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“Controlled cord traction” versus “minimal intervention”: Techniques in delivery of the placenta: A randomized-controlled trial
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SPO Abstracts
A PROSPECTIVE EVALUATION O F THE UTILITY O F B L O O D C U D TURES 1N TREATING ANTEPARTUM PYELONEPHR1TIS. B. Dozier ~, L. Nathan,. Department of Gynecology & Obstetrics, Emoi2e University School of Medicine, Atlanta, GA OBJECTIVE: To determine the clinical utility and cost-effectiveness of routine blood cultures in the m a n a g e m e n t of antepartum pyelonephritis. STUDY DESIGN: Pregnant women admitted to the obstetric service at Grady Memorial Hospital with a diagnosis of pyelonephritis were enrolled and randomized by sealed envelope method. Those assigned to the control group received routine care for anteparturn pyelonephritis which included two sets of blood cultures. Those assigned to the study group received identical care however blood culture results were not made available to the prinaary health care team. Outcome and managenmnt were compared between the two groups and a cost analysis was performed. RESULTS: Thirty-three control patients were compared to 25 study patients over a 27 month period. The two groups were similar with respect to age, race, estimated gestational age, initial white blood cell count, side of kidney involvement mad incidence of bacteremia. Escherichia coil was the most frequently isolated organism. Patient management and outcome did not significantly direr between groups. This was measured by duration of parenteral antimicrobial therapy, duration of hospital stay, change in antimicrobiaI therapy and complications such as respiratory insutficiency or recurrent pyelonephritis. Cost analysis revealed that omission of routine blood cultures on a national basis would save in excess of $5 million per year. CONCLUSION: The elimination of blood cultures in the m a n a g e m e n t of uncomplicated anteparmm pyelonephritis appears to be a safe means of reducing cost without compromising care.
J a n u a r y 1997 A m J Obstet Gynecol
56
"CONTROLLED CORD TRACTION" VERSUS "MINIMAL INTERVENTION": TECHNIQUES IN DELIVERY O F THE PLACENTA: A RANDOMIZED-CONTROLLED TRIAL. _G. Quadir Khan, x I.S. Joh'n, ~ S. Wahl, x "1". Dolwrt), ~ and B.M. Sibai. Depts. of OB/GYN, Corniche Hospital, Abu Dhabi, UAE, and Univ. of Tennessee, Memphis, TN. OBJECTIVE: To compare the controlled cord traction (CCT) technique (British method) to the mininlal intervention (MI) technique (USA method) for delivery of the placenta. Primary outcome was the incidence of postpartum (pp) hemorrhage. Secondary outcomes included duration of third stage of labor, frequency of retained placenta requiring manual removal, frequency of hemorrhagic shock, need for blood transfusions, and need of Ergonovin or 15-methylotPG administration to control pp hemorrhage. STUDY DESIGN: 1648 women delivered vaginally were randomly allocated during labor to the CCT group ( n - 8 2 7 ) or MI group ( n - 8 2 1 ) . In the CCT group, women received oxytocin 10 units with delivery of the baby's anterior shoulder; placenta was delivered actively by CCT after the uterus contracted (Brandt-Andrews nmthod). In the M1 group, placenta was delivered physiologically by maternal pushing. Continuous 1V oxytocin was then given after delivery of placenta. Odds ratio (OR) with 95% confidence intervals (CI) were calculated for each variable. RESULTS: The two groups were similar regarding m e a n gestational age, birthweight, parity, duration of labor, instrumental delivery, fi-equency of oxytocin use for induction-stimulation, and obstetric complications. Median duration of third stage of labor was significantly lower in the CCT group (4 rain vs. 14 min). Frequency of pp hemorrhage and significant secondary outcomes are summarized in the table. Min. Intervention
OR (95 % CI)
48 (5.8)
90 (11.0)
0.50 (0.340.73)
42 6 12 3 19 2
64 26 37 9 42 8
0.63 0.22 0.31 0.33 0.44 0.25
CCT
pp hemorrhage (>500 ml) 500-999 ml ->1000 ml Retained placenta (>30 rain) >60 min Ergonovin-15 methylaPG Hemorrhagic shock
(5.1) (0.72) (1.58) (0.36) (2.3) (0.24)
(7.8) (3.16) (4.5) (1.1) (5.1) (0.97)
(0.424).96) (0.08-0.57) (0.15-0.63) (0.07-1.32) (0.24-0.78) (0.04-1.25)
CONCLUSION: The controlled cord traction technique for delivery of the placenta results in significantly lower incidence of pp hemorrhage and lower incidence of retained placenta than the minimal technique.
