Risk Of Primary Postpartum Haemorrhage Research Articles

Efficacy of Balloon Tamponade in Postpartum Hemorrhage

Aim: An estimated loss of more than 500 mL of blood after vaginal delivery and more than 1000 mL of blood following caesarean delivery from the birth canal within 24 hours is considered primary postpartum haemorrhage (PPH). Rightfully termed the "obstetrician's nightmare," primary postpartum haemorrhage remains a major contributor to maternal mortality and morbidity in underdeveloped countries like Pakistan, where it accounts for 21-31% of maternal deaths. As a result, investigating PPH management strategies is vital. Objectives: To determine the efficacy of intrauterine balloon tamponade in the management of post-partum hemorrhage Study Design: Descriptive study Study Setting: Department of Obstetrics and Gynecology, Sheikh Zayed Medical from 21st May 2021 till 20th November 2021. Methods: Total 126 women aged 18-35 years, parity 1-6 and 31-41 weeks of gestation, who develop atonic post-partum hemorrhage not responding to uterotonics following normal vaginal delivery or caesarean section were enrolled using non-probability consecutive sampling technique. Women having postpartum hemorrhage were treated with balloon tamponade to stop bleeding. Efficacy was noted after 06 hours of procedure. Data was entered and analyzed using SPSS 25. Results: In this study total 126 patients were enrolled with mean age of 25.6±5.3 years. Mean gestational age was 38.2±3.2 weeks. Mean blood loss was 1032.1±379.6 ml. Mean parity was4.1±1.3. Most of patients had middle education i.e. 33.3%. Majority of patients belonged to middle socioeconomic status i.e. 47.6%. There were 41.3% patients who were booked and 2 had regular antenatal visits. Vaginal delivery was done in 55.6% patients. Balloon tamponade was effective in 81% patients. Practical Implication: Since balloon tamponade is a relatively new procedure, there is little information about its efficacy compared to the more traditional method of uterovaginal packing in Pakistan. Conclusion: Balloon tamponade is effective in stopping postpartum hemorrhage. The success rate (81%) of balloon tamponade in preventing PPH is high. It's convenient for use in situations with a higher risk of PPH. Keywords: Postpartum Hemorrhage, Balloon Tamponade, Delivery, Efficacy, Blood Loss, Management

The Impact of Overweight and Obesity in Early Pregnancy on Maternal and Fetal Outcome

The recent increase in prevalence of overweight and obesity in pregnancy has become a major public health problem as it is associated with increased risk of obstetric and neonatal complications. A hospital based observational comparative study was done on women attending obstetrics and gynecology outpatient department of a tertiary care hospital in Kathmandu from September 2021 to January 2022 after taking ethical clearance from Institutional Review Committee. A total of 113 overweight/obese women in first trimester of singleton pregnancies and similar number of women with normal BMI were recruited for the study and followed throughout pregnancy for the development of maternal complications like gestational hypertension, gestational diabetes mellites, antepartum hemorrhage, preterm labor and postpartum hemorrhage. The neonatal outcome compared were birth weight, low Apgar score at birth and NICU admission. Maternal overweight/obesity as compared to normal BMI was associated with increased risk of gestational diabetes mellites (RR 2.06, 95% CI: 1.2 to 3.52; P value = 0.006), gestational hypertension (RR 2.2, 95% CI: 1.09 to 4.43; P value = 0.02) and caesarean delivery (RR 1.81, 95% CI: 1.28 to 2.55; P value = 0.004). The risk of primary postpartum hemorrhage was also increased in overweight/ obese women than in normal weight women (RR 2.8, 95% CI: 1.04 to 7.51; P value=0.03). In neonatal outcomes, the mean birth weight (3.18 + 0.54 kg vs 2.9 + 0.33kg, P value < 0.001) and admission to NICU (28.3% vs 10.61%, P value = 0.008) were significantly higher in overweight/ obese women. Maternal overweight/obesity in early pregnancy is associated with higher risk of adverse pregnancy and neonatal outcome.

