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Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor
Bardeguez et al.
7. Worley G, Lipman B, Gewolb IH, et al. Creatine kinase brain isoenzyme: relationship of cerebrospinal fluid concentration to the neurologic condition of newborns and cellular localization in the human brain. Pediatrics 1985; 76:15. 8. Becker M, Menzel K. Brain-typical creatine kinase in the serum of newborn infants with perinatal brain damage. Acta Paediatr Scand 1978;67:177. 9. Cuestas RA. Creatine kinase isoenzymes in high risk infants. Pediatr Res 1980;14:935. 10. Shields WD, Feldman RC. Serum CK-BB isoenzyme in preterm infants with periventricular hemorrhage. Pediatrics 1982;100:464. II. Fischer WM, Stude I, Brandt H. Ein Vorschlag zur Beurteilung des antepartalen Kardiotokogramms. Z Geburtshilfe Perinatol 1976;180:117. 12. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evaluation of subependymal and intraventricular
January 1989 Am J Obstet Gynecol
13.
14.
15. 16.
hemorrhage: a study of infants with birth weights less than 1500 grams. J Pediatr 1978;92:529. Chemnitz G, Nevermann L, Schmidt E, Schmidt FW, LobersJ. Creatine kinase (EC-NO 2.7.3.2) and creatine kinase isoenzymes during pregnancy and labor and in cord blood. Clin Biochem 1979;12:277. Thompson RJ, GrahamJG, McQueen INF, Kynoch PAM, Brown KW. Radioimmunoassay of brain-type creatine kinase BB isoenzyme in human tissues and in serum of patients with neurologic disorders. J Neural Sci 1980;47:241. Pape KE, Wigglesworth JS. Haemorrhage ischaemia and perinatal brain. Philadelphia: JB Lippincott, 1979. (Clinics in developmental medicine; no 69/70). Hameed C, Tejani N, Tuck S, et al. Correlation of fetal heart rate monitoring and acid-base status with periventricular/intraventricular hemorrhage in the low birth weight neonate. Am J Perinatol 1986;3:24.
Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor Virginia V. Reddy, MD, and J. Chris Carey, MD Oklahoma City, Oklahoma The use of umbilical vein injection of oxytocin was compared with traditional management of the third stage of labor. Pregnant women were randomized to receive intravenous oxytocin after the delivery of the placenta (n = 25) or oxytocin via the umbilical vein immediately after cord clamping (n = 25). Those who received umbilical vein oxytocin had a shorter third stage of labor (4.1 versus 9.4 minutes), less measured blood loss (135 versus 373 ml), and a lower drop in hematocrit (3.9% versus 6.2%). Intraumbilical vein oxytocin appears to be a useful alternative to traditional management of the third stage of labor. (AM J OBSTET GVNECOL 1989;160:206-8.)
Key words: Intraumbilical oxytocin, third-stage labor, puerperal hemorrhage
Golan et al. 1 described a method to deliver a retained placenta. They injected 10 units of oxytocin in 20 ml of normal saline solution into the umbilical vein of each of 10 women, whose placentas were retained for more than 30 minutes. All were delivered spontaneously, with a mean expulsion time of 3 minues 40 seconds after injection. In a Letter to the Editors, Golan et al." reported using the method of 12 additional patients, "with excellent results and no maternal ill effects whatsoever." Kristiansen et al.' studied this method in 51 patients who received, via the umbilical vein, either 10 units of oxytocin in 10 ml of normal saline solution or 10 ml of From the Department of Obstetncs and G.vnecology, The University of Oklahoma Health SCience Center. ReceIved for publzcatzon December 9,1987; revtsedJuly 21,1988; accepted July 29, 1988. Reprint requests: Dr. J. Chns Carey, POB 26901, Oklahoma Czty, OK 73190.
206
normal saline solution alone or underwent manual removal of the placenta. Kristiansen's group found no significant advantage in using the procedure. This study did not report the length of time from injection to delivery for any group. No ill effects from intraumbilical oxytocin were reported. Chestnut and Wilcox' compared intra umbilical oxytocin to intraumbilical saline solution injections.' but they did not compare the method with traditional management. Chestnut and Wilcox injected 10 units of oxytocin in 20 ml of saline solution into the umbilical vein only if the placenta was not expelled within 5 minutes. They found no difference in the mean injectionexpulsion interval or the mean second-day hemoglobin levels between the two groups. We elected to study the use of intraumbilical oxytocin in normal pregnancies without retained placentas as an alternative to the traditional management of the third stage of labor.
