Management Of Third Stage Research Articles

Pattern of implementation of Emergency Obstetric Life-Saving Skills in public health facilities in Nsukka Local Government Area of Enugu State, Nigeria

Maternal mortality and morbidity can be minimised if adequate timely emergency obstetric life-saving care is provided especially at the primary health level. We conducted a descriptive cross-sectional study among 167 community health workers to investigate the pattern of performance of implementation of emergency obstetric life-saving skills (EmOLSS) in health facilities in Nsukka Local Government Area (LGA) of Enugu State. A pre-tested, paper-based questionnaire was utilised and data was analysed using descriptive and Chi-square statistics. Almost all were female (99.4%) and mean age was 39.5 ± 8.17 years. The pattern of core EmOLSS showed that 8.4% always use partograph and 60.8% use oxytocin for active management of third stage of labour. Only 15% had high level of confidence to carry out intrapartum and postpartum EmOLSS activities. Increased workload (66.3%), lack of supportive supervision (91.0%) and lack of infrastructure to work with (81.3%) influenced the pattern of implementation while poor basic knowledge of EmOLSS and lack of time influenced the level of confidence of the health workers. Health workers displayed poor pattern of EmOLSS implementation and low level of confidence. Regular training with supervision and provision of infrastructure will be beneficial to ensure improvement in the quality of care and reduction in maternal mortality. IMPACT STATEMENT What is already known on this subject? Emergency obstetric life-saving care is a key interventional strategy in the reduction of maternal mortality and morbidity. Reports showed that effective coordination and implementation of this care especially at the primary care level could reduce birth complications. Yet, there are gaps in the implementation of this essential care in the low and middle income countries. What do the results of this study add? This study revealed poor pattern of implementation of emergency obstetric life-saving care and low level of confidence among frontline health workers in public primary healthcare facilities in Nsukka Local Government Area of Enugu State, Nigeria. While there are efforts geared towards training of these health workers, the pattern of implementation of emergency obstetric life-saving care was affected by other health workers’ intrapersonal, client-related and institutional factors. What are the implications of these findings for clinical practice and/or further research? Information from this study is useful to the government and other maternal health stakeholders to formulate policies, and design ecological programs that target the clients, health workers and institutions.

FREQUENCY OF ATONIC UTERUS DUE TO PRIMARY POSTPARTUM HEMORRHAGE: A CROSS-SECTIONAL STUDY

Postpartum hemorrhage (PPH) is loss of 500 mL of blood from genital tract after normal vaginal delivery or 1000 mL after cesarean section. PPH is one of an important cause of maternal mortality and morbidity worldwide, the only strategy that has shown a significant reduction in maternal mortality in patients with PPH is active treatment and management of third stage of labor.In this study we aim to determine the frequency of atonic uterus due to postpartum hemorrhage.A descriptive cross-sectional study was carried out on women attending at Shar –Ara teaching hospital in Kabul from 1th January 2020 -1th January 2021.In general, this study included 170 women with postpartum hemorrhage out of these 105 (61.8%) of whom had uterine atony, followed by other causes retained placenta tissue 22.4%, genital tract tears 14.7%, coagulopathies at 1.2%. It was found that 53.3% of patients were between 20-28 years old, 43.8% women were grand multipara, 87,6% cases were seen in full term pregnancies while 9.5% in post term pregnancies. 92.4% of women were found with previous history of PPH. Finally 47.6% cases managed by uterotonic agents (Metergin + Misoprostol + Oxytocin), 13.3% - only by Misoprostol, 10.5% - by Oxytocin + Misoprostol are used. B lynch compression sutures and uterine courage and massage was performed in 9,5% cases while 1.9% total abdominal hysterectomy was performed.In our study the frequency of uterine atony due to postpartum hemorrhage was found in 61.8% of cases. Most cases have been seen in women with full term gestational age, and Uterine atony is common in grand multipara, and young patients. Uterine atony mostly managed by uterotonic agents. Any delay in diagnosis and managements of PPH lead to maternal death and disability.

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.

