Uso de uterotônicos no terceiro período do parto em uma maternidade da Zona da Mata Mineira / Uso de uterotónicos en el tercer período de parto en una maternidad en la Región de Mata Mineira / Use of uterotonics in the third stage of labor in a maternity in the mata mineira area

RESUMO OBJETIVO: avaliar o uso de uterotônico em parturientes primíparas durante o terceiro período de trabalho de parto, segundo via de nascimento e fatores assistenciais associados, em uma maternidade de um município Zona da Mata Mineira. MÉTODO: estudo transversal, descritivo e analítico, com 222 mulheres. A coleta de dados ocorreu por meio de entrevistas. A análise descritiva foi realizada mediante frequências relativas e absolutas. O teste qui-quadrado de Pearson foi utilizado para identificar as diferenças estatísticas relacionadas ao uso do uterotônico, tendo em vista as características sociodemográficas e a assistência obstétrica. Modelos de regressão de Poisson foram utilizados para estimar as razões de prevalência bruta e ajustada. RESULTADO: mais de 80% das puérperas receberam uterotônico independentemente da via de administração. Após ajustes por características sociodemográficas, identificou-se que: não estar em trabalho de parto na internação; ter tido parto normal; amamentar na sala de parto; ter acompanhante na sala de parto; ter contato pele a pele; e receber massagem para extração da placenta foram condições associados ao uso do uterotônico intramuscular. Evidenciou-se que: ter sido submetida à cesariana; não amamentar na sala de parto; não receber contato pele a pele; e não ser submetida à massagem para extração da placenta associaram-se ao uso intravenoso. CONCLUSÃO: concluiu-se que fatores da assistência obstétrica estão associados à aplicação de uterotônico em parturientes primíparas durante o terceiro período de trabalho de parto, independentemente da via de administração, e que seu uso é uma medida realizada para o manejo do terceiro período do trabalho de parto.

RESUMEN OBJETIVO: evaluar el uso de uterotónicos en parturientas primíparas durante el tercer período de trabajo de parto, según la vía del parto y los factores asistenciales asociados al mismo, en una maternidad de un municipio de la región de Mata Mineira. MÉTODO: estudio transversal, descriptivo y analítico con 222 mujeres. La recogida de datos se realizó mediante entrevistas. El análisis descriptivo se realizó mediante frecuencias relativas y absolutas. Se utilizó la prueba de chi-cuadrado de Pearson para identificar diferencias estadísticas relacionadas con el uso de uterotónicos, dadas las características sociodemográficas y la atención obstétrica. Se utilizaron modelos de regresión de Poisson para estimar las razones de prevalencia brutas y ajustadas. RESULTADO: más del 80% de las puérperas recibieron uterotónicos independientemente de la vía de administración. Despés de ajustar las características sociodemográficas, se identificó que: no estar en trabajo de parto durante la hospitalización; haber tenido un parto normal; amamantar en la sala de partos; la presencia de un acompañante en la sala de partos; el contacto piel a piel y los masajes para extraer la placenta fueron condiciones asociadas al uso de uterotónicos intramusculares. Se evidenció que: haber sido sometida a cesárea; no amamantar en la sala de partos; no tener contacto piel a piel y no someterse a masajes para extraer la placenta se asociaron al uso intravenoso. CONCLUSIÓN: se observó que durante la atención obstétrica hay factores asociados a la aplicación de uterotónicos en parturientas primíparas durante el tercer período del trabajo de parto, independientemente de la vía de administración, y que su aplicación es una maniobra para el control del tercer período del parto.

ABSTRACT OBJECTIVE: to evaluate the use of uterotonics in primiparous parturient during the third period of labor, according to the route of birth and associated care factors, in a maternity hospital in a municipality in the Zona da Mata Mineira. METHOD: cross-sectional, descriptive, and analytical study with 222 women. Data collection took place through interviews. The descriptive analysis was performed using relative and absolute frequencies. Pearson's chi-square test was used to identify statistical differences related to the use of uterotonics, in view of sociodemographic characteristics and obstetric care. Poisson regression models were used to estimate the crude and adjusted prevalence ratios. RESULT: more than 80% of the puerperal women received uterotonic regardless of the route of administration. After adjusting for sociodemographic characteristics, it was identified that: not being in labor during hospitalization; having had a normal birth; breastfeed in the delivery room; having a companion in the delivery room; having skin to skin contact; and receiving a massage to extract the placenta were conditions associated with the use of intramuscular uterotonics. It was evidenced that: having been submitted to cesarean section; not breastfeeding in the delivery room; not receiving skin-toskin contact; and not being subjected to massage to extract the placenta were associated with intravenous use. CONCLUSION: it was concluded that factors of obstetric care are associated with the application of uterotonic in primiparous parturient during the third period of labor, regardless of the route of administration, and that its use is a measure performed for the management of the third period of labor.

