Misoprostol and active management of the third stage of labor.

OBJECTIVE: To compare current practices for the active management of the third stage of labor (AMTSL) with the use of 600 mug of oral misoprostol. METHODS: An operations research study was designed to compare blood loss with current AMTSL practices and misoprostol use. RESULTS: Women in the misoprostol group were less likely to bleed 500 ml or more (adjusted odds ratio, 0.30; 95% confidence interval, 0.16-0.56) compared with those in the current practices group. In the current practices group 73% women required interventions because of postpartum hemorrhage, compared with 11% in the misoprostol group. CONCLUSION: In situations where oxytocin and or ergometrine are not consistently and appropriately used during third stage of labor, misoprostol should be considered for inclusion in the AMTSL protocol.     

Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor

AIM: To assess the effectiveness of oral misoprostol compared with methylergometrine in the prevention of primary post-partum hemorrhage during the third stage of labor. METHODS: This was a randomized controlled trial of 864 singleton low-risk pregnant women. The outcomes were total blood loss, duration of the third stage of labor and peripartal change in hematocrit. Comparisons were by the chi2-test and Student t-test. Relative risks were calculated for side-effects profile. A P-value of less than 0.05 was statistically significant. RESULTS: The biodata of all the participants were similar. The mean blood loss for the misoprostol and methylergometrine groups was 191.6 +/- 134.5 mL and 246.0 +/- 175.5 mL, respectively (95% CI: -79.3 to -39.5 mL). The mean duration of the third stage of labor was 19.6 +/- 2.4 min and 9.4 +/- 3.3 min in the misoprostol and methylergometrine groups, respectively (95% CI: 9.82-10.58 min). More subjects had blood loss >500 mL, 42 (9.7%) versus 6 (1.4%), and peripartal hematocrit change greater than 10%, 38 (8.8%) versus 5 (1.2%), in the methylergometrine group than in the misoprostol group, respectively. Also, more subjects received additional oxytocic in the methylergometrine group, compared to the misoprostol group (80 [18.5%] versus 33 [7.6%] patients, respectively). CONCLUSIONS: Orally administered misoprostol was more effective in reducing blood loss during the third stage of labor than intramuscular methylergometrine. However, there were more subjects in the misoprostol group in whom duration of the third stage of labor was greater than 15 min and who also had manual placental removal than in the methylergometrine group.     

Prospective randomized trial of oxytocin administration for active management of the third stage of labor

Objective

To determine the most efficient route and timing of oxytocin administration for active management of the third stage of labor.

Methods

A prospective randomized study was done at one center in Ankara, Turkey, between January and October 2010. Women with a singleton pregnancy (> 37 weeks) who had a live vaginal birth were randomly allocated to four groups: iv-A (intravenous oxytocin after delivery of the fetus), iv-B (when anterior shoulder seen), im-A (intramuscular oxytocin after delivery), and im-B (when anterior shoulder seen). Postpartum blood loss within the first hour, hemoglobin, hematocrit, and duration of the third stage were compared.

Results

A total of 600 eligible women were recruited; 150 were assigned to each group. Postpartum blood loss, prepartum and postpartum hemoglobin and hematocrit, and need for additional uterotonics were similar among groups (P > 0.05). The duration of the third stage of labor and changes in hemoglobin and hematocrit were significantly reduced in group iv-B (P < 0.05). Among women not exposed to oxytocin before delivery, postpartum blood loss was significantly lower in group iv-B (P = 0.019). Labor augmentation was related to significantly increased postpartum blood loss in all groups except iv-A.

Conclusion

Although postpartum blood loss was similar in all groups, early intravenous administration seemed to have beneficial effects.ClinicalTrials.gov: NCT01954186.     

Management of the third stage of labor

Management of the third stage of labor has been an issue of discussion, concern, and continued debate for the past two decades. Despite the many strategies employed and the divergent approaches to care and philosophies espoused, there has not been a significant, consistent reduction in the postpartum hemorrhage rates reported in industrialized countries in recent times. This article explores the strategies that have been and are currently being used in an effort to reduce the risk of postpartum hemorrhage.     

