Active Management Of Third Stage Of Labour Research Articles

Knowledge and factors associated with active management of the third stage of labor in sub-Saharan Africa: A systematic review and meta-analysis.

Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality in sub-Saharan Africa. Implementing active management in the third stage of labor has significantly reduced the incidence of PPH. Thus, understanding the level of healthcare providers' knowledge of active management in the third stage of labor can inform guidelines, policies, and practices for effectively preventing PPH. This review aimed to assess the level of healthcare providers' knowledge and associated factors of active management in the third stage of labor in sub-Saharan Africa. We conducted a search using PubMed, Scopus, Web of Science, Google Scholar, Cochrane Library, and the African Journals online international databases. The inclusion criteria were determined before the review of the articles and adhere to the criteria of population, intervention, comparison, and outcome. Statistical analysis was performed using STATA data analysis software version 14, while Microsoft Excel was utilized for data abstraction. We checked publication bias using a funnel plot and Egger and Begg regression tests. A P value less than 0.05 was considered statistically significant, suggesting the presence of presence publication bias. The I2 statistic was used to assess heterogeneity between studies. The study's overall effect was evaluated using the random effects model. The study included 20 studies to conduct a pooled prevalence analysis. The overall prevalence of healthcare providers' knowledge of active management of third-stage labor in sub-Saharan Africa was 47.975% (95% CI: 32.585, 63.365). Having pre- and in-service training (AOR: 2.25, 95% CI: 1.00, 5.08), having a higher degree (AOR: 1.98, 95% CI: 1.39, 2.82), and having good practices (AOR: 8.91, 95% CI: 4.58, 17.40) were significantly associated with healthcare provider's knowledge regarding active management third stage of labor. The overall healthcare providers' knowledge of active management of the third stage of labor (AMTSL) was low in sub-Saharan Africa. Obstetric healthcare providers should undertake comprehensive training covering all AMTSL components through pre- and in-service diploma training programs.

A study to assess the knowledge, expressed practice and attitude on an active management of third stage of labour (AMTSL) among fourth year B.Sc. nursing students of selected nursing colleges of Gujarat state

A study to assess the knowledge, expressed practice and attitude on an active management of third stage of labour (AMTSL) among fourth year B.Sc. nursing students of selected nursing colleges of Gujarat state

A Study to Assess the Usage, Perception and Effect of Safe Delivery Application Regarding Emergency Obstetrics and Newborn Care in Final Year Students of Selected Nursing Colleges, NCR

Introduction: Health professionals who oversee routine and complex deliveries in remote places might utilize the Safe Delivery Application, a mobile health tool. The programme includes practical training DVDs on important obstetric procedures that can aid health professionals in putting their newly acquired knowledge into practice and can decrease the rate of infant mortality rate and maternal mortality rate. Objectives: The main objective of the study to assess the usage, perception and effect of safe delivery application regarding emergency obstetrics and newborn care in final year students of selected nursing colleges. Methodology: -The research design for this study was Quasi experimental design to assess the usage, perception and effect regarding SDA. Total enumerative sampling technique were used to select 300 final year nursing students, NCR. Informed written consent was taken from each nursing student. A structured questioners and likert scale were administered to assess the usage, perception and effect for SDA. The collected data was analyzed by using descriptive statistics and inferential statistics. Frequency and percentage distribution was used for demographic variables and assessing the usage, perception and effect among nursing students. Chi-square was used to find out the association between usage and perception among final year nursing students and selected demographic variables. Result: The data obtained was analyzed by using descriptive and inferential statistics. The results show that there was a usage & knowledge gap among nursing students (mean 11.66, SD 3.34) but after using the safe delivery application the post-test scores improved to (mean 20.67 SD 12.26) in terms of usage & perception were significantly higher than the pre-test score. This shows that the safe delivery application was effective in improving the knowledge regarding the usage, perception and effect of SDA regarding final-year nursing students on active management of third-stage labor, postpartum hemorrhage, and neonatal resuscitation were successful.

