Diagnostic accuracy of the partograph alert and action lines to predict adverse birth outcomes: a systematic review.

BACKGROUND: There are questions about the use of the 'one-centimetre per hour rule' as a valid benchmark for assessing the adequacy of labour progress. OBJECTIVES: To determine the accuracy of the alert (1-cm/hour) and action lines of the cervicograph in the partograph to predict adverse birth outcomes among women in first stage of labour. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies. SELECTION CRITERIA: Observational studies and other study designs reporting data on the correlation between the alert line status of women in labour and the occurrence of adverse birth outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers at a time independently identified eligible studies and independently abstracted data including population characteristics and maternal and perinatal outcomes. MAIN RESULTS: Thirteen studies in which 20 471 women participated were included in the review. The percentage of women crossing the alert line varied from 8 to 76% for all maternal or perinatal outcomes. No study showed a robust diagnostic test accuracy profile for any of the selected outcomes. CONCLUSIONS: This systematic review does not support the use of the cervical dilatation over time (at a threshold of 1 cm/h during active first stage) to identify women at risk of adverse birth outcomes. TWEETABLE ABSTRACT: Alert line of partograph does not identify women at risk of adverse birth outcomes.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies.

BACKGROUND: The partograph (sometimes known as partogram) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partograph is to provide a pictorial overview of labour, and to alert midwives and obstetricians to deviations in maternal or fetal well-being and labour progress. Charts have traditionally contained pre-printed alert and action lines. An alert line, which is based on the slowest 10% of primigravid women's labours, signifies slow progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour.This review is an update of a review last published in 2013. OBJECTIVES: The primary objective was to determine the effectiveness and safety of partograph use on perinatal and maternal morbidity and mortality. The secondary objective was to determine which partograph design is most effective for perinatal and maternal morbidity and mortality outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2017), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised, cluster-randomised, and quasi-randomised controlled trials involving a comparison of partograph use with no partograph, or comparison between different partograph designs. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining review authors assessed the studies independently. We assessed the evidence using the GRADE approach. MAIN RESULTS: We have included 11 studies, involving 9475 women in this review; three studies assessed partograph use versus no partograph, seven assessed different partograph designs, and one assessed partograph use versus labour scale. Risk of bias varied in all studies. It was infeasible to blind staff or women to the intervention. Two studies did not adequately conceal allocation. Loss to follow-up was low in all studies. We assessed the evidence for partograph use versus no partograph using the GRADE approach; downgrading decisions were due to study design, inconsistency, indirectness, and imprecision of effect estimates.Most trials reported caesarean section rates and Apgar scores less than 7 at five minutes; all other outcomes were not consistently reported (e.g. duration of first stage of labour and maternal experience of childbirth).Partograph versus no partograph (3 trials, 1813 women)It is uncertain whether there is any clear difference between partograph use and no partograph in caesarean section rates (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.40 to 1.46; n = 1813; 3 trials; I² = 87%; very low-quality evidence); oxytocin augmentation (RR 1.02, 95% CI 0.95 to 1.10; n = 1156; 1 trial; moderate-quality evidence); duration of first stage of labour (mean difference (MD) 0.80 hours, 95% CI -0.06 to 1.66; n = 1156; 1 trial; low-quality evidence); or Apgar score less than 7 at five minutes (RR 0.76, 95% CI 0.29 to 2.03; n = 1596; 2 trials; I² = 87%; very low-quality evidence).Partograph with different placement of action lines (4 trials, 5051 women)When compared to a four-hour action line, women in the two-hour action line group were more likely to receive oxytocin augmentation (average RR 2.44, 95% CI 1.36 to 4.35; n = 4749; 4 trials; I² = 96%). There was no clear difference in caesarean section rates (RR 1.06, 95% CI 0.88 to 1.28; n = 4749; 4 trials); duration of first stage of labour (RR 0.81 hours, 95% CI 0.32 to 2.04; n = 948; 1 trial); maternal experience of childbirth (average RR 0.61, 95% CI 0.28 to 1.35; n = 2269; 2 trials; I² = 83%); or Apgar score less than 7 at five minutes (RR 0.93, 95% CI 0.61 to 1.42; n = 4749; 4 trials) between the two- and four-hour action line.The following comparisons only include data from single studies. Fewer women reported negative childbirth experiences in the two-hour action line group compared to the three-hour action line group (RR 0.49, 95% CI 0.27 to 0.90; n = 348; 1 trial). When we compared the three- and four-hour action line groups, the caesarean section rate was higher in the three-hour action line group (RR 1.70, 95% CI 1.07 to 2.70; n = 613; 1 trial). We did not observe any clear differences in any of the other outcomes in these comparisons.Partograph with alert line only versus partograph with alert and action line (1 trial, 694 women)The caesarean section rate was lower in the alert line only group (RR 0.68, 95% CI 0.50 to 0.93). There were no clear differences between groups for oxytocin augmentation, low Apgar score, instrumental vaginal birth and perinatal death.Partograph with latent phase (composite) versus partograph without latent phase (modified) (1 trial, 743 women)The caesarean section and oxytocin augmentation rates were higher in the partograph with a latent phase (RR 2.45, 95% CI 1.72 to 3.50; and RR 2.18, 95% CI 1.67 to 2.83, respectively). There were no clear differences between groups for oxytocin augmentation, and Apgar score less than 7 at five minutes.Partograph with two-hour action line versus partograph with stepped dystocia line (1 trial, 99 women)Fewer women received oxytocin augmentation in the dystocia line group (RR 0.62, 95% CI 0.39 to 0.98). We did not observe any clear differences in any of the other primary outcomes in this comparison.Partograph versus labour scale (1 trial, 122 women)The use of the partograph compared with the labour scale resulted in fewer women receiving oxytocin augmentation (RR 0.32, 95% CI 0.18 to 0.54), but did not produce any clear differences for any of the other primary outcomes. AUTHORS' CONCLUSIONS: On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.