Tecnologias de cuidado para prevenção e controle da hemorragia no terceiro estágio do parto: revisão sistemática / Care technologies to prevent and control hemorrhage in the third stage of labor: a systematic review / Tecnologías de cuidado para prevención y control de la hemorragia en la tercera etapa del parto: revisión sistemática

Objetivo identificar evidências acerca das contribuições das tecnologias de cuidado usadas para prevenção e controle da hemorragia no terceiro estágio do parto. Método revisão sistemática com busca em bases de dados. Dois investigadores selecionaram os textos de forma independente na primeira etapa e, na segunda, em reunião de conciliação. Para avaliação da concordância, aplicou-se o coeficiente Kappa; para avaliação do risco de viés e classificação dos níveis de evidência, adotou-se o Grading of Recommendations, Assessment, Development and Evaluation. Resultados incluíram-se 42 artigos; desses, 34 classificados como tecnologias de produto, sendo a maioria produtos farmacológicos; dois referentes ao uso do saco plástico transparente para a coleta de sangue e contribuição do intervalo de nascimento e dos cuidados pré-natais. Os oito artigos classificados como tecnologias de processo se referiam a manejo ativo do terceiro estágio do parto, tração controlada de cordão, massagem uterina e intervenções educacionais. Conclusão as tecnologias de produto e de processo apresentaram evidência alta e moderada confirmada em 61,90% dos artigos. Os níveis de evidência demonstram contribuições das tecnologias para prevenção e controle da hemorragia. Na prática clínica, o enfermeiro deve oferecer cuidados à mulher fundamentados em evidências científicas e construir protocolos sobre as ações de cuidado da enfermagem.

Objective to identify evidence concerning the contribution of health technologies used to prevent and control hemorrhaging in the third stage of labor. Method systematic review with database searches. First, two researchers independently selected the papers and, at a second point in time, held a reconciliation meeting. The Kappa coefficient was used to assess agreement, while the Grading of Recommendations, Assessment, Development and Evaluation was adopted to assess risk of bias and classify level of evidence. Results in this review, 42 papers were included, 34 of which addressed product technologies, most referred to pharmacological products, while two papers addressed the use of blood transparent plastic bags collector and the contribution of birth spacing and prenatal care. The eight papers addressing process technologies included the active management of the third stage of labor, controlled cord traction, uterine massage, and educational interventions. Conclusion product and process technologies presented high and moderate evidence confirmed in 61.90% of the papers. The levels of evidence confirm the contribution of technologies to prevent and control hemorrhaging. Clinical nurses should provide scientific-based care and develop protocols addressing nursing care actions.

Objetivo identificar las evidencias acerca de las contribuciones de las tecnologías de cuidado usadas para la prevención y el control de la hemorragia en la tercera etapa del parto. Método revisión sistemática con búsqueda en bases de datos. Dos investigadores seleccionaron los textos, de forma independiente, en la primera etapa; y, en la segunda en reunión de conciliación. Para evaluación de la concordancia fue aplicado el coeficiente Kappa; para evaluación del riesgo de sesgo y clasificación de los niveles de evidencia, se adoptó el Grading of Recommendations, Assessment, Development and Evaluation. Resultados fueron incluidos 42 artículos; de estos, 34 fueron clasificados como: tecnologías de producto (siendo la mayoría productos farmacológicos), dos referentes a la contribución del saco plástico transparente recolector de sangre y del intervalo de nacimiento y de los cuidados prenatales. Los ocho artículos clasificados como tecnologías de proceso se referían al manejo activo de la tercera etapa del parto, a la tracción controlada del cordón, al masaje uterino y a intervenciones educacionales. Conclusión las tecnologías de producto y de proceso presentaron evidencia alta y moderada, lo que fue confirmado en 61,90% de los artículos. Los niveles de evidencia demuestran las contribuciones de las tecnologías para la prevención y el control de la hemorragia. En la práctica clínica, el enfermero debe ofrecer cuidados a la mujer fundamentados en evidencias científicas y construir protocolos sobre las acciones de cuidado de la enfermería.

Ventajas y desventajas del parto vertical en contraste con el parto horizontal: una revisión de la literatura / Advantages and Disadvantages of Upright Position in Contrast to Supine Position: A Review of Literature / Vantagens e desvantagens do parto vertical em contraste com o parto horizontal: uma revisão da literatura

El parto vertical es una práctica ancestral que puede ofrecer ventajas para la madre y su recién nacido. Objetivo: integrar los hallazgos que informa la literatura sobre ventajas y desventajas del parto vertical en contraste con el parto horizontal. Método: revisión integrativa de la literatura publicada en el periodo 2005-2015. Se seleccionaron quince estudios, luego de un proceso de búsqueda y crítica de literatura. Los datos se extrajeron, analizaron y compararon con apoyo en la herramienta ATLAS.ti, versión 7.0. Resultados: esta revisión integró los hallazgos de los artículos seleccionados, de los cuales emergieron doce subtemas que se clasificaron en los dos temas planteados: ventajas y desventajas del parto vertical en contraste al parto horizontal. Se encontraron las siguientes ventajas: disminución en el tiempo en la segunda etapa, menos desgarros de tercer y cuarto grado, menor edema vulvar, menor necesidad de instrumentación, menor necesidad de episiotomía, menos casos de presión del fondo uterino, menos casos de placenta retenida, menor dolor, mejor percepción de la materna y mejores resultados fetales y neonatales. Como desventajas se encontraron: mayor sangrado y dificultad de mantener la posición. Conclusión: esta revisión encontró que el parto en posición vertical tiene más ventajas en contraste a la posición horizontal, lo que beneficia fisiopsicológicamente tanto a la madre como al neonato.