Age and Parity in the Incidence Of Primary Post Partum Hemorrhage at Panembahan Senopati Hospital, Bantul Yogyakarta

Post partum hemorrhage is the main cause of 150,000 maternal deaths every year in the world and almost 4 out of 5 deaths due to postpartum hemorrhage occur within 4 hours after delivery. The direct causes of maternal death in Indonesia are bleeding 45.20%, eclampsia 12.90%, abortion complications 11.10%, postpartum sepsis 9.60%, prolonged labor 6.50%, anemia 1.60% and indirect causes of death. by 14, 10%. The purpose of this study was to determine the relationship between parity and age with the incidence of primary postpartum hemorrhage at Panembahan Senopati General Hospital. Analytical survey studies or case control surveys use a retrospective time approach. The sampling technique was purposive sampling with a ratio of the number of samples 1: 1, namely the case sample was 70 and the control sample was 70. The analysis technique was Chi Square. The results of Chi Square analysis showed that age and parity had a significant relationship with the incidence of primary postpartum hemorrhage, age (OR = 14.22 and p-value 0.000) while parity (OR 3.010 and p-value 9.643). It means that mothers with maternal age at risk (<20 and > 35 years) have a risk of 14.22 greater than the age not at risk (20-35 years). Mothers with parity at risk (1 and >3) had a 3.010 greater risk of primary postpartum hemorrhage than mothers with parity at no risk (2 and 3). This study concluded that there is a relationship between age and parity with the incidence of primary postpartum hemorrhage.

Disparities in Incidences of Cesarean Section Among Women With Gestational Diabetes Mellitus in the United States.

BackgroundIn this study, we explored the interaction between women’s race/ethnicity and insurance type and determined how these interactions affect the incidences of cesarean section (CS) among women with gestational diabetes mellitus (GDM).MethodologyWe utilized the National Inpatient Sample (NIS) database from January 2000 to September 2015 to conduct a retrospective analysis of all GDM-associated hospitalizations. We then explored the interaction between race/ethnicity and insurance types and determined how these interactions affect the incidences of CS among GDM patients, controlling for traditional risk factors for CS and patients’ sociodemographics. Subsequently, we determined the risk of primary postpartum hemorrhage (PPH) in the CS group and a propensity score-matched control group who had vaginal deliveries.ResultsThere were 932,431 deliveries diagnosed with GDM in the NIS database from January 2000 to September 2015. The mean age of the study population was 30.6 ± 5.9 years, 44.5% were white, 14.0% were black, and 26.7% were Hispanic. The CS rate was 40.5%. After controlling for covariates, women who utilized private insurance had the highest CS rate across the different races/ethnicities; white (odds ratio (OR) = 1.21 (1.17-1.25)) blacks (OR = 1.33 (1.26-1.41)), and Hispanic (OR = 1.12 (1.06-1.18)). CS patients were less likely to develop PPH compared to their matched controls with vaginal deliveries (OR = 0.67 (0.63-0.71)).ConclusionsPrivate insurance is associated with higher incidences of CS among women with GDM, irrespective of race/ethnicity.

The Effect of Von Willebrand Disease on Pregnancy, Delivery, and Postpartum Period: A Retrospective Observational Study

Background and Objectives Several reports indicate that women with von Willebrand disease (VWD) are at an increased risk of bleeding and other complications during pregnancy and childbirth. The aim of this study was to investigate the effect of VWD on the course of pregnancy, childbirth, and the postpartum period. Materials and Methods This was a retrospective study that compared many variables between women with VWD (n = 26) and women without VWD (n = 297,111) who gave birth between 2002 and 2016 in Slovenia. Data were obtained from the Slovenian National Perinatal Information System. Results Women with VWD were not more likely to have a miscarriage, vaginal bleeding during pregnancy, anemia, intrauterine growth restriction, or imminent premature labor. However, women with VWD were more likely to experience childbirth trauma-related bleeding (OR, 10.7; 95% CI: 1.4, 78.9), primary postpartum hemorrhage (OR, 3.7; 95% CI: 0.9, 15.8), and require blood transfusion after childbirth (OR, 16.3; 95% CI: 2.2, 120.3). No cases of stillbirth or early neonatal death were observed in women with VWD. Conclusion Although women with VWD did not demonstrate an increased risk of vaginal bleeding during pregnancy or poor fetal outcomes, they had a higher risk of primary postpartum hemorrhage and requiring blood transfusion.

