Prophylactic use of oxytocin in the third stage of labour.

BACKGROUND: Many maternal deaths across the world result from complications of the third stage of labour (when the placenta is delivered). OBJECTIVES: To examine the effect of oxytocin given prophylactically in the third stage of labour on maternal and neonatal outcomes. SEARCH STRATEGY: Relevant trials were identified in the Cochrane Collaboration Controlled Trials Register and the Pregnancy and Childbirth Review Group's Specialised Register of Controlled Trials. Date of last search: May 2001. SELECTION CRITERIA: All acceptably randomised or quasi-randomised controlled trials including pregnant women anticipating a vaginal delivery where oxytocin was given prophylactically for the third stage of labour. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed studies for relevance and methodological quality, and extracted data. Analysis was by intention to treat. Subgroup analyses were based on extent of selection bias, oxytocin in the context of active or expectant management of the third stage, and timing of administration. Results are presented as relative risks, and weighted mean difference, both with 95% confidence intervals using a fixed effects model. MAIN RESULTS: In seven trials involving over 3000 women in hospital and/or developed country settings, prophylactic oxytocin showed benefits (reduced blood loss (relative risk (RR) for blood loss > 500 ml 0.50; 95% confidence interval (CI) 0.43, 0.59) and need for therapeutic oxytocics (RR 0.50; 95% CI 0.39, 0.64).) compared to no uterotonics, although there was a non-significant trend towards more manual removal of the placenta (RR 1.17; 95% CI 0.79, 1.73) which was most marked in the expectant management subgroup, and blood transfusions (RR 1.30; 95% CI 0.50, 3.39) in the trials with more manual removals of the placenta). In six trials involving over 2800 women, there was little evidence of differential effects for oxytocin versus ergot alkaloids, except ergot alkaloids are associated with more manual removals of the placenta (RR 0.57; 95% CI 0.41, 0.79), and with the suggestion of more raised blood pressure (RR 0.53; 95% CI 0.19, 1.58) than with oxytocin. In five trials involving over 2800 women, there was little evidence of a synergistic effects of adding oxytocin to ergometrine versus ergometrine alone. For all other outcomes in the comparisons either there are no data or the number of adverse events is very small, and so definite conclusions cannot be drawn. REVIEWER'S CONCLUSIONS: There are strong suggestions of benefit for oxytocin in terms of postpartum haemorrhage, and the need for therapeutic oxytocics, but without sufficient information about other outcomes and side-effects it is difficult to be confident about the trade-offs for these benefits, especially if the risk of manual removal of the placenta may be increased. There seems little evidence in favour of ergot alkaloids alone compared to either oxytocin alone, or to Syntometrine, but the data are sparse. More trials are needed in domiciliary deliveries in developing countries, which shoulder most of the burden of third stage complications.

Active versus expectant management in the third stage of labour.

BACKGROUND: Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord. OBJECTIVES: The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by the reviewers. MAIN RESULTS: Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64.37); post partum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference -9.77 minutes, 95% confidence interval -10.00 to -9. 53). Active management was associated with an increased risk of maternal nausea (relative risk 1.95, 95% confidence interval 1.58 to 2.42), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby. REVIEWER'S CONCLUSIONS: Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

Active versus expectant management in the third stage of labour.

BACKGROUND: Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic after delivery, early cord clamping and cutting, and controlled cord traction of the umbilical cord. OBJECTIVES: The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing active and expectant management of the third stage of labour in women with singleton pregnancies whose babies were presenting head first and who were expecting a vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by the reviewers. MAIN RESULTS: Four studies were included. Three of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64. 37); post partum haemorrhage of more than 500 millilitres (odds ratio 0.34, 95% confidence interval 0.28 to 0.41); prolonged third stage of labour (weighted mean difference -3.40 minutes, 95% confidence interval -4.66 to -2.13). Active management was associated with an increased risk of maternal nausea (odds ratio 1. 95, 95% confidence interval 1.58 to 2.42), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby. REVIEWER'S CONCLUSIONS: Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active managment is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting a single baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

Prophylactic syntometrine versus oxytocin for delivery of the placenta.

