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Clinical inquiries. Prophylactic oxytocin: Before or after placental delivery?
Abstract
Prophylactic oxytocin is fine before or after placental delivery. Timing alone doesn't influence the drug's efficacy in preventing postpartum bleeding (recommendation based on randomized controlled trial and prospective cohort studies).
... Oxytocin acts quickly and effectively with minimal adverse effects and can be used in all women, which makes it the main interven- tion for reducing PPH and is the first uterotonic drug option (23). The administration of oxytocin during the TSL reduces the risk of PPH by 40% (24). Immediately after fetal delivery, starting intravenous infusion of 20 IU of oxytocin in 500 mL RL and given within 2 hours is the routine protocol in our institute for AMTSL. ...
Objective: Prolongation of the third stage of labor may cause serious postpartum complications. Thus, timely expulsion of the placenta is essential for preventing complications of the third stage of labor. We conducted a prospective cohort study to determine the effect of placental cord drainage on the duration of the TSL in women administered intravenous oxytocin during this stage.
Study Design: This was a prospective cohort study in which 112 low risk pregnant women were allocated to the study. There were 53 women in the placental cord drainage group, and 59 women in the cord clamping group without drainage. Immediately after fetal delivery, intravenous infusion of 20 IU oxytocin in 500 mL Ringers’ Lactate was started and infused within 2 hours in women in both groups. Outcome measures were the third stage duration and hemoglobin differences between admission and the postpartum sixth hour.
Results: There were no significant differences between the two groups with regard to duration of stages 1 and 2 of labor, hemoglobin level on admission, and at the postpartum sixth hour, and hemoglobin differences between admission and the postpartum sixth hour. The median third stage duration in the study group was 3.40 (range: 0.35-16.20) minutes, and 5.10 (range: 2.30-11.00) minutes in the control group. This difference between the groups was statistically significant (p
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.
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.
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.
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.
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.
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.
To determine the safety and efficacy of intramuscular oxytocin plus ergometrine compared to intravenous oxytocin for prevention of postpartum haemorrhage, and the significance of administration at the end of the second stage of labour compared with that after the third stage.
A prospective cohort study.
A university affiliated tertiary medical centre.
Two thousand one hundred and eighty-nine women delivering singletons during 40 consecutive weeks.
Postpartum haemorrhage (> 500 ml), prolonged third stage (> 30 min), retained placenta (> 60 min), elevated blood pressure (systolic > 150 mmHg, diastolic > 100 mmHg).
The rate of postpartum haemorrhage was not significantly different for oxytocin-ergometrine compared with oxytocin, when administered at the end of the second stage of labour (odds ratio 1.10, 95% confidence interval (CI) 0.75-1.61) or after the third stage (odds ratio 0.95, 95% CI 0.68-1.34). The patients receiving oxytocics at the end of the second stage of labour had significantly lower rates of postpartum haemorrhage, for both oxytocin-ergometrine (odds ratio 0.69, 95% CI 0.49-0.98) and oxytocin (odds ratio 0.60, 95% CI 0.41-0.87), compared with those treated after the third stage.
Administration of oxytocin alone is as effective as the use of oxytocin plus ergometrine in the prevention of postpartum haemorrhage, but associated with a significantly lower rate of unpleasant maternal side effects. Oxytocics administered after delivery of the fetal head compared with after the placental expulsion are associated with a significantly lower rate of postpartum haemorrhage.
Recent claims that routine active management of the third stage of labour increases rather than decreases maternal and neonatal morbidity have prompted us to conduct a systematic review of the relevant controlled trials. In this paper we have analysed data derived from a total of nine published reports of controlled trials in which an oxytocic drug was compared with either a placebo or no routine prophylactic. Oxytocic drugs used routinely appear to reduce the risk of postpartum haemorrhage by about 40% (typical odds ratio 0.57, 95% confidence interval 0.44-0.73) implying that for every 22 women given such an oxytocic, one postpartum haemorrhage could be prevented. The available data are insufficient to assess the possible effects of this policy on the incidence of retained placenta, hypertension and other possible adverse effects.
Our purpose was to compare the controlled cord traction technique with the minimal intervention technique for delivery of the placenta. The primary outcome was the incidence of postpartum hemorrhage. Secondary outcomes included duration of third stage of labor, frequency of retained placenta, hemorrhagic shock, the need for blood transfusion, and the need for uterotonic agents to control postpartum hemorrhage.
A total of 1648 women who were delivered vaginally were randomly allocated during labor to the controlled cord traction group (n = 827) or the minimal intervention group (n = 821). In the controlled cord traction group women received oxytocin, 10 units intramuscularly, with delivery of the baby's anterior shoulder, after which the placenta was delivered actively by controlled cord traction (Brandt-Andrews method). In the minimal intervention group the placenta was delivered by maternal pushing. Continuous intravenous oxytocin was given after delivery of the placenta. Odds ratios with 95% confidence intervals were calculated for each variable.