Comparative study of oxytocin versus tranexamic acid and ethamsylate in preventing primary postpartum hemorrhage in women undergoing lower-segment cesarean section

Background: Worldwide, 21% of deliveries are by elective cesarean sections (C/S) as a procedure to reduce maternal and neonatal mortality and morbidity. Blood loss during C/Ss is more than vaginal delivery. Therefore, reducing blood loss during the C/Ss is essential and challenging for anesthesiologists and obstetricians. This study aimed to assess the efficacy of intravenous oxytocin versus tranexamic acid + ethamsylate (TXA + Eth) in reducing blood loss in pregnant women at high risk of primary PPH undergoing elective lower-segment cesarean section. Materials and Methods: A single-center, prospective, randomized, and double-blind study was started after obtaining institutional ethical approval. The study involved women undergoing elective C/Ss at full-term pregnancy at high risk for primary postpartum hemorrhage (PPH) at the SAMSRI between September 2021 and March 2022. The study participants received an infusion of either oxytocin 10 International Unit or TXA 1 g + Eth 250 mg before the skin incision. The primary outcome was the blood loss calculation, alongside hemoglobin and hematocrit before and after the surgery. The secondary outcome was the percentage of participants who progressed into primary PPH and required blood transfusion. Results: Analyses included 132 women in each group, and results showed that TXA + Eth significantly reduced bleeding during and after cesarean section in pregnant women at high risk for PPH. In oxytocin and TXA + Eth groups, postoperative blood loss was (613.7 ± 123.7 and 406.2 ± 116.5) ml, respectively, P < 0.001. The duration of surgery in oxytocin and TXA + Eth groups were (48.5 ± 9.3) and (44.3 ± 9.8) minutes, respectively (P = 0.287). The blood transfusion requirement in the oxytocin and TXA + Eth groups were 10.69% and 0.75%, respectively (P = 0.023). The PPH in the oxytocin and TXA + Eth groups were 2.30% and 0%, respectively (p < 0.017). Pre- and postoperative hemoglobin and hematocrit values at 24 h after cesarean section in the oxytocin (10.78 and 8.29) and (32.23 + 25.10) and TXA + Eth groups were (11.07 and 10.02) and (33.20 and 30.73), respectively (P < 0.001). Conclusion: The use of TXA and Eth is safe and more effective than oxytocin in minimizing blood loss, and the demand for blood transfusion after cesarean section.

Comparison of Oral Misoprostol with Intravenous Oxtocin in the In the Management of the Third Stage of Labour: A Randomized Controlled Trial