Oral misoprostol in the third stage of labor.

OBJECTIVE: To compare the efficacy of intravenous ergometrine, intramuscular oxytocin, and oral misoprostol in the control of postpartum hemorrhage. METHODS: Mean blood loss, rates of blood loss between 500 and 1000 ml, hematocrit fall greater than 10%, and need for additional oxytocic agents and nature and rates of adverse effects were assessed in this prospective, randomized, controlled study. RESULTS: All outcomes were similar in the 3 groups. The main adverse effects in the misoprostol group were temperatures higher than 99 degrees F, which normalized within 2 h and shivering, which was mild and self-limiting. CONCLUSIONS: Oral misoprostol is as effective as conventional oxytocic agents in preventing postpartum hemorrhage and can be recommended for use in low-resource settings.     

Misoprostol use during the third stage of labor.

OBJECTIVES: To systematically review the efficacy of misoprostol compared with placebo or other uterotonics in preventing maternal morbidity associated with the third stage of labor. METHODS: We identified, retrieved, evaluated, abstracted data, and assessed the quality of all published studies (from January 1996 to May 2002) which assessed misoprostol's efficacy in minimizing uterine blood loss during the third stage of labor. Seventeen studies included 28170 subjects; of these, approximately one-half received misoprostol with the remainder receiving either a placebo or another uterotonic agent. An estimate of the odds ratio (OR) and risk difference for dichotomous outcomes was calculated using a random- and fixed-effects model. Continuous outcomes were pooled using a variance-weighted average of within-study difference in means. RESULTS: In assessing studies comparing misoprostol with placebo, those who received oral misoprostol had a decreased risk of needing additional uterotonics (OR 0.64, 95% confidence interval 0.46, 0.90). Compared with placebo, use of misoprostol was associated with an increased risk for shivering and pyrexia. In contrast, in studies comparing misoprostol with oxytocin, oxytocin was associated with significantly lower rates of postpartum hemorrhage, maternal shivering and pyrexia. In studies comparing misoprostol with Syntometrine, misoprostol was associated with higher rates of the need for additional uterotonic agent as well as shivering. CONCLUSIONS: Misoprostol was inferior to oxytocin and other uterotonics with regard to any of the third stage of labor outcomes assessed. However, when compared to placebo, misoprostol had a decreased risk of needing additional uterotonics. Thus, in less-developed countries where administration of parenteral uterotonic drugs may be problematic, misoprostol represents a reasonable agent for the management of the third stage of labor. Additional randomized clinical trials examining objective outcome measures (i.e. need for blood transfusion or 10% hemoglobin change) may further define benefits and risks of misoprostol use during the third stage of labor.     

Reoccurrence of retained placenta at a subsequent delivery: an observational study

Objective: To test the generalizability of previously reported increased risk of reoccurrence of retained placenta in yet another setting.

Methods: In this observational retrospective study we longitudinally followed women who had a vaginal delivery complicated by a partial or complete retained placenta at Edith Wolfson Medical Center between 1 January 2009 and 31 December 2012. The study group included parturient women who had a partial or complete retained placenta after a vaginal delivery (n?=?90). The control group included parturient women who did not have a partial or complete retained placenta after a vaginal delivery from the same time period using the same inclusion criteria (n?=?90).

Results: Retained partial or complete placenta at a previous delivery was found to be an independent risk factor for retained partial or complete placenta in a subsequent delivery (adjusted OR 9.8, 95%CI 1.2 to 80.6, p?=?0.032) and for retained partial or complete placenta and/or postpartum hemorrhage in a subsequent delivery (adjusted OR 14.1, 95% CI 1.7 to 111.9, p?=?0.012), after controlling for gestational age and induction of labor at previous delivery.

Conclusion: Retained partial or complete placenta at an index delivery increases the risk of reoccurrence of retained partial or complete placenta in a subsequent delivery.     

A randomized comparative study of prophylactic oxytocin versus ergometrine in the third stage of labor.