SPO Abstracts
A PROSPECTIVE EVALUATION O F THE UTILITY O F B L O O D C U D TURES 1N TREATING ANTEPARTUM PYELONEPHR1TIS. B. Dozier ~, L. Nathan,. Department of Gynecology & Obstetrics, Emoi2e University School of Medicine, Atlanta, GA OBJECTIVE: To determine the clinical utility and cost-effectiveness of routine blood cultures in the m a n a g e m e n t of antepartum pyelonephritis. STUDY DESIGN: Pregnant women admitted to the obstetric service at Grady Memorial Hospital with a diagnosis of pyelonephritis were enrolled and randomized by sealed envelope method. Those assigned to the control group received routine care for anteparturn pyelonephritis which included two sets of blood cultures. Those assigned to the study group received identical care however blood culture results were not made available to the prinaary health care team. Outcome and managenmnt were compared between the two groups and a cost analysis was performed. RESULTS: Thirty-three control patients were compared to 25 study patients over a 27 month period. The two groups were similar with respect to age, race, estimated gestational age, initial white blood cell count, side of kidney involvement mad incidence of bacteremia. Escherichia coil was the most frequently isolated organism. Patient management and outcome did not significantly direr between groups. This was measured by duration of parenteral antimicrobial therapy, duration of hospital stay, change in antimicrobiaI therapy and complications such as respiratory insutficiency or recurrent pyelonephritis. Cost analysis revealed that omission of routine blood cultures on a national basis would save in excess of $5 million per year. CONCLUSION: The elimination of blood cultures in the m a n a g e m e n t of uncomplicated anteparmm pyelonephritis appears to be a safe means of reducing cost without compromising care.
J a n u a r y 1997 A m J Obstet Gynecol
56
"CONTROLLED CORD TRACTION" VERSUS "MINIMAL INTERVENTION": TECHNIQUES IN DELIVERY O F THE PLACENTA: A RANDOMIZED-CONTROLLED TRIAL. _G. Quadir Khan, x I.S. Joh'n, ~ S. Wahl, x "1". Dolwrt), ~ and B.M. Sibai. Depts. of OB/GYN, Corniche Hospital, Abu Dhabi, UAE, and Univ. of Tennessee, Memphis, TN. OBJECTIVE: To compare the controlled cord traction (CCT) technique (British method) to the mininlal intervention (MI) technique (USA method) for delivery of the placenta. Primary outcome was the incidence of postpartum (pp) hemorrhage. Secondary outcomes included duration of third stage of labor, frequency of retained placenta requiring manual removal, frequency of hemorrhagic shock, need for blood transfusions, and need of Ergonovin or 15-methylotPG administration to control pp hemorrhage. STUDY DESIGN: 1648 women delivered vaginally were randomly allocated during labor to the CCT group ( n - 8 2 7 ) or MI group ( n - 8 2 1 ) . In the CCT group, women received oxytocin 10 units with delivery of the baby's anterior shoulder; placenta was delivered actively by CCT after the uterus contracted (Brandt-Andrews nmthod). In the M1 group, placenta was delivered physiologically by maternal pushing. Continuous 1V oxytocin was then given after delivery of placenta. Odds ratio (OR) with 95% confidence intervals (CI) were calculated for each variable. RESULTS: The two groups were similar regarding m e a n gestational age, birthweight, parity, duration of labor, instrumental delivery, fi-equency of oxytocin use for induction-stimulation, and obstetric complications. Median duration of third stage of labor was significantly lower in the CCT group (4 rain vs. 14 min). Frequency of pp hemorrhage and significant secondary outcomes are summarized in the table. Min. Intervention
OR (95 % CI)
48 (5.8)
90 (11.0)
0.50 (0.340.73)
42 6 12 3 19 2
64 26 37 9 42 8
0.63 0.22 0.31 0.33 0.44 0.25
CCT
pp hemorrhage (>500 ml) 500-999 ml ->1000 ml Retained placenta (>30 rain) >60 min Ergonovin-15 methylaPG Hemorrhagic shock
(5.1) (0.72) (1.58) (0.36) (2.3) (0.24)
(7.8) (3.16) (4.5) (1.1) (5.1) (0.97)
(0.424).96) (0.08-0.57) (0.15-0.63) (0.07-1.32) (0.24-0.78) (0.04-1.25)
CONCLUSION: The controlled cord traction technique for delivery of the placenta results in significantly lower incidence of pp hemorrhage and lower incidence of retained placenta than the minimal technique.