Umbilical vein oxytocin
Volume 160 Number I
207
Table I. lntraumbilical oxytocin versus standard management Variable
Parity Birth weight (gm) Placental weight (gm) First stage (hr) Second stage (min) Third stage (min) Preoperative hemoglobin (gm/dl) Preoperative hematocrit (%) Postoperative hemoglobin (gm/d\) Postoperative hematocrit (%) Decrease in hemoglobin (gm/dl) Decrease in hematocrit (%) Measured blood loss in third stage (ml)
Group 1: Urnbllzcal
0.92 3227 666 7.3 39.3 4.1 12.0 35.5 10.7 31.5 1.3 3.9 135
Material and methods Fifty pregnant women at 37 to 41 weeks' gestation were studied. Women were excluded from the study if they had grand multiparity (more than five preg'1ancies), multiple gestation, previous uterine scar, abr .ptio placentae, or preeclampsia or had received magnesium sulfate or oxytocin in labor. Women who were delivered by cesarean section also were excluded. Informed consent was obtained from all patients, who then were randomized by even or odd medical records number. On admission to the labor suite, a complete blood count was obtained on all study patients. All patients were followed up through the first and second stages of labor. Patients in group 1 (umbilical oxytocin) received 20 units of oxytocin, diluted in 30 ml of normal saline solution, into the umbilical vein immediately after the cord was clamped and cut. These patients did not receive oxytocin in the first liter of intravenous fluid post partum but received 20 units in the second liter, for a total of 40 u of oxytocin. Women in group 2 (standard management) did not receive any umbilical injection. They received 20 units of oxytocin in 1000 ml of lactated Ringer's solution intravenously at 125 mllhr after delivery of the placenta. All women received 20 units of oxytocin in 1000 ml of lactated Ringer's with 5% dextrose as a second liter of intravenous fluid, at 125 mllhr. All women were given a total of 40 units of oxytocin, with group 1 receiving 20 units intravenously and 20 units into the umbilical vein, and group 2 receiving 40 units intravenously. All deliveries were performed by first- or second-year residents. The third stage of labor was managed by observation until signs of separation occurred, followed by gentle traction of the cord for expulsion. Blood loss in the third stage of labor was measured by the obstetrician, who collected all blood loss in a basin. The blood loss was then measured in a graduated cylinder. All women had a complete blood count on the morning of the first postpartum day.
± ± ± ± ± ± ± ± ± ± ± ± ±
Group 2: Standard
0.95 382 98 3.0 32.1 2.4 1.5 4.4 1.8 4.9 0.92 2.4 122
0.72 3207 651 12.1 38.5 9.4 \3.0 39.0 11.2 32.9 \.8 6.2 373
± ± ± ± ± ± ± ± ± ± ± ± ±
0.79 353 151 16 33.7 5.8 1.3 3.8 1.5 4.0 1.1
3.3 467
p Value
NS NS NS NS NS <0.0001 <0.02 <0.003 NS NS <0.07 <0.01 <0.02
Data were analyzed on a Hewlett-Packard personal computer with NWA Statpack software. Student's t test with two-tailed significance was used to compare means.
Results The results are summarized in Table I. The two groups of women were similar in parity, birth weight, placental weight, and length of the first and second stages of labor. By chance, the intraumbilical oxytocin group began labor with significantly lower hemoglobin and hematocrit values. The third stage of labor was significantly shorter in the intraumbilical oxytocin group. In this group, the measured blood loss during the third stage of labor and the postpartum decrease in hematocrit were both significantly less. No patient in either group had a placenta retained longer than 30 minutes, and no patient had a manual removal of the placenta. One woman who received intraumbilical oxytocin had a blood loss of 500 ml and became tachycardiac and mildly hypotensive after the delivery of the placenta. She responded quickly to fluid replacement and did not require blood transfusion. This reaction could have been due to the umbilical i~ection of oxytocin, possibly because oxytocin has a direct hypotensive effect. No patient in either group required blood transfusion.
