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Prophylactic oxytocin: before or after placental delivery?

Evidence-based answer

Either is fine.

Timing alone doesn't influence the drug's efficacy in preventing postpartum bleeding (strength of recommendation: B, randomized controlled trial [RCT] and prospective cohort studies).

* Evidence summary

The prophylactic use of oxytocic drugs reduces the risk of postpartum hemorrhage (PPH) by about 40% and has been widely adopted as a routine policy in the active management of the third stage of labor. (1) A number of studies have evaluated the timing of oxytocin after delivery (TABLE).

Which timing is best? It depends on the study

A well-constructed double-blinded RCT found no significant difference in the incidence of PPH when oxytocin was given after delivery of the anterior shoulder or the placenta. (2) The study included 1486 patients; 745 received 20 units of oxytocin on delivery of the anterior shoulder, and 741 received an identical dose of oxytocin on delivery of the placenta. The incidence of PPH was 5.4% for the anterior shoulder group and 5.8% for the placenta group (P=.72). Likewise, no significant difference between the groups was noted in the proportion of women with estimated blood loss (EBL) [greater than or equal to] 500 mL (7.5% vs 9.7%; P=.15).

A much smaller double-blinded RCT found that PPH occurred significantly less often when oxytocin was delayed until after delivery of the placenta. (3) The study comprised 51 patients; 27 received 10 units of oxytocin on delivery of the anterior shoulder and 24 received an identical dose after delivery of the placenta. The incidence of PPH [greater than equal to] 500 ml was 0% when oxytocin was given after delivery of the placenta vs 14.8% when it was given on delivery of the anterior shoulder (P=.049). However, the study was limited by its size and potential inaccuracies in estimating blood loss.

A prospective cohort study noted a significant reduction in the risk of PPH when oxytocin was given after delivery of the anterior shoulder, compared with the placenta. (4) In this study, 82 patients received 5 units of oxytocin on delivery of the anterior shoulder, and 52 received an identical dose after delivery of the placenta. The incidence of PPH [greater than equal to] 500 mL was 7.3% in the anterior shoulder group and 19.2% in the placenta group. However, the study was not blinded and was limited by its small sample size.

Two earlier studies, an RCT and a prospective cohort study, concluded that oxytocin is more effective in reducing PPH when given before placental delivery (after delivery of the anterior shoulder and head, respectively). (5,6) Neither of these studies was blinded nor controlled for nonpharmacologic interventions, however.

Recommendations

The American College of Obstetricians and Gynecologists (ACOG) states that ongoing blood loss accompanied by decreased uterine tone requires uterotonic agents as first-line treatment for PPH. (7) ACOG doesn't make specific recommendations regarding the timing of oxytocin administration.

The American Academy of Family Physicians (AAFP) recommends oxytocin as the uterotonic agent of choice for preventing PPH. (8) The AAFP further advocates active management of the third stage of labor to decrease PPH by administering oxytocin as soon as possible after delivery of the anterior shoulder and before delivery of the placenta.

The World Health Organization (WHO) also recommends oxytocin as the uterotonic of choice. (9) WHO advocates administration within 1 minute of delivery of the baby.

References

(1.) Prendiville W, Elbourne D, Chalmers I. The effects of routine oxytocic administration in the management of the third stage of labour: an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1988;95:3-16.

(2.) Jackson KW Jr, AIIbert JR, Schemmer GK, et al. A randomized, controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage. Am J Obstet Gynecol. 2001;185:873-877.

(3.) Huh WK, Chelmow D, Malone F. A double-blinded, randomized controlled trial of oxytocin at the beginning versus the end of the third stage of labor for prevention of postpartum hemorrhage. Gynecol Obstet Invest. 2004;58:72-76.

(4.) Fujimoto M, Takeuchi K, Sugimoto Met al. Prevention of postpartum hemorrhage by uterotonic agents: comparison of oxytocin and methylergometrine in the management of the third stage of labor. Acta Obstet Gynecol Scand. 2006;85:1310-1314.

(5.) Khan GQ, John IS, Wani S, et al. Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial. Am J Obstet Gynecol. 1997;177:770-774.

(6.) Soriano D, Dulitzki M, Schiff E, et al. A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. 1996;103:1068-1073.

(7.) American College of Obstetricians and Gynecologists. Practice Bulletin Number 76, June 2006. Post-partum hemorrhage. Obstet Gyneco. 2006;76:1-9.

(8.) Quinlan J, Bailey E, Dresang L, et al, for the Advanced Life Support in Obstetrics Advisory Board. 2007-2008 Advanced Life Support in Obstetrics Course Syllabus. Leawood, Kan: American Academy of Family Physicians; 2006.

(9.) Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. Geneva, Switzerland: World Health Organization, 2003. Available at: www.who.int/reproductivehealth/impac/ clinical_principles/normal_lobour_C57_C76.html. Accessed May 12, 2008.

Scott Kahn, MD

Albert Meyer, MD

Janalynn Beste, MD

New Hanover Regional Medical Center Residency in Family Medicine, Wilmington, NC

Donna Flake, MSLS, MSAS

Health Sciences Library, South East Area Health Education Center, Wilmington, NC
TABLE
What studies say about the timing of oxytocin and PPH risk

                               OXYTOCIN GIVEN AFTER

STUDY TYPE          DELIVERY OF ANTERIOR   DELIVERY OF
(YEAR)                  SHOULDER (N)       PLACENTA (N)

DBRCT (2001) (2)            745                741

DBRCT (2004) (3)             27                 24

Cohort (2006) (4)            82                 52

RCT (1997) (5)              827                821

Cohort (1996) (5)     524 (given after         478
                     delivery of head)

STUDY TYPE
(YEAR)              OUTCOMES (RISK OF PPH)

DBRCT (2001) (2)    No difference
                    (OR=0.92; 95% CI, 0.59-1.43)

DBRCT (2004) (3)    Incidence lower when given after
                    delivery of placenta (P=.049)

Cohort (2006) (4)   Incidence lower when given
                    after delivery of anterior shoulder
                    (OR=0.33; 95% CI, 0.11-0.98)

RCT (1997) (5)      Incidence lower when given
                    after delivery of anterior shoulder
                    (OR=0.50; 95% CI, 0.34-0.73)

Cohort (1996) (5)   Incidence lower when given
                    after delivery of head
                    (OR=0.60; 95% CI, 0.41-0.87)

CI, confidence interval; DBRCT, double-blinded randomized controlled
trial; OR, odds ratio; PPH, postpartum hemorrhage; RCT, randomized
controlled trial.
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Title Annotation:CLINICAL INQUIRIES: Evidence Based Answers from the Family Physicians Inquiries Network
Author:Kahn, Scott; Meyer, Albert; Beste, Janalynn; Flake, Donna
Publication:Journal of Family Practice
Article Type:Clinical report
Geographic Code:1USA
Date:Dec 1, 2008
Words:1063
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