Upright position is an ancestral practice which can offer advantages to the mother and her newborn. Objective: To intégrate findings from literature on advantages and disadvantages of upright position in contrast to supine position. Methodology: Integrative review of literature published in the period 2005-2015. Fourteen studies were selected after a search process and review of literature. Data were extracted, analyzed, and compared through ATLAS.ti 7.0. Outcomes: This review integrated the findings from the selected articles. Twelve subtopics were grouped into the two topics proposed: Advantages and disadvantages of upright position in contrast to supine position. Among the advantages of this review are: Shorter duration of the second stage of labor, less third- and fourth-degree tears, less vulvar edema, less need for instrumentation, less need for episiotomies, less cases of uterine fundal pressure, less cases of retained placenta, less pain, better mother's perception, and better fetal and neonatal outcomes. As disadvantage, more bleeding and difficulty in maintaining the position. Conclusión: This review found that upright position birth has more advantages in contrast to supine position, thus benefitingphysio-psychologically both to the mother and her newborn.

O parto vertical é uma prática ancestral que pode oferecer vantagens para a mãe e seu recém-nascido. Objetivo: integrar os achados que a literatura informa sobre as vantagens e as desvantagens do parto vertical em contraste com o parto horizontal. Metodologia: revisão integrativa da literatura publicada no período 2005-2015. Foram selecionados 15 estudos, logo de um processo de busca e crítica da literatura. Os dados foram extraídos, analisados e comparados com apoio na ferramenta ATLAS.ti, versão 7.0. Resultados: esta revisão integrou os achados dos artigos selecionados dos quais surgiram 12 sub-temas que foram classificados nos dois temas estabelecidos: vantagens e desvantagens do parto vertical em contraste com o parto horizontal. Foram encontradas as seguintes vantagens: diminuição do tempo na segunda etapa, menos desgarres de terceiro e quarto grau, menor edema vulvar, menor necessidade de instrumentação, menor necessidade de episiotomia, menos casos de pressão do fundo uterino, menos casos de placenta retida, menor dor, melhor percepção da materna e melhores resultados fetais e neonatais. Como desvantagens foram encontradas: maior sangramento e dificuldade de manter a posição. Conclusão: esta revisão indicou que o parto em posição vertical possui mais vantagens comparado com a posição horizontal, beneficiando fisio-psicologicamnte tanto a mãe como o neonato.

Prophylactic use of misoprostol in management of third stage of labour and prevention of atonic uterus

To assess the prophylactic use of misoprostol in management of third stage of labour and prevention of atonic uterus, and comparing it with conventional i/v syntocinon use in third stage of labour. This quasi experimental study was conducted at department of obstetrics and gynecology unit A, Mardan Medical Complex Hospital Mardan, from May 2011 to May 2012. Two hundreds labouring females were included in the study and divided into 2 groups, a control group [100 women who received 5 units syntocinon] and a study group [100 women who received 800 ug rectal misoprostol] immediately after delivery of the baby. Duration of third stage of labour, blood loss after delivery were recorded and compared between the two groups. Side effects of both drugs were also noted. There was not any significant difference in blood loss and duration of third stage of labour in both groups. The frequency of atonic PPH [postpartum hemorrhage] in study and control groups was also similar. Misoprostol can be used for the management of third stage of labour and it can reduce atonic PPH. It efficacy and safety is similar to that of syntocinone

Active versus conservative management of prelabour rupture of membranes at term

To compare maternal and foetal outcome of active versus conservative management of premature rupture of membranes after 37 completed weeks of pregnancy. This quasi-experimental study was carried out at Gynae unit, Lady Reading Hospital, Peshawar from September 2004 to September 2005 and included 100 patients out of which 50 were managed conservatively and 50 actively. After confirming the leakage of amniotic fluid, patients were randomized by lottery method to conservative or induced group. The patients in the group that was managed conservatively were shifted to obstetrical ward to await the onset of regular uterine activity for at least 48 hrs. After Bishops scoring, patients were induced with vaginal prostaglandin E2 tablet. Both groups received intravenous antibiotics. Total number of patients with PROM at term was 3.84%. Total cost of stay in hospital and management was greater in induced group [P. value <0.05%]. Latent time was short in induced group whereas hospital stay was prolonged in induced group. About 80% of patients in conservative group delivered by NVD as compared to 60% in induced group. Among complications mild fever and PPH were significantly [P. value <0.05] more common in conservative group. There was neither neonatal death nor stillbirth in both groups. No statistically significant difference [P. value >0.05] was observed in respect of perinatal outcome and infectious morbidity in babies. Conservative management of PROM at term should be viewed more positively for at least 48 hrs under appropriate antibiotic cover and with active management of 3[rd] stage of Labour