The Effect of Tranexamic Acid on Preventing Post-partum Hemorrhage Due to Uterine Atony: A Triple-blind Randomized Clinical Trial.

BACKGROUND: Postpartum haemorrhage (PPH) is an important cause of early maternal death which needs to be controlled. OBJECTIVE: This study was designed to compare the effect of intravenous tranexamic acid (TXA) and prostaglandin analogue on reducing PPH resulted from uterine atony in women undergoing C section or vaginal delivery. METHOD: A randomized, triple-blind, placebo-controlled study was conducted on 248 pregnant women with PPH due to uterine atony who were randomly assigned into two groups of TXA as the intervention group (n=124) and prostaglandin analogue as the control group (n=124). The intervention group received 4 g TXA for an hour and then 1 g over 6 hours infusion intravenously and the control group received prostaglandin analogue. RESULTS: Postoperative bleeding did not significantly differ between the two groups (68.2±6.1 ml and 69.1±175.73 ml, respectively, P =0.6). Moreover, hemoglobin declines were 1±0.4 g/dl and 1.2±0.5 g/dL in TXA and prostaglandin group respectively, indicating that the difference was not statistically significant (P =0.7). CONCLUSION: The results of the present study showed that administrating intravenous TXA had comparable effects with prostaglandin analogue on reducing PPH in women with uterine atony and in those undergoing C section or vaginal delivery. Therefore, TXA can be used instead of prostaglandin in managing such patients.

Intramuscular oxytocin versus intravenous oxytocin to prevent postpartum haemorrhage at vaginal delivery (LabOR trial): study protocol for a randomised controlled trial.

BACKGROUND: Primary postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. The most common cause of primary PPH is uterine atony. Atonic PPH rates are increasing in developed countries despite routine active management of the third stage of labour. In less-developed countries, primary PPH remains the leading cause of maternal death. Although the value of routine oxytocics in the third stage of labour has been well established, there is inconsistent practice in the choice of agent and route of administration. Oxytocin is the preferred agent because it has fewer side effects than other uterotonics with similar efficacy. It can be given intravenously or intramuscularly; however, to date, the most effective route of administering oxytocin has not been established. METHODS/DESIGN: A double-blind randomised controlled trial is planned. The aim of the study is to compare the effects of an intramuscular bolus of oxytocin (10 IU in 1 mL) and placebo intravenous injection (1 mL 0.9% saline given slowly) with an intravenous bolus of oxytocin (10 IU in 1 mL given slowly over 1 min) and placebo intramuscular injection (1 mL 0.9% saline) at vaginal delivery. The study will recruit 1000 women at term (>36 weeks) with singleton pregnancies who are aiming for a vaginal delivery. The primary outcome will be PPH (measured blood loss ≥ 500 mL). A study involving 1000 women will have 80% power at the 5% two-sided alpha level, to detect differences in the proportion of patients with measured blood loss > 500 ml of 10% vs 5%. DISCUSSION: Given the increasing trends of atonic PPH it is both important and timely that we evaluate the most effective route of oxytocin administration for the management of the third stage of labour. To date, there has been limited research comparing the efficacy of intramuscular oxytocin vs intravenous oxytocin for the third stage of labour. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN14718882 . Registered on 4 January 2016. Pilot commenced 12.12.2015; trial commenced 04.01.2016. The protocol (Ref 012012) was approved by the National Maternity Hospital Research Ethics Committee on 10.06.2015 and the Research Ethics Committee of the Coombe Women & Infants University Hospital (Ref 26-2015) on 09.12.2015.

