery Embolization

BACKGROUND

Uterine artery embolization (UAE) is used to treat severe postpartum hemorrhage (PPH). According to a few studies, UAE for PPH was associated with preterm birth, fetal growth restriction (FGR), and placenta accreta spectrum (PAS) in subsequent pregnancies. These previous studies, however, lacked controls, and to the best of our knowledge, no systematic literature reviews have been conducted thus far. We report the results of our retrospective case-control study of pregnancies after UAE at a single center and include a literature review to evaluate the risk of PAS in pregnancies after UAE.

METHODS

We retrospectively reviewed data from deliveries at our hospital between January 2012 and October 2017. We divided the delivery data into cases with previous UAEs performed for PPH (the post-UAE group) and those without UAEs (the non-UAE group, which included women without previous PPH). We defined PAS as cases in which hysterectomy was performed and pathological examination confirmed the diagnosis. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

We used data from 3155 patients in this study, of whom 16 patients had undergone UAE (post-UAE group) and 3139 had not (non-UAE group). We found no differences between the groups in terms of frequency of preterm births (12.5% versus 14.2%, respectively; OR, 0.863; 95% CI, 0.218 to 3.414; P = 0.84) or FGR (6.2% versus 10.0%, respectively; OR, 0.602; 95% CI, 0.104 to 3.584; P = 0.61). However, cases of PAS were significantly more common in the post-UAE group (37.5%) than in the non-UAE group (1.2%; OR, 50.303; 95% CI, 17.38 to 145.592; P < 0.01).

CONCLUSION

Our results suggest that previous UAE is a significant risk factor for PAS.

Pictorial methods to assess heavy menstrual bleeding in research and clinical practice: a systematic literature review

Background

Pictorial blood loss assessment charts (PBACs) represent the most widely used method to assess menstrual blood loss (MBL) in clinical trials. The aims of this review were to: (1) determine the diagnostic accuracy of PBACs that have been validated against the reference alkaline hematin technique; (2) categorize the pitfalls of using obsolete and nonvalidated charts; (3) provide guidelines for development of a new PBAC or use of an existing chart to measure MBL in clinical trials; and (4) consider the feasibility of using pictorial charts in primary care.

Methods

A literature review was conducted using Embase and MEDLINE databases. The review identified reports of women with self-perceived or actual heavy menstrual bleeding (HMB), bleeding disorders, abnormal uterine bleeding, leiomyomata (uterine fibroids) or endometriosis, and women undergoing treatment for HMB, as well as those with normal menstrual periods. Data were reviewed from studies that focused on the development and validation of PBACs and from those that used derivative noncertified charts to assess HMB.

Results

Nine studies reported validation of PBAC scoring systems against the alkaline hematin technique. Across these studies, the sensitivity was 58–97%, the specificity was 7.5–95.5%, the positive and negative likelihood ratios were 1.1–13.8 and 0.14–0.56, respectively, and the diagnostic odds ratio was 2.6–52.4. The cut-off score above which the diagnosis of HMB was made ranged from 50 to 185. Several modifications of these PBACs were used in other studies; however, objective confirmation of their validity was not reported. Overall, there was widespread inconsistency of chart design, scoring systems, diagnostic cut-off limits and post-treatment outcome measures.

Conclusions

PBACs are best suited to the controlled and specific environment of clinical studies, where clinical outcome parameters are defined. The current lack of standardization precludes widespread use of the PBAC in primary care.

Review registration number

PROSPERO international prospective register of systematic reviews: CRD42016030083.