Rajiv Gandhi University of the Health Sciences

RAJIV GANDHI UNIVERSITY OF THE HEALTH SCIENCES,

KARNATAKA, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“God could not be everywhere, so he created mothers”
Jewish Proverb

Pregnancy is the sensational journey of a woman towards motherhood. The word ‘Mother’ is associated with tenderness, care, affection, and love. Mother’s love is boundless and her care is infinite. Women and children health is the strength of society. Care during pregnancy and labour is very essential to ensure that we have a healthy mother and a healthy baby at the end of the pregnancy. So it is very important for the doctors, nurses and the midwives to have thorough knowledge about various stages of pregnancy and labour1.

Labour purely in the physical sense may be described as the process by which the foetus, placenta, membrane are expelled through the birth canal. The WHO, 1997 defines normal labour as low risk throughout spontaneous in onset with the foetus presenting by the vertex, culminating in the mother and infants in good condition following action2.

The process of giving birth is normally divided into stages. First stage is mainly concerned with preparation of birth canal so as to facilitate expulsion of foetus in the second stage. Second stage is that of expulsion of foetus. It begins when the cervix is fully dilated in physiological labour the women usually feels the urge to expel the foetus. It is complete when the baby is born. The third stage is defined as the period from the birth of the baby to complete expulsion of the placenta and membrane. During the third stage separation and expulsion of placenta and membranes occur as a result of mechanical and haemostatic factor3.

The principles underlying the management of third stage are to ensure strict vigilance aid to follow the management guidelines strictly in practice. Two methods of management are currently in practice. They are expectant management and active management. Expectant management is the placental separation and is descent to the vagina is allowed to occur spontaneously. Minimal assistance may be given for the placental expulsion if it is needed. In assistant expulsion, controlled cord traction (modified Brandt- Andrews method) and fundal pressure method are used. Injection of Oxytocin 5 to 10 units intra veinously or methargin 0.2mg is given intra muscularly.

Active management of third stage is to excite powerful uterine contraction following birth of the anterior shoulder by parenteral Oxitocin which facilitate not only early separation of placenta but also produce effective uterine contraction following its separation. Injection of Ergo metrine 0.25 mg or methargineis given with intra veinously following the birth of anterior shoulder. This is followed by slow delivery of baby taking at least two to three minutes. Placenta not delivered instantaneously will be delivered by controlled cord traction method. If the first attempt fails another attempt is made after two to three minutes failing which leads to further attempts with same intervals.

According to a WHO study, the normal duration of the third stage of labour is from 5 to 30 minutes with the mean delivery time of 8.3 minutes. The WHO recommends that in the absence of haemorrhage, the woman should be observed for a further 30 minutes following the initial 30 minutes before manual removal of the placenta is attempted and the timing of manual removal as the definitive treatment is left to the judgment of the clinician. If it fails placenta is removed manually and examination of placenta, cord, vulva, vagina and perineum are done carefully4.

The main complications of third stage of labour are postpartum haemorrhage, retained placenta, uterine inversion and placenta accerta. The studies have identified the need to improve safe motherhood knowledge of ANM students to reduce the maternal mortality.

6.2 NEED FOR THE STUDY

The pregnancy-related (direct) maternal mortality rate in the United States is approximately 7-10 women per 100,000 live births. National statistics suggest that approximately 8% of these deaths are caused by postpartum hemorrhage. In the developing world, several countries have maternal mortality rates in excess of 1000 women per 100,000 live births, and World Health Organization (WHO) statistics suggest that 25% of maternal deaths are due to postpartum haemorrhage, accounting for more than 100,000 maternal deaths per year. The death of these mothers has serious implications for the newborn and any other surviving children6.