Excessive Primary Postpartum Hemorrhage.

The diagnosis and treatment of excessive bleeding within the first 24 hours after delivery and its main causes, namely uterine atony, retained placental fragments, vascular lesions by local tissue rupture, and blood clotting disorder are presented. Of great interest is the iconography, which is suggestive and original.

Peripartum hysterectomy in a tertiary hospital in Western Sydney.

The aim of this study was to review the incidence, indication, management and complications of peripartum hysterectomy (PH) in a tertiary level hospital over a decade. A retrospective review of all cases of PH performed at Westmead Hospital, Western Sydney, 2003-2012, was undertaken. PH was defined as hysterectomy performed after 20 weeks' gestation or any time after delivery but within 6 weeks' postpartum ( Awan et al. 2011 ). There were 56 cases of peripartum hysterectomy of 46,177 births, a rate of 1.22 per 1,000 births. The most common indication for PH was morbid adherence of the placenta (58.2%) followed by uterine atony. Having a history of both caesarean section and placenta praevia is highly associated with a morbidly adherent placenta in the index pregnancy (p = 0.002). The most common complication was coagulopathy followed by febrile illness and urinary tract injury. Our data showed previous caesarean section and placenta praevia to be associated with abnormal placentation, the leading indication for PH. Since there is an association between a planned caesarean hysterectomy and reduced amount of estimated blood loss and blood transfused, the knowledge of placentation and adequate preoperative planning and consideration for elective hysterectomy could be beneficial. The morbidity associated with PH is considerable.

Complete tamponade system for management of severe postpartum vaginal haemorrhage due to uterine atony.

A 30-year-old, 39 weeks pregnant, multiparous woman with single fetus, attended our obstetric clinic with complete cervical dilation in intractable mentum anterior presentation. The fetus was delivered by caesarean section with vertical uterine incision under general anaesthesia and lithotomy position. After surgery, examination of the vagina revealed multiple, serious tears with severe haemorrhage. Vaginal bleeding could not be controlled by sutures and concurrently uterine atony developed, which could not be controlled with medical treatment. Owing to intractable bleeding from uterus and vagina, a complete tamponade system was used. After the instillation of the uterine balloon with 500 mL and vaginal balloon with 300 mL liquid, the bleeding was controlled. The estimated blood loss was 3200 mL. The vaginal wound healed well during the postoperative 2 weeks. A complete tamponade system may be an effective treatment method for treatment of postpartum haemorrhage owing to vaginal lacerations and uterine atony.

Patterns of second-line uterotonic use in a large sample of hospitalizations for childbirth in the United States: 2007-2011.

BACKGROUND: The incidence of postpartum hemorrhage due to uterine atony has increased significantly in the United States during the past decade. For patients with refractory uterine atony after oxytocin administration, second-line uterotonics including methylergonovine maleate, carboprost, and misoprostol are recommended. In this study, we describe hospital-level patterns of second-line uterotonic use in a large, nationwide sample of admissions for childbirth in the United States. METHODS: The Premier Research Database was used to define a cohort of 2,180,916 patients hospitalized for delivery at 1 of 367 hospitals from 2007 to 2011. Mixed-effects logistic regression models were used to estimate the hospital-specific frequency of second-line uterotonic use adjusting for measured patient-level and hospital-level characteristics that might be risk factors for uterine atony. RESULTS: The median hospital-level frequency of second-line uterotonic use was 7.1% (interquartile range 5.2-% to 10.8%). In the fully adjusted model, the mean (SE) predicted probability of second-line uterotonic use was 7.02% (0.26%), with 95% of the hospitals having a predicted (SE) probability between 1.69% (0.12%) and 24.96% (1.28%). CONCLUSIONS: We observed wide interhospital variation in the use of second-line uterotonics that was not explained by patient-level or hospital-level characteristics. Studies aimed at defining the optimal pharmacologic strategies for the management of uterine atony are needed, particularly in light of the increasing incidence of atonic postpartum hemorrhage in the United States and other developed countries.

