A framework proposal for digital interventions in perinatal education: the result of a content analysis to WHO intra-partum care recommendations

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.

Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes

Failure of the uterus to contract adequately after childbirth (atonicity) is the most common cause of postpartum haemorrhage (PPH), the leading cause of maternal death in Africa and Asia.1 Attempts to identify women at risk of atonic PPH have been unsuccessful. Numerically, more women without risk factors have atonic PPH compared to those with risk factors. To prevent atonic PPH, interventions should therefore be targeted at all women during childbirth. Active management of the third stage of labour has been described as a package comprising the following interlocking interventions: administration of a prophylactic uterotonic after birth of the baby, and usually also early cord clamping and cutting, and controlled cord traction.2 Other definitions in this package include uterine massage, but without reference to the timing of cord clamping.3 In contrast, expectant (also called physiological or conservative) management involves waiting for signs of separation and allowing the placenta to deliver spontaneously, or aided by gravity or nipple stimulation.2 While there is agreement on the beneficial effects of active management of the third stage of labour for prevention of PPH, there is less consensus on issues such as importance of the intervention’s individual components, the best methods and the requirements for safe administration of this intervention under conditions of limited resources. In particular, the choice of uterotonics has been the subject of discussion and debate. Injectable oxytocin has been recommended for routine use in the active management of the third stage of labour;3 however, a safe injection requires skills and sterile equipment. Oxytocin may be inactivated if exposed to high ambient temperatures.4 In contrast, misoprostol, a prostaglandin analogue with uterotonic effects, is reportedly more stable than oxytocin and has been administered by oral, sublingual and rectal routes in several studies.5 Misoprostol use for prevention of PPH has been approved6 or included in national guidelines7 in some countries. Suggestions have been made to provide misoprostol tablets where oxytocin is not available8 to non-skilled providers9 and to women themselves to prevent PPH.10 The WHO Technical Consultation on the Prevention of Postpartum Haemorrhage in Geneva on 18–20 October 2006 reviewed the evidence and provided answers to some of these questions following a widely-accepted methodology for guideline development.11 In head-to-head comparisons of uterotonics in the context of active management of labour, injectable oxytocin and injectable ergometrine are equally effective for preventing PPH. Injectable ergometrine has more side-effects and is less stable in heat and light compared to oxytocin. Oral ergometrine is thought to be ineffective.4,12 Compared to oxytocin, severe PPH and the use of additional uterotonics occur significantly more often with oral misoprostol. This uterotonic has more side-effects and higher acquisition costs than oxytocin. There is insufficient evidence to support the use of misoprostol by other routes, or injectable prostaglandins instead of oxytocin for prevention of PPH. Therefore, oxytocin is the drug of choice for the prevention of atonic PPH. (The complete set of recommendations13 from this consultation and its supporting evidence are available at www.who.int/making_pregnancy_safer/en) What should maternal health programme managers do with these recommendations? When national guidelines are updated and informed decisions are made on preventing the major cause of maternal deaths, the WHO recommendations can form the basis of local judgements. Additional factors to consider may include cost: at programme level, oxytocin with disposable syringes and needles is currently less expensive to procure than misoprostol in the dose used for PPH prevention. The increased incidence of severe PPH and the increased need for additional uterotonics among women receiving misoprostol for PPH prevention have significant programmatic implications, especially in settings where anaemia is common and access to emergency obstetric care is limited. Concerns about oxytocin’s stability in tropical environments without refrigeration possibly overstate the problem. Oxytocin is relatively stable at temperatures below 30 °C.4 Moreover, when oxytocin is used routinely for active management of the third stage (for every parturient), the rapid turnover of stock will result in shorter environmental exposures. Surveys in Africa show that oxytocin is available and accessible in most health facilities and the lack of oxytocin is often due to health system failures that affect any commodity.14,15 Maternal health programme managers should also use the experience of cold chain management for immunization programmes to ensure a more stable environment for oxytocin. If private enterprises can keep cola drinks or beer cold, even in remote areas of countries without stable power supplies, the same should be possible for oxytocin. Training for skilled providers should ensure competency in safe injection and infection-prevention practices, as well as competency in active management of the third stage of labour as a routine in all childbirths. Making oxytocin available as a single-dose disposable pack will further help to reduce concerns related to injection safety. In addition, programme activities should seek to expand community awareness, response and demand for quality maternal health services, and should include activities within the health system to review all maternal deaths and severe morbidity and to act on lessons learned. While there is evidence that administration of misoprostol alone by skilled providers in the absence of other components of active management of the third stage of labour is likely to reduce the risk of PPH,16 there is currently insufficient evidence for the safe use of misoprostol by lay providers in non-facility settings. Inappropriate use of powerful uterotonic drugs, especially before childbirth, can be associated with significant maternal and perinatal morbidity and even death. ■

