- Email: [email protected]
P252 Labor induction with oral misoprostol
S484
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
In the manual extraction group, 6 of 80 women had uterine extensions, and 1 of the 80 had a cervical laceration documented at the time of surgery. Whereas, there were no uterine extensions or cervical lacerations evident in the study group (use of the Kiwi® OmniCup® ). Neonatal outcomes revealed no difference between the two groups in APGAR scores or birth weight (7.28 lbs vs. 7.35 lbs; P < 0.62), but there were slightly more scalp effects (bruising, abrasion, and chignon) in the study group. Statistical analysis of the 80 deliveries carried out using the vacuum at differing levels of station are pending. Conclusions: The cesarean section rate continues to increase worldwide However, the technique for this procedure has undergone very little change. Delivery of the infant at time of cesarean section can be difficult, depending on the size and station of the fetal head. Even unengaged and mid-pelvic stationed infants can present difficulties when attempting to deliver the head through the hysterotomy. Lateral extensions in the uterine incision and even lacerations down to the cervix may occur. Thus, using a vacuum device to minimize the space requirements for the hysterotomy can reduce the incidence of these unwanted extensions and lacerations. The 9 reported scalp effects in the study group were all minor and spontaneously resolved within 1 week without treatment. The majority of the scalp effects were due to misplacement of the cup and subsequent pop-offs during the delivery. Those cups that were appropriately placed over the flexion point (three centimeters anterior to the posterior fontanelle along the sagittal suture) had no pop-offs and revealed no evidence of scalp effects. Thus, the minor scalp effects can be largely avoideable if the cup is appropriately placed over the flexion point. The new hand-held vacuums, such as the Kiwi® OmniCup® , decrease the chance of contamination of the surgical field due to their all-in-one design. This study showed that the use of the vacuum extractor at time of cesarean section is a safe and effective method to affect delivery of the fetal head. It limits the traumatic extensions of the hysterotomy and provides a less invasive alternative for the surgeon. Given the increasing rate of cesarean sections worldwide, it is important to evaluate alternative techniques for this antiquated method of delivery. It is clear that more studies are needed to further evaluate this technique. Areas that warrant specific attention are: 1) the use of the vacuum at differing levels of head engagement and the resultant neonatal outcomes; 2) the use of the vacuum at cesarean section with a compromised fetal status. P250 Score to predict the outcome of external cephalic version 1 J. Burgos1 , P. Cobos1 , B. Otero1 , L. Fernandez-Llebrez ´ , J. Pijoan ´ 2, 1 1 J. Melchor . Department Obstetrics & Gynecology, Cruces University Hospital, Vizcaya. Spain, 2 Department Epidemiology. Cruces University Hospital. Vizcaya. Spain
Objective: To design an index based on clinical parameters to predict the outcome of external cephalic versions at term. Materials and Methods: A three-phase study was conducted (index analysis and design, internal validation and prospective validation) regarding 500 versions performed between March 2002 and March 2008. The first 300 patients were included under phases one and two, which took place between March 2002 and March 2006. This sample was randomly divided into two sub-groups: one group of 200 patients (derivation group) and another one of 100 patients (validation group). During the first phase, the first group was used to determine the variables that were potentially associated with the success of the procedure and to design the predictive index. During the second phase, the second group was used for the analysis of the internal validation of results. The third phase of the study, i.e. the prospective phase, included the 200 versions performed between March 2006 and March 2008. The variables considered in the index
were selected based on logistic regression models and multiple correspondence analyses. The predictive capacity was estimated through the area under the ROC curve. Results: Parity, placental location, breech variety and fetal cephalic pole with regards to the average line are variables associated with ECV success. The combination of parity, placental location and breech variety accounted for a predictive capacity of 75% (95% CI 68–82%; p < 0.01). These results were confirmed both in the internal and prospective validation phases. Predictive index proposed
Parity Placental location Breech variety
1
2
3
I-Parous Anterior Incomplete
II-Parous Fundus-Lateral Frank
III-Parous or more Posterior Complete-Footling