OBJECTIVE: To compare the effect of prophylactic use of oxytocin and ergometrine in management of the third stage of labor. METHODS: A prospective randomized study of 600 women assigned to receive either oxytocin or ergometrine in the third stage of labor. Outcome measures were the predelivery and 48-hour postdelivery hematocrit, duration of the third stage, specific side effects, and incidence of postpartum hemorrhage. Statistical analyses were done using the t test for continuous variables and chi2 test for categorical variables. The level of significance was set at P<0.05. RESULTS: There were no significant differences between the 2 groups in maternal age, gestational age, duration of third stage, birth weights, risk for retained placenta, manual removal of placenta, or need for additional oxytocics. Patients in the ergometrine group were at significant risk for nausea, vomiting, headaches, and elevated blood pressure (P=0.0001). CONCLUSION: Oxytocin is as effective as ergometrine at reducing the incidence of postpartum hemorrhage, but without the undesirable side effects of nausea, vomiting, and elevated blood pressure associated with ergometrine.     

Effects of combined spinal–epidural analgesia on first stage of labor: a cohort study

Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal–epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal–epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal–epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes.

Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6?cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered.

Results: We enrolled 400 patients: 176 in the combined spinal–epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120–300) minutes for both the groups (p?=?.7). Combined spinal–epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p?p?=?.002). Onset of analgesia was quicker for combined spinal–epidural analgesia: 31 versus 20%, with VAS <4 after 5?minutes, (p?Conclusions: Combined spinal–epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.     

Comparative study of induction of labor in nulliparous women with premature rupture of membranes at term compared to those with intact membranes: duration of labor and mode of delivery

AIM: To evaluate the effect of premature rupture of membranes (PROM) at term on the duration of labor and mode of delivery in comparison with intact membranes in nulliparous women with an unfavorable cervix whose labor was induced. METHODS: This retrospective cohort study included all term nulliparous women with an unfavorable cervix requiring labor induction over a 2-year period. Prostaglandin E(2) (dinoprostone) and oxytocin were used for labor induction. Criteria for enrolment included (i) singleton pregnancy; (ii) term nulliparous women; or (iii) Bishop score below 6. Statistics were analyzed with Student's t-test, chi(2)-test, Fisher's exact test, and multiple logistic regression. RESULTS: Our study subjects were 82 women whose labor was induced for PROM and 219 women with intact membranes whose labor was induced for social or fetal reasons. The mean durations of active phase of labor were not significantly different between women with PROM and those with intact membranes. However, the women with PROM had a significantly longer mean duration of second stage and a higher rate of cesarean delivery for failure to progress than those with intact membranes. Multiple logistic regression demonstrated that only PROM and fetal macrosomia were significantly associated with an increased risk of cesarean delivery for failure to progress after other confounding variables were adjusted. CONCLUSIONS: Labor induction for PROM at term in nulliparous women with an unfavorable cervix is associated with longer duration of the second stage and a higher risk of cesarean delivery for failure to progress in comparison to those with intact membranes.     

Uterine electric activity during the third stage of labor; a look into the physiology of a deserted stage

Abstract

Objective: To evaluate uterine activity during the third stage of labor and compare it to that observed in the second stage of labor.

Study design: Uterine electric activity was prospectively measured using electrical uterine myography (EUM) in 44 women with singleton pregnancy at term during the final 30?min of the second stage and throughout the third stage of labor. Results are reported using a scoring index of 1–5?mWS (micro-Watt-Second). Patients were stratified into two groups based on the duration of the third stage (<15?min and >=15?min)

Results: The mean durations of the second and third stages were 51.9?±?63.5 and 15.4?±?7.5?minutes, respectively. During the third stage, uterine activity (contractions peaks) was similar to that observed during the second stage of labor (3.43?±?0.64?mWS versus 3.42?±?0.57?mWS, p?=?0.8). No correlation was found between the duration of the third stage and EUM measurements during the third (p?=?0.9) or the second (p?=?0.2) stages of labor. No association was found between EUM measurements during the third stage and parity, maternal age, fetal weight, duration of labor, gestational age, gravity or BMI. The rate of oxytocin use during the second stage and EUM measurements during the second or third stage did not differ among women with short versus long duration of the third stage.

