Uterine massage for preventing postpartum haemorrhage

Based on one small study which was available for evaluation of this intervention the authors concluded that sustained uterine massage following active management of the third stage of labour may help to reduce mean maternal blood loss. However, the possible benefits of uterine massage should be weighed against the potential pain and discomfort for the mother.

RHL Commentary by Soltani H

1. INTRODUCTION

Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide (1). It is the leading cause of maternal death in developing regions such as sub-Saharan Africa (2) and in under-resourced settings in countries such as Egypt (3). PPH has been attributed to poor management of the third stage of labour, in addition to factors such as poor nutrition (anaemia), lack of sufficient resources and access to health care, delays in transferring women to hospital and infectious diseases (e.g. malaria).

Active management of the third stage of labour has been shown to be effective in reducing blood loss and preventing PPH in well-resourced settings (4, 5). The definition of active management of the third stage of labour used in the trials done to date includes early cord clamping and cutting and routine administration of uterotonic drugs at the delivery of the anterior shoulder of the baby. This may or may not be accompanied with uterine massage. However, WHO (6) and the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians (7) recommend delayed cord clamping and routine massage of the uterus as components of active management of the third stage of labour. Uterine massage is done by making gentle squeezing movements repetitively with one hand on the woman’s lower abdomen in order to stimulate the uterus. It is believed that such repetitive movements stimulate the production of prostaglandins and this leads to uterine contraction and reduced blood loss, although women may find the massage itself uncomfortable or even painful. There has been a lack of clarity with regard to the effects of the uterine massage in preventing PPH. This review (8) is therefore aimed to determine the effectiveness of uterine massage (after birth and before or after delivery of the placenta, or both) in reducing postpartum blood loss and associated morbidity and mortality.

2. METHODS OF THE REVIEW

All randomized controlled trials that had evaluated uterine massage alone (or in addition to uterotonics) before or after delivery of the placenta, or both, in women who had delivered vaginally or by caesarean section, were considered for inclusion. The intervention consisted of uterine massage after delivery of the baby and before or after the delivery of the placenta. The primary outcomes to be studied were: blood loss of 500 ml or more and placenta delivered later than 30 minutes after the birth.

The authors searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (March 2008) without placing any language restrictions. The search itself was conducted with the help of the search co-ordinator of the trials resister. Studies were evaluated for their quality and only those with adequate (using central allocation and sealed opaque envelops) or unclear allocation concealment (but with an attrition rate of less than 10%) were included.

3. RESULTS OF THE REVIEW

Only one small study from Egypt with 200 participants met the inclusion criteria. The allocation concealment was adequate and there were no drop-outs. Owing to the nature of the intervention, the clinicians or participants could not be blinded to the treatment. The trial was evaluated by the authors of the review as being of moderate quality. In the trial, the women were randomly allocated to receive uterine massage or no massage after active management of the third stage of labour, which included use of routine oxytocin (10 units, intramuscularly). The study did not show a statistically significant difference in the incidence of PPH (defined as ≥ 500 ml of blood loss) between the intervention and control groups [risk ratio (RR) 0.52; 95% confidence interval (CI) 0.16–1.67]. No cases of retained placenta and blood transfusion were reported in either of the groups. Mean blood loss in 30 minutes after enrolment was significantly lower in the intervention group compared with the control group [mean difference (MD) -41.60; 95% CI −75.16 to −8.04]. Administration of additional uterotonics was significantly higher in the control group compared with the intervention group (RR 0.20; 95% CI 0.08–0.50]). No results on maternal experience or discomfort were reported in the trial.

4. DISCUSSION

4.1. APPLICABILITY OF THE RESULTS

The intervention in this study, included a sustained uterine massage every 10 minutes, carrying on up to 60 minutes after the birth of the baby, following active management of the third stage of labour. It did not show a significant difference in the incidence of PPH, probably due to lack of sufficient statistical power. It however, showed a significantly lower mean blood loss in the uterine massage group compared with the none-massage group. The use of additional uterotonics was also higher in the intervention group. One may argue that the use of uterotonics is a subjective measure and since the clinicians were not blinded to the process, it may be considered as a source of bias. The other important issue which was not addressed in this review is women’s sensitivity to being touched in the lower abdomen during and after the third stage of labour. Women’s experiences