Afaf Aly Ismail, Doaa Mahmoud Effat, Hanaa AbdlelHamid Ebisy, Amira Mohamed Farahat
Introduction: Prolonged third-stage of labor can be associated with a high risk of serious maternal complications. Nonetheless, active management of the prolonged third stage of labor can effectively reduce the risk of these complications.
The objective of this study: To evaluate the efficacy of the following three different protocols on shortening the duration of the third stage of labor and reduction of blood loss during the third and fourth stages of labor using umbilical vein oxytocin injection, umbilical vein misoprostol injection, and placental aspiration.
Methods: We recruited one hundred and twenty pregnant women with spontaneous onset of labor, including those who anticipated normal vaginal delivery from the maternity ward of Al- Zahraa University Hospital. Following spontaneous vaginal delivery of the baby, parturients were randomly assigned to one of the following three groups (each included 40 patients): group A that was subjected to intra-umbilical vein injection of 20 IU of oxytocin diluted in 30 ml normal saline; group B that underwent intra-umbilical vein injection of 800 μg of misoprostol diluted in 30 ml normal saline; and group C that was managed by syringe aspiration of blood from the umbilical vein. The duration of third-stage labor, amount of blood loss, need for manual placental separation, additional uterotonic drugs, blood transfusion, hemoglobin (HB), and hematocrit (HTC) deficits were evaluated. Also, drug-related side effects were monitored.
Result: The mean duration of the third stage of labor was significantly shorter in the oxytocin group (2.78 min) compared to the misoprostol group (4.78 min) and placental aspiration group (5.19 min; p <0.001). The average blood loss in the third stage was 160.5±17.08ml, 203.5±16.4ml, and 210.50±81.27 ml in groups A, B, and C, respectively (p <0.001). The average blood loss one hour postpartum (fourth stage) was 29±2.88, 33.55±4.02, and 35.05±4.26 ml in groups A, B, and C, respectively, with significant difference (p <0.001). No case of manual separation of placenta or blood transfusion was recorded across the studied groups. The average HB deficit was 0.51±0.14, 0.99±0.29, and 0.99±0.55gm/dl in group A, B, and C, respectively (p<0.001). The average HCT% drop was 1.06±0.27, 1.76±0.36, and 1.39±0.59% in groups A, B, and C, respectively (p <0.001). The need for additional uterotonic drugs was 2.5% in group A, compared to 7.5% in group B and 12.5% in group C, which was statistically insignificant (p>0.05). Concerning the side effects, only two cases (5%) had shivering and pyrexia in group B, which was statistically insignificant (p>0.05).
Conclusion: Active management of the third stage of labor decreases postpartum hemorrhage risk and should be offered to all parturients. Intraumbilical oxytocin injection is the best method in the active management of labor. It effectively shortens the duration of the third stage of labor and reduces blood loss compared to the other two strategies. The need for additional uterotonic drugs is also minimal using intraumbilical oxytocin injection; however, we found it statistically insignificant. Intraumbilical injection of misoprostol (800 μg)may be used as an alternative intervention before attempting the manual removal of the placenta. Although placental blood aspiration was comparatively the least effective method in shortening the duration of placental delivery and reducing blood loss, it can be considered an effective, easy, safe, and cost-effective method with no side effects; particularly, in situations with restricted availability of uterotonic drugs.
Third stage of labor, Maternal mortality,Postpartum hemorrhage,Oxytocin, misoprostol, Intraumbilical route