The overall incidence of postpartum hemorrhage was significantly lower in the controlled cord traction group (5.8% vs 11%; odds ratio 0.50, 95% confidence interval 0.34 to 0.73). The incidence of retained placenta (> or = 30 minutes) was 1.6% in the controlled cord traction group and 4.5% in the minimal intervention group (odds ratio 0.31, 95% confidence interval 0.15 to 0.63). Significantly more patients in the minimal intervention group required additional uterotonic agents to control hemorrhage (5.1% vs 2.3%; odds ratio 0.44, 95% confidence interval 0.24 to 0.78).
The controlled cord traction technique for delivery of the placenta results in a significantly lower incidence of postpartum hemorrhage and retained placenta, as well as less need for uterotonic agents, compared with the minimal intervention technique.
To determine if the timing of the administration of prophylactic oxytocin influences the incidence of postpartum hemorrhage caused by uterine atony, retained placenta, and third-stage duration.
Parturients who presented for vaginal delivery were randomized in a double-blinded fashion to receive oxytocin, 20 units in a 500-mL crystalloid intravenous bolus, beginning upon delivery of either the fetal anterior shoulder or placenta. For all patients, the third stage of labor was managed with controlled cord traction until placental expulsion, followed by at least 15 seconds of fundal massage. Patients were excluded if they had a previous cesarean section, multiple gestation, antepartum hemorrhage, or bleeding disorder.
A total of 1486 patients were enrolled: 745 in the before-placenta group and 741 in the after-placenta group. The groups were similar with respect to gestational age, fetal weight, labor duration, maternal age, parity, and ethnicity. The incidence of postpartum hemorrhage did not differ significantly between the two groups (5.4% vs 5.8%; crude OR, 0.92; 95% CI, 0.59 to 1.43). There were no significant differences between the two groups with respect to incidence of retained placenta (2.4% vs 1.6%; OR, 1.49; 95% CI, 0.72 to 3.08), or third-stage duration (7.7 minutes vs 8.1 minutes; P =.23).
The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta.
The objective of this study was to compare the administration of oxytocin at the beginning and end of the third stage of labor for the prevention of postpartum hemorrhage.
Patients with documented singleton pregnancies were randomly assigned to two groups. The first received 10 units of oxytocin intramuscularly at delivery of the anterior shoulder of the fetus and an identical appearing placebo injection following delivery of the placenta. The second received the opposite medication sequence. The study was double blinded. Blood loss was measured by weighing all fluids collected, visual estimation, and serial blood counts.
27 women received oxytocin at the delivery of the fetal shoulder and 24 after the placenta. Oxytocin given after placenta delivery resulted in lower blood loss (345 vs. 400 ml, p = 0.28), lower collection bag weight (763 vs. 833 g, p = 0.55), lower change in HgB (-1.26 vs. -1.32 g, p = 0.86), lower DeltaHCT (-3.43 vs. -3.64%, p = 0.85), and a shorter third stage of labor duration (8.6 vs. 9.2 min, p = 0.75). The incidence of postpartum hemorrhage, defined as estimated blood loss >500 ml (0 vs. 14.8%) was significantly lowered with oxytocin following placental delivery (p = 0.049).
In our study, postpartum hemorrhage was less frequent when oxytocin administration was delayed until after placenta delivery.
To determine the efficacy of intravenous oxytocin administration compared with intravenous methylergometrine administration for the prevention of postpartum hemorrhage (PPH), and the significance of administration at the end of the second stage of labor compared with that after the third stage.
A prospective study was undertaken: two major groups (oxytocin group and methylergometrine group) of 438 women with singleton pregnancy and vaginal delivery were studied during a 15-month period. These two groups were subdivided into three subgroups: 1. intravenous injection (two minutes) group immediately after the delivery of the fetal anterior shoulder, 2. intravenous injection (two minutes) group immediately after the delivery of the placenta, and 3. drip infusion (20 min) group immediately after the delivery of the fetal head. In each group, quantitative postpartum blood loss, frequencies of blood loss >500 ml, and need of additional uterotonic treatment were evaluated.
As compared with methylergometrine, oxytocin administration was associated with a significant reduction in postpartum blood loss and in frequency of blood loss >500 ml. The risk of PPH was significantly reduced with intravenous injection of oxytocin after delivery of the fetal anterior shoulder, compared with intravenous injection of oxytocin after expulsion of the placenta (OR 0.33, 95%CI 0.11-0.98) and intravenous injection of methylergometrine after delivery of the fetal anterior shoulder (OR 0.31, 95%CI 0.11-0.85).
Intravenous injection of 5 IU oxytocin immediately after delivery of fetal anterior shoulder is the treatment of choice for prevention of PPH in patients with natural course of labor.
Postpartum hemorrhage
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