BACKGROUND: The routine prophylactic administration of an oxytocic agent is an integral part of active management of the third stage of labour. These agents help prevent postpartum haemorrhage. OBJECTIVES: The objective of this review was to assess the effects of ergometrine-oxytocin (syntometrine) with oxytocin alone in reducing the risk of postpartum haemorrhage (blood loss of equal to or greater than 500 millilitres) and other maternal and neonatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Trials of oxytocic drugs (syntometrine or oxytocin) in women having the third stage of labour managed actively. DATA COLLECTION AND ANALYSIS: Eligibility, trial quality assessment and data extraction were done independently by three reviewers. Study authors were contacted for additional information. MAIN RESULTS: Six trials were included. Compared with oxytocin, ergometrine-oxytocin (syntometrine) was associated with a small reduction in the risk of postpartum haemorrhage (odds ratio 0.74, 95% confidence interval 0.65 to 0.85). This advantage was smaller but still significant when 10 international units of oxytocin was used. There was no difference seen between the groups using either five or 10 international units for blood loss equal to or greater than 1000 millilitres. Adverse effects of vomiting and hypertension were associated with the use of ergometrine-oxytocin. No significant differences were found in other maternal or neonatal outcomes. REVIEWER'S CONCLUSIONS: The use of the combination preparation syntometrine (oxytocin and ergometrine) as part of the routine active management of the third stage of labour appears to be associated with a statistically significant reduction in the risk of postpartum haemorrhage when compared to oxytocin where blood loss is less than 1000ml. No difference was seen between the groups using either five or 10 international units for blood loss equal to or greater than 1000 millilitres. This needs to be weighed against the more common adverse effects associated with the use of syntometrine.

The prevention of post partum haemorrhage: optimising routine management of the third stage of labour.

This paper concerns itself with the use of oxytocic therapy as part of the routine management of the third stage of labour. It attempts to answer three different questions: (1) do oxytocics reduce the risk of post partum haemorrhage (PPH) when used during the routine management of the third stage of labour? (2) does the clinical package of active management reduce the risk of PPH (3) which is the best oxytocic to use during routine active management of the third stage? It attempts to answer these questions by presenting the evidence from formal meta-analytical reviews of the randomised controlled trials of the pertinent intervention and by presenting the results of the two trials that were undertaken as a result of the hypotheses which were generated from the formal reviews.

Cesarean section and operative vaginal delivery in low-risk primiparous women, Western Australia.

OBJECTIVES: A major component of the increasing trend in cesarean sections in Western Australia is the rise in emergency cesarean sections in primiparous women. The aim of this study was to identify independent risk factors (particularly those known early in pregnancy) associated with operative delivery in low-risk primiparous women. METHODS: Retrospective multivariate logistic regression analyses of antenatal and perinatal data were conducted for all low-risk primiparous women entering labor spontaneously and giving birth in Western Australia in 1987 (n = 3641). RESULTS: Of the subjects, 58% had a spontaneous vaginal delivery, 8% had an emergency cesarean section, and 34% had an operative vaginal delivery. The significant independent risk factors for emergency cesarean section were older maternal age, shorter maternal height, heavier infant birthweight, and long labor. The risk factors for operative vaginal delivery were older maternal age, shorter maternal height, heavier infant birthweight, epidural anesthesia, labor/delivery complications, male infant, private patient status, and being married. CONCLUSIONS: This multivariate analysis confirms known risk factors for operative delivery in low-risk primiparous women and suggests that it may be possible to predict the likelihood of operative delivery for an individual woman by using knowledge of maternal age and height and assessment of infant birthweight.

Randomised controlled trial of oxytocin alone versus oxytocin and ergometrine in active management of third stage of labour.

OBJECTIVE: To compare intramuscular oxytocin alone and intramuscular oxytocin with ergometrine (Syntometrine) for their effect in reducing the risk of postpartum haemorrhage when both are used as part of the active management of the third stage of labour. DESIGN: Double blind, randomised controlled trial. SETTING: Two metropolitan teaching hospitals in Perth, Western Australia. SUBJECTS: All women who expected a vaginal birth during the period of the trial. Informed consent was obtained. MAIN OUTCOME MEASURES: Postpartum haemorrhage, nausea, vomiting, and increased blood pressure. RESULTS: 3497 women were randomly allocated to receive oxytocin-ergometrine (n = 1730) or oxytocin (n = 1753). Rates of postpartum haemorrhage (> or = 500 ml or > or = 1000 ml) were similar in both arms (odds ratio 0.90 (0.82); 95% confidence interval 0.75 to 1.07 (0.59 to 1.14) at 500 ml (1000 ml) threshold). The use of oxytocin-ergometrine was associated with nausea, vomiting, and increased blood pressure. CONCLUSIONS: There are few advantages but several disadvantages for the routine use of oxytoxinergometrine when prophylactic active management of the third stage of labour is practised. Further investigation of dose-response for oxytocin may be warranted.