Background: Postpartum haemorrhage (PPH) is defined as the loss of 500ml of blood or more from the vagina following vaginal birth or 1000ml following caesarean delivery. The third stage of labour is the period between the delivery of the baby and the delivery of the placenta and membranes and its management is central to the prevention of postpartum haemorrhage (PPH). There are basically two methods of managing the third stage of labour namely active and physiological/expectant. The active management includes the use of uterotonic drugs immediately following delivery of the fetus, early cord clamping and cutting, and controlled umbilical cord traction. The active management of the third stage of labour with oxytocin has been found to reduce the risk of primary PPH significantly; however, the problem of inadequate supply of electricity, high cost and paucity of skilled manpower to administer it has negatively affected its use in developing countries and has made the search for a more suitable alternative expedient. Misoprostol on the other hand has been found to have good uterotonic activities, affordable and stable at room temperature; making its use in the resource-poor countries a veritable alternative. Aims: To determine if there is any difference in the efficacy of intravenous oxytocin over oral misoprostol in the management of the third stage of labour Study Design: This was a prospective, double-blinded, randomized trial of uncomplicated pregnant women who had vaginal delivery in the labour ward of the ESUT Teaching Hospital, Enugu. Sample Size: Two hundred (200) pregnant women who satisfied the inclusion criteria were recruited into the study with each arm accommodating 100 participants. Methodology: The eligible women were recruited on presentation to the labour ward after giving their consent. They were randomly allocated into 2 groups: A and B. Group A received 2 tablets (400µg) of oral misoprostol and 1mililtre(ml) of sterile water intravenously while group B received 2 tablets of white vitamin c and 1ml (10iu) of intravenous oxytocin immediately after cord clamping and cutting following the delivery of the baby. The patient was observed for significant clinical vaginal bleeding or PPH. For the purposes of this study, any bleeding/PPH accompanied with a greater than 30% rise in baseline pulse rate qualified for transfusion. A proforma was used to record the necessary data Statistical Analysis: Data collected from the study was analyzed with the Statistical Package for Social Sciences (SPSS) computer software version 20.0 for Windows. Statistical analysis was both descriptive and inferential at 95% confidence level. The socio-demographic variables were used to categorize the data and this was subjected to comparative statistical evaluation to yield frequencies, means, and percentages. Test of significance between class differences was by Pearson’s Chi-square test for categorical variables and student’s t-test for continuous variables. All P&lt;0.05 at one degree of freedom (df=1) was considered statistically significant. Results and Conclusion: There was no significant difference in the number of women that received blood transfusion, the amount of blood transfused and the need for additional oxytocics on both arms of the study. However, there was a significant difference in the occurrence of side-effects with shivering and vomiting being prominent in the misoprostol and oxytocin arms respectively. Conclusion: There was no difference in the efficacy of oxytocin over misoprostol in the management of the 3rd stage of labour. We therefore, recommend that misoprostol can be adopted as an alternative/substitute to oxytocin in the management of the third stage of labour especially in developing countries.

Assessment of von Willebrand disease and pregnancy outcomes at regional Australian hospitals.

von Willebrand disease (vWD) is a heterogeneous hereditary bleeding disorder and is associated with risk of primary postpartum haemorrhage (PPH). An observational study at a tertiary referral centre in Australia of 16 women with 23 deliveries with a median age of 27.5years (range, 21-39; IQR=9). Median gestational age at delivery was 39weeks (range, 35-41; IQR=1.1). All cases had type 1 vWD, apart from one case with type 2. Patients were managed in combined obstetrics and haematology clinics. PPH occurred in ten deliveries (44%). Intravenous desmopressin was administered in 6 cases, and IV human vWF was administered in 4 cases. Two cases with mild vWD had received oral tranexamic acid. The median Apgar score at 1 and 5min was 9 (IQR=1.0), while the median Apgar score at 10min was 10.0 (IQR=0.0). One case required transfusion of blood products postdelivery. There were no other significant complications observed. vWD was associated with a high incidence of primary PPH. Individualised treatment to restore haemostasis, according to the severity of the disease, could achieve as possible, normal haemostasis with favourable outcomes for both mothers and their infants. Further studies to confirm our findings are warranted.

Efficacy of balloon tamponade in control of primary postpartum haemorrhage (PPH).