Comment The third stage of labor is usually managed by observation until separation and expulsion occur, followed by the administration of intravenous oxytocin to reduce hemorrhage.' Third-stage hemorrhage is a significant cause of puerperal anemia. With increasing risk of transfusion-borne infections, any mechanism to reduce blood loss and risk of transfusion is of value. The effect of intraumbilical oxytocin on the retained placenta and on the third stage oflabor is controversial. Some authors!' 2 have found the method to be advantageous whereas others' 4 have not. The differences
208 Reddy and Carey
may be attributable to differences in study design. Golan et al. proposed that the injection of intra umbilical oxytocin leads to a high concentration of oxytocin at the uterine wall. We gave a higher dose than other investigators. Perhaps the effect is dose related. Chestnut and Wilcox delayed injection of oxytocin until 5 minutes after birth. We administered oxytocin to the intraumbilical group as soon as the cord was clamped, and the mean third stage was <5 minutes. Perhaps earlier injection has a greater effect. It is also possible that the effect is due to the volume injected and not due, specifically, to oxytocin. Neither our study nor Chestnut's study answered this question. Umbilical vein injection of oxytocin appears to be a useful alternative to the traditional management of the third stage of labor. We noted a shorter third stage of labor and less puerperal blood loss in women who received intra umbilical oxytocin. This method could be
January 1989 Am J Obstet Gynecol
of use in women in whom intravenous access is limited, in whom it is desirable to limit intravenous fluid, or in whom it is important to hold blood loss to a minimum. REFERENCES 1. Golan A, (Baruch)Lidor AL, Wexler S, David MP. A new method for management of the retained placenta. AM J 08ST£T GYN£COL 1983;146:708-9. 2. Golan A, (Baruch)Lidor AL, Wexler S, David MP. Reply to Liner [Letter]. AM J 08STET GYNECOL 1984; 148:232. 3. Kristiansen FV, Frost L, Kaspersen P, Moller BR. The effect of oxytocin injection into the umbilical vein for the management of the retained placenta. AM J 08STET GYNECOL 1987; 156:979-80. 4. Chestnut DH, Wilcox LL. Influence of umbilical vein administration of oxytocin on the third stage of labor: a randomized, double blind, placebo-controlled study. AM J 08STET GYNECOL 1987;157:160-2. 5. Pritchard JA, MacDonald PC, Gant NF, eds. Williams' obstetrics. 17th ed. Norwalk, Connecticut: AppletonCentury-Crofts, 1985:342-5.
7. Worley G, Lipman B, Gewolb IH, et al. Creatine kinase brain isoenzyme: relationship of cerebrospinal fluid concentration to the neurologic condition of newborns and cellular localization in the human brain. Pediatrics 1985; 76:15. 8. Becker M, Menzel K. Brain-typical creatine kinase in the serum of newborn infants with perinatal brain damage. Acta Paediatr Scand 1978;67:177. 9. Cuestas RA. Creatine kinase isoenzymes in high risk infants. Pediatr Res 1980;14:935. 10. Shields WD, Feldman RC. Serum CK-BB isoenzyme in preterm infants with periventricular hemorrhage. Pediatrics 1982;100:464. II. Fischer WM, Stude I, Brandt H. Ein Vorschlag zur Beurteilung des antepartalen Kardiotokogramms. Z Geburtshilfe Perinatol 1976;180:117. 12. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evaluation of subependymal and intraventricular
January 1989 Am J Obstet Gynecol
13.
14.
15. 16.
hemorrhage: a study of infants with birth weights less than 1500 grams. J Pediatr 1978;92:529. Chemnitz G, Nevermann L, Schmidt E, Schmidt FW, LobersJ. Creatine kinase (EC-NO 2.7.3.2) and creatine kinase isoenzymes during pregnancy and labor and in cord blood. Clin Biochem 1979;12:277. Thompson RJ, GrahamJG, McQueen INF, Kynoch PAM, Brown KW. Radioimmunoassay of brain-type creatine kinase BB isoenzyme in human tissues and in serum of patients with neurologic disorders. J Neural Sci 1980;47:241. Pape KE, Wigglesworth JS. Haemorrhage ischaemia and perinatal brain. Philadelphia: JB Lippincott, 1979. (Clinics in developmental medicine; no 69/70). Hameed C, Tejani N, Tuck S, et al. Correlation of fetal heart rate monitoring and acid-base status with periventricular/intraventricular hemorrhage in the low birth weight neonate. Am J Perinatol 1986;3:24.
Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor Virginia V. Reddy, MD, and J. Chris Carey, MD Oklahoma City, Oklahoma The use of umbilical vein injection of oxytocin was compared with traditional management of the third stage of labor. Pregnant women were randomized to receive intravenous oxytocin after the delivery of the placenta (n = 25) or oxytocin via the umbilical vein immediately after cord clamping (n = 25). Those who received umbilical vein oxytocin had a shorter third stage of labor (4.1 versus 9.4 minutes), less measured blood loss (135 versus 373 ml), and a lower drop in hematocrit (3.9% versus 6.2%). Intraumbilical vein oxytocin appears to be a useful alternative to traditional management of the third stage of labor. (AM J OBSTET GVNECOL 1989;160:206-8.)
Key words: Intraumbilical oxytocin, third-stage labor, puerperal hemorrhage
Golan et al. 1 described a method to deliver a retained placenta. They injected 10 units of oxytocin in 20 ml of normal saline solution into the umbilical vein of each of 10 women, whose placentas were retained for more than 30 minutes. All were delivered spontaneously, with a mean expulsion time of 3 minues 40 seconds after injection. In a Letter to the Editors, Golan et al." reported using the method of 12 additional patients, "with excellent results and no maternal ill effects whatsoever." Kristiansen et al.' studied this method in 51 patients who received, via the umbilical vein, either 10 units of oxytocin in 10 ml of normal saline solution or 10 ml of From the Department of Obstetncs and G.vnecology, The University of Oklahoma Health SCience Center. ReceIved for publzcatzon December 9,1987; revtsedJuly 21,1988; accepted July 29, 1988. Reprint requests: Dr. J. Chns Carey, POB 26901, Oklahoma Czty, OK 73190.
206
normal saline solution alone or underwent manual removal of the placenta. Kristiansen's group found no significant advantage in using the procedure. This study did not report the length of time from injection to delivery for any group. No ill effects from intraumbilical oxytocin were reported. Chestnut and Wilcox' compared intra umbilical oxytocin to intraumbilical saline solution injections.' but they did not compare the method with traditional management. Chestnut and Wilcox injected 10 units of oxytocin in 20 ml of saline solution into the umbilical vein only if the placenta was not expelled within 5 minutes. They found no difference in the mean injectionexpulsion interval or the mean second-day hemoglobin levels between the two groups. We elected to study the use of intraumbilical oxytocin in normal pregnancies without retained placentas as an alternative to the traditional management of the third stage of labor.
Umbilical vein oxytocin
Volume 160 Number I
207
Table I. lntraumbilical oxytocin versus standard management Variable
Parity Birth weight (gm) Placental weight (gm) First stage (hr) Second stage (min) Third stage (min) Preoperative hemoglobin (gm/dl) Preoperative hematocrit (%) Postoperative hemoglobin (gm/d\) Postoperative hematocrit (%) Decrease in hemoglobin (gm/dl) Decrease in hematocrit (%) Measured blood loss in third stage (ml)
Group 1: Urnbllzcal
0.92 3227 666 7.3 39.3 4.1 12.0 35.5 10.7 31.5 1.3 3.9 135
Material and methods Fifty pregnant women at 37 to 41 weeks' gestation were studied. Women were excluded from the study if they had grand multiparity (more than five preg'1ancies), multiple gestation, previous uterine scar, abr .ptio placentae, or preeclampsia or had received magnesium sulfate or oxytocin in labor. Women who were delivered by cesarean section also were excluded. Informed consent was obtained from all patients, who then were randomized by even or odd medical records number. On admission to the labor suite, a complete blood count was obtained on all study patients. All patients were followed up through the first and second stages of labor. Patients in group 1 (umbilical oxytocin) received 20 units of oxytocin, diluted in 30 ml of normal saline solution, into the umbilical vein immediately after the cord was clamped and cut. These patients did not receive oxytocin in the first liter of intravenous fluid post partum but received 20 units in the second liter, for a total of 40 u of oxytocin. Women in group 2 (standard management) did not receive any umbilical injection. They received 20 units of oxytocin in 1000 ml of lactated Ringer's solution intravenously at 125 mllhr after delivery of the placenta. All women received 20 units of oxytocin in 1000 ml of lactated Ringer's with 5% dextrose as a second liter of intravenous fluid, at 125 mllhr. All women were given a total of 40 units of oxytocin, with group 1 receiving 20 units intravenously and 20 units into the umbilical vein, and group 2 receiving 40 units intravenously. All deliveries were performed by first- or second-year residents. The third stage of labor was managed by observation until signs of separation occurred, followed by gentle traction of the cord for expulsion. Blood loss in the third stage of labor was measured by the obstetrician, who collected all blood loss in a basin. The blood loss was then measured in a graduated cylinder. All women had a complete blood count on the morning of the first postpartum day.