Primary post partum hemorrhage. An obstetric catastrophe: a review of 270 cases

To see the frequency, causes of Primary Postpartum Hemorrhage [PPH], and identify the management options and to apply them successfully for control of primary PPH. So as to reduce the maternal morbidity and mortality rate. Retrospective study. This study was conducted in Gynae Unit-IV, Bolan Medical Complex Hospital, Quetta from January 2011 to July 2012. The data was collected from the records of patients who were admitted as case of Primary PPH and developed PPH during the delivery / Cesarean section. The data was noted on predesigned Proforma which include, complete obstetrical history, abdominal and pelvic examination and relevant laboratory investigations. The maternal condition was assessed and managed according to Hospital protocol. All maternal complications were noted. The patients who were bleeding at the time of delivery due to non - obstetrical condition were excluded from study. A total 270 cases of PPH were diagnosed. Major causes of Primary PPH were uterine atony in 143 [53%] retained placenta, in 49 [18%] ruptured uterus in 43 [16%] cases. The risk factors for uterine atony were prolonged 1[st] and 2[nd] stage of labour, grand multipara and retained placental tissues. Patients were managed both medically and surgically. The major morbidities were anemia 32%, hypovolemic shock 26%, puerperal sepsis 15% and acute renal failure 5%. Primary PPH is an important cause of serious morbidity and one of the leading causes of maternal mortality in the developing and developed world. The majority of deaths are preventable by the active management of 3[rd] stage of labour followed by a logical management protocol

The Valsalva maneuver duration during labor expulsive stage: repercussions on the maternal and neonatal birth condition / Duração da manobra de Valsalva durante o período expulsivo do parto: repercussões maternas e nas condições neonatais de nascimento

OBJECTIVES: This cross-sectional study was designed to examine the effects of the Valsalva Maneuver (VM) and its duration on the acid- base equilibrium of the neonate and its maternal repercussions during the expulsive stage of labor, after standard breathing and pushing instructions were given. METHODS: A convenience sample of women with low risk pregnancy (n=33; mean age 22.5±3.7y and gestational age 38.1±1.12wks) and their newborns were studied during the expulsive stage of vaginal labor. Coaching consisted of standard recommendations for breathing including prolonged VMs coordinated with pushing. Maternal outcomes included the need for uterus fundal pressure maneuver and episiotomy, perineal trauma and posture. Neonatal outcomes included blood gases sampled from the umbilical cord, and Apgar scores. Data were analyzed with the Fisher's exact test, chi-square test, and Pearson correlation coefficient. RESULTS: None of the maternal outcomes were associated with VM duration. With respect to neonatal outcomes, increased VM duration was associated with reduced venous umbilical pH (r=-0.40; p=0.020), venous base excess (r=-0.42; p=0.014) and with arterial base excess (r=-0.36; p=0.043). Expulsive stage time was negatively associated with umbilical venous and arterial pH. CONCLUSIONS: VM duration during fetal expulsion in labor negatively affects fetal acid-base equilibrium and potentially the wellbeing of the neonate. Our results support the need to consider respiratory strategies during labor, to minimize potential risk to the mother and neonate.

OBJETIVOS: O presente estudo de corte transversal teve como objetivo avaliar os efeitos da Manobra de Valsalva (MV) e sua duração no equilíbrio ácido-básico fetal e nas repercussões maternas durante o período expulsivo do parto, após instrução respiratória padronizada. MÉTODOS: Uma amostra de conveniência em gestantes de baixo risco (n=33, média de idade 22,5±3.7 anos e idade gestacional 38.1±1.12 semanas) e seus neonatos foi avaliada durante o período expulsivo do parto vaginal. O treinamento consistiu em recomendações padronizadas para respiração, incluindo MV prolongadas associadas ao puxo. Os desfechos maternos incluíram o uso da manobra de pressão para o fundo do útero, episiotomia, trauma perineal e postura. Os desfechos neonatais incluíram análise dos gases sanguíneos do cordão umbilical e valores de Apgar. Os dados foram analisados por meio do teste exato de Fisher, teste qui-quadrado e Coeficiente de Correlação de Pearson. RESULTADOS: Nenhum dos desfechos maternos foi associado com a duração da MV. No entanto, em relação aos desfechos neonatais, o aumento da duração da MV foi associado com redução do pH venoso umbilical (r=-0,40; p=0,020) e excesso de base (r=-0.42; p=0.014) e com o excesso de base arterial (r=-0,36; p=0,043). O tempo do período expulsivo do parto foi negativamente associado com o pH venoso e arterial. CONCLUSÕES: A duração da MV durante esse período do parto interfere negativamente no equilíbrio ácido-básico fetal e potencialmente no bem-estar do neonato. Esses resultados fornecem suporte para a necessidade de os fisioterapeutas considerarem estratégias de orientações respiratórias para o puxo durante o trabalho de parto para minimizar potenciais riscos para a mãe e o neonato.