Engaging National Professional Society to Combat Postpartum Hemorrhage Using Bundle Approach - A FIGO-SAFOG-OGSB-MGH Project: Experience of Implementation in Bangladesh

Objective: To reduce the incidence and death due to post-partum Hemorrhage (PPH) and capacity building of health service providers by using PPH Emergency response using Bundle Approach. Method: Planning and implementation of WHO formulated PPH Bundles [Active Management of Third Stage of Labour (AMTSL), First response Bundle and Refractory PPH Bundle] by Obstetrical and Gynaecological Society of Bangladesh (OGSB) in 14 different levels of public and private hospitals in Bangladesh. After discussion with International Federation of Gynaecology and Obstetrics (FIGO) and South Asian Federation of Obstetrics and Gynaecology (SAFOG) team, a Memorandum of understanding (MOU) was signed; permission from Ministry of Health and Family welfare (MOHFW) was obtained through Directorate General of Health Services (DGHS) and also from all the institutions. The project period was from November 2019 to September 2022 in a spoke-and-hub fashion. A group of master trainers and a technical advisory group were developed comprising of senior obstetricians and gynecologist of Bangladesh. Data were obtained through record keeping of the respective hospitals and Management Information System (MIS) of DGHS, monitoring was done by OGSB and Massachusetts General Hospital (MGH)-FIGO team. Results: Consultative and planning meetings were organized among OGSB, FIGO, SAFOG and MGH: 16 master trainers, 74 trainers were produced and 740 health service providers (Doctor, Nurses, midwives) and 450 non clinical staffs were trained. All clinical and nonclinical bundles were implemented in 14 facilities in spoke-and-hub fashion. Occurrence of PPH, detection rate of PPH, filling up PPH checklist and debrief forms were improved. Data collection system, understanding about data improved a lot. Facility readiness, team work, data monitoring & supervision, network integration and leadership skills were instituted and shown excellent positive changes. Regular simulations were continued which helped old & new service providers to learn and continue proper use of the clinical and non-clinical interventions. Scale up was planned and continued. Conclusion: PPH emergency response using bundle approach was found to be an important practical way to reduce occurrence, death and disability related to PPH. Needs for surgery has reduced also. Quality of services improved in terms of providing standard care, record keeping and reporting. Regular supervision and monitoring; data management and personal motivation are the challenges. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(2): 98-108

The Adverse Effects of Carbetocin Administration in the Third Stage of Labor

Introduction: The pharmacologic agents currently used routinely to prevent postpartum hemorrhage are mainly oxytocin, syntometrine (a combination of oxytocin and ergometrine), and carbetocin. Syntometrine is associated with a statistically significant reduction in the risk of postpartum hemorrhage when compared with oxytocin alone. So, this study aimed to assess the adverse effects of carbetocin administration in the third stage of labor. This study aimed to analyze the adverse effects of carbetocin administration in the third stage of labor. Methods: This cross-sectional observational study was conducted at the Department of Obstetrics and Gynaecology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh. The study period was from May 2016 to October 2016. 100 women undergoing normal vaginal delivery were the study subject. A convenient sampling technique was used in this study. Necessary data was collected in the data collection sheet. Women received a bolus of 100 microgram carbetocin IV at delivery of the anterior shoulder. A standardized deliver mat (Quaiyum's mat) was used before placental removal for measuring blood loss. Statistical analysis was carried out by using the Statistical Package for Social Sciences version 19.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The mean values were calculated by frequencies and percentages. Result: In this study, the majority (54, 54.0%) of patients belonged to age 20-25 years, followed by (30, 30.0%) >25 years. It was observed that the majority 93(93.0%) patients had regular menstrual history. Concerning the clinical indices, anaemia was found 69(69.0%), jaundice 08(8.0%) and edema 24(24.0%). Additional uterotonices was used in 15(15.0%) and blood transfusion 07(7.0%) patients. Mean blood loss before the use of the weight of Q-mat was found 74.81±1.23 gram, mean blood loss after the use of the weight of Q-mat was 246.28±99.98 gram, and mean net blood loss was 141.61±59.93 gram. Majority 61(61.0%) babies had birth weight ≥2.5 kg. Majority 68(68.0%) patients had Hb% <10.5. The mean Hb% before delivery was 10.3±0.47 gm/dl with a range from 9.40 to 11.20 gm/dl The mean birth weight was found 2.57±0.41 kg with a range from 2.3 to 3.10 kg. Conclusion: Carbetocin appears to be an effective new drug in the active management of third-stage labor. Carbetocin has associated with a lower risk of various adverse effects and preventing postpartum hemorrhage in women undergoing vaginal delivery.