Intramuscular versus intravenous oxytocin for the third stage of labor after vaginal delivery to prevent postpartum hemorrhage: a meta-analysis of randomized controlled trials

Reply

Background: The third stage of labor is defined as the time between the delivery of the baby and delivery of the placenta. The third stage of labor is potentially the most dangerous part for the mother. The main risk is the occurrence of postpartum hemorrhage. Objective: To compare the efficacy and safety of oral misoprostol with intramuscular oxytocin in the active management of third stage of labor for the prevention of postpartum hemorrhage. Patient and Methods: The study was conducted in the labor ward of Obstetrics and Gynecology Department at Imbaba General Hospital from September 2018 till September 2019. This study included four hundred healthy pregnant women during the course of normal labor. Patients in this study were randomly divided into two equal groups: Group (I) received 600 mcg Misoprostol orally within 1 minute of delivery of the baby and Group (II) received 10 IU oxytocin intramuscularly within 1 minute of delivery of the baby. We compared the two groups using computer programs to evaluate the safety and efficacy of each drug. The primary outcome measure was postpartum fall in haemoglobin after 8 h of delivery. Secondary outcome measure was duration of third stage of labor, need for an additional uterotonic drug, need for blood transfusion and side effects of both the drugs. Results: There was no significant difference between the two groups regarding the duration of the third stage of labor, the change in hemoglobin and hematocrit levels from before labor to 8 hours postpartum, and the occurrence of complications (the need for more utrotonic drugs and the need for blood transfusion). As regard the duration of third stage of labor, there was a slight advantage for the oxytocin group over the misoprostol group, 4% of cases in oxytocin group have side effects, while 13% of cases in misoprostol group have sides effects in the form of nausea, vomiting, fever, shivering. Conclusions: No major difference in oral misoprostol and intramuscular oxytocin in the management of third stage of labor.

Post-partum haemorrhage occurs in over 10% of all births and is the leading cause of maternal mortality, accounting for 25% of all maternal deaths worldwide. Active management of the third stage of labor is the most important intervention for reducing maternal morbidity and mortality by preventing postpartum hemorrhage. Previously, documented primary studies had been great discrepancy, inconsistent results, and there is a lack of comprehensive study. Hence, this systematic review and meta-analysis were intended to assess the prevalence and associated factors of the practice of active management of the third stage of labour among obstetric care providers in Ethiopia. Cross-sectional studies were systematically searched from January 01, 2010, to December 24, 2020, using PubMed, Google Scholar, HINARI, Cochrane Library, and grey literature. The pooled prevalence of active management of the third stage of labour practice and associated factors was estimated using DerSemonial-Laird Random Effect Model. Stata (version 16.0) was used to analyze the data. The I-squared statistic was used to assess the studies' heterogeneity. A funnel plot and Egger's test were used to check for publication bias. A subgroup analysis was performed to minimize the underline heterogeneity depending on the study years and the sample sizes. Seven hundred fifty articles were extracted. The final ten studies were included in this systematic review, including 2438 participants. The pooled prevalence of practices of active management of the third stage of labour among obstetric care providers in Ethiopia was 39.65% (30.86, 48.45%). Educational status (OR = 6.11, 95%CI, 1.51-10.72), obstetric care training (OR = 3.56, 95% CI: 2.66, 4.45), work experience (OR = 2.17, 95%CI, 0.47, 3.87) and knowledge of active management of the third stage of labour (OR = 4.5, 95% CI: 2.71, 6.28) were significantly associated with active management of the third stage of labour practices. The practice of active management of the third stage of labour in Ethiopia was low. This study showed that educational status, taking obstetric care training, knowledge of AMTSL, and work experience of obstetric care providers were associated with of practices of active management of the third stage of labour. Therefore, obstetric care professionals should improve their academic level, knowledge, and skills in order to provide useful service to AMTSL and save mothers' lives. All obstetric care providers should get obstetric care training. Furthermore, the government should increase obstetric care professionals' educational level.

