Uterine massage for preventing postpartum haemorrhage

Bleeding after childbirth (postpartum haemorrhage) is the leading cause of maternal deaths in Sub-Saharan Africa and Egypt, and yet it is largely preventable. Possible causes of heavy bleeding directly following childbirth or within the first 24 hours are that the uterus fails to contract after delivery (uterine atony), a retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal tears.

In well-resourced settings haemorrhage is reduced by routine active management of delivery of the placenta, called the third stage of labour, using a drug to stimulate contraction of the uterus such as oxytocin. Uterine massage after delivery of the placenta can also promote contraction of the uterus. This involves placing a hand on the woman's lower abdomen and stimulating the uterus by repetitive massaging or squeezing movements.

This review included two controlled trials in which women were randomly assigned to receive uterine massage or no massage with active management of the third stage of labour, including the routine use of oxytocin.

In one trial involving 200 women, uterine massage was given every 10 minutes for 60 minutes after delivery of the placenta effectively reduced blood loss, and the need for additional uterotonics, by some 80%. The numbers of women losing more than 500 mL of blood were too small for meaningful comparison. Two women in the control group and none in the uterine massage group needed blood transfusions.

The second trial involved 1964 women who were assigned to receive oxytocin, uterine massage or both after delivery of the baby and before delivery of the placenta. There was no added benefit for uterine massage when oxytocin was used.

The results of this review are inconclusive. The methodological quality of the two included trials was high but it is possible that there were differences in the procedures used in the study sites. Disadvantages of uterine massage include the use of staff time, and discomfort caused to women. The findings should not change the recommended practice. It is likely that any reduction in blood loss was limited with the use of oxytocin in these trials. Uterine massage may also have increased apparent blood loss by pressing pooled blood out from the uterine cavity. There is a need for more trials, especially in settings where uterotonics are not available. Uterine massage could be a simple inexpensive intervention if proved effective.

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.

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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 strategy: 

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).

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