Conclusion: our study develops a predictive index for the outcome of external cephalic version at term that can be used by gynaecologists as a simple tool in clinical decision making. Its scientific methodology, which has been specifically designed for this three-phase study, validates the model’s results and predictability. P251 Fetal blood sampling – How quick are we? U. Esen, R. Meneni. South Tyneside Hospital, United Kingdom Background: Fetal blood sampling aims at detecting significant fetal hypoxia leading to fetal acidemia. NICE guidelines recommend that fetal blood sampling be repeated in 30min if the pH is 7.2–7.25 and expedite delivery if less than 7.2. Hence the time taken for fetal blood sampling is an important factor in the outcome of these fetuses, as well as in the decision to proceed to c/s or repeat the sample. Aim: The aim of the study was to determine the time taken from a decision to perform the fetal blood sampling to the result being available in our unit. Material and Methods: A retrospective case note analysis of 100 women who had FBS performed in labour from 1st January 2008 to 31st Aug 2008 at the South Tyneside Maternity Unit was performed. The notes were identified from the blood gas analyser in the delivery suite. Results: Ninety six percent of attempts yielded a result. The median time from decision to availability of results was 19min (interquartile range – 11–29). In 15% of women the result took longer than 30 min. Body Mass Index, cervical dilatation, the grade of the operator and technical problems with the analyser influenced the decision to result interval. FBS was performed in 9.3% of all deliveries. Conclusion: The time taken to perform the FBS should be considered in the delivery decision – making process in cases with suspected fetal compromise. Each unit should be aware of the average time taken for the process within their delivery suite. P252 Labor induction with oral misoprostol H. Mets, T. Angerjas Objective: Misoprostol (PGE1) has been widely investigated as an agent for induction of labor. There are many systematic reviews that focus on the use of both oral and vaginal misoprostol. Misoprostol appears to be safer when given orally then vaginally. To evaluate the success rate and the safety of labor induction with oral misoprostol, we collected the data. Methods: We retrospectively reviewed hospital delivery records of 598 women with singleton pregnancies, fetal cephalic position and ≥37 weeks of pregnancy from period Januar 2007–December 2008. Pregnancies with previous S-section in history were excluded. The
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
oral misoprostol was used for induction in 50 microgram tablet sublingually every four hours (2 to 3 times a day). Results: There were recorded a total of 8338 live births in our hospital during this period. Labor induction with misoprostol was used in 7.17% of cases. The causes of induction were:pregnancy after 41 weeks 54% (323), preeclampsia 26.7% (160), diabetes 3.8% (23), intrahepatic cholestasis 3.3% (20) and other 12.2% (72). Labor started after the first tablet in 43.3% of cases (259), after second tablet in 41.9% (251). After the induction 35.6% (213) of parturients needed oxytocin stimulation. Cesarean section rate was 23.6% (141). The main reason of S-section was fetal hypoxia – 50% (71). Induction failure was in 0.6% (4) of cases, hyperstimulation with fetal heart rate changes was in 1.3% (8) of cases. Neonatal outcome was good, Apgar below 7 was only in 23 cases – 3.8%. Conclusion: Oral misoprostol in small regimens appears to be effective and safe induction agent in obstetrics. Compared to recommended vaginal PGE2 preparations misoprostol is significantly cheaper and heat-stable. P253 Caesarean section on request – A reality in Oman S. Minocha, A. Zutshi Objective: To study if the trend of caesarean section on patient request is a contributory factor for increasing rates of caesarean sections in a tertiary referral centre of Oman & its effect on perinatal outcome. Material and Methods: This was a retrospective study conducted at Royal hospital over 8 years from 1999–2006. Computer data & hospital records were utilised to collect information. Statistical analysis was done through p value using SPSS. Results: The number of deliveries revealed yearly rise along with number of caesarean sections. The rate of caesarean section increased from 11.07% in 1999 to 18.6% in 2006 which was statistically significant. This was contributed by increase in almost all indications but patient request showed significant rise after 2002. Only 0.5% of caesarean sections were planned elective sections on request from 1999–2002 which increased to 2.8% from 2003–2006 (p < 0.001). No change was noticed in perinatal morbidity with liberalisation of caesarean sections which is in consistence with the literature. Conclusion: Although caesarean section on patient request has become a reality in this part of the world but