A Model Practice Template for Hydrotherapy in Labor and Birth.

Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial

BackgroundPostpartum hemorrhage (PPH) and the amount of blood loss are directly related to management of the third stage of labor. No previous report has compared the effects of carbetocin to those of misoprostol. The aim of this systematic review was to compare the effects of carbetocin to those of misoprostol for management of the third stage of labor and for the prevention of PPH.MethodsWe searched the Cochrane Library (Central), Web of Science, Scopus, Science Direct, Ovid, clinicaltrial.gov, and PubMed databases on December 28, 2017. Data extraction and risk of bias assessment were performed by 2 of the authors independently. Individual and pooled incidences were calculated for the included studies, with 95% confidence intervals (CIs). We used a fixed model for forest plots without heterogeneity and a random effect model for those with heterogeneity.ResultsOur search identified 117 studies; however, 29 studies were duplicate. Of the 88 non-duplicate studies, 5 met the inclusion criteria. Of these five studies, two are currently underway. Hence, three studies were finally included in our meta-analysis. The pooled estimate of the impact of carbetocin on PPH (500–1000 ml) was (OR 0.27, 95% CI 0.14–0.50). Carbetocin significantly reduced the need for additional uterotonics (RR 0.28, 95% CI 0.15 to 0.49). Reduction in the hemoglobin level and blood loss during the third stage of labor was significantly lower in women who received carbetocin than in those who received misoprostol. The length of the third stage of labor was significantly lower in women who received carbetocin than in those who received misoprostol. The incidence of side effects, such as heat sensation, metallic taste, fever, and shivering, were significantly lower in women who received carbetocin than in those who received misoprostol.ConclusionAlthough this review showed that carbetocin is effective for decreasing PPH, blood loss, the length of the third stage of labor, and the need for additional uterotonics, this conclusion should be considered with caution. Because assessment of PPH is a subjective issue and it is uncertain whether outcomes were assessed blindly in respect to treatment. We recommend future research to verify our findings. Also clinicians may like to consider use of carbetocin for women with low risk for PPH.

Placental cord drainage impact on third stage of labor: a randomized controlled trial

Aims: This study aimed at comparing the efficacy of oral misoprostol 600 mcg with intramuscular oxytocin 10 IU in the active management of third stage of labour. Methods: This prospective comparative study was performed in Tribhuvan University Teaching Hospital to compare the efficacy of oral misoprostol with intramuscular oxytocin in the third stage of labour for the prevention of postpartum hemorrhage. One hundred and twenty women without risk of PPH were randomly allocated to receive either 600 mcg misoprostol orally (Group A) or 10 unit of oxytocin intramuscularly (Group B) within 1 minute of delivery. The efficacy and the safety of these two drugs were analyzed on the basis of percentages fall in hemoglobin (Hb) and hematocrit (Hct) level from before delivery to 8 completed hours after delivery, need for additional uterotonic agents, need for exploration and uterine evacuation, need for blood transfusion, duration of third stage of labour and the numbers of retained placenta and need for MRP. Results: Oral misoprostol was observed to be equally effective as intramuscular oxytocin in prevention of post-partum hemorrhage (PPH). There was no statistical difference in the duration of third stage of labour, need for additional uterotonics, need for uterine exploration/evacuation and need for blood transfusion in the two groups. Conclusions: Routine use of oral misoprostol 600 mcg appears to be as effective as 10 IU intramuscular oxytocin in minimizing blood loss during the third stage of labour.