Trends in caesarean section in Western Australia, 1980-1987.

During the 1980s the incidence of both emergency and elective caesarean section in Western Australia increased, accompanied by a decrease in that of all other delivery methods. The proportion of emergency caesarean sections increased from 5.9%. of all deliveries in 1980 to 8.2% in 1987 and that of elective sections from 5.3% to 8.7%. For each year studied less than 50% of primiparous women delivering singletons had a normal vaginal delivery. Emergency caesarean sections were more common in primiparas and at the teaching hospital and elective sections in multiparas and at the metropolitan private hospitals. The proportion of primiparas having either emergency or elective caesarean sections rose with maternal age, but for multiparas the proportion having elective sections rose, but there were few differences in emergency sections with increasing age. Repeat caesarean sections, which made up 28.8% of the total in 1987, have contributed increasingly to the rising proportion of caesarean section deliveries. Unless the number of emergency sections in primiparous women falls and the challenge of vaginal birth after caesarean section is met, it is likely that the caesarean section rate in Western Australia will continue to increase over the next decade.

Vulval lymphangiectasia.

Three cases of lymphangiectasia of the vulva are reported. One case followed Wertheim's hysterectomy for carcinoma of the cervix; two other cases had Crohn's disease with perineal involvement. Lymphangiectasia is a secondary phenomenon resulting from obstruction of previously normal lymphatics. This is in contrast with lymphangioma which is an anatomical abnormality. A review of the literature suggests that the vulval skin may be particularly susceptible to the formation of lymphangiectasia, and our patients' experiences suggest that they are easily mis-diagnosed.

Views of mothers and midwives participating in the Bristol randomized, controlled trial of active management of the third stage of labor.

Mothers and midwives who had participated in the Bristol randomized controlled trial of active versus physiologic management of the Third Stage of Labor were asked for their views. One hundred ninety-one mothers (11% of the total randomized) and 49 midwives completed self-administered questionnaires. Both mothers and midwives commented adversely about the length of the third stage under physiologic management. In general, their views were in accord with the conclusions of the main trial (based on clinical data, including maternal blood loss, length of third stage, need for therapeutic oxytocic agents, and specified neonatal morbidity) in favor of continuing with the current practice of active management.

The Bristol third stage trial: active versus physiological management of third stage of labour.

OBJECTIVE: To compare the effects on fetal and maternal morbidity of routine active management of third stage of labour and expectant (physiological) management, in particular to determine whether active management reduced incidence of postpartum haemorrhage. DESIGN: Randomised trial of active versus physiological management. Women entered trial on admission to labour ward with allocation revealed just before vaginal delivery. Five months into trial high rate of postpartum haemorrhage in physiological group (16.5% v 3.8%) prompted modification of protocol to exclude more women and allow those allocated to physiological group who needed some active management to be switched to fully active management. Sample size of 3900 was planned, but even after protocol modification a planned interim analysis after first 1500 deliveries showed continuing high postpartum haemorrhage rate in physiological group and study was stopped. SETTING: Maternity hospital. PARTICIPANTS: Of 4709 women delivered from 1 January 1986 to 31 January 1987, 1695 were admitted to trial and allocated randomly to physiological (849) or active (846) management. Reasons for exclusion were: refusal, antepartum haemorrhage, cardiac disease, breech presentation, multiple pregnancy, intrauterine death, and, after May 1986, ritodrine given two hours before delivery, anticoagulant treatment, and any condition needing a particular management of third stage. INTERVENTIONS: All but six women allocated to active management actually received it, having prophylactic oxytocic, cord clamping before placental delivery, and cord traction; whereas just under half those allocated to physiological management achieved it. A fifth of physiological group received prophylactic oxytocic, two fifths underwent cord traction and just over half clamping of the cord before placental delivery. ENDPOINT: Reduction in incidence of postpartum haemorrhage from 7.5% under physiological management to 5.0% under active management. MEASUREMENTS AND MAIN RESULTS: Incidence of postpartum haemorrhage was 5.9% in active management group and 17.9% in physiological group (odds ratio 3.13; 95% confidence interval 2.3 to 4.2), a contrast reflected in other indices of blood loss. In physiological group third stage was longer (median 15 min v 5 min) and more women needed therapeutic oxytocics (29.7% v 6.4%). Apgar scores at one and five minutes and incidence of neonatal respiratory problems were not significantly different between groups. Babies in physiological group weighed mean of 85 g more than those in active group. When women allocated to and receiving active management (840) were compared with those who actually received physiological management (403) active management still produced lower rate of postpartum haemorrhage (odds ratio 2.4;95% CI1.6 to 3.7). CONCLUSIONS: Policy of active management practised in this trial reduces incidence of postpartum haemorrhage, shortens third stage, and results in reduced neonatal packed cell volume.