Post-Partum Haemorrhage at the Federal Medical Centre, Yenagoa, South-South Nigeria: A 5-Year Review

Postpartum haemorrhage complicates about 3 – 5% of deliveries. It is the leading cause of maternal morbidity and mortality worldwide, especially in sub-Saharan Africa (of which Nigeria is a part), where it significantly contributes to the burden of maternal and perinatal morbidity and mortality. The objective of this study was to determine the incidence, maternal and perinatal outcomes of postpartum haemorrhage and its maternal outcome at the Federal Medical Centre, Yenagoa, South-South, Nigeria. This retrospective survey was conducted between 1st January 2016 and 31st December 2020. Data were retrieved, entered into a pre-designed proforma, and analysed using IBM SPSS version 25.0. Results were presented in frequencies and percentages for categorical variables and mean and standard deviation for continuous variables. Out of 4,571 deliveries within the study period, postpartum haemorrhage complicated 66; representing a case incidence rate of 14.4 per 1,000 deliveries. Majority of the women were multiparous/grand-multiparous (53, 80.3%) and unbooked (56, 84.4%). Primary postpartum haemorrhage was the more common (56, 84.8%) type of postpartum haemorrhage, with uterine atony being the most (39, 59.1%) implicated aetiology. The most common (12, 18.2%) perinatal complications were birth asphyxia and admission into special care baby unit. There were 5 cases of maternal mortality giving a rate of 10.9 deaths per 10,000 pregnant women. Postpartum haemorrhage is one of the leading causes of maternal morbidity and mortality, especially in developing countries. Therefore, antenatal booking, recognition of risk factors and active management of third stage of labour are key in the prevention of postpartum haemorrhage and its associated complications. Women should be encouraged to book for antenatal care early and be regular at the visits, as this will help recognise danger signs early and establish plans to prevent postpartum haemorrhage.

Clinical Study on Role and Efficacy of Lower Dose of Carboprost [125 μg] and its Comparision with Oxytocin [10 Units] in Prevention of Postpartum Haemorrhage in Caesarean Section

Introduction: Post-partum hemorrhage (PPH) is an important cause of maternal mortality accounting for nearly 25% of maternal deaths worldwide. It is reported to occur in ~4-6% of all deliveries, and the risk is significantly greater with caesarean delivery than vaginal delivery. Oxytocin is universally accepted as drug of choice but carboprost has also been found to be effective in management of third stage of labour. Carboprost 250 microgram (μg) is associated with significant side effects; however its lesser dose may prove a better uterotonic with fewer side effects. Aims and objective: To evaluate the role and scope of using prophylactic intramuscular carboprost [125 μg] in comparison with intramuscular oxytocin [10 units] in prevention of PPH in caesarean section. Material and methods: 200 pregnant women admitted in labour room undergoing caesarean section were included in this study after taking informed consent and were randomly divided into group 1 and 2, where Group 1 received intramuscular carboprost 125 microgram and Group 2 received intramuscular oxytocin 10 units, within 1 min of delivery of baby. Comparative study was done in both the groups and assessment was done in terms of blood loss, incidence of PPH, additional requirement of drugs and side effects. Results and conclusion: Patients who received carboprost [125 μg] had lesser blood loss as compared to patients who received oxytocin. Mean blood loss was 405 ml and 560 ml in patients who received carboprost and oxytocin respectively. Also there was less need of additional uterotonics in patients who were given carboprost. Out of 50 patients receiving carboprost only 4 patients complained of vomiting and 8 complained of nausea.

A Prospective Study of Severe Acute Maternal Morbidity and Maternal Near Miss in a Tertiary Care Hospital.

The identification of severe cases of maternal morbidity has emerged as an approach to mitigating maternal deaths. The main objective of the study was to analysethe causes of (severe acute maternal morbidity) SAMM and maternal (near miss) NM among pregnant women and the associated risk factors. The study was conducted on pregnant women (n = 300) who were diagnosed as SAMM (n = 269) and NM (n = 31). Patient details including age, parity, gestational age at admission, antenatal history, morbidity conditions, mode of delivery, and ICU admission with life-saving medical and surgical interventions were recorded. Multinomial logistic regression analysis was performed to assess the risk factors associated with SAMM and NM. The most common cause of maternal death was hemorrhage. The maternal NM incidence ratio was 11.58/1000 live births, maternal NM mortality ratio was 2.5:1, and the mortality index was 3.8% with SAMM and NM and 27% with life-threatening complications.Women with low education status, multiparity, third trimester and postpartum period, suboptimal antenatal visits, and a lack of awareness were at increased risk of SAMM and NM. This study adds on to the existing knowledge of SAMM and NM highlighting the need of early diagnosis and need of overall improvement in quality critical care management for maternal health and its timely accessibilityto substantially reduce maternal deaths. Active management of third-stage of labor, early recognition and emergency management of severe hypertension widely contribute toward reducing the number of both SAMM and NM.