considering the social requirement of multiparity, it should be after adequate informed consent. P254 6-year review of all anal sphincter injuries during vaginal deliveries in a DGH and its management S. Mittal, M. Das, M. O’neill Objectives: To explore any recent trends in occurrence & risk factors for obstetric anal sphincter injury (OASI) & ways to improve outcome. Materials and Methods: retrospective study of 150 patients with OASI in 6 years (2003–2008). Data accessed & collected through clinical audit on designed proformas. Results: Overall occurrence was 1.4% of vaginal deliveries. Majority were in age group of 25–35, normal BMI & nullipara. Postdate pregnancy was a risk in two thirds, which could be indirectly linked to factors such as induction/augmentation of labour etc. Associated risk was 2% with induction of labour & epidural, 6% with syntocinon augmentation, 3% with ventouse & over 8% with forceps deliveries. Episiotomy was given in 12% spontaneous & 84% instrumental delivery in this group. Women with babies of over 3.5 kg had 2.6% risk. Junior medical staff, perhaps competent, repaired one third of injuries. 10% were symptomatic with faecal urgency & incontinence. Extent of sphincter injury didn’t seem
S485
to be co-related with symptoms. 50% reported improvement with supervised pelvic floor exercises. Conclusions: Association of nulliparity, prolonged second stage, instrumental delivery, and big babies were confirmed. Medio-lateral episiotomy appeared to be protective for both ventouse & forceps deliveries and should be considered in nulliparous women and others with increased risk. There is scope for more training, support and competency assessment of Junior Medical staff undertaking repair to improve outcome. Diverse factors ranging from maternal age, previous bowel symptoms, and nutrition could be related to subsequent symptoms and need further evaluation. P255 The efficacy of wound infiltration with combination of bupivacaine 0.5% and epinephrine in decreasing post-operative pain in patients with transverse cesarean section V. Modarres Nejad. Kerman University Introduction: Post-operative pain has been always an important surgical complication and surgeons have always been concerned with this issue. Among various suggested techniques for postcesarean pain relief, use of narcotics or non-steroid antiinflammatory drugs are not accepted due to the problems caused for breast-feeding and gynecologists prefer pre-operative or post-incision analgesic techniques. In this study, the efficacy of Bupivacaine-H combined with epinephrine in post-cesarean pain relief was investigated. Methods: In a randomized double-blind clinical trial in summer and autumn 2004 in Afzalipour Hospital (Kerman/ Iran), 70 women candidate of elective cesarean were randomly divided into case and control groups (n = 35). Inclusion criteria were 18–28 years age, 60–80 kg weight, no addiction, no accompanying surgical operation, general anesthesia with the same type and amount of medicines. Incision length was similar in all women and injection of Bupivacaine (case group) and normal saline (control group) was performed after fetus expulsion. Pain evaluation was performed in 0, 6, 12, 24 and 48 post-operative hours by using Visual Analogue Scale. Data were analyzed through SPSS and using Mann-Whitney, Wilcoxon Rank and repeated measure ANOVA tests. The power of tests was analyzed by STATA’s Sampsi command. Results: Mean age of subjects was 25.36±2.48 years and their age range was 18–28 years. The educational level of about two third of subjects was higher than secondary school. Previous history of cesarean with the relative frequency of 38.5% was the most frequent cause of cesarean candidacy. During the first 24 post-operative hour pain was less severe in the control group as compared to the control group (P<). After 24 hours two groups showed no significant difference in pain severity (P>). Discussion: The analgesic effect of Bupivacaine during the first 24 post-operative hours is significant and in whole, it is concluded that wound infiltration with Bupivacaine in cesarean section is an efficient way for post-operative pain management and has no serious side effect. P256 Controlled cord traction in active management of the third stage (AMTSL) for the prevention of postpartum hemorrhage: FIGO saving mothers and newborns project activities in Ukraine I. Mogilevkina1 , V. Chaika2 , N. Morozova3 , A. Shipunova4 , Y. Khaletskiy4 , V. Senikas5 , A. Lalonde5 , L. Perron5 . 1 Donetsk National Medical University, RNGO UMP, Ukraine, 2 Donetsk National Medical University, Donetsk ObsGyn Association, Ukraine, 3 Donetsk National Medical University, Ukraine, 4 Donetsk Regional Center for Mother and Child Care, Ukraine, 5 SOGC, Canada AMTSL properly performed helps to prevent postpartum hemorrhage (PPH). This procedure although supported by Ministry of Public Health, Ukraine still receives much opposition from health