Assistência ao segundo e terceiro períodos do trabalho de parto baseada em evidências / Assistance to the second and third periods of labor based on evidence

A conduta ideal a ser adotada no segundo período do trabalho de parto deveria se basear no balanço entre a probabilidade de um parto vaginal, que deve ser maximizada, contra os riscos maternos e perinatais, que devem ser minimizados. Entretanto, ainda não existe consenso sobre o manejo do período expulsivo, a começar por sua definição e os limites estabelecidos para sua duração. Realizou-se uma revisão da literatura em busca das melhores evidências disponíveis sobre a assistência ao trabalho de parto. Foram abordados aspectos como duração do período expulsivo, posição e puxos das pacientes, monitorização fetal, necessidade de episiotomia, manobras para redução do trauma perineal, parto instrumental, acolhimento do recém-nascido e ligadura do cordão umbilical. Também foi abordada a conduta no terceiro e quarto períodos. Não há evidências suficientes para delimitar a duração ideal do período expulsivo; porém, há guidelines, como os do American College of Obstetricians and Gynecologists (ACOG), que estabelecem limites de acordo com a paridade e a utilização ou não de analgesia. Posições não supinas devem ser priorizadas durante o segundo estágio, respeitando-se a preferência das parturientes. A monitorização da frequência cardíaca fetal deve ser intermitente, reservando-se a monitorização contínua para casos especiais. O uso rotineiro de cardiotocografia intraparto associa-se com o aumento das indicações de cesariana. A episiotomia não deve ser realizada de rotina, documentando-se diversos benefícios quando o procedimento pode ser evitado: menos perda sanguínea, menor uso de suturas, menos dor e menos complicações perineais. O parto instrumental só está indicado em situações especiais, e a decisão por vácuo ou fórceps deve considerar potenciais vantagens e desvantagens, habilidade do operador e opinião da parturiente. O contato precoce pele a pele entre mãe e bebê deve ser estimulado, e o cordão umbilical deve ser ligado tardiamente...

The ideal management of the second stage of labor should be based in the balance between the vaginal delivery probability, which should be maximized, against the maternal and perinatal risks, which should be minimized. Notwithstanding, there is no consensus about second stage management, beginning with its definition and the limits for its duration. A literature review was conducted in search of the best available evidence about labor and delivery management. Several aspects were analyzed, such as maternal position, pushing, fetal monitoring, episiotomy, perineal protection, instrumental delivery, neonatal care and cord clamping. The third and fourth stages management was also considered. There is not enough evidence to establish the ideal duration of the second stage of labor, but American College of Obstetricians and Gynecologists (ACOG) guidelines suggest limits according to parity and analgesia utilization. Nonsupine positions should be considered according to the woman's preference. Fetal heart rate monitoring should be intermittent, and continuous monitoring should be used only in special conditions. Routine use of intrapartum cardiotocography is associated with the increased rate of cesarean sections. The episiotomy should not be routinely performed, and several benefits are documented when this procedure can be avoided: reduced blood loss, fewer sutures, less pain and fewer perineal complications. Instrumental delivery is indicated only in special conditions, and the decision for forceps or vacuum should take into account potential advantages and disadvantages, the operator's skills and the woman's opinion. Early skin contact between mother and baby should be encouraged and late cord clamping should be performed. The safest and most effective recommendation for the third stage management is routine use of oxytocin for preventing postpartum hemorrhage.

Active management of third stage of labour, post­partum haemorrhage and maternal death rate in the Vanga Health Zone, Province of Bandundu, Democratic Republic of the Congo

Background: Post-partum haemorrhage (PPH) is the single largest cause of maternal death worldwide and a particular burden for developing countries. In Africa, about 33.9 % of maternal deaths are due to PPH. In the Democratic Republic of the Congo (DRC), the prevalence of PPH is unknown. PPH can be prevented with active management of the third stage of labour (AMTSL). Objectives: To describe the practice of AMTSL in Vanga Health Zone and to calculate the incidence of PPH in Vanga Health Zone. Method: An intervention study with post-test-only design was conducted among health maternity wards using a data collection sheet to obtain information. All pregnant women attending Vanga Health maternity wards constituted the study population. Frequencies were determined for variables of interest. Results: From April 2007 to March 2008, 6339 deliveries took place at Vanga Health maternity wards, representing 71% of the institutional delivery rate. The number of deliveries realised with the practice of (AMTSL) were 5562; 366 cases of PPH were reported, making an incidence of 5.77%. Three cases of maternal deaths ­ two of which were related to PPH ­ were reported during the study period, which means there was a decline of 70% compared with the previous two years. Conclusion: The prevalence of PPH has been estimated to be 5.77%; PPH represents the cause of 67% of all maternal deaths. The extension of AMTSL practice, combined with the assurance of better supplies of oxytocin to enhance drug management, is strongly advised/suggested. As a number of births still take place outside the health maternity wards, the introduction of oral misoprostol could be considered a part of AMTSL for use by patients being treated by traditional midwives

