Placental Cord Drainage Research Articles

Placental cord drainage after vaginal delivery as part of the management of the third stage of labour

Cord drainage in the third stage of labour involves unclamping the previously clamped and divided umbilical cord and allowing the blood from the placenta to drain freely into an appropriate receptacle. The objective of this review was to assess the specific effects of placental cord drainage on the third stage of labour following vaginal birth, with or without prophylactic use of uterotonics in the management of the third stage of labour. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2010). Randomised controlled trials comparing placental cord draining with no placental cord drainage as part of the management of the third stage of labour. Two review authors independently assessed the quality of trials and extracted data. This was then verified by the third review author who then entered the agreed outcomes to the review. Three studies involving 1257 women met our inclusion criteria. Cord drainage reduced the length of the third stage of labour (mean difference (MD) -2.85 minutes, 95% confidence interval (CI) -4.04 to -1.66; three trials, 1257 women (heterogeneity: T² = 0.87; Chi²P=17.19, I² = 88%)) and reduced the average amount of blood loss (MD -77.00 ml, 95% CI -113.73 to -40.27; one trial, 200 women).No incidence of retained placenta at 30 minutes after birth was observed in the included studies, therefore, it was not possible to compare this outcome. The differences between the cord drainage and the control group were not statistically significant for postpartum haemorrhage or manual removal of the placenta. None of the included studies reported fetomaternal transfusion outcomes and there were no data relating to maternal pain or discomfort during the third stage of labour. There was a small reduction in the length of the third stage of labour and also in the amount of blood loss when cord drainage was applied compared with no cord drainage. The clinical importance of such observed statistically significant reductions, is open to debate. There is no clear difference in the need for manual removal of placenta, blood transfusion or the risk of postpartum haemorrhage. Due to small trials with medium risk of bias, the results should be interpreted with caution.

A randomised controlled trial of placental cord drainage to reduce feto-maternal transfusion

ObjectivesTo determine whether placental drainage via the umbilical cord prior to placental delivery reduces the size of feto-maternal transfusion and thus the chance of rhesus isoimmunisation in rhesus negative women. Study designA randomised controlled trial conducted in a tertiary hospital setting in the UK compared 18 rhesus negative women who had placental drainage (10 caesarean section and 8 vaginal deliveries) with 18 rhesus negative women where the cord remained clamped until placental delivery (8 caesarean section and 10 vaginal deliveries). Maternal venous blood samples were taken before delivery and at a mean of 142min after delivery of the placenta, and analysed using flow cytometry to calculate the size of the feto-maternal transfusion. The statistical analysis was performed using SPSS Version 13 statistical software. The main outcome measure was the quantification of the volume of fetal cells in the maternal circulation before and after delivery. ResultsIn the 72 specimens taken, 40 demonstrated measurable amounts of fetal cells in the maternal circulation. In the 18 women who had placental drainage, the mean (SD) size of the feto-maternal transfusion was 0.50ml (0.79) before and 0.39ml (0.58) after delivery. In the 18 women who had a clamped cord, the mean (SD) feto-maternal transfusion was 0.46ml (0.84) before and 0.78ml (1.1) after delivery. There was no significant difference between the net feto-maternal transfusions in the two groups (Mann–Whitney U 122.5, p 0.19). ConclusionPlacental drainage does not reduce the amount of feto-maternal transfusion and this method of placental delivery is not recommended to reduce feto-maternal transfusion.

Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage

ObjectiveTo review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000. EvidenceMedline, PubMed, the Cochrane Database of Systematic Reviews, ACP Journal Club, and BMJ Clinical Evidence were searched for relevant articles, with concentration on randomized controlled trials (RCTs), systematic reviews, and clinical practice guidelines published between 1995 and 2007. Each article was screened for relevance and the full text acquired if determined to be relevant. Each full-text article was critically appraised with use of the Jadad Scale and the levels of evidence definitions of the Canadian Task Force on Preventive Health Care. ValuesThe quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. SponsorThe Society of Obstetricians and Gynaecologists of Canada. RecommendationsPrevention of Postpartum Hemorrhage1.Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. (I-A)2.Oxytocin (10IU), administered intramuscularly, is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. Care providers should administer this medication after delivery of the anterior shoulder. (I-A)3.Intravenous infusion of oxytocin (20 to 40IU in 1000mL, 150mL per hour) is an acceptable alternative for AMTSL. (I-B)4.An IV bolus of oxytocin, 5 to 10IU (given over 1 to 2minutes), can be used for PPH prevention after vaginal birth but is not recommended at this time with elective Caesarean section. (II-B)5.Ergonovine can be used for prevention of PPH but may be considered second choice to oxytocin owing to the greater risk of maternal adverse effects and of the need for manual removal of a retained placenta. Ergonovine is contraindicated in patients with hypertension. (I-A)6.Carbetocin, 100μg given as an IV bolus over 1minute, should be used instead of continuous oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the need for therapeutic uterotonics. (I-B)7.For women delivering vaginally with 1 risk factor for PPH, carbetocin 100μg IM decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin. (I-B)8.Ergonovine, 0.2mg IM, and misoprostol, 600 to 800μg given by the oral, sublingual, or rectal route, may be offered as alternatives in vaginal deliveries when oxytocin is not available. (II-1B)9.Whenever possible, delaying cord clamping by at least 60seconds is preferred to clamping earlier in premature newborns (<37weeks’ gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (I-A)10.For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6months of age conferred by delayed cord clamping. (I-C)11.There is no evidence that, in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45minutes will reduce the risk of PPH. (II-2C)12.Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH. (II-1C)13.Intraumbilical cord injection of misoprostol (800μg) or oxytocin (10 to 30IU) can be considered as an alternative intervention before manual removal of the placenta. (II-2C) Treatment of PPH14.For blood loss estimation, clinicians should use clinical markers (signs and symptoms) rather than a visual estimation. (III-B)15.Management of ongoing PPH requires a multidisciplinary approach that involves maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss. (III-C)16.All obstetric units should have a regularly checked PPH emergency equipment tray containing appropriate equipment. (II-2B)17.Evidence for the benefit of recombinant activated factor VII has been gathered from very few cases of massive PPH. Therefore this agent cannot be recommended as part of routine practice. (II-3L)18.Uterine tamponade can be an efficient and effective intervention to temporarily control active PPH due to uterine atony that has not responded to medical therapy. (III-L)19.Surgical techniques such as ligation of the internal iliac artery, compression sutures, and hysterectomy should be used for the management of intractable PPH unresponsive to medical therapy. (III-B)Recommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).