Predictors of labor abnormalities in university hospital: unmatched case control study.

BACKGROUND: Abnormal labor is one of the common emergency obstetric problems contributing for more than two-thirds of the unplanned cesarean section. In Ethiopia, although labor abnormality and its complications like obstetric fistula are highly prevalent, there is no published study that determines the predictors of labor abnormalities. METHODS: The study design was an unmatched case control which included 844 women (408 cases and 436 controls). Cases were identified when a woman was diagnosed to have one of the labor abnormalities at term (prolonged latent stage, active phase disorder, prolonged second stage, descent disorder and obstructed labor). Subgroup logistic regression analyses were done taking the different type of labor abnormalities as the dependent variable. RESULTS: Nearly half of the cases (48.6%) were found to have the active phase disorder. Obstructed labor alone accounted for about 16.8% of the cases. The mean gestational age of cases and controls was almost comparable. More than a quarter of cases and controls came to the hospital in the second stage of labor. More than two-thirds of the cases (67.4%) gave birth by cesarean section. The logistic regression analysis demonstrated an independent association of overall labor abnormality with pelvic inadequacy. The subgroup analysis, however, revealed that several obstetric factors were associated with one or more types of labor abnormalities. CONCLUSION: Active phase disorders were the commonest type of labor abnormalities. Cases were late in reporting to the hospital. Malposition, inadequate pelvis and inadequate uterine contraction were some of the predictors of specific types of labor abnormalities.

Hemorragia postparto por causas diferentes a atonia uterina severa en el Hospital Escuela Universitario de Tegucigalpa / Postpartum hemorrhage due to different causes not owing to severe uterine atony at the Hospital Escuela Universitario in Tegucigalpa

Objetivo: caracterizar los casos de Hemorragia Post-Parto (HPP) que ocurren por etiologías diferentes a la hemorragia por atonía uterina en el Hospital Escuela de Tegucigalpa. Material y métodos: se realizó un estudio descriptivo-transversal, se tomó como población a todas las pacientes que ingresaron al Hospital Escuela por atención de parto vía vaginal, cesárea o ingresadas en el puerperio inmediato durante los meses de junio a diciembre del año 2011. La muestra se tomó de las pacientes complicadas con hemorragia postparto diagnosticadas clínicamente según la clasificación de Benedetti. Se consideró la presencia de factores de riesgo asociados al manejo y complicaciones. Resultados: ocurrieron 10,701 nacimientos y 56 casos de hemorragia postparto poratonía grado I, trauma del canal del parto, retención de tejido o trastornos de la coagulación, con una frecuencia de 0.5% de casos, las causas de hemorragia fueron: 22(39%) casos por trauma del canal del parto, de estos, 17(77%) fueron nacimientos por cesárea; ocurrieron 19(34%) por retención de tejido. Se clasificó la gravedad de la hemorragia que presentaron las pacientes al momento del ingreso en grado III y grado IV, resultando 9 (16%) casos de cada uno. Las complicaciones fueron: coagulopatía, falla renal, sepsis y Síndrome Anémico. La mayoría de las pacientes 45 (80%) presentó gestaciones a término; los factores de riesgo fueron: 13(23%) enfermedad hipertensiva, en 4 (7%) se aumentó la labor del parto con fármacos, la mayoría 30 (54%) no tuvieron factores asociados. El manejo inicial se realizó con reanimación con cristaloides, el uterotónico más utilizado fue la combinación de oxitocina y prostaglandinas en 20 (36%) pacientes, se realizó manejo quirúrgico en 14 (25%) y ocurrieron 3(5%) muertes por complicaciones asociadas a hemorragia. Conclusiones: La causa más frecuente de hemorragia postparto encontrada en la población de estudio fue el trauma del canal del parto; en su mayoría...

Effect of partogram use on outcomes for women in spontaneous labour at term.