Objectives: Primary postpartum haemorrhage (PPH) refers to excessive blood loss (&gt;500ml) during 3rd stage of labour in the 1st 24 hours after delivery, thereafter, significant bleeding is referred to as secondary PPH. Its incidence is about 5% of deliveries. This study was conducted to note the efficacy of balloon tamponade in the control of PPH. Study Design: Experimental study. Setting: Department of Obstetrics and Gyne, Civil Hospital, Bahawalpur. Period: 1st January 2018 to 30th June 2018. Material &amp; Methods: A total of 80 cases with Primary PPH after vaginal delivery were considered for this study. Cases with Bleeding disorders, ruptured uterus, retained products of conception, genital tract injuries or on anticoagulant therapy were excluded. All patients received balloon tamponade. Failure of control of bleeding was observed amongst all the patients. Results: Mean age, gestational age and parity were 24.54 years, 37.88 weeks and 3.17 respectively. Mean estimated blood loss was found to be 1125+320 ml, SBP 90.10+20.6 mmHg, DBP 57+7.2 mmHg and pulse 106+9.2 bpm. As far efficacy of balloon tamponade is concerned, it was noted in 71 (88.8%) women. When women were analyzed for maternal age, gestational age and parity status, no significant difference was found (P value &gt; 0.05). Conclusion: Balloon tamponade has good efficacy (88.8%) in controlling PPH. Its ease of use in cases at increased risk of PPH makes it a suitable option.

Postpartum Hemorrhage Outcomes in Women with Mild Factor XI Deficiency

Introduction: Factor XI (FXI) deficiency is a rare bleeding disorder with a prevalence of approximately one in one million in the general population but more prevalent in the Ashkenazi Jewish community, in whom 10% are heterozygous with mild deficiencies. An ever increasing number of women are referred to hematology specialists without a clear bleeding history but a mild FXI deficiency identified initially through genetic panel testing. For instance, direct-to-consumer genetic testing has become commonplace with certain platforms such as 23andMe receiving FDA authorization to specifically include genetic testing for the most common FXI polymorphisms (i.e. F283L, E117X, and IVS14+1G&amp;gt;A). Unlike other inherited bleeding disorders, FXI levels do not reliably correlate with bleeding severity. There is limited data to guide the appropriate management of mild FXI deficiency during delivery. Considering postpartum hemorrhage accounts for approximately 10% of maternal mortality, we evaluated delivery outcomes among women with mild factor XI deficiency. Methods We performed a matched, retrospective, case control single-institution analyses. Pregnant women were identified with mild factor XI deficiency with levels between 20-70%. The control population consisted of 200 women undergoing deliveries between 2016 and 2018 identified by successive medical record numbering. Primary postpartum hemorrhage (PPH) was defined as estimated blood loss (EBL) &amp;gt; 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after delivery. Results Among the 40 FXI deficient women there were 71 deliveries, and outcomes were compared with 200 controls deliveries. A similar percentage of deliveries in the FXI deficient women and controls were vaginal (63% versus 63%, P=1.0). The groups were well matched for age and number of primigravid deliveries. The median estimated blood loss were the same FXI and controls for vaginal deliveries (300 mL for both groups) and caesarean deliveries (800 mL for both groups). There were no PPH recorded among the 45 vaginal deliveries in women with factor XI deficiency compared with one of 125 deliveries in the control cohort. In contrast, women with mild factor XI deficiency undergoing cesarean delivery were approximately 2-fold more likely to develop PPH relative to controls (odds ratio 2.73, 95% CI 1.02-7.26). The overall rates of PPH among those FXI women who underwent cesarean delivery was 38.4% (10 of 26 deliveries) compared with 18.7% (14 of 75 deliveries, p=0.04). No women in the FXI deficient cohort required RBC transfusions, while three women in the control cohort required red cell transfusions. Prior history of hemorrhage was the best predictor of PPH following cesarean delivery. The majority of women who developed PPH following caesarean delivery had a prior history of hemorrhage (7 of 10). Only two of the women with PPH received prophylactic measures prior to delivery. Among the women 16 caesarean deliveries in the FXI deficiency group without PPH, significantly fewer had a history of bleeding (2 of 16, p=0.009). Conclusions: In this case control study, we did not observe any cases of PPH among women with FXI deficiency who underwent a vaginal delivery but noted a greater than 2-fold increase in PPH among those women who underwent a cesarean delivery. In those women with a bleeding history the risk of PPH following cesarean section the risk of PPH was nearly 10-fold higher compared to women without a history of hemorrhage supporting the role for prophylactic measures in this high-risk group. Disclosures Zwicker: Portola: Consultancy; Daiichi: Consultancy; Incyte: Research Funding; Seattle Genetics: Consultancy; Bayer: Consultancy; Parexel: Consultancy; Quercegen: Research Funding.