Prevention of Post-Partum Hemorrhage: Comparison of Oxytocin and Misoprostol. A Two center study in the Bamenda and Nkwen Health Districts

Background: Postpartum hemorrhage is one of the most common obstetrical complications affecting up to 18% of deliveries. Globally, it is responsible for 35 – 55% of peripartum maternal deaths. In Cameroon, the maternal mortality rate is at 406 maternal death per 100,000 live births, with PPH being the leading cause accounting for about 25%. This study aimed to compare the efficacy and safety of misoprostol versus oxytocin in the prevention of postpartum hemorrhage in the Bamenda Health District and Nkwen Health District. Methods: This was a hospital-based randomized clinical trial study in the Bamenda Regional Hospital and Nkwen District Hospital. The study was conducted from March 1st to May 31st 2021 including pregnant women who delivered at the maternity at these two hospitals. All their pregnancy was singleton gestation at term and haven given their informed consent. Women with known history of cardiac, renal, hepatic diseases or any coagulopathy, Cesarean delivery were excluded. We randomized 308 participants in a 1:1 ratio to receive 800 μg of oral misoprostol or 10IU of oxytocin intramuscularly during the active management of third stage of labor (AMSTL). The Hemoglobin (Hb) concentration and hematocrit (HCT) of the participants were measured before and 24hrs after delivery. Our primary outcome of interest was (Post-Partum Hemorrhage) PPH, defined as Hb change ≥ 1g/dl within 24hrs of delivery. Secondary outcomes included; mean Hb change, Hb change ≥2g/dl (severe PPH). Dichotomous outcomes between study groups were compared by estimating crude relative risks (RRs) with 95% confidence intervals. Logistic regression (the chi-square test) was done to determine the factors associated with the occurrence of postpartum hemorrhage, with a level of significance at 5%. Results: After 24hrs, Postpartum hemorrhage (PPH) occurred in 41 (26.6%) and 47 (30.5%) participants in the misoprostol and oxytocin groups respectively (RR= 0.87, 95% C.I= 0.61 - 1.24, p=0.449). Severe postpartum hemorrhage occurred in 3 (1.9%) and 5 (3.2%) participants in the misoprostol and oxytocin groups respectively (RR= 0.6, 95% C.I=0.15 - 2.47, p=0.723). Past history of PPH (aOR=10.1 (3.5 – 28.6), p<0.0001), augmentation of labor (aOR=3.4 (1.6 – 7.1), p=0.0011), fetal birth weight ≥3.5Kg (aOR=2.5 (1.3 – 4.8), p=0.0074) and retained products (aOR= 8.4 (4.2 – 16.7), p<0.0001) were risk factors of PPH. Participants in the misoprostol group more commonly experienced shivering (RR 3.2, 95% CI 2.0 - 5.1, p<0.0001) and nausea/vomiting (RR 35.5, 95% CI 8.9 – 142.2, p<0.0001). Conclusion: Oral misoprostol at the dose of 800μg is as effective as 10 IU IM Oxytocin in the prevention of PPH and is a potent alternative to oxytocin. Most common risk factors of PPH are past history of PPH, augmentation of labor, fetal weight ≥ 3.5kg and retained products. Side effects were mostly associated with 800μg of oral Misoprostol.

The Causes of Post-Partum Hemorrhage in Patients Attending in a Tertiary Care Hospital

Background: Post-partum hemorrhage is defined as excessive bleeding following a vaginal delivery or cesarean section of more than 500ml and 1000ml respectively. Post-partum hemorrhage is a potentially life-threatening complication of vaginal and cesarean delivery. The aim of the study was to identify the causes of PPH cases and find out modalities and maternal outcomes of PPH cases and different presentations of PPH patients, to identify the causes of primary & secondary PPH. Methods: This cross-sectional study was conducted at Dhaka Medical College & Hospital, Dhaka, Bangladesh during the period from July 2011 to December 2011. The total number of patients in the present study was 200. Patients were selected from those who developed PPH after vaginal delivery or LSCS or instrumental delivery. Patients who were admitted as cases of PPH after home or other institutional delivery. The data were entered into a computer and statistical analysis of the results was obtained by using windows-based computer software devised with Statistical Packages for Social Sciences version 24. Results: During the study period, 407 PPH cases were admitted and the incidence of PPH was 5.72% of the total obstetric cases. Out of 407 cases, 317 (77.89%) were primary PPH cases and 90 (22.11%) were secondary PPH. Among the study people, 89% of patients developed primary PPH, and only 11% developed secondary PPH, 77% of the patients developed no complications other than PPH. 0.5% of patients expired remaining 23% of the patients developed some kind of complication following PPH. Conclusion: Maternal mortality has been used traditionally as a measure of the quality of health care. Recently maternal mortality is being taken into account to assess the burden of the disease. Safe motherhood policies, systematic evaluation, aggressive and appropriate treatment, prompt resuscitation, and volume replacement minimize the potentially serious outcomes associated with PPH. Most of the patients can be managed at the upazilla level by properly trained personnel. Only one-tenth of the patients require surgical management with active management of third-stage labor. So detecting the complications as early as possible and early referred to the tertiary level hospital would be able to reduce the complications and will improve the maternal outcome.