Aim: Aimed at comparing the efficacy of prophylactic intramuscular methylergometrine with intramuscular oxytocin in reducing blood loss in the third stage of labour (TSL). Methods: This is a randomized, comparative, clinical trial to compare the efficacy of intramuscular methylergometrine with intramuscular oxytocin in the third stage of labour for the prevention of postpartum hemorrhage Two hundred women undergoing normal vaginal delivery were recruited, 100 in each group- Group A receiving .2mg methylergometrine intramuscularly and Group B receiving 10U oxytocin intramuscularly immediately after the delivery of the anterior shoulder of the baby. The efficacy and the safety of these two drugs were analyzed on the basis of percentages fall in haemoglobin (Hb) and haematocrit (Hct) level from before delivery to 24 completed hours after delivery, need for additional uterotonic agents, need for exploration and uterine evacuation, need for blood transfusion, duration of third stage of labour and the numbers of retained placenta and need for MRP. Results: Intramuscular methylergometrine was observed to be equally effective as intramuscular oxytocin in prevention of post partum haemorrhage (PPH) [defined as fall in Hb and /or Hct level³ 10% from before delivery to 24 hours after delivery]. There was no difference in the risk of prolonged third stage, need for additional uterotonic agents, need for exploration and uterine evacuation and need for blood transfusion in the two groups. The side effects were all mild in nature and the overall incidence was too low for statistical significance to be elicited. Conclusion: Intramuscular methylergometrine is as efficacious as intramuscular oxytocin in the prevention of third stage blood loss with comparable side effects. Keywords: Third stage of labour, postpartum hemorrhage, methylergometrine, oxytocin. doi:10.3126/njog.v2i2.1451 N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 24 - 28