Active versus expectant management for women in the third stage of labour.

Active versus expectant management for women in the third stage of labour.

Comparison of the effect of carbetocin versus oxytocin during cesarean section in women with high risk of postpartum hemorrhage

Objectives To compare the hemodynamic effects of oxytocin and carbetocin and to assess the efficacy of these two drugs in terms of blood loss and the additional uterotonic needed in cesarean section in women with high risk of primary postpartum hemorrhage (PPH). Background Prevention of PPH is a major issue owing to its effect on maternal morbidity and mortality. Although oxytocin is the most widely accepted uterotonic agent, carbetocin can be given as an intravenous bolus instead of continuous oxytocin infusion. Patients and methods This is a prospective, randomized controlled study conducted from March 2016 and October 2017 within the Department of Obstetrics and Gynecology in Menoufia University Hospitals. The study included 100 pregnant women with high risk of PPH; women were divided randomly into group A, which received oxytocin infusion of 20 international units, and group B, which received 100 μg carbetocin as an intravenous bolus. Results Regarding the hemodynamic effects, there was a significant lower reduction in blood pressure within the oxytocin group. Significantly more women needed additional uterotonic agents in the oxytocin group. Uterine fundal level was significantly below 2 cm from the umbilical point in carbetocin group. The mean cost in oxytocin group is lower with a highly significant difference. Conclusion Single injection of carbetocin has more safe hemodynamic profile and less need of uterotonics, but the introduction of oxytocin appears to provide improved clinical outcomes along with cost savings.

Maternal obesity and the risk of primary postpartum haemorrhage. 10 year retrospective study in an Australian regional obstetric population

Maternal obesity and the risk of primary postpartum haemorrhage. 10 year retrospective study in an Australian regional obstetric population

Does skin-to-skin contact and breast feeding at birth affect the rate of primary postpartum haemorrhage: Results of a cohort study

Objectiveto examine the effect of skin-to-skin contact and breast feeding within 30 minutes of birth, on the rate of primary postpartum haemorrhage (PPH) in a sample of women who were at mixed-risk of PPH. Designretrospective cohort study. Settingtwo obstetric units plus a freestanding birth centre in New South Wales (NSW) Australia. Participantsafter excluding women (n=3671) who did not have opportunity for skin to skin and breast feeding, I analysed birth records (n=7548) for the calendar years 2009 and 2010. Records were accessed via the electronic data base ObstetriX. Interventionskin to skin contact and breast feeding within 30 minutes of birth. Measuresoutcome measure was PPH i.e. blood loss of 500ml or more estimated at birth. Data was analysed using descriptive statistics and logistic regression (unadjusted and adjusted). Findingsafter adjustment for covariates, women who did not have skin to skin and breast feeding were almost twice as likely to have a PPH compared to women who had both skin to skin contact and breast feeding (aOR 0.55, 95% CI 0.41–0.72, p<0.001). This apparently protective effect of skin to skin and breast feeding on PPH held true in sub-analyses for both women at ‘lower’ (OR 0.22, 95% CI 0.17–0.30, p<0.001) and ‘higher’ risk (OR 0.37 95% CI 0.24–0.57), p<0.001. Key conclusions and implication for practicethis study suggests that skin to skin contact and breastfeeding immediately after birth may be effective in reducing PPH rates for women at any level of risk of PPH. The greatest effect was for women at lower risk of PPH. The explanation is that pronurturance promotes endogenous oxytocin release. Childbearing women should be educated and supported to have pronurturance during third and fourth stages of labour.

