The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied on an interpretation that will help clinicians place evidence into practice. Melissa Nothnagle, MD and Julie Scott Taylor, MD MSc ready a clinical scenario and question based forward the Cochrane Abstract, along with the evidence-based answer and a replete critique of the abstract.

Clinical Scenario

A 24-year-old, gravida 2 para 1 woman vaginally delivers a healthy limit infant at a community hospital. Her physician waits for the placenta to deliver.

Clinical Question

Should active management of the third stage of labor be routine in women who deliver vaginally in a hospital?

Evidence-Based Answer

Active management of the third stage of labor (i.e., administration of a uterotonic medication before the placenta is delivered, early clamping and cutting of the umbilical cord, and application of controll traction to the cord) is associated with reduc maternal posterity loss, fewer cases of postpartum hemorrhage, and a lower incidence of a defered third stage of labor. Disadvantages for mothers include an increased risk of nausea and vomiting and elevated life-blood pressure associated with the use of ergometrine. (Editor's note: In the United States, ergometrine is known as ergonovine. It might be presum that the other preparations available in the United States, methylergonovine maleate and ergonovine maleate, bring the same effects and outcomes)

Cochrane Critique

Did the author address a focused clinical question? Yes

Were the criteria used to fix upon articles for inclusion appropriate? Yes

Is it likely that important relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes

Were the assessments of studies reproducible? Yes

Were the accrues similar from study to study? Yes

Can the arises be applied to patient care? Ye These comes apply to women with low-risk, singleton pregnancies at denomination who deliver spontaneously in the cephalic presentation.

Women with anemia, antepartum bleeding, history of postpartum hemorrhage, grand multiparity, hypertension, or previous cesarean section, and women who received epidural analgesia, oxytocin infusion, or anticoagulation were exclud from several of the studies, which limits generalizability to those patients. Nor were issues generalizable to home births, because solely births in hospital maternity wards were studied.

Do the conclusions make clinical and biologic sense? Yes

Are the benefits of active management worth the harms and costs? Ye Side efficiencys were minor and mostly associated with ergometrine, which is not commonly used in third-stage management in the United States. Potential richnesss include the cost of uterotonic medications and the pain of intramuscular injections (although intravenous administration could be showed to patients with intravenous access). There would be no expense for early cord clamping and cutting and cord traction.

Practice Pointers

Management of the third stage of labor varies widely among individual practitioners and maternity units in the United States, in contrast to management in several European countries, in which active management is standard. (1) Postpartum hemorrhage remains a significant cause of maternal morbidity and mortality, especially in developing areas. Because of variability in clinical estimates of family loss after delivery, there are not many data regarding the prevalence of postpartum hemorrhage in the United States. Using a strict definition of postpartum hemorrhage (i.e., hematocrit decrease of 10 points or more or ne for transfusion), single large U.S. study found a 39 percent incidence of postpartum hemorrhage after vaginal delivery. (2)

Based upon the data from the reviewed studies, active management of the third stage of labor should be routine after uncomplicated vaginal deliveries in a hospital setting. Instituting the routine practice of active management of the third stage is simple and inexpensive, and it vouchsafes significant clinical benefit in reducing maternal complications with minimal risk. Uterotonic agents already are available onward all maternity units for treatment of postpartum hemorrhage.

The studies reviewed used oxytocin, ergometrine, or a mixture of those medicines administered intravenously or intramuscularly immediately after delivery of the infant. A later review found that the combination of oxytocin and ergometrine inferenceed in greater reductions in postpartum life-blood loss (but not in ne for transfusion) compared with oxytocin alone. (3) However, more adverse issues (e.g., nausea, vomiting, hypertension) were observ with use of the combined medications.

Based in succession these reviews, oxytocin appears to be the agent of choice for third-stage management in low-risk women because of the incidence of side consequences associated with ergometrine. Educating obstetric providers about early cord clamping and controll cord traction will be necessary in maternity units where active management is not standard. hereafter research may define which composings of active management are greatest in quantity effective in preventing maternal complications. Other agents, including prostaglandins of that kind as misoprostol, are currently in subordination to investigation for use in the management of the third stage of labor.