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.

Comparing the Effectiveness of Transrectal Misoprostol with Intravenous Oxytocin in Active Management of Third Stage of Labour in Preventing Post-partum Hemorrhage

Background: PPH which is 500 ml or more blood loss in 24 hours of birth . Uterine atony has been the commonest cause of PPH. To prevent PPH uterotonics like oxytocin and misoprostol should be given. Intravenous route of oxytocin has rapid effect, but is associated with cardiovascular side effects like rise in heart rate and decrease in blood pressure. Slower rate of absorption, lower peak levels and reduced adverse effects is seen with misoprostol given rectally when compared to sublingual and oral routes. This study aims to compare the effectiveness of transrectal misoprostol and intravenous oxytocin in preventing post-partum haemorrhage.
 Objectives: To compare the effectiveness of 600mcg transrectal misoprostol with 10IU intravenous oxytocin in active management of third stage of labour in preventing PPH and recommend technique for active management of third stage of labour in preventing PPH.
 Methodology: Women randomized into two groups for prevention of PPH and are given 600ug of misoprostol per rectally and 10IU oxytocin intravenously. Duration of third stage, the blood volume in kidney tray and additional blood loss in sterile surgical pads for 24hrs will be noted. The blood loss due to episiotomy will be taken as 50ml.Need of additional uterotonics(oxytocin or misoprostol), blood transfusion, removal of placenta manually, haemoglobin before and after delivery will be noted. Monitoring of patients for vital signs, uterine tone, fundal height and vaginal bleeding for 2 hour will be done.
 Result: The expected outcome of the study will be a significant difference in the blood loss during third stage of labour and 24 hours in post-partum period when uterotonics like oxytocin or misoprostol are used in managing third stage of labour actively.
 Conclusion: Our study will show the effect of intravenous oxytocin and transrectal misoprostol in managing third stage of labour actively to prevent post-partum hemorrhage.

Carbetocin versus Oxytocin in Active Management of 3rd stage of Labour following Vaginal Delivery

Background: Every day more than 220 women around the world die from severe bleeding after childbirth. Globally post-partum hemorrhage is the number one direct cause of maternal mortality. Most postpartum hemorrhages are caused by uterine atony and occur in the immediate postpartum period. Most of these tragic deaths can be prevented by active management of third stage of labour. Active management of the third stage of labor should be practiced routinely to decrease the risk of postpartum hemorrhage. Oxytocin is used for enhancing uterine contraction after delivery. But oxytocin has some limitations like shorter half- life, less contraction time and more side effects, whereas carbetocin has prolonged duration of action which ensures more contraction time and less adverse effects. This study was done to see the efficacy and safety of carbetocin over oxytocin for prevention of PPH after vaginal delivery.
 Methodology: A randomized controlled clinical trial was conducted in the Department of Obstetrics and Gynecology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh over a period of 9 months from January 2015 to September 2015. Ninety four patients undergoing vaginal delivery at term were randomized into two groups receiving either 10IU oxytocin or 100 μg carbetocin. Outcome measures such as primary PPH, massive blood loss, need for additional uterotonic drug, additional blood transfusion as well as adverse effects were documented.
 Results: In this study, massive blood loss did not occur none of patients in carbetocin group. But massive blood loss occured 6.4% women of oxytocin group. Further fundal massage , immediate blood transfusion and additional uterotonics didn’t need any patient in carbetocin group. In oxytocin group, fundal massage required in 8.5% of women, blood transfusion needed in 10.6% patients and additional uterotonics needed in 10.6% women. Average amount of blood loss was 88 ml less in carbetocin group and adverse effects of drugs were almost similar in both group. Primary PPH developed in oxytocin group 8.5% but none of patients had developed PPH in carbetocin group.
 Conclusion: Carbetocin is an effective new drug than oxytocin for prevention of postpartum hemorrhage in vaginal delivery.
 Bioresearch Commu. 7(1): 927-931, 2021 (January)

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.