Primary postpartum haemorrhage in federal medical centre, Owerri, Nigeria: A six year review

Primary postpartum hemorrhage is an obstetric emergency and is a leading cause of maternal morbidity and mortality in developing countries. It a condition that requires vigilance, prompt and appropriate management. To determine the prevalence and determinants of primary post partum haemorrhage in Federal Medical Centre Owerri. All cases of all cases of primary post partum haemorrhage managed at FMC Owerri. The case notes were retrieved from the hospital's Records Department and information on socio-demographic characteristics, nature of labour (spontaneous, induced or augmented) duration of labour and mode of delivery and birth weight, estimated blood loss and the need for blood transfusion were obtained. Out of a total of 4889 deliveries, 3725 (76.2%) women had vaginal delivery while 1,164 (23.8%) women had caesarean section. Out of these deliveries, 166 women had Primary Post Partum Hemorrhage (PPH), giving a prevalence of 3.4%. Multiparous women had higher prevalence compared to nulliparas: 88 (48.3%) versus 37 (22.2%) respectively. The commonest cause of primary PPH was uterine atony 72 (43.4%) and cervical laceration was the least cause constituting 13 (7.7%). Caesarean section was associated with higher prevalence of post partum haemorrhage, 94 (56.4%). Duration of second and third stages of labour lasting more than 30 minutes and 10 minutes respective were associated with higher risk of primary PPH:82 (49.5%) and 87 (52.3) respectively. Supervised antenatal care, active management of labour and emergency obstetric care, if employed religiously will drastically reduce post partum haemorrhage and thus its associated complications.

Reducing the risk of postpartum haemorrhage in paramedic practice

Primary postpartum haemorrhage is the most common form of obstetric haemorrhage. Poor recognition and treatment of this condition has been linked to cases of mortality in recent years. Greater choice over birth settings for mothers and a national shortage of midwives are likely to result in more frequent exposure to maternity cases for paramedics in future years. Active management of the third stage of labour reduces the risks of primary postpartum haemorrhage and shortens the length of the third stage of labour. UK ambulance service guidelines are currently based upon physiological management of the third stage of labour, so in the absence of a midwife, paramedics cannot actively manage the third stage. Paramedic training has moved to higher education university programmes in recent years and undergraduate paramedic students receive additional training about the management of obstetric emergencies. This article discusses current clinical practice and recommends that paramedics adopt active management of the third stage of labour, in order to reduce the risk of primary postpartum haemorrhage. In addition, the author asks whether current paramedic practice is effective in treating primary postpartum haemorrhage within the pre-hospital setting, when a midwife is not present at the scene.

Analysis of 348 consecutive cases of primary postpartum haemorrhage at a tertiary hospital in Nigeria

A retrospective analysis of 348 cases of primary postpartum haemorrhage (PPH) that occurred at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between 1 January 1993 and 31 December 1996 was carried out. The incidence of PPH was 4.5%. Booking status of the patients had no relation with occurrence of PPH in this study (P > 0.05). The risk of PPH in advanced maternal age (over 35 years) and grandmultiparity (para 5 and over) was twofold higher than low maternal age (< 25 years) and low parity (para 0–1), P < 0.05, respectively. The incidence of PPH was higher in deliveries conducted by midwives than doctors (P < 0.05). Anaemic patients (PCV ⩽ 30%) were more at risk than non-anaemic patients (P < 0.05). Uterine atony, 183 (53.8%) was the most common cause of PPH and a combination of uterotonic agents and uterine massage were effective in controlling PPH in 171 (49.1%) of the cases. Seven (2.0%) patients required hysterectomy. One-third of the patients had a blood transfusion. To reduce the incidence of PPH, we recommend that doctors should supervise the delivery of parturients at risk of PPH and advocate health education against high parity.