Around 515 000 women die each year in childbirth, mostly in developing countries. Severe bleeding in the postpartum period is the single most important cause of maternal deaths worldwide. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive blood loss. It is estimated that some 140 000 women die each year from postpartum haemorrhage (PPH) .postpartum haemorrhage also causes serious morbidity in many women7

A case-control study was conducted between July 1, 2007 and June 30, 2008 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. To identify health-related risk factors for the development of post partum heamorrhage (PPH) in Saudi women. One hundred and one patients with post partum haemorrhage and 209 control patients were included. Bivariate associations between the different risk factors for the development of post partum haemorrhage were studied. Multivariate logistic regression analysis to identify significant risk factors for the occurrence of this obstetrics complication was carried out. High parity was associated with a 17% increased risk of postpartum haemorrhage. Risk factors in preeclampsia was associated with >6-fold increase. History of ante partum haemorrhage (APH) increased the risk for post partum haemorrhage by >8-fold. Other factors were: multiple pregnancy, vaginal delivery,and prolonged third stage of labour8.

In India the single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. Post Partum haemorrhage-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of post partum haemorrhage-related mortality in these areas, but there is comparatively little data available outside of a hospital setting9.In Karnataka Maternal Mortality Ratio is 213 which are lower than the National average10.

Postpartum haemorrhage is one of the leading causes of maternal death worldwide; it occurs in about 10.5% of births and accounts for over 130 000 maternal deaths annually. Active management of the third stage of labour is highly effective at preventing postpartum haemorrhage among facility-based deliveries. In a systematic review of randomized controlled trials, active management of the third stage of labour was more effective than physiological management in preventing blood loss, severe postpartum haemorrhage (> 500 ml) and prolonged third stage of labour. Further research is needed to determine why certain providers or teams within a facility have adopted active management of the third stage of labour, and why in-service training in such management has little effect on practice. Important insights could be gained from qualitative enquiry into provider practices where active management is common practice, such as the Dublin maternity centre, where its use was documented at nearly 100% and in those health facilities in this sample where its use reached 60–80%.11

The prior studies in management of third stage of labour has revealed that there is a major contribution to the maternal mortality from this stage. One reason among many would be the lack of expertise in this area, thus I chose this study as my research topic, through this study the knowledge of management of third stage of labour can be improved. Since ANM students play a major role in the labour process. This knowledge will be very useful for the professional growth as well as contribution to the society. Using video assisted teaching programme more insight can be provided for the ANM students at Hassan.

6.3 REVIEW OF LITERATURE:

Literature review is a standard requisition of scientific research. Review of literature provides you with the current theoretical and scientific knowledge about a particular problem, and resulting in a synthesis of what is known or not known. Review of literature is presented under the following heading.

6.3.1 Review of Literature related to the prevalence of complication of third stage of labour.

6.3.2 Review of Literature related to the management of third stage of labour.

6.3.3 Review of Literature related to the knowledge on management of third stage of labour among ANM students.

6.3.1 Review of literature related to the prevalence of complication of third stage of labour:

A study was conducted on ‘Risk factors of postpartum haemorrhage in Latin American population’ in South American countries Argentina and Uruguay to reveal the postpartum heamorrhage and other risk factors that are associated with third stage of labour. The population was all the women who gave vaginal birth during a two year period. The total population included 11,323 women. The Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum heamorrhage and severe postpartum heamorrhage were defined as blood loss of at least 500 ml and at least 1,000 ml, respectively. Moderate and severe postpartum heamorrhage occurred in 10.8% and 1.9% of deliveries, respectively. There were many factors which were contributing to the cause of postpartum heamorrhage and the details are retained placenta (33.3%); multiple pregnancy (20.9%); macrosomia (18.6%); and need for perineal suture. Active management of third stage of labour, multiparity and a low birth weight baby, were found to be protective factors.12

A study was conducted at Ibidan, Nigeria to determine the frequency of retained placenta at the University College Hospital Ibadan (UCH). This was a descriptive study of five years which was carried out till 2007. During the study period, 4980 deliveries took place at the University College Hospital, Ibadan and 106 cases of retained placenta were managed making, which made the incidence 2.13 per cent of all birth. In this population Fifty-eight patients (64.8%) presented with anaemia (packed cell volume less than 30 per cent) and 35 patients (38.8%) had blood transfusion ranging between 1-4 pints. 1 patient required hysterectomy on account of morbidly adherent placenta. Eleven patients (12.2%) had placenta retention in the past, 28 patients (31%) had a previous dilatation and curettage, 14 patients (15.5%) had previous caesarean sections and 47 patients (41.3%) had no known predisposing factor. The study concluded that Retained placenta still remains a potentially life threatening condition in the tropics due to the associated haemorrhage, and other complications related to its removal.13