A randomized comparison of rectal misoprostol with syntometrine on blood loss in the third stage of labour / Comparación randomizada del misoprostol rectal con la sintometrina en la pérdida de sangre en la tercera etapa del parto

OBJECTIVES: a) To compare the clinical effect of rectal misoprostol with intramuscular syntometrine in reducing blood loss in the third stage of labour, b) to determine the severity and incidence of side effects of both drugs and c) to measure blood loss, patient tolerance and acceptance of rectal misoprostol. METHODS: One hundred and forty parturients were randomly allocated to receive intramuscular syntometrine (syntocinon 10 IU + ergometrine 0.5 mg) or rectal misoprostol 400 ?g within five minutes of the delivery of the anterior shoulder. Blood loss was measured by the use of a plastic collection drape. Additional oxytocic therapy was instituted for uterine atony or if blood loss was in excess of one litre. RESULTS: There was no significant difference in patient demographics of each treatment group (Table 1). There was no difference in mean duration of the third stage of labour (8.4 ± 14 min vs 7.8 ± 6.6 min). The mean blood loss from those parturients receiving misoprostol (180.1 ± 120 mls) was not significantly different (p = 0.5) from those receiving syntometrine (197 ± 176.97 mls) for the active management of the third stage of labour. Treatment with syntometrine was associated with a significant elevation of post-partum systolic blood pressure compared with misoprostol treatment (mean increase 0.57 ± 18.79 mmHg vs -1.43 ± 14.17 mmHg, (mean ± SD), p < 0.04). Rectal misoprostol was well tolerated in 88.5% of participants, 11.4% reported that insertion was uncomfortable, of which 2.8% reported that they would have preferred parenteral drug administration. CONCLUSION: The clinical effect of rectal misoprostol and intramuscular syntometrine were not different at the doses used in the active management of the third stage of labour in this study. Rectal misoprostol was well tolerated by the patients and had a low side effect profile. Blood loss assessment using the blood collection drape is of invaluable benefit in resource-poor settings.

OBJETIVOS: a) Comparar el efecto clínico del misoprostol rectal con la sintometrina intramuscular en la reducción de la pérdida de sangre en la tercera etapa del parto, b) determinar la severidad y la incidencia de los efectos colaterales de ambos medicamentos, y c) medir la pérdida de sangre, la tolerancia de las pacientes y la aceptación del misoprostol rectal. MÉTODOS: Ciento cuarenta parturientas fueron elegidas de forma aleatoria para que recibieran la sintometrina intramuscular (syntocinon 10 IU + ergometrina 0.5 mg) o el misoprostol rectal 400 µg dentro de los cinco minutos de la salida del hombro anterior. Se midió la pérdida de sangre usando una bolsa plástica de recolección de sangre. Se instituyó una terapia oxitócica adicional para la atonía uterina o para el caso de que la pérdida de sangre excediera un litro. RESULTADOS: No hubo diferencia significativa en la demografía de los pacientes de cada grupo de tratamiento (tabla 1). No hubo diferencia en la duración promedio de la tercera etapa del parto (8.4 ± 14 min vs 7.8 ± 6.6 min). La pérdida promedio de sangre de las parturientas que recibieron el misoprostol (180.1 ± 120 mls) no fue significativamente diferente (p = 0.5) de las que recibieron sintometrina (197 ± 176.97 mls) para el tratamiento activo de la tercera etapa del parto. El tratamiento con sintometrina estuvo asociado con una elevación significativa de la presión sistólica postparto comparada con el tratamiento con misoprostol (aumento promedio 0.57 ± 18.79 mmHg vs -1.43 ± 14.17 mmHg, (media ± sd), p < 0.04). El misoprostol rectal fue bien tolerado por el 88.5% de las participantes, 11.4% reportaron que la inserción fue incómoda, y de ellas 2.8% reportó que hubieran preferido una administración parenteral del medicamento. CONCLUSIÓN: El efecto clínico del misoprostol rectal y el de la sintometrina intramuscular, no fueron diferentes en las dosis usadas en el tratamiento activo de la tercera etapa del parto en este estudio. El misoprostol rectal fue bien tolerado por las pacientes y tuvo un perfil de efecto colateral bajo. La evaluación de la pérdida de sangre utilizando una bolsa de recolección de sangre posee un valor inapreciable en escenarios de recursos pobres.