A prospective randomised trial to compare the efficacy and safety of Hemabate and Syntometrine for the prevention of primary postpartum haemorrhage

In a prospective, open-label, assessor-blind, randomised parallel group study the efficacy and safety of Hemabate (Pharmacia-Upjohn Pharmaceuticals, Milton Keynes, Buckinghamshire) an analogue of 15-methyl-prostaglandin (PGF2α) analogue was compared with Syntometrine (Alliance Pharmaceuticals, Chippenham, Wilts) the standard combination of ergometrine and syntocinon used for the active management of the third stage of labour and the prevention of primary postpartum haemorrhage (PPH). The study was set in a district general hospital with approximately 4,000 deliveries annually. The study was discontinued at the time of the interim analysis because of unacceptable gastrointestinal side effects. At the time of the interim analysis, a total of 529 women had completed the study with 263 randomised to receive PGF2α and 266 to receive ergometrine and syntocinon. In a pre-specified subgroup analysis, women delivered vaginally were further subdivided into those considered to be at high or low risk of primary PPH. The measured blood loss and incidence of PPH was similar in both treatment groups whether delivered by caesarean section or vaginally independent of whether women were considered to be at high or low risk. Adverse gastrointestinal events were recorded more often in the Hemabate group. The most common symptom was diarrhoea which occurred in 21% of women who received Hemabate compared to only 0.8% of Syntometrine users. PGF2α is as effective as Syntometrine in the prophylaxis of primary PPH in all groups studied but there was a statistically significantly increased risk of diarrhoea among users of PGF2α.

Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial

This study tested the hypotheses that active management of the third stage of labour lowers the rates of primary postpartum haemorrhage (PPH) and longer-term consequences compared with expectant management, in a setting where both managements are commonly practised, and that this effect is not mediated by maternal posture. 1512 women judged to be at low risk of PPH (blood loss >500 mL) were randomly assigned active management of the third stage (prophylactic oxytocic within 2 min of baby's birth, immediate cutting and clamping of the cord, delivery of placenta by controlled cord traction or maternal effort) or expectant management (no prophylactic oxytocic, no cord clamping until pulsation ceased, delivery of placenta by maternal effort). Women were also randomly assigned upright or supine posture. Analyses were by intention to treat. The rate of PPH was significantly lower with active than with expectant management (51 [6.8%] of 748 vs 126 [16.5%] of 764; relative risk 2.42 [95% CI 1.78-3.30], p<0.0001). Posture had no effect on this risk (upright 92 [12%] of 755 vs supine 85 [11%] of 757). Objective measures of blood loss confirmed the results. There was more vomiting in the active group but no other important differences were detected. Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.

Obstetric management in von Willebrand's disease: a report of 24 pregnancies and a reivesw of the literature.

The case records of 13 patients (24 pregnancies) with von Willebrand's disease (vWD) were studies rettospectively. The overall incidence of primary and secondary post-partum haemorrhage (PPH) was 15.8% and 25% respectively, all primary PPH occurring in tyre 2 discase (3/14 deliveries, 21.4%). The risk of primary PPH in type 2 patients who did not receive prophylactic factor VIII was 37.5% (3/8 deliveries). Factor VIII coagulant activity (VIII:C) and von Willebrand factor antigen (vWF:Ag) rose above bascline values by a factor of at least 1.5 during the pregnancy in most case. More severely affected patients were less likely to benefit significatntly. A baseline VIII:C of <15 iu/dl (4/14 cases) was predictive of a third trimester level of <15 iu/dl. Improvements in the von Willebrand factor activity were less marked. The baseline von Willebrand factor activity was <15 iu/dl in all patients with serial data, none of whom achieved a third-trimester von Willebrand factor activity of >50 iu/dl. The bleeding times were unaltered significantly in all but one of the cases, reflecting a general failure of the primary haemostatic defect to improve with pregnancy. The findings demonstrate that coagulation parameters do not universally improve in pregnancy in vWD, especially when preconception levels are low. The risk of primary PPH is generally higher in type 2 diseases. The level of factor VIII:C is not a good predictor of the risk of primary PPH in type 2 patients. Secondary PPH is a significatnt risk in both type 1 and type 2 patients.