Medical dilatation of the non-pregnant cervix: the effect of ethinyl oestradiol on the visibility of the transformation zone.

The cervical transformation zone (TZ) was not fully visible in 25 women referred to the colposcopy clinic with cytological suspicion of cervical intraepithelial neoplasia (CIN). Each was given a 5-day course of oral ethinyl oestradiol during the follicular phase of the menstrual cycle, and colposcopy was then repeated. The transformation zone was visible at this second examination in 16 of the 25 patients. Of these patients, 11 were treated with a local destructive technique, nine by laser, two by cryocautery; one patient had a cone biopsy, and four patients did not require treatment. Although cone biopsy was necessary in 8 of the remaining 9 patients it is encouraging that the use of a simple medical regimen allowed us to avoid conisation and its morbidity in almost two thirds of these patients.

Management of spontaneous rupture of the membranes in the absence of labor in primigravid women at term.

One hundred and thirty-five healthy primigravid women at or near term with spontaneous rupture of the membranes without uterine contractions were submitted to a prospective trial of management. Rupture of the membranes was diagnosed by speculum examination. If labor did not commence, induction was performed by oxytocin infusion starting at 9 AM following admission. One hundred and five women went into labor spontaneously before induction became necessary. Sixty-three of these women required augmentation with oxytocin. Twenty-seven percent of the induced group required cesarean section delivery compared to 10% of those in spontaneous labor augmented by oxytocin and to none of those who did not require oxytocin (p less than 0.01). Ninety-four percent of those in spontaneous labor were delivered vaginally compared to 73% of the induced group (p less than 0.01). Forty-one percent of the augmented group were delivered by forceps. Awaiting the spontaneous onset of labor for 24 hours or less did not result in clinical maternal or neonatal infection. We would therefore advocate awaiting the spontaneous onset of labor after spontaneous rupture of membranes without contractions at or near term in healthy primigravid women for up to 24 hours because it seems to confer significant advantages without producing any additional hazard.

Plasma concentrations of catecholamines following adrenaline infiltration during gynaecological surgery.

High pressure liquid chromatography with electrochemical detection has been used to measure plasma catecholamine concentrations in six gynaecological patients undergoing halothane anaesthesia for cervical cone biopsy. Mean catecholamine concentrations before infiltration were 1.01 +/- 0.23 (SEM) nmol litre-1 (185 +/- 43 pg ml-1) for adrenaline, and 2.2 +/- 0.25 nmol litre-1 (364 +/- 41 (185 +/- 43 pg ml-1) for adrenaline, and 2.2 +/- 0.25 nmol litre-1 (364 +/- 41 pg ml-1) for noradrenaline. Following infiltration with 0.5% bupivacaine 15 ml with adrenaline 1:200 000, plasma adrenaline concentrations increased to a mean peak concentration of 18.6 +/- 3.7 nmol litre-1 (3.4 +/- 0.69 ng litre-1). The lack of sympathoneuronal response was confirmed by simultaneous measurements of plasma noradrenaline concentrations, which did not change significantly. The proportion of the injected adrenaline measured in the intravascular compartment was 21.8%. The significance of intravascular absorption of exogenous adrenaline is discussed in relation to the use of halothane anaesthesia and the concurrent injection of a local anaesthetic solution.