Study the effects of initiation of early breast suckling during the third stage of the labor on the maternal outcome

The aim of this quasi-experimental study is to examine the effect of early newborn suckling immediately after delivery on the time duration of placental separation and the amount of maternal blood loss during the 3[rd] stage of labor among Jordanian mothers. 60 mothers were recruited from labor and delivery department. Two groups were constituted: a group of 30 mothers who underwent the routine care provided by the department [control group], and a group of 30 mothers who have their newborn suckle at their breast for at least 5 minutes immediately after delivery. Time of the placental separation was counted for both groups, and the amount of blood loss through the first was measured by weighing the pad and towels used in delivery before and after using by the subjects. Chi square revealed a significant statistical differences between both group in relation to time duration of placental [P=0.031], while the amount of blood loss didn't revealed any significant differences [p.=0.442]

Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania.

The study sought to identify determinants of blood loss at childbirth and 24 hours postpartum. The study was nested in a community-based randomized trial of treatments for anaemia during pregnancy in Wete Town, Pemba Island, Zanzibar, United Republic of Tanzania. Status of anaemia during pregnancy, nutritional information, obstetric history, and socioeconomic status were assessed at enrollment during routine antenatal care. Pregnant women presented for spontaneous vaginal delivery, and nurse-midwives collected information on labour and delivery via partograph. Blood-stained sanitary napkins and pads from childbirth and 24 hours postpartum were quantified using the alkaline hematin method. Moderate-to-severe anaemia (Hb <90 g/L) at enrollment was strongly associated with blood loss at delivery and the immediate postpartum period, after adjusting for maternal covariates and variables of biological relevance to blood loss. Greater blood loss was associated (p<0.10) with duration of the first stage of labour, placental weight, receipt of oxytocin, preterm birth, and grand multiparity. The findings provide unique evidence of a previously-suspected link between maternal anaemia and greater blood loss at childbirth and postpartum. Further research is needed to confirm these findings on a larger sample of women to determine whether women with moderate-to-severe anaemia are more likely to experience postpartum haemorrhage and whether appropriate antenatal or peripartum care can affect the relationships described here.

Uterine inversion; a case report

The puerperal uterine inversion is a rare and severe complication occurring in the third stage of labour. The mechanisms are not completely known. However, extrinsic factors such as oxytocic arrests after a prolonged labour, umbilical cord traction or abdominal expression are pointed. Other intrinsic factors such as primiparity, uterine hypotonia, various placental localizations, fundic myoma or short umbilical cord were also reported. The diagnosis of the uterine inversion is mainly supported by clinical symptoms. It is based on three elements: haemorrhage, shock and a strong pelvic pain. The immediate treatment of the uterine inversion is required. It is based on a medical reanimation associated with firstly a manual reduction then surgical treatment using various techniques. We report an observation of a 25 years old grand multiparous patient with a subacute uterine inversion after delivery at home

Influence of umbilical vein oxytocin on blood loss and length of third stage of labour.

In this study the effect of intraumbilical vein oxytocin on duration and amount of blood loss in third stage of labour was studied. Pregnant women were randomized into two groups of fifty each. Study group was managed with 10 units of oxytocin diluted with 10 ml of normal saline given through umbilical vein while control group was managed with 10 units of oxytocin in 500 ml of normal saline through intravenous infusion after delivery of the baby. The mean blood loss in the third stage of labour was 143.30 ml for the control group and 151.43 ml for the study group while the duration of the third stage of labour was 6.02 and 5.42 minutes for each group. There was no significant difference in the duration and amount of blood loss between the two groups.

Hemorragia puerperal: qual melhor uterotônico para profilaxia? / Postpartum haemorrhage: what is the best uterotonic agent for prophylaxis?

A hemorragia puerperal é a principal causa isolada de morbimortalidde materna no mundo. O uso rotineiro de uterotônicos no terceiro período do parto mostrou reduzir a incidência de hemorragia puerperal em 40 a 50 porcento, mas a droga de escolha ainda é desconhecida por muitos obstetras. Foi feita uma atualização sobre as drogas comumente usadas para profilaxia da hemorragia puerperal, comparando principalmente a eficácia e os efeitos colaterais.

[Effect of amniotomy in latent and active phases on rate of cesarean section]

Increase in number of cesarean sections has caused some alarming advices by clear-sighted authorities. So, it is necessary to study the factors affecting the rate of cesarean sections. To compare the effect of amniotomy on mode of delivery in both active and latent phases. This was an analytical cohort study carried out at Kosar hospital, Qazvin [Iran] in 2003-2004. The study population consisted of all admitted women [n=305] whose labor was induced by amniotomy. The patients were further divided into two groups marked as study group [n=174] and comparison group [n=131] based on being in latent phase or active phase, respectively. Statistical analyses was performed using t-test, chi-square, and Mann-Whitney tests. Cesarean section was significantly higher [p=0.001] in study group than in comparison group, 19 [10.9%] vs. 2 [1.5%]. Non-progressive labor during the first stage of labor showed to be considerably higher in study group [p=0.001]. Also non-progressive labor during the second stage was [2.9%] in study group [1.5%] in comparison group with no statically significant difference. Abnormal fetal heart rate patterns showed no significant difference, statistically. Oxytocin administration in study group was [43.7%] and in comparison group [4.6%] showing statically a significant difference [p=0.000]. Regarding our data, cesarean section, none progressive labor during the first stage, and oxytocin administration were all higher in latent phase group than in active phase group. It sees that early amniotomy may increase the need for cesarean section

Active management of third stage of labour saves facility costs in Guatemala and Zambia.