± ± ± ± ± ± ± ± ± ± ± ± ±
Group 2: Standard
0.95 382 98 3.0 32.1 2.4 1.5 4.4 1.8 4.9 0.92 2.4 122
0.72 3207 651 12.1 38.5 9.4 \3.0 39.0 11.2 32.9 \.8 6.2 373
± ± ± ± ± ± ± ± ± ± ± ± ±
0.79 353 151 16 33.7 5.8 1.3 3.8 1.5 4.0 1.1
3.3 467
p Value
NS NS NS NS NS <0.0001 <0.02 <0.003 NS NS <0.07 <0.01 <0.02
Data were analyzed on a Hewlett-Packard personal computer with NWA Statpack software. Student's t test with two-tailed significance was used to compare means.
Results The results are summarized in Table I. The two groups of women were similar in parity, birth weight, placental weight, and length of the first and second stages of labor. By chance, the intraumbilical oxytocin group began labor with significantly lower hemoglobin and hematocrit values. The third stage of labor was significantly shorter in the intraumbilical oxytocin group. In this group, the measured blood loss during the third stage of labor and the postpartum decrease in hematocrit were both significantly less. No patient in either group had a placenta retained longer than 30 minutes, and no patient had a manual removal of the placenta. One woman who received intraumbilical oxytocin had a blood loss of 500 ml and became tachycardiac and mildly hypotensive after the delivery of the placenta. She responded quickly to fluid replacement and did not require blood transfusion. This reaction could have been due to the umbilical i~ection of oxytocin, possibly because oxytocin has a direct hypotensive effect. No patient in either group required blood transfusion.
Comment The third stage of labor is usually managed by observation until separation and expulsion occur, followed by the administration of intravenous oxytocin to reduce hemorrhage.' Third-stage hemorrhage is a significant cause of puerperal anemia. With increasing risk of transfusion-borne infections, any mechanism to reduce blood loss and risk of transfusion is of value. The effect of intraumbilical oxytocin on the retained placenta and on the third stage oflabor is controversial. Some authors!' 2 have found the method to be advantageous whereas others' 4 have not. The differences
208 Reddy and Carey
may be attributable to differences in study design. Golan et al. proposed that the injection of intra umbilical oxytocin leads to a high concentration of oxytocin at the uterine wall. We gave a higher dose than other investigators. Perhaps the effect is dose related. Chestnut and Wilcox delayed injection of oxytocin until 5 minutes after birth. We administered oxytocin to the intraumbilical group as soon as the cord was clamped, and the mean third stage was <5 minutes. Perhaps earlier injection has a greater effect. It is also possible that the effect is due to the volume injected and not due, specifically, to oxytocin. Neither our study nor Chestnut's study answered this question. Umbilical vein injection of oxytocin appears to be a useful alternative to the traditional management of the third stage of labor. We noted a shorter third stage of labor and less puerperal blood loss in women who received intra umbilical oxytocin. This method could be
January 1989 Am J Obstet Gynecol
of use in women in whom intravenous access is limited, in whom it is desirable to limit intravenous fluid, or in whom it is important to hold blood loss to a minimum. REFERENCES 1. Golan A, (Baruch)Lidor AL, Wexler S, David MP. A new method for management of the retained placenta. AM J 08ST£T GYN£COL 1983;146:708-9. 2. Golan A, (Baruch)Lidor AL, Wexler S, David MP. Reply to Liner [Letter]. AM J 08STET GYNECOL 1984; 148:232. 3. Kristiansen FV, Frost L, Kaspersen P, Moller BR. The effect of oxytocin injection into the umbilical vein for the management of the retained placenta. AM J 08STET GYNECOL 1987; 156:979-80. 4. Chestnut DH, Wilcox LL. Influence of umbilical vein administration of oxytocin on the third stage of labor: a randomized, double blind, placebo-controlled study. AM J 08STET GYNECOL 1987;157:160-2. 5. Pritchard JA, MacDonald PC, Gant NF, eds. Williams' obstetrics. 17th ed. Norwalk, Connecticut: AppletonCentury-Crofts, 1985:342-5.