UTEROTONIC USE IN THE ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMTSL): SYSTEMATIC REVIEW

<p><strong>Background:</strong> Maternal mortality rate in Indonesia has decreased from 184/100,000 live birth (LB) (2016) to 177/100,000 LB (2017), but this number is still high enough than SDGs target of 70/100,000 LB. The one of direct cause of maternal death is hemorrhage, especially postpartum hemorrhage (PPH). Causes of PPH are uterine atony, laceration of birth canal, resistant placenta and uterine inversion. PPH prevention method is Active Management of Third Stage of Labor (AMTSL). The objective of this systematic review is to analyze the use of uterotonics in AMTSL.</p><p><strong>Methods:</strong> This systematic review used the PRISMA protocol, articles taken from Google Scholar, Science Direct, and Pub Med. The time span of the research article was 2010 to 2021.</p><p><strong>Result:</strong> The results of the study describe that the use of uterotonics in single use or combination in third stage of labor can reduce the risk of PPH and shorten the time of the stage. The side effects were reported in misoprostol and methyl ergometrine than oxytocin. In addition, combination therapy with oxytocin and misoprostol can reduce the length of the third stage and the potential for a decrease in hemoglobin within 24 hours of delivery. In Indonesia, if oxytocin is not available, maternal nipple stimulation is performed as nonpharmacological therapy or ergometrine 0.2 mg is given to patients without complications of high blood pressure.</p><p><strong>Conclusion:</strong> The use of uterotonics is adjusted to its cost-effectiveness, ability to store and refrigerate also the benefits compare to the side effects to the patients.</p>

Knowledge and skills on active management of third stage of labor for prevention of post-partum haemorrhage among health care providers in Lake Zone, Tanzania: a cross sectional study

BackgroundHealth care providers (HCPs) knowledge and skills are both crucial in saving the lives of mothers and their newborns during childbirth. This study aimed to assess the knowledge and skills of HCPs on active management of third stage of labor (AMTSL) for prevention of PPH in Lake Zone Tanzania.MethodsA cross-sectional analytical hospital-based study which included 340 HCPs who were randomly selected, the study was conducted from March to May 2019 in lake zone, Tanzania. Data were collected using standardized questionnaire and observational checklist. Predictors of knowledge and skills on AMTSL were determined using binary logistic regression under multivariable analysis using SPSS version 23.0. p-value less than 0.05 was considered significant.ResultsMost 200 (58.8%) of the participants were aged between 25 and 34 years with mean age 31.4 ± 6.26 years. Majority 240 (67.6%) were females. Of all HCPs, 171 (50.3%) had adequate knowledge whereas 153 (45.0%) had adequate skills on AMTSL. Males (AOR = 1.96, 95% CI 1.18–3.26), HCPs with University education (AOR = 3.29, 95% CI 1.19–9.13) and previous BEmONC training (AOR = 2.20, 95% CI 1.24–3.91) were found to be the predictors of adequate knowledge on AMTSL. HCPs aged ≥ 45 years (AOR = 9.35, 95% CI 1.74–10.28) and HCPs working at a hospital (AOR = 1.78, 95% CI 1.12–2.82) were associated with having adequate skills on AMTSL.ConclusionHCPs included in this study demonstrated low skills on AMTSL as compared to knowledge which needs immediate attention. We recommend continuous in-service training and supportive supervision among HCPs working in labour wards for improving their knowledge and skills on AMTSL. This will help to reduce maternal morbidity and mortality related to PPH.