BACKGROUND: The partogram (sometimes known as partograph) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partogram is to provide a pictorial overview of labour, to alert midwives and obstetricians to deviations in maternal or fetal wellbeing and labour progress. Charts often contain pre-printed alert and action lines. An alert line represents the slowest 10% of primigravid women's labour progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour. OBJECTIVES: To determine the effect of use of partogram on perinatal and maternal morbidity and mortality.To determine the effect of partogram design on perinatal and maternal morbidity and mortality. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials involving a comparison of partogram with no partogram, or comparison between different partogram designs. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining authors assessed the studies independently. MAIN RESULTS: We have included six studies involving 7706 women in this review; two studies assessed partogram versus no partogram and the remainder assessed different partogram designs. There was no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06) between the groups. When compared to a four-hour action line, women in the two-hour action line group were more likely to require oxytocin augmentation (RR 1.14, 95% CI 1.05 to 1.22). When the three- and four-hour action line groups were compared, caesarean section rate was lowest in the four-hour action line group and this difference was statistically significant (RR 1.70, 95% CI 1.07 to 2.70, n = 613, one trial). When a partogram with a latent phase (composite) and one without (modified) were compared, the caesarean section rate was lower in the partograph without a latent phase (RR 2.45, 95% CI 1.72 to 3.50, n = 743, one trial). AUTHORS' CONCLUSIONS: On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care. Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Further trial evidence is required to establish the efficacy of partogram use.

Morbilidad de la paciente obstétrica extremadamente grave en la Isla de la Juventud, 2002-2010 / Serious obstetric morbidity in patients in Youth Island, 2002 2010

Se realizó un estudio descriptivo retrospectivo para caracterizar el comportamiento de la morbilidad en la paciente obstétrica extremadamente grave en el Hospital General Docente «Héroes del Baire» de la Isla de la Juventud, durante el período comprendido entre enero del 2002 y diciembre del 2010. Se estudió a las 42 pacientes obstétricas que, cumpliendo con la definición anterior, fueron atendidas en la Unidad de Cuidados Intensivos del citado hospital durante el período de estudio. La morbilidad obstétrica extremadamente grave fue más frecuente durante el horario nocturno, en pacientes de 30-34 años y durante el período gestacional, siendo el 2009 el año de mayor incidencia, aunque en los años 2003 y 2006 también se observaron un mayor número de casos. La hemorragia masiva fue la causa más importante de morbilidad, relacionada predominantemente con la atonía uterina. Los trastornos hipertensivos también fueron causa importante de morbilidad. La cesárea fue el proceder quirúrgico más utilizado, seguida de la histerectomía obstétrica, siendo necesarias más de 2 intervenciones solo en la minoría de los casos. Predominaron las pacientes con pérdidas sanguíneas entre 1.501-2.000mL (AU)

A retrospective descriptive study was conducted to characterize severe morbidity in patients treated in the intensive care unit of the «Heroes of the Baire» General Teaching Hospital in Youth Island from January 2002 to December 2010. There were 42 patients who met the inclusion criteria and who were treated in the intensive care unit during the study period. Serious obstetric morbidity was more common during the night hours, in patients aged 30-34 years old, and during pregnancy. The highest incidence occurred in 2009, although a higher number of cases were also observed in 2003 and 2006. The most important cause of morbidity was massive bleeding, which was mainly related to uterine atony. Hypertensive disorders were also a major cause of morbidity. The most widely used surgical procedure was cesarean section, followed by obstetric hysterectomy. More than two interventions were required in only a minority of patients. Blood use was predominantly 1501 and 2000ml (AU)

Intrapartum hemorrhage.

Intrapartum hemorrhage is a serious and sometimes life-threatening event. Several etiologies are known and include placental abruption, uterine atony, placenta accreta, and genital tract lacerations. Prompt recognition of blood loss, identification of the source of the hemorrhage, volume resuscitation, including red blood cells and blood products when required, will result in excellent maternal outcomes.

Effect of partogram use on outcomes for women in spontaneous labour at term.

