Uterine massage for preventing postpartum haemorrhage

Abstract

Background: Postpartum haemorrhage (PPH) (bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under-resourced areas. In these settings, uterotonics are often not accessible. There is a need for simple, inexpensive techniques which can be applied in low-resourced settings to prevent and treat PPH. Uterine massage is recommended as part of the routine active management of the third stage of labour. However, it is not known whether it is effective. If shown to be effective, uterine massage would represent a simple intervention with the potential to have a major effect on PPH and maternal mortality in under-resourced settings.

Objectives: To determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013).

Selection criteria: All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or in addition to uterotonics before or after delivery of the placenta, or both, with non-massage.

Data collection and analysis: Two researchers independently considered trials for eligibility, assessed risk of bias and extracted the data using the agreed form. Data were checked for accuracy. The effect of uterine massage commenced before or after placental delivery were first assessed separately, and then the combined for an overall result.

Main results: This review included two randomised controlled trials. The first trial included 200 women who were randomised to receive uterine massage or no massage following delivery of the placenta, after active management of the third stage of labour including use of oxytocin. The numbers of women with blood loss more than 500 mL was small, with no statistically significant difference (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.16 to 1.67). There were no cases of retained placenta in either group. The mean blood loss was significantly less in the uterine massage group at 30 minutes (mean difference (MD) -41.60 mL, 95% CI -75.16 to -8.04) and 60 minutes after trial entry (MD -77.40 mL, 95% CI -118.71 to -36.09). The need for additional uterotonics was significantly reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50).For use of uterine massage before and after delivery of the placenta, one trial recruited 1964 women in Egypt and South Africa. Women were assigned to receive oxytocin, uterine massage or both after delivery of the baby but before delivery of the placenta. There was no added benefit for uterine massage plus oxytocin over oxytocin alone as regards blood loss greater than or equal to 500 mL (average RR 1.56, 95% CI 0.44, 5.49; random-effects) or need for additional use of uterotonics (RR 1.02, 95% CI 0.56 to 1.85).The two trials were combined to examine the effect of uterine massage commenced either before or after delivery of the placenta. There was substantial heterogeneity with respect to the blood loss 500 mL or more after trial entry. The average effect using a random-effects model found no statistically significant differences between groups (average RR 1.14, 95% CI 0.39 to 3.32; random-effects).

Authors' conclusions: The results of this review are inconclusive, and should not be interpreted as a reason to change current practice. Due to the limitations of the included trials, more trials with sufficient numbers of women are needed in order to estimate the effects of sustained uterine massage. All the women compared in this review received oxytocin as part of the active management of labour. Recent research suggests that once an oxytocic has been given, there is limited scope for further reduction in postpartum blood loss. Trials of uterine massage in settings where uterotonics are not available, and which measure women's experience of the procedure, are needed.

Conflict of interest statement

HA and GJH are co‐authors of Abdel‐Aleem 2006. HA, MA and GJH are co‐authors of Abdel‐Aleem 2010 Egypt / Abdel‐Aleem 2010 S Africa. One of the Pregnancy and Childbirth Group editors (AM Gulmezoglu) evaluated the studies for inclusion in the review, including assessment for risk of bias.

Figures

1.1. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.

1.2. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.

1.3. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 3 Use of additional uterotonics.

1.4. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 4 Blood transfusion.

1.5. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 5 Need for manual removal of placenta.

1.6. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 6 Blood loss > 1000 mL.

1.9. Analysis

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 9 Haemoglobin

2.1. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.

2.2. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.

2.4. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 4 Mean blood loss in 30 minutes after trial entry.

2.5. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 5 Mean blood loss in 60 minutes after delivery (mL).

2.6. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 6 Use of additional uterotonics.

2.8. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 8 Blood transfusion.

2.9. Analysis

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 9 Maternal death or severe morbidity.

3.1. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.

3.2. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.

3.3. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 3 Use of additional uterotonics.

3.4. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 4 Blood transfusion.

3.5. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 5 Need for manual removal of placenta.

3.6. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 6 Blood loss > 1000 mL.

3.7. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 7 Mean blood loss at 30 minutes.

3.8. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 8 Mean blood loss at 60 minutes.

3.9. Analysis

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 9 Haemoglobin

References

References to studies included in this review Abdel‐Aleem 2006 {published data only}

Abdel‐Aleem 2010 Egypt {published data only} Abdel‐Aleem 2010 S Africa {published data only} Additional references Abdel‐Aleem 2010 Deeks 2001 Egger 1997 Fawcus 1995 Gates 2005 Harbord 2006 Higgins 2005 Higgins 2011 ICM/FIGO 2004 Lazarus 2005 MOH 2000 NCCEMD 2006 RevMan 2008 [Computer program] RevMan 2011 [Computer program] WHO 2000 Widmer 2010 References to other published versions of this review Hofmeyr 2008