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
In the manual extraction group, 6 of 80 women had uterine extensions, and 1 of the 80 had a cervical laceration documented at the time of surgery. Whereas, there were no uterine extensions or cervical lacerations evident in the study group (use of the Kiwi® OmniCup® ). Neonatal outcomes revealed no difference between the two groups in APGAR scores or birth weight (7.28 lbs vs. 7.35 lbs; P < 0.62), but there were slightly more scalp effects (bruising, abrasion, and chignon) in the study group. Statistical analysis of the 80 deliveries carried out using the vacuum at differing levels of station are pending. Conclusions: The cesarean section rate continues to increase worldwide However, the technique for this procedure has undergone very little change. Delivery of the infant at time of cesarean section can be difficult, depending on the size and station of the fetal head. Even unengaged and mid-pelvic stationed infants can present difficulties when attempting to deliver the head through the hysterotomy. Lateral extensions in the uterine incision and even lacerations down to the cervix may occur. Thus, using a vacuum device to minimize the space requirements for the hysterotomy can reduce the incidence of these unwanted extensions and lacerations. The 9 reported scalp effects in the study group were all minor and spontaneously resolved within 1 week without treatment. The majority of the scalp effects were due to misplacement of the cup and subsequent pop-offs during the delivery. Those cups that were appropriately placed over the flexion point (three centimeters anterior to the posterior fontanelle along the sagittal suture) had no pop-offs and revealed no evidence of scalp effects. Thus, the minor scalp effects can be largely avoideable if the cup is appropriately placed over the flexion point. The new hand-held vacuums, such as the Kiwi® OmniCup® , decrease the chance of contamination of the surgical field due to their all-in-one design. This study showed that the use of the vacuum extractor at time of cesarean section is a safe and effective method to affect delivery of the fetal head. It limits the traumatic extensions of the hysterotomy and provides a less invasive alternative for the surgeon. Given the increasing rate of cesarean sections worldwide, it is important to evaluate alternative techniques for this antiquated method of delivery. It is clear that more studies are needed to further evaluate this technique. Areas that warrant specific attention are: 1) the use of the vacuum at differing levels of head engagement and the resultant neonatal outcomes; 2) the use of the vacuum at cesarean section with a compromised fetal status. P250 Score to predict the outcome of external cephalic version 1 J. Burgos1 , P. Cobos1 , B. Otero1 , L. Fernandez-Llebrez ´ , J. Pijoan ´ 2, 1 1 J. Melchor . Department Obstetrics & Gynecology, Cruces University Hospital, Vizcaya. Spain, 2 Department Epidemiology. Cruces University Hospital. Vizcaya. Spain
Objective: To design an index based on clinical parameters to predict the outcome of external cephalic versions at term. Materials and Methods: A three-phase study was conducted (index analysis and design, internal validation and prospective validation) regarding 500 versions performed between March 2002 and March 2008. The first 300 patients were included under phases one and two, which took place between March 2002 and March 2006. This sample was randomly divided into two sub-groups: one group of 200 patients (derivation group) and another one of 100 patients (validation group). During the first phase, the first group was used to determine the variables that were potentially associated with the success of the procedure and to design the predictive index. During the second phase, the second group was used for the analysis of the internal validation of results. The third phase of the study, i.e. the prospective phase, included the 200 versions performed between March 2006 and March 2008. The variables considered in the index
were selected based on logistic regression models and multiple correspondence analyses. The predictive capacity was estimated through the area under the ROC curve. Results: Parity, placental location, breech variety and fetal cephalic pole with regards to the average line are variables associated with ECV success. The combination of parity, placental location and breech variety accounted for a predictive capacity of 75% (95% CI 68–82%; p < 0.01). These results were confirmed both in the internal and prospective validation phases. Predictive index proposed
Parity Placental location Breech variety
1
2
3
I-Parous Anterior Incomplete
II-Parous Fundus-Lateral Frank
III-Parous or more Posterior Complete-Footling