Duration of third stage labour and postpartum blood loss: a secondary analysis of the WHO CHAMPION trial data

BackgroundObstetric haemorrhage continues to be a leading cause of maternal mortality, contributing to more than a quarter of the 2,443,000 maternal deaths reported between 2003 and 2009. During this period, about 70% of the haemorrhagic deaths occurred postpartum. In addition to other identifiable risk factors for greater postpartum blood loss, the duration of the third stage of labour (TSL) seems to be important, as literature shows that a longer TSL can be associated with more blood loss. To better describe the association between the duration of TSL and postpartum blood loss in women receiving active management of third stage of labour (AMTSL), this secondary analysis of the WHO CHAMPION trial data has been conducted.MethodsThis was a secondary analysis of the WHO CHAMPION trial conducted in twenty-three sites in ten countries. We studied the association between the TSL duration and blood loss in the sub cohort of women from the CHAMPION trial (all of whom received AMTSL), with TSL upto 60 min and no interventions for postpartum haemorrhage. We used a general linear model to fit blood loss as a function of TSL duration on the log scale, arm and center, using a normal distribution and the log link function. We showed this association separately for oxytocin and for Heat stable (HS) carbetocin.ResultsFor the 10,040 women analysed, blood loss rose steeply with third stage duration in the first 10 min, but more slowly after 10 min. This trend was observed for both Oxytocin and HS carbetocin and the difference in the trends for both drugs was not statistically significant (p-value = 0.2070).ConclusionsThere was a positive association between postpartum blood loss and TSL duration with either uterotonic. Blood loss rose steeply with TSL duration until 10 min, and more slowly after 10 min.Study registration The main trial was registered with Australian New Zealand Clinical Trials Registry ACTRN12614000870651 and Clinical Trial Registry of India CTRI/2016/05/006969

Efficacy of Rectal Misoprostol in Active Management of Third Stage of Labour in Comparison with Oxytocin

Background Third stage of labour is defined as the time from delivery the baby to complete delivery of the placenta and its attached membranes Most common complications of the third stage of labour are postpartum hemorrhage (PPH). Active management of third stage of labour (AMTL) prevents PPH. Misoprostol is a prostaglandin E1 analogue has been suggested as an alternative of the routine prophylactic oxytocic agents in AMTL. Rectal route had been chosen because it avoids gastrointestinal side effects Objectives: To asses effectiveness of (400 mcg) rectally administered misoprostol tablet in the AMTL in comparison with standard oxytocin regimen Patients and Methods In prospective case-control study, 100 women were randomized, 50 patients received either 400mcg misoprostol tablets rectally (study medication) the other 50 received 10 IU oxytocin in 500 ml Ringer lactate solution IV. As a method of AMTL. Patient with risk factor for PPH had been excluded. A comparison between the two groups in their amount of blood loss, drop in hemoglobin level from admission to 24 hr. after delivery, duration of third stage of labour and any side effects appear done Results Maximum amount of blood loss in both groups of the study was 440 ml, so we had no case of PPH. There was no stastically significant difference in mean blood loss, mean difference in Hb level (gm/dl) on admission and 24 hours after delivery, and duration of third stage of labour found between study groups [p values= 0.138, 0.227, 0.08 respectively]. More shivering occurs in cases but the difference was not significant. Conclusions: Misoprostol in a dose of 400 mcg rectally shows promising results, it seems safe and effective drug that can be used in the management of third stage of labour.

Assessment on the Effect of Active Management of Third Stage of Labour With and Without Uterine Massage on Maternal Outcome among Postnatal Mothers

The most common cause of maternal death worldwide is postpartum hemorrhage (PPH) and Active Management of Third Stage of Labour (AMTSL) is the most important prophylactic intervention for prevention of PPH. A study was undertaken to assess the effect of AMTSL with and without uterine massage on maternal outcome among postnatal mothers in a selected hospital, WB. In this quasi-experimental study, Total 60 (Experimental Group-30, Control Group-30) postnatal mothers who undergone spontaneous vaginal delivery were selected by non-probability purposive sampling technique followed by randomization. The uterine massage is applied for 1 min immediately after placental delivery to 2 hours of postpartum at every 15 mins interval. The results revealed that there was no statistically significant difference of mean amount of postpartum bleeding between experimental and control group at 1st hour, 2nd hour, 24 hours, and 48 hours [t1= 1.06, t2= 1.52, t3=0.47, t4=0.26 at df (58), p>0.05]. The general condition (BP, Pulse, Respiration) after 1st hour, 2nd hour, 24 hours and 48 hours were comparable and statistically not significant between the two groups. There was no significant association between amount of postpartum bleeding and obstetrical parameters like parity, gravida, POG, presence of episiotomy, birth weight, time of placental delivery, presence of tear and time of initiation of breast feeding etc. for both groups. Based on the results of the current study, it can be concluded that the mothers who received the uterine massage along with AMTSL get no additional benefit as compared to control group. Keywords: Active management of third stage of labour (AMTSL); Uterine massage; Maternal outcome; Postnatal mother.