Conclusion: Uterine activity during the third stage is comparable and as intense as that occurring during the second stage. Third stage length cannot be predicted by contraction intensity during the second or third stage of labor.     

Uterine activity during the two hours after placental delivery among low-risk pregnancies: an observational study

Objective: The purpose of this study was to describe uterine activity within the first two hours after placental delivery among low-risk pregnant women.

Materials and methods: Participants were 17 low-risk pregnant women who had a singleton birth at midwifery birth centers in Japan. Contractile waves of uterine activity were measured by using an external tocodynamometer.

Results: Spontaneous uterine contraction frequency during the first two hours after the placental delivery decreased over time (F_9,?54?=_?19.7, p?<?0.001). The mean contraction intervals were 1.9?±?0.3?min, 2.4?±?0.9?min, 4.2?±?0.7?min and 7.9?±?2.1?min for the second stage, third stage, and the first hour and second hour after placental delivery, respectively. Uterine contraction frequency increased with oxytocin administration and infant suckling; however, an icepack to cool the uterus did not change the contraction waves. No correlations were found between uterine activity and blood loss or pain.

Conclusion: Contraction of the myometrium is the primary mechanism for hemostasis. The uterine contraction intervals became prolonged over time, and blood loss did not increase. The findings provide insight into the role of myometrium contraction as a hemostasis mechanism.     

Effect of birth ball usage on pain in the active phase of labor: a randomized controlled trial

Introduction: Anxiety can be a contributor to labor pain, which is known to be multifactorial. Because there is little information available on the efficacy of birth ball use for labor pain management, this study aimed to evaluate the effectiveness of use of a birth ball on labor pain, contractions, and duration of the active phase of labor. Methods: In this randomized controlled trial, 60 primiparous women aged 18 to 35 years were divided into birth ball and control groups. Pain scores were measured by a visual analogue scale. Results: Mean pain scores in the birth ball group were significantly lower than the mean pain scores in the control group (P < .05). There were no significant differences between duration of the active phase of labor or the interval between uterine contractions in the 2 groups (P > .05). Discussion: Although the use of a birth ball had no effect on the duration of the active phase of labor, the duration of uterine contractions, or the interval between contractions, this complementary treatment could reduce the intensity of pain during the active phase of labor.     

Outcomes of physiological and active third stage labour care amongst women in New Zealand

Background

during the third stage of labour there are two approaches for care provision – active management or physiological (expectant) care. The aim of this research was to describe, analyse and compare the midwifery care pathway and outcomes provided to a selected cohort of New Zealand women during the third stage of labour between the years 2004 and 2008. These women received continuity of care from a midwife Lead Maternity Carer and gave birth in a variety of birth settings (home, primary, secondary and tertiary maternity units).

Methods

retrospective aggregated clinical information was extracted from the New Zealand College of Midwives research database. Factors such as type of third stage labour care provided; estimated blood loss; rate of treatment (separate to prophylaxis) with a uterotonic; and placental condition were compared amongst women who had a spontaneous onset of labour and no further assistance during the labour and birth. The results were adjusted for age, ethnicity, parity, place of birth, length of labour and weight of the baby.

Findings

the rates of physiological third stage care (expectant) and active management within the cohort were similar (48.1% vs. 51.9%). Women who had active management had a higher risk of a blood loss of more than 500 mL, the risk was 2.761 when a woman was actively managed (95% CI: 2.441–3.122) when compared to physiological management. Women giving birth at home and in a primary unit were more likely to have physiological management. A longer labour and higher parity increased the odds of having active management. Manual removal of the placenta was more likely with active management (0.7% active management – 0.2% physiological p<0.0001). For women who were given a uterotonic drug as a treatment rather than prophylaxis a postpartum haemorrhage of more than 500 mL was twice as likely in the actively managed group compared to the physiological managed group (6.9% vs. 3.7%, RR 0.54, CI: 0.5, 0.6).

Conclusions

the use of physiological care during the third stage of labour should be considered and supported for women who are healthy and have had a spontaneous labour and birth regardless of birth place setting. Further research should determine whether the use of a uterotonic as a treatment in the first instance may be more effective than as a treatment following initial exposure prophylactically.