I have followed research developments in the area of prevention and treatment of postpartum hemorrhage in the last decade with interest. The fact that contractions of the uterus are necessary to prevent bleeding after placental separation has been known for centuries, so attempts to devise interventions to facilitate this process were a logical quest. These interventions, now referred to as active management of third stage of labor (AMTSL), initially involved the pharmacological stimulation of uterine muscle fibers with oxytocics and later included measures aimed at facilitating rapid placental separation and delivery. AMTSL has been demonstrated in randomized controlled trials to reduce the incidence of postpartum hemorrhage (>500 ml) compared to an expectant or ‘hands-off’ approach. Thus, AMTSL is being promoted globally by international health partners as the major effort to reduce the incidence of maternal mortality secondary to atonic postpartum bleeding. While there is general agreement on the beneficial effects of AMTSL, there appears to be no consensus on its exact components and their individual definition. This is reflected in the disparities in internationally recommended guidelines on AMTSL over the last few years and the gross variations in the adoption and practice of active management and its components throughout the world (1, 2). A Cochrane review described it as a set of interlocking interventions comprised of administration of a prophylactic uterotonic with or after delivery of the baby, early umbilical cord clamping and cutting, and placental delivery by controlled cord traction (3). A joint recommendation issued by the International Confederation of Midwives and International Federation of Gynecology and Obstetrics (ICM/FIGO) in 2003 (4) included the following components: administration of uterotonic agent within one minute following delivery of the baby, controlled cord traction and uterine massage after placental delivery without any reference to the timing of cord clamping, while in the WHO Recommendations for the Prevention of Postpartum Haemorrhage (5), delayed cord clamping was added to the components recommended by ICM/FIGO, to accommodate recent evidence suggesting beneficial effects of delayed cord clamping to the baby. These recommendations differ in the timing and clarity of their description/definition of some of the components as well as the various components constituting AMTSL (Table I). There is no specific time recommended by the Cochrane review for administration of prophylactic uterotonic, while the recommended time limits of ‘within one minute’ by ICM/FIGO and WHO were not supported by any scientific evidence. Similarly, the Cochrane review on active vs. passive management does not refer to the use of uterine massage as part of AMTSL whereas the ICM/FIGO statement on AMTSL does include uterine massage. It is interesting to note that uterine massage was included in the ICM/FIGO recommendation, even though the only pilot trial on the subject that was published three years after the statement was issued showed no significant difference in the incidence of postpartum hemorrhage (>500 ml) between women who had massage and those who did not (6). Available evidence from randomized trials evaluating relative effectiveness of alternative definitions of each component of AMTSL has so far questioned the need for strict adherence to existing guidelines regarding individual components of AMTSL. For instance, a double-blinded randomized controlled trial of 1,486 women receiving AMTSL to isolate the effect of timing of uterotonic agent demonstrated that administration of uterotonic agent before and after delivery of the placenta has equal effectiveness in the prevention of postpartum hemorrhage (7). In practical terms, it is reasonable to suppose that administration of uterotonics after placental delivery is outside the recommended time limits of ICM/FIGO and WHO. The physiological relation between the recommended steps of AMTSL which primarily guided their combination indicates that one cannot assume that each component has no interaction with the others and such interactions could occur for either single or multiple components. This suggests that an intervention which may not be individually effective can become effective when applied in consonance with another component. For example, there could be synergism between administered uterotonics and uterine massage. Another important aspect of this concept is that not only the type but also the nature of the interventions performed in the name of AMTSL (e.g. timing, choice of drug, and dose) may affect overall outcome. Simply put, different combination and timing of AMTSL components could produce different level of effectiveness on the prevention of postpartum hemorrhage and maternal and fetal outcome in general. In our global quest for the best possible evidence on maternal care, the relative importance of the uncertainties surrounding differing definitions of AMTSL demands well-conducted randomized controlled trials to test the comparative effectiveness of existing packages in the prevention of postpartum hemorrhage. This is supported by a prospective direct observational study of variations in third stage of labor practice in southwest Nigeria that showed no difference in the outcomes of third stage of labor between women who received the full complements of AMTSL according to the ICM/FIGO definition and those who did not (8). In view of the evidence in support of administration of uterotonic drugs after placental delivery, delayed cord clamping and cutting and the promising result of uterine massage, the time has come for researchers to put a well-defined set of interventions to test so as to produce a standardized definition that can be adopted by all. Such a step would lead to a significant reduction in the existing disparities in the adoption and practice of AMTSL occurring as a result of unclear and sometimes conflicting recommendations and prevent the waste of resources that often accompanies the introduction and dissemination of ‘new’ recommendations.

Aims: The purpose of the study was to compare the efficacy of misoporstol 600mg orally (Group A), injection oxytocin 10 IU intramuscularly (Group B) and injection methylergometrine 0.2 mg intravenously (Group C) on reducing blood loss in third stage of labour, duration of third stage of labour, effect on haemoglobin of the patient, need of additional oxytocics or blood transfusion and associated side effects and complications. Methods: A prospective study enrolling 510 women and randomising them into three groups was done in S P Medical College, Bikaner, Rajasthan, India. Active management of third stage of labour was done using one of the three uterotonics as per the group of the patient. Results: Methylergometrine was superior to rest of the drugs with lowest duration of third stage of labour (p = 0.02), lowest amount of blood loss (p = 0.0001) and lowest rate of post partum hemorrhage (p = 0.08). The need of additional oxytocics and blood transfusion was highest with oral misoprostol as compared to all other drugs used in the study with p value of 0.08 and 0.009 respectively. Conclusions: Methylergometrine has the best uterotonic drug profile amongst the drugs used, strongly favouring its routine use as oxytocic for active management of third stage of labour. Oral misoprostol resulted in a higher blood loss compared to other drugs and hence it should be used only in low-resource settings where other drugs are not available. However, a large multi-centre study is needed for the confirmation of the finding. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 34-36 DOI: http://dx.doi.org/10.3126/njog.v8i1.8859