The Impact of Low Fidelity Simulation on Nurse Competence in Active Management of Third Stage of Labor: An Intervention Study in Primary Health Care Settings in Tanzania

BackgroundSimulation-based training on obstetric management has demonstrated promising results. However, its impact has not been well documented particularly in low and middle income countries. Therefore, this study aimed to test the effectiveness of a low fidelity simulation-based training intervention in improving knowledge and skills of nurses on Active management of third stage of labor (AMTSL). MethodsA quasi experimental study including 172 randomly selected nurses using low fidelity simulation-based training was conducted. Baseline, immediate and retention assessments were done. FindingsOverall knowledge and skills on AMTSL were significantly improved after simulation training, skills retained even after six months. ConclusionsA low fidelity simulation intervention showed positive change in knowledge and skills immediately after intervention and skills were highly retained even after six months of training.

Prophylactic Administration of Per Rectal Misoprostol vs Intramuscular Injection of Oxytocin in Third-stage of Labour for Prevention of Postpartum Haemorrhage: A Randomised Controlled Trial

Introduction: In India, the routine Active Management of Third- Stage of Labour (AMTSL) with conventional intramuscular oxytocin, at the rural, resource-constrained areas, is often compromised due to lack of trained healthcare personnel and proper maintenance of cold chain system, causing maternal mortality and morbidity from Postpartum Haemorrhage (PPH). In these scenarios, tablet misoprostol, can be efficacious and convenient alternative. Aim: To evaluate efficacy and safety of misoprostol administered per rectum with respect to intramuscular oxytocin for effective control of PPH in a Randomised Controlled Trial (RCT). Materials and Methods: In this RCT, conducted in Sambhunath Pandit Hospital, kolkata, West Bengal, India from September 2015 to August 2016, total 80 eligible pregnant mothers in normal labour with prior consent and fulfilled criteria, were allocated to two separated groups (n=40) by computer generated randomisation table. Control group received 10 IU injection oxytocin and case group received 600 μg misoprostol tablet per rectally within one minute of cord clamping and cutting. The primary outcome measures were mean third- stage and mean postpartum blood loss up to eight hours after delivery. Secondary outcome variables were Mean Arterial Pressure (MAP) after eight hours postdelivery, haemoglobin and haematocrit after 24 hours of delivery and reported side effects. Data was entered into a Microsoft excel spreadsheet and statistical analysis was done by Statistical Package for the Social Sciences (SPSS) version 20.0.1 and Graph Pad Prism version 5.0. Results: Total sample size was 80 equally divided into two groups, with a mean age of 23.20±3.1558 years and 23.7750±3.8927 years in case and control group respectively. The mean third-stage blood loss (332.4105±72.6632 mL versus {vs} 329.0088±59.4503 mL, p=0.8193) and mean total blood loss (426.5575±80.0215 mL vs 424.8783±61.5808 mL, p=0.9165) were statistically indifferent between misoprostol and oxytocin groups by two-sample t-tests. The mean for eight hours postpartum MAP (p=0.0894), 24 hours postpartum haemoglobin (p=0.4534) and haematocrit (p=0.1325) were statistically insignificant between the two groups by two- sample t-tests. Incidence of adverse effects like shivering, diarrhoea, compared by Pearson’s Chi-square test, were found to be more but non significant in misoprostol group. Conclusion: This study concludes that per-rectal misoprostol is equally effective as intramuscular oxytocin to control PPH without significant adverse effects.

Knowledge and barriers on correct use of modified guidelines for active management of third stage of labour: a cross sectional survey of nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania.