A five year study regarding the Prevalence, risk factors and severe obstetric haemorrhage on third stage of labour was conducted in Norway in a population of All women giving birth (307 415) in a period of five years. In this study, Cross-tabulation was used to study prevalence, causes and acute maternal complications of severe obstetric haemorrhage. Associations of severe obstetric haemorrhage with demographic, medical and obstetric risk factors were estimated using multiple logistic regression models. Severe obstetric haemorrhage was considered to be blood loss of > 1500 ml or blood transfusion. As a result of this study Severe obstetric haemorrhage was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma were identified causes in 30, 18 and 13.9% of women, respectively. The demographic factors of a maternal age of ≥30 years and South-East Asian ethnicity were significantly associated with an increased risk of haemorrhage. The risk was lower in women of Middle Eastern ethnicity. The risks were substantially higher for multiple pregnancies, von Willebrand’s disease and anaemia (haemoglobin<9 g/dl) during pregnancy.14

6.3.2 Review of literature related to the management of third stage of labour:

A study Conducted among Zambian women found out that postpartum haemorrhage is the major complication that is contributing to the maternal morbidity. The ratio in Zambian women was found out to be 561 out of 100000 births given. In this study Midwives employed in five public hospitals and eight health centers were interviewed (N = 62), and 82 observations were conducted during the second through fourth stages of labour. The observations proved that the births which followed AMTSL (Active management of the third stage of labour). Data from facilities in which oxytocin was available (62 births in 11 settings) indicated that a uterotonic was used in 53 of the births (85.5%); however, AMTSL was conducted in strict accord with the currently recommended protocol (a time-specific use of the uterotonic, controlled cord traction, and fundal massage) in only 25 (40.4%) of births. The results were concluding that the maternal morbidity was comparatively low when the Active management of the third stage of labour methods was followed. 15

A small pilot trial (n = 200) was conducted in Assiut, Egypt, used 'sustained uterine massage' started after delivery applied every 10 minutes and continued for 60 minutes. The findings are promising, since women receiving massage had less blood loss > 500 ml and received less additional uterotonics than women not receiving uterine massage. In the two surveys conducted by Prevention of Postpartum Heamorrhage Initiative massage before placental delivery was practiced in about one third of all deliveries. In the same surveys massage after placental delivery was used in 80–90% of women although it was not possible to observe how long after delivery the massage was continued .Williams Obstetrics states "massage is not employed but the fundus is frequently palpated to make certain that the organ does not become atonic and filled with blood from placental separation". In the United States and some other countries, palpating the uterus and massaging if "soft" for the first few hours after childbirth is considered standard of care. A systematic review to evaluate the effects of sustained uterine massage from the time of birth of the baby currently contains very little evidence to guide practice.16

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) and need for therapeutic oxytocics.) compared to no uterotonics, although there was a non-significant trend towards more manual removal of the placenta which was most marked in the expectant management subgroup, and blood transfusions 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, and with the suggestion of more raised blood pressure 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.17

A study was conducted at Sweden regarding the Comparison of Active and Expectant management of third stage of labour and also the relation of it towards the after pain. A single-blind, randomized, controlled trial was performed at two delivery units in Sweden in a population of healthy women with normal, singleton pregnancies, gestational age of 34 to 43 weeks, cephalic presentation, and expected vaginal delivery. Women (n = 1,802) were randomly allocated to either active management or expectant management of the third stage of labour. After pains were assessed by Visual Analog Scale and the Pain-o-Meter. 2 hours after delivery of the placenta and the day after childbirth. At 2 hours after childbirth, women in the actively managed group had lower VAS pain scores than expectantly managed women (p = 0.014). After pains were scored as more intense the day after, compared with 2 hours after, childbirth in both groups. Multiparas scored more intense afterpains, compared with primiparas, irrespective of management (p < 0.001). In this study it was concluded that active management of the third stage of labour does not provoke more intense after pains than expectant management.18