This study calculated the net benefit of using active management of the third stage of labour (AMTSL) rather than expectant management of the third stage of labour (EMTSL) for mothers in Guatemala and Zambia. Probabilities of events were derived from opinions of experts, publicly available data, and published literature. Costs of clinical events were calculated based on national price lists, observation of resources used in AMTSL and EMTSL, and expert estimates of resources used in managing postpartum haemorrhage and its complications, including transfusion. A decision tree was used for modelling expected costs associated with AMTSL or EMTSL. The base case analysis suggested a positive net benefit from AMTSL, with a net cost-saving of US $18,000 in Guatemala (with 100 lives saved) and US $145,000 in Zambia (with 467 lives saved) for 100,000 births. Facilities have strong economic incentives to adopt AMTSL if uterotonics are available.

effect of umbilical vein oxytocin injection on third stage of labor time and postpartum hemmorrhage

Postpartum hemorrhage is one of the most important complications of delivery and is among the first five causes of maternal mortality and morbidity in developed and developing countries. To investigate the effect of umbilical vein oxytocin injection on third stage of labor and degree of postpartum hemorrhage in primiparous women. This study was down on 100 primiparas which admitted to labor department, Afzalipour hospital of in 2003 and had no history of bleeding tendency. According primiparas, age and demographic data they divided into study and control groups. Blood count was down before delivery. In study group 20 IU oxytocin in 20ml normal saline were injected in umbilical vein immediately after cord clamped. In control group 20ml normal saline were injected in umbilical vein. Placental delivery time, weight and number of used gauzes during the third stage, blood count 4 hours after delivery, sex and weight of newborn were recorded. The data was analyzed using T-student and mann-whithney tests. No statically significant difference was found when patient age, gestational age, fundal height, newborn weight and sex, HCT, Hb and placental delivery time were compared in two groups. Postpartum bleeding study group was less than in control group [141.82 +/- 91.6ml vs. 177.51 +/- 84.9cc] with a statistically significant difference [p=0.046]. The difference number of used gauzes was also significant [8.68 +/- 3.12 vs. 10.82 +/- 3.5], statistically [p=0.002]. Oxytocin injection into umbilical vein is an effective procedure to reduce the postpartum hemorrhage but has no remarkable effect on placental delivery time.

randomised controlled trial of orally and rectally administered prostaglandin E1 analogue misoprostol and standard management of the third stage of labour in the prevention of postpartum haemorrhage

Misoprostol may have the potential to prevent atonic postpartum haemorrhage, when administered orally or rectally, and may be an alternative to conventional standard oxytocic regimens for the active management of third stage of labour. To examine the efficacy and side effects of oral versus rectal misoprostol compared to standard oxytocics for the prevention of postpartum haemorrhage. A prospective randomised controlled trial. Obstetric Unit of Cairo University Hospital [Kasr El-Aini]. Five hundred low risk women with anticipated vaginal delivery. In the third stage of labour, the women were randomised to 600 micro g misoprostol given orally [Group I; n=150] rectally [Group II; n= 150] after clamping and division of the cord, or to standard oxytocic regimens of syntometrine or syntocinon [Group III; n=200] after the delivery of the anterior shoulder. The main primary outcomes were changes in haemoglobin concentration and haematocrit from before delivery to 12 hours postpartum. Secondary outcomes were the side effects of drug regimens, including, nausea, vomiting, diarrhoea, shivering and elevated temperature. The baseline demographic characteristics and labour variables were similar. There were no statistically significant differences [P>0.05] between the groups in the changes of haemoglobin concentrations and haematocrit [the main primary outcomes], the estimated blood loss, the incidence of postpartum haemorrhage, the incidence of severe postpartum haemorrhage, the proportions of women requiring blood transfusion, the length of the third stage, the incidence of prolonged third stage, the need for manual removal of the placenta, the percentage of women requiring additional oxytocic administration and the incidence of delayed haemorrhage in post natal ward. The main side effects were shivering and a rise in temperature, which occurred more frequently in the oral misoprostol group [P-overall <0.001 and 0.012 respectively]. Other side effects were mild with no differences between the groups. Oral and rectal misoprostol were comparable to standard oxytocics for the prevention of postpartum haemorrhage. Shivering and pyrexia were the main side effects of oral misoprostol. Of importance is the apparent lack of these side effects with the rectal route. Further randomised controlled trials are required to identify the best drug combinations, route, and dose for the prevention of postpartum hemorrhage