Despite the fact that it is possibly preventable, postpartum haemorrhage (PPH) is the global most deadly form of obstetric bleeding, mainly sub-Saharan Africa with at least one-fourth of maternal deaths in East African regions. Active management of third stage of labour (AMTSL) is recommended to prevent PPH. However, AMTSL guidelines have been revised since 2006. To examine the current status of nurse-midwives' knowledge on modified AMTSL guidelines and highlight barriers to AMTSL correct use. Descriptive cross sectional survey was conducted to 160 nurse-midwives at three referral hospitals in Dar es Salaam, Tanzania. One-way, interactive modes ANOVA and Chi square (χ2) test were run in SPSS 21 version to compare the association of independent and dependent variables. Virtually all nurse-midwives knew the first recommended uterotonic (99.4%) and delayed cord clamping (98.8%) protocols as modified. Knowledge was significantly contributed by multiple factors; p=0.001. Reported correct AMTSL use was 46.8% which was significantly affected by AMTSL training (χ2 = 6.732, p = 0.009) and prioritizing atteding an asphyxiated baby (χ2 = 5.647, p = 0.017). Regardless of high nurse-midwives' AMTSL knowledge; it is imperative that responsible authorities plan appropriate strategies to solve reported barriers affecting correct AMTSL use.

Active Management of the Third Stage of Labour: A Brief Review and Update

Blood loss due to postpartum haemorrhage (PPH) and its complications constitute one ofthe major causes of maternal mortality and morbidity. Active management of third stage oflabour (AMTSL) plays an immense role in preventing maternal death due PPH. But till dateobstetricians all over the world and the concerned international bodies could not reach to asingle agreement about its universal use. This approach is practiced widely in many centresand there are some specific guidelines regarding its practical use. AMTSL as a prophylacticintervention and is composed of a package of three components or steps: 1) administrationof a uterotonic, preferably oxytocin, immediately after birth of the baby; 2) controlled cordtraction (CCT) to deliver the placenta; and 3) massage of the uterine fundus after the placentais delivered. In 2012, the results of a large WHO-directed, multi-centred clinical trial showedthat the most important AMTSL component was the administration of an uterotonic, theother two steps contributes relatively less in blood loss. But WHO recommends to continueall three steps of AMTSL for management and training of third stage of labour. This article isa brief review of the recent guidelines and evidence based practice of active management ofthe third stage of labour.
 Bangladesh J Obstet Gynaecol, 2018; Vol. 33(2) : 149-156

Risk Factors and Maternal Outcome of Secondary Post Partum Haemorrhage in Rangpur Medical College Hospital. - A one year study

Background: Post partum haemorrhage (PPH) is one of the most common causes ofmaternal mortality worldwide. Primary PPH (which occurs within 24 hours of delivery) hasbeen studied a lot. But data regarding secondary PPH (which occurs 24 hours after deliveryupto to 6 weeks post partum) is sparse. Our aim was to find out the risk factors and maternaloutcome of secondary PPH.
 Materials and Methods: A cross sectional analytic study of 32 cases admitted with secondaryPPH in Gynae and Obstetric department of Rangpur Medical College Hospital during 1 yearstudy period was carried out.
 Result: Frequency of secondary PPH was 0.58%. Mean age of the patient was 25.23±2.79years; 22(69%) patients were multi para; 17 (53%) patients had education up to primarylevel. Maximum patients [18 (56%)] were from low socio economic status. Mean time ofpresentation was 13.5±2.78 days after delivery; 14(44%) patients delivered vaginally and18(56%) patients delivered by caesarean section. Most of the vaginal delivery 9 (28%) wereconducted by untrained dai or other family member. Among 32 patients, 31 were referredfrom outside the Hospital. Retained bits of placenta was the leading cause (15,47%) andcaesarean wound dehiscence was the second cause (13,41%); 13 (40%) patients had feveron presentation. All were anemic with mean hemoglobin concentration 7.4±1.4gm and 24(75%) of them required blood transfusion. Four patients was in shock. Antibiotic was givento all patients. DE&C was done in 15(47%) cases and laparotomy followed by total abdominalhysterectomy was done in 12 cases and repair in 1 case. Among 15 patients who underwentsurgical evacuation there was histological evidence of placental tissue in only 6(40%) patients.
 Conclusion: In present study retained bits of placenta and caesarean wound dehiscenceare found as main cause of secondary postpartum hemorrhage So care should be takenduring active management of third stage of labour (AMTSL). Choosing appropriate suturematerial, maintaining personal hygine of patient and sterility of operation theate, usingappropriate antibiotic to combat microbials and last but not list improving skillness of surgeonare the key to reduce the rate of secondary PPH.
 Bangladesh J Obstet Gynaecol, 2018; Vol. 33(2) : 107-112

Evaluation of the oxytocin use in the active management of third stage of labour among Sudanese women: a prospective, hospital-based study

Background: Active management of third stage of labour (AMTSL) by administration of prophylactic uterotonic drugs immediately after delivery can reduce the rate of postpartum haemorrhage (PPH). This study aimed to evaluate oxytocin use in the prevention of primary PPH at Omdurman Maternity Hospital, Khartoum, Sudan.