BACKGROUND: The partogram (sometimes known as partograph) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partogram is to provide a pictorial overview of labour, to alert midwives and obstetricians to deviations in maternal or fetal wellbeing and labour progress. Charts often contain pre-printed alert and action lines. An alert line represents the slowest 10% of primigravid women's labour progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour. OBJECTIVES: To determine the effect of use of partogram on perinatal and maternal morbidity and mortality. To determine the effect of partogram design on perinatal and maternal morbidity and mortality. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2012). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials involving a comparison of partogram with no partogram, or comparison between different partogram designs. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining authors assessed the studies independently. MAIN RESULTS: We have included six studies involving 7706 women in this review; two studies assessed partogram versus no partogram and the remainder assessed different partogram designs. There was no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06) between the groups. When compared to a four-hour action line, women in the two-hour action line group were more likely to require oxytocin augmentation (RR 1.14, 95% CI 1.05 to 1.22). When the three- and four-hour action line groups were compared, caesarean section rate was lowest in the four-hour action line group and this difference was statistically significant (RR 1.70, 95% CI 1.07 to 2.70, n = 613, one trial). When a partogram with a latent phase (composite) and one without (modified) were compared, the caesarean section rate was lower in the partograph without a latent phase (RR 2.45, 95% CI 1.72 to 3.50, n = 743, one trial). AUTHORS' CONCLUSIONS: On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care. Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Further trial evidence is required to establish the efficacy of partogram use.

Actualización en el uso de uterotónicos / Update on the use of uterotonic agents

La hemorragia posparto supone la pérdida de más de 500 ml de sangre tras un parto vaginal o de más de 1.000 ml tras una cesárea en las primeras 24 h posparto. Aunque la incidencia de muerte materna por hemorragia posparto ha disminuido, esta continúa siendo la causa más frecuente de muerte materna por hemorragia obstétrica. La incidencia de atonía uterina, primera causa de hemorragia posparto, va en aumento tanto en el parto vaginal como en la cesárea. Aunque en más de dos terceras partes las hemorragias posparto tienen lugar en pacientes sin factores de riesgo identificables, el tercer estadio del parto prolongado es el principal factor de riesgo. El manejo activo de este periodo incluye la administración de uterotónicos, fármacos que producen una contracción uterina adecuada, tras el nacimiento del neonato. Se puede administrarlos de forma profiláctica o terapéutica. Se ha comprobado que la administración profiláctica se relaciona con un tercer estadio más corto, menor riesgo de hemorragia y menor necesidad de uterotónicos adicionales. Actualmente existen cuatro fármacos o grupos de fármacos con actividad uterotónica: oxitocina, carbetocina, alcaloides del cornezuelo del centeno y prostaglandinas. Aunque la literatura es heterogénea, la oxitocina es el uterotónico de elección en la profilaxis y el tratamiento de la hemorragia posparto, pero se debe disminuir la dosis; la metilergometrina es uterotónico de segunda línea en la profilaxis y el tratamiento; a pesar de los efectos secundarios, el carboprost (prostaglandina F2alfa) es la prostaglandina de elección en el tratamiento de la hemorragia; el misoprostol puede ser una alternativa a la oxitocina, y el uso profiláctico de carbetocina debe individualizarse(AU)

Postpartum haemorrhage (PPH) is defined by the WHO as a blood loss >500 mL after vaginal delivery or >1000 mL after caesarean section during the first 24 hours post-delivery. Although the incidence of maternal mortality caused by PPH has decreased, it continues to be the major cause of maternal mortality due to obstetric haemorrhage. Furthermore, the incidence of uterine atony, which is the most prevalent cause of PPH, is still increasing in both vaginal delivery and caesarean section. Although PPH occurs in more than two thirds of patients without any identifiable risk factor, a prolonged third stage of labour is the main risk factor. Active management of the third stage of labour has been postulated to reduce the risk of bleeding in this period. It includes the administration of uterotonic agents after the birth of the baby. Uterotonic agents are defined as drugs that produce adequate uterine contraction. These drugs can be used as prophylactic therapy or treatment. The prophylactic use of uterotonic agents has been reported to be associated with a shorter third stage of labour, less risk of PPH and less need of additional uterotonic agents. There are currently four drugs or groups of drugs with uterotonic action: oxytocin, carbetocin, ergot derivatives and prostaglandins. The literature on this subject is extensive, heterogeneous and sometimes discordant. Oxytocin is still the first-line uterotonic drug for prophylaxis and treatment of uterine atony. There is a common trend to use high doses of uterotonics for fear of inadequate uterine contraction, but the current literature recommends its reduction. Methylergonovine continues being the second-line uterotonic agent in the prophylaxis and treatment of PPH, because of its side effects. Despite carboprost (PGF2alpha) side effects, it is still the first-line prostaglandin for PPH treatment. Misoprostol may be an alternative to oxytocin when it is not available, although it needs further studies to support this. Finally, the prophylactic use of carbetocin should be individualised(AU)

Primary uterine inertia in four labrador bitches.