A comparative study on rectal misoprostol versus intramuscular oxytocin to prevent postpartum haemorrhage

Objective: 1. To compare the efficacy of 800 mcg of rectal misoprostol with 10U I.M Oxytocin in prevention of postpartum haemorrhage 2. To assess the safety of both the drugs.Methodology: A prospective, double-blind study carried out for a period of 1 year. 240 cases had been taken for the study, which were divided randomly into two groups containing 120 cases each i.e. Group A were given 10 IU oxytocin intramuscularly immediately after delivery. Group B were given 800 mcg rectal misoprostol immediately after delivery. The personal information and medical data of the selected cases were collected in structured proforma. Statistical analysis was done using Epidemiological Information Package (EPI2002).Results: Mean Blood loss for Group A – 224.4 ml and mean Blood Loss for Group B – 240.4 ml and with insignificant difference (p 0.132). The mean blood loss in the injection Oxytocin group was lower than mean blood loss in the tablet Misoprostol group but the difference was not statistically significant. The incidence of PPH was 5.82% in Group A and 6.6% in Group B. The difference was not statistically significant.Shivering, pyrexia was found more in misoprostol group than oxytocin with the incidence being 12.5% versus 7% (shivering) and 8.3% versus 2.5% (pyrexia) respectively. Conclusion: It is observed that the misoprostol 800µg rectally is as effective as intramuscular oxytocin 10 IU when used during the active management of third stage of labour for prevention of postpartum haemorrhage.

MIDWIVES’ PERCEPTIONS OF THE CONCEPT OF THIRD STAGE OF LABOUR IN DI RS DR TADJUDDIN CHALID MAKASAR

AbstractBackground: Active management of third stage of labour is an intervention that is considered to reduce the risk of post partum hemorrhage which is the leading cause of maternal mortality. The results of a preliminary study conducted in the labour ward of Dr.Tadjuddin Chalid Makassar hospital it was found that active management was a midwifery care during third stage of labour, besides catheterization and exploration of the uterus routinely carried out in all normal childbirth as part of midwifery care during third stage of labour. This routine interventions can increase the risk of infection and not suitable with the midwives philosophy which states that childbirth is normal physiological processes. Objectives: This study aimed to explore the influence of midwives’ perceptions toward attitudes and behaviour during third stage of labour. Method: A descriptive research study using qualitative methods was conducted in Dr.Tadjuddin Chalid Makassar Hospital. A purposive sample of 5 midwives’ who represent different characteristics participated in this study. Data collection was carried out through in-depth interview and observations. The data analysed according to thematic analysis methods. Findings: The findings included three main themes, 1) Midwives believe that third stage of labour is the most risky phase for all women during childbirth, 2) Midwives’ efforts to minimize the risk of post partum haemorrhage by implementing active management of third stage of labour, 3) Midwives’ perceptions influence attitudes and behaviors in providing care by using risk management approach. Conclusion: Midwives’ perceptions have a pivotal role in attitudes and behaviour during third stage of labour. The application of medical models identified as a result of this perception. Midwives’ need to understand the philosophy of midwifery care to avoid unnecessary medical interventions in all normal childbirth.

ORAL MISOPROSTOL VERSUS INTRAMUSCULAR OXYTOCIN IN THE ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

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.

ORAL MISOPROSTOL VERSUS INTRAMUSCULAR OXYTOCIN IN THE ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

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.

Comparative study between active management and expectant management of third stage of labour

Comparative study between active management and expectant management of third stage of labour

A Comparative Study: Is Misoprostol as Effective as Oxytocin in Active Management of Third Stage of Labor?