EFFECTS OF SUBLINGUAL MISOPROSTOL AS ADJUNCT TO OXYTOCIN FOR ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR IN PATURIENTS AT RISK OF POST-PARTUM HAEMORRHAGE IN ABAKALIKI : A COMPARISON OF 200 VERSUS 400 MICROGRAMS

Background: Postpartum Haemorrhage (PPH) still remains a major cause of maternal mortality despite adequate knowledge of its causes and treatment. Oxytocin administration is one of the major components of active management of third stage of labour (AMTSL). Evidence suggest benefit of misoprostol as an adjunct however optimal dose is yet to be determine considering the dose depended side effect profile of misoprostol. . Objective: This study evaluated the efficacy and side effect profile of 200µg versus 400µg of prophylactic sublingual misoprostol as adjunct to AMTSL among parturient at risk for PPH. Methods: This was a double blinded, single centre, randomized controlled trial involving two hundred and forty parturient with 2.1% drop out rate , thus 235 of them were analyzed; 117 (48.8%) and 118(49.2%) for 200 and 400 microgram group respectively. Data was analyzed using Statistical Package for Social Science (IBM SPSS) software (version 24, Chicago II, USA). Continuous variables were presented as mean and standard deviation (Mean ± 2SD), while categorical variables were presented as numbers and percentages. Chi-square test (X2) was used for comparison between groups for qualitative variables while t-test was used for comparison between groups for quantitative variables. A difference with a P value <0.05 was considered statistically significant. Results: The mean blood loss was similar between the 200µg and 400µg groups of the study with 280.68±179.40mls and 253.86±169.80mls for the 200µg and 400µg groups respectively and p=0.240. The occurrence of primary postpartum haemorrhage (PPH) was equally similar between the two groups with incidence of 9.4% and 7.6% for the 200µg and 400µg groups respectively, p=0.7997. The risk ratio (RR) for developing PPH was 0.888 (95% CI; 0.537-1.467). The need for additional oxytocics to control bleeding was equally the same between the study groups with p=0.132. However, more participants in the 400µg group had one or more of the side effects of sublingual misoprostol compared to the participants in the 200µg group with RR 1.5759 (95% CI; 1.239-2.004), p<0.001. Shivering and fever were the side effects with significant difference between the two groups with p-values of 0.015 and 0.023 for shivering and fever respectively. Conclusion: Sublingual misoprostol as an adjuvant to AMTSL in the doses of 200µg and 400µg are equally effective in reducing blood loss and the incidence of primary PPH, among women at increased risk for PPH. However, misoprostol induced side effects were significantly higher with 400µg.

Knowledge and Practice of Active Management of Third Stage of Labour (AMTSL) among Nursing Students in Selected Hospitals, Gangtok, Sikkim

Introduction: Active Management of Third Stage of Labour (AMTSL) as a prophylactic intervention is composed of a package of three components. WHO recommendations have supported active management of the third stage of labour (AMTSL) as a critical intervention for PPH prevention. The study aimed to assess the knowledge and practice of AMTSL among nursing students in selected hospitals, Gangtok, Sikkim. Materials and Methods: Investigators adopted quantitative approach with descriptive co-relational research design where 40 students were selected by convenient sampling technique. Validated structured knowledge questionnaire and observational checklist were used to collect the data. Pretesting and reliability of the tool was done which was found to be reliable. Results: The findings revealed that majority of the students i.e. out of 40 students, 33 (82.5%) had average knowledge, 5 (15%) students had poor knowledge and 1 (2.5%) had good knowledge. Majority 21 (52.5%) had poor practice and 19 (47.5%) had good practice on AMTSL. There was a positive correlation between knowledge and practice of AMTSL among nursing students which means with the increase of knowledge, the practice of AMTSL improves. Also, there was an association of practice with the number of return demonstration shown to the supervisor. Conclusion: Knowledge of Active Management of Third Stage of labor is a vital possession for the nurses and birth attendants to be skillful in the practice of AMTSL to prevent post-partum hemorrhage and other obstetric complication, which may risk the life of the women. Knowledge based skill is optimal solution for reducing the maternal mortality rate.