Uterine inertia is a common cause of dystocia in the bitch and is designated as primary (i.e., uterine contractions fail to ever be initiated) or secondary (i.e., uterine contractions cease after a period of time but before labor is completed). The etiology of primary uterine inertia is not well understood. The accurate diagnosis of primary uterine inertia requires the use of tocodynamometry (uterine monitoring). Primary uterine inertia has been postulated to result from a failure of luteolysis resulting in persistently elevated progesterone concentrations. In this study, primary uterine inertia was diagnosed in a series of four bitches in which luteolysis was documented suggesting some other etiopathogenesis for primary uterine inertia.

[Use of acupuncture for labour augmentation]. / Akupunktur til vestimulering under fødslen.

INTRODUCTION: In Denmark, 45% of all primiparas and 12% of multiparas with uneventful pregnancies are augmented in order to treat dystocia. Augmentation using oxytocin is associated with uterine hyperstimulation, uterine rupture and foetal death. Currently, no studies show that acupuncture is effective for augmentation. MATERIAL AND METHODS: A single-blinded randomized controlled trial with women diagnosed with dystocia. In the acupuncture group, the women had acupuncture in SP6, KI3, KI6, BL60, LI4 and acupressure on BL67. The control group received no treatment. The primary outcome was progression in cervical dilatation within two hours. The secondary outcomes were length of labour, length of second stage, use of augmentation, use of analgesia, caesarean section rate and number of instrumental deliveries. RESULTS: A total of 84 women were randomised. There was no significant difference between the groups with regard to dilatation from randomization to effect assessment (p = 0.54). In the acupuncture group, the mean difference was 1.3 cm (0.69-1.91). In the control group, the mean difference was 1.56 (0.6-2.52). 27% of the women with dystocia delivered spontaneously without augmentation. No major side effects of acupuncture treatment were reported. CONCLUSION: This study showed no effect of acupuncture treatment for primary or secondary inertia.

External aortic compression device: the first aid for postpartum hemorrhage control.

AIM: To evaluate the external aortic compression device (EACD) as a first aid to control postpartum hemorrhage (PPH). METHODS: Three hundred women whose deliveries were complicated with PPH were recruited into a quasi-randomization study. Groups comprised 120 women each who had atonic PPH. The EACD was used together with traditional management in study women, while traditional management alone was used in control women. Outcome measures were maternal mortality, morbidity (hysterectomy), amount of blood transfusion (BT), uterotonic drugs and time to stop bleeding. Side effects of the EACD were assessed. Atonic PPH was defined as a blood loss of >or=500 mL from an atonic uterus with circulatory compromise within 24 hrs of childbirth. Controls were treated with i.v. access, nasal oxygen, fresh BT, uterine massage, El-Menia air inflated balloon and uterotonic drugs. Study women were treated using EACD together with conventional management. RESULTS: Time to stop bleeding was significantly shorter (36.8 +/- 23.4 vs 118.6 +/- 36.8 min) in study women than in control women (P < 0.001); 87.5% of study women, but no single woman in the control group had their bleeding stopped within the first 45 min of PPH onset. No morbidities or mortality among those who received EACD compared with control women, among who had five surgical hysterectomies and one mortality. The amount of BT units (302 vs 200), ergometrine ampoules (3.6 +/- 0.5 vs 2.5 +/- 0.8), syntocinon units (30.6 +/- 0.5 vs 20.5 +/- 0.8) and misoprostol tablets (6.7 +/- 1.8 vs 3.8 +/- 0.7) received were significantly more in the control group than in the study group (P < 0.001). Adverse effects of EACD were rarely observed. CONCLUSION: EACD is a cost-effective and easily applied maneuver that allows satisfactory management of PPH without maternal mortality or morbidity. It is of value in developing countries.