Conclusion: our study develops a predictive index for the outcome of external cephalic version at term that can be used by gynaecologists as a simple tool in clinical decision making. Its scientific methodology, which has been specifically designed for this three-phase study, validates the model’s results and predictability. P251 Fetal blood sampling – How quick are we? U. Esen, R. Meneni. South Tyneside Hospital, United Kingdom Background: Fetal blood sampling aims at detecting significant fetal hypoxia leading to fetal acidemia. NICE guidelines recommend that fetal blood sampling be repeated in 30min if the pH is 7.2–7.25 and expedite delivery if less than 7.2. Hence the time taken for fetal blood sampling is an important factor in the outcome of these fetuses, as well as in the decision to proceed to c/s or repeat the sample. Aim: The aim of the study was to determine the time taken from a decision to perform the fetal blood sampling to the result being available in our unit. Material and Methods: A retrospective case note analysis of 100 women who had FBS performed in labour from 1st January 2008 to 31st Aug 2008 at the South Tyneside Maternity Unit was performed. The notes were identified from the blood gas analyser in the delivery suite. Results: Ninety six percent of attempts yielded a result. The median time from decision to availability of results was 19min (interquartile range – 11–29). In 15% of women the result took longer than 30 min. Body Mass Index, cervical dilatation, the grade of the operator and technical problems with the analyser influenced the decision to result interval. FBS was performed in 9.3% of all deliveries. Conclusion: The time taken to perform the FBS should be considered in the delivery decision – making process in cases with suspected fetal compromise. Each unit should be aware of the average time taken for the process within their delivery suite. P252 Labor induction with oral misoprostol H. Mets, T. Angerjas Objective: Misoprostol (PGE1) has been widely investigated as an agent for induction of labor. There are many systematic reviews that focus on the use of both oral and vaginal misoprostol. Misoprostol appears to be safer when given orally then vaginally. To evaluate the success rate and the safety of labor induction with oral misoprostol, we collected the data. Methods: We retrospectively reviewed hospital delivery records of 598 women with singleton pregnancies, fetal cephalic position and ≥37 weeks of pregnancy from period Januar 2007–December 2008. Pregnancies with previous S-section in history were excluded. The
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
oral misoprostol was used for induction in 50 microgram tablet sublingually every four hours (2 to 3 times a day). Results: There were recorded a total of 8338 live births in our hospital during this period. Labor induction with misoprostol was used in 7.17% of cases. The causes of induction were:pregnancy after 41 weeks 54% (323), preeclampsia 26.7% (160), diabetes 3.8% (23), intrahepatic cholestasis 3.3% (20) and other 12.2% (72). Labor started after the first tablet in 43.3% of cases (259), after second tablet in 41.9% (251). After the induction 35.6% (213) of parturients needed oxytocin stimulation. Cesarean section rate was 23.6% (141). The main reason of S-section was fetal hypoxia – 50% (71). Induction failure was in 0.6% (4) of cases, hyperstimulation with fetal heart rate changes was in 1.3% (8) of cases. Neonatal outcome was good, Apgar below 7 was only in 23 cases – 3.8%. Conclusion: Oral misoprostol in small regimens appears to be effective and safe induction agent in obstetrics. Compared to recommended vaginal PGE2 preparations misoprostol is significantly cheaper and heat-stable. P253 Caesarean section on request – A reality in Oman S. Minocha, A. Zutshi Objective: To study if the trend of caesarean section on patient request is a contributory factor for increasing rates of caesarean sections in a tertiary referral centre of Oman & its effect on perinatal outcome. Material and Methods: This was a retrospective study conducted at Royal hospital over 8 years from 1999–2006. Computer data & hospital records were utilised to collect information. Statistical analysis was done through p value using SPSS. Results: The number of deliveries revealed yearly rise along with number of caesarean sections. The rate of caesarean section increased from 11.07% in 1999 to 18.6% in 2006 which was statistically significant. This was contributed by increase in almost all indications but patient request showed significant rise after 2002. Only 0.5% of caesarean sections were planned elective sections on request from 1999–2002 which increased to 2.8% from 2003–2006 (p < 0.001). No change was noticed in perinatal morbidity with liberalisation of caesarean sections which is in consistence with the literature. Conclusion: Although caesarean section on patient request has become a reality in this part of the world but considering the social requirement of