Background: The third stage of labor is that period from birth of the infant until the delivery of the placenta. Active management of the third stage of labor plays an important role in reducing maternal morbidity and mortality. Oxytocin is an effective drug in preventing postpartum hemorrhage (PPH) however; it requires a controlled environment and intramuscular administration. Misoprostol is an orally active uterotonic agent,stable at room temperature.The purpose of this study was to compare the efficacy of misoprostol with oxytocin in active management of third stage of labor.
 Materials and Methods: This was a hospital based study carried out in Paropakar Maternity and Women Hospital, Kathmandu, Nepal during six months period from February 2012 to July 2012. One hundred patients fulfilling inclusion criteria were recruited to receive either 10 unit of IM oxytocin or 600 mcg of oral misoprostol for the management of the third stage of labor.
 Results: The mean blood loss in misoprostol and oxytocin group was 209±76.7ml and 197±68.8 ml respectively with p value-0.41 which was insignificant. Similarly mean hemoglobin change was also not significant. The additional uterotonics needed in misoprostol was higher (9 cases) than that in oxytocin (5 cases) but it was also not significant. Shivering and fever were significantly high among misoprostol group than in oxytocin group.
 Conclusion: Efficacy of oxytocin and misoprostol is equal in active management of third stage of labor.

A comparative study of efficacy of rectal misoprostol with intravenous methyl ergometrine and intramuscular PGF2a in active management of third stage of labor

PPH is almost entirely a preventable condition when management is based on scientifically proven methods. It occurs in approximately 4% of vaginal deliveries, and estimates are that it causes significant morbidity and 25% of all the maternal child birth related deaths. We conducted this study with the following aims to compare the effectiveness of rectal misoprostol (600mcg) with intravenous methylergometrine (0.2mg) and intramuscular PGF2α (125mcg). To find out the percentage of pregnant women having postpartum hemorrhage, amount of blood loss and efficacy and safety of uterotonic drugs during third stage of labor. Patients with full-term singleton pregnancy in the age group of 20-35 years admitted in the maternity ward for vaginal delivery were enrolled in the study after taking written informed consent. The third stage of labor was actively managed in these patients by either 600mcg of misoprostol per rectally (Group A) or 0.2mg of IV methylergometrine (Group B) or 125mcg of PGF2α intramuscularly (Group C) and some were given any prophylactic oxytocic (Group D). Majority 110 (55%) of the studies participants were in the age group of 20-24 years. Moreover, 109 (54.5%) belonged to upper middle (II) socioeconomic class as per modified Kuppuswamy’s socioeconomic scale update for 2018. Only, 7 (3.5%) of the participants were grand multipara’s while 24 (12%) had gestational age greater than 40 weeks. Mean maternal age, gestational age and duration of third stage of labor was comparable in all the study groups. Maximum amount of blood loss was seen among participants who were in control group (201.80 ± 122.81 ml) and the maximum ‘mean difference in Hb’ was also seen in control group (0.83 gm%). Reported side effects during the study included diarrhea, nausea, shivering and vomiting in (1.5%) participants. Postpartum hemorrhage and retained placenta was reported among 7 (3.5%) and 2 (1%) participants only.Misoprostol can be used as a safe and effective alternative agent in active management of third stage of labor.

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.

Frequency of retained placenta in patients presenting with postpartum haemorrhage after active management of third stage of labour

Background: Postpartum haemorrhage (PPH) is a potentially life-threatening complication. PPH is defined as blood loss of more than 500 ml in vaginal delivery or 1000 ml in caesarean delivery. The most frequent causes are uterine atony, genital tract trauma followed by retained placenta. Active management of third stage of labour reduces the risk of postpartum haemorrhage and should be offered and recommended to all women.Methods: It was a descriptive (cross sectional study) conducted to determine the frequency of retained placenta in patients presenting with postpartum haemorrhage after active management of third stage of labour, conducted in ward 8, Jinnah Post Graduate Medical Centre, Karachi from October, 2013 to April, 2014. A total of 189 patients with postpartum haemorrhage after receiving active management of third stage labour were included in this study. All patients were subjected to detailed history and vaginal examination to confirm retained placenta. Data was recorded in a pre-designed proforma.Results: Frequency of retained placenta presenting with postpartum haemorrhage after active management of third stage of labour was observed in 20.11%.Conclusion: It is concluded that active management of the third stage of labour has proved beneficial compared with expectant management based on the decrease in the PPH rate, use of additional uterotonic medication and cost of the care.