Hemorragia postparto / Postpartum haemorrhage

La hemorragia postparto es una de las complicacionesobstétricas más temidas y es una de las tresprimeras causas de mortalidad materna en el mundo.Universalmente se define como la pérdida hemática superiora 500 ml tras un parto vaginal o a 1.000 ml trasuna cesárea. La hemorragia postparto precoz (HPP) esaquella que ocurre durante las primeras 24 horas trasel parto y es generalmente la más grave. Las causas deHPP incluyen atonía uterina, traumas/laceraciones, retenciónde productos de la concepción y alteracionesde la coagulación, siendo la más frecuente la atonía. Eldiagnóstico es clínico y el tratamiento ha de abarcarunas medidas generales de soporte vital y otras másespecíficas de carácter etiológico. Afortunadamente, espotencialmente evitable en la mayoría de los casos sise sigue una adecuada estrategia de prevención activay sistemática en la fase de alumbramiento de todos los partos(AU)

Postpartum haemorrhage is one of the most dreadedobstetric complications and one of the three maincauses of maternal mortality in the world. It is universallydefined as haematic loss above 500 ml followinga vaginal delivery or above 1,000 ml following a caesarean.An early postpartum haemorrhage (EPH) is onethat occurs during the first 24 hours following deliveryand is generally the most serious. The causes of EPHinclude uterine atony, trauma/lacerations, retention ofproducts of conception and alterations of coagulation,with atony being the most frequent. Diagnose is clinicaland treatment must include general life support measuresand other more specific measures of an etiologicalcharacter. Fortunately, in the majority of cases it is potentiallyavoidable if an adequate strategy of active andsystematic prevention is followed in the delivery phaseof all labors(AU)

Hemorragia obstétrica / Obstetric haemorrhage

La hemorragia masiva obstétrica es una causa muy importante de mortalidad y morbilidad materna en los países industrializados y del tercer mundo. La hemorragia masiva obstétrica tiene un componente vascular y/o quirúrgico y un componente de coagulopatía. Aunque en dos tercios de los casos de hemorragia postparto precoz no se encuentre ningún factor de riesgo asociado, es muy importante la identificación de los mismos. La hemorragia obstétrica puede, en ocasiones, no ser tratada adecuadamente. La apreciación clínica habitualmente infra estimada pérdida hemática. La hemorragia postparto suele ser la responsable del 95% de las hemorragias postparto y la atonía uterina es la causa más frecuente. El objetivo de la reanimación es restaurar el volumen sanguíneo circulante y mantener una presión de perfusión adecuada. Una vez diagnosticada una hemorragia obstétrica es fundamental actuar de manera secuencial y rápida. El uso racional de los derivados sanguíneos y el trabajo en equipo con el banco de sangre, así como la utilización de medidas tanto quirúrgicas como farmacológicas precoces y decididas en las hemorragias graves, son actitudes necesarias, por lo que se recomienda la implicación directa del personal con más experiencia en la resolución de una hemorragia obstétrica grave. Se recomienda que toda maternidad tenga un protocolo consensuado y conocido por todo el personal de la misma. El protocolo de actuación debe estar adaptado a las características de cada unidad obstétrica y debe revisarse periódicamente. Las enfermas con factores de riesgo de presentar una hemorragia obstétrica deben ser trasladas a un centro de asistencia de nivel III (AU)

Massive obstetric haemorrhage is a very important cause of maternal morbidity and mortality in developed countries and in third world countries. Massive obsteric haemorrhage has a coagulopathic component and a vascular or surgical component that are often associated in the same patient. Nearly two thirds of patients cannot be identified with risk factors for obstetric haemorrhage, although a good knowledge and early identification of associated risk factors is helpful for its prevention in many cases. Obstetric haemorrhage is not always adequately identified or treated, because blood loss is underestimated by clinical observation. Postpartum haemorrhage is the cause of 95% of all obstetric haemorrhages. In this group, the main cause is uterine atony. Women’s resuscitation objective is thr intravascular volume restoration, to reach and adequate tissue perfussion pressure. Once an obstetric haemorrhage is diagnosed, it is very important a coordinated, rapid and protocolized treatment. Rational use of blood components, team work with the blood bank, the use of pharmacological and surgical resources readily, are necessary actions in this context. It is highly recommended prompt implication of senior staff in severe obstetric haemorrhage resolution. It is recommended the use of local protocols for each maternity. This protocol must be known by all team members and it must be adapted to local hospital characteristics, and should be periodically revised. High risk patients for obstetric haemorrhage, must be transferred to a level III hospital where all resources can be used if necessary (AU)