multiparity, it should be after adequate informed consent. P254 6-year review of all anal sphincter injuries during vaginal deliveries in a DGH and its management S. Mittal, M. Das, M. O’neill Objectives: To explore any recent trends in occurrence & risk factors for obstetric anal sphincter injury (OASI) & ways to improve outcome. Materials and Methods: retrospective study of 150 patients with OASI in 6 years (2003–2008). Data accessed & collected through clinical audit on designed proformas. Results: Overall occurrence was 1.4% of vaginal deliveries. Majority were in age group of 25–35, normal BMI & nullipara. Postdate pregnancy was a risk in two thirds, which could be indirectly linked to factors such as induction/augmentation of labour etc. Associated risk was 2% with induction of labour & epidural, 6% with syntocinon augmentation, 3% with ventouse & over 8% with forceps deliveries. Episiotomy was given in 12% spontaneous & 84% instrumental delivery in this group. Women with babies of over 3.5 kg had 2.6% risk. Junior medical staff, perhaps competent, repaired one third of injuries. 10% were symptomatic with faecal urgency & incontinence. Extent of sphincter injury didn’t seem
S485
to be co-related with symptoms. 50% reported improvement with supervised pelvic floor exercises. Conclusions: Association of nulliparity, prolonged second stage, instrumental delivery, and big babies were confirmed. Medio-lateral episiotomy appeared to be protective for both ventouse & forceps deliveries and should be considered in nulliparous women and others with increased risk. There is scope for more training, support and competency assessment of Junior Medical staff undertaking repair to improve outcome. Diverse factors ranging from maternal age, previous bowel symptoms, and nutrition could be related to subsequent symptoms and need further evaluation. P255 The efficacy of wound infiltration with combination of bupivacaine 0.5% and epinephrine in decreasing post-operative pain in patients with transverse cesarean section V. Modarres Nejad. Kerman University Introduction: Post-operative pain has been always an important surgical complication and surgeons have always been concerned with this issue. Among various suggested techniques for postcesarean pain relief, use of narcotics or non-steroid antiinflammatory drugs are not accepted due to the problems caused for breast-feeding and gynecologists prefer pre-operative or post-incision analgesic techniques. In this study, the efficacy of Bupivacaine-H combined with epinephrine in post-cesarean pain relief was investigated. Methods: In a randomized double-blind clinical trial in summer and autumn 2004 in Afzalipour Hospital (Kerman/ Iran), 70 women candidate of elective cesarean were randomly divided into case and control groups (n = 35). Inclusion criteria were 18–28 years age, 60–80 kg weight, no addiction, no accompanying surgical operation, general anesthesia with the same type and amount of medicines. Incision length was similar in all women and injection of Bupivacaine (case group) and normal saline (control group) was performed after fetus expulsion. Pain evaluation was performed in 0, 6, 12, 24 and 48 post-operative hours by using Visual Analogue Scale. Data were analyzed through SPSS and using Mann-Whitney, Wilcoxon Rank and repeated measure ANOVA tests. The power of tests was analyzed by STATA’s Sampsi command. Results: Mean age of subjects was 25.36±2.48 years and their age range was 18–28 years. The educational level of about two third of subjects was higher than secondary school. Previous history of cesarean with the relative frequency of 38.5% was the most frequent cause of cesarean candidacy. During the first 24 post-operative hour pain was less severe in the control group as compared to the control group (P<). After 24 hours two groups showed no significant difference in pain severity (P>). Discussion: The analgesic effect of Bupivacaine during the first 24 post-operative hours is significant and in whole, it is concluded that wound infiltration with Bupivacaine in cesarean section is an efficient way for post-operative pain management and has no serious side effect. P256 Controlled cord traction in active management of the third stage (AMTSL) for the prevention of postpartum hemorrhage: FIGO saving mothers and newborns project activities in Ukraine I. Mogilevkina1 , V. Chaika2 , N. Morozova3 , A. Shipunova4 , Y. Khaletskiy4 , V. Senikas5 , A. Lalonde5 , L. Perron5 . 1 Donetsk National Medical University, RNGO UMP, Ukraine, 2 Donetsk National Medical University, Donetsk ObsGyn Association, Ukraine, 3 Donetsk National Medical University, Ukraine, 4 Donetsk Regional Center for Mother and Child Care, Ukraine, 5 SOGC, Canada AMTSL properly performed helps to prevent postpartum hemorrhage (PPH). This procedure although supported by Ministry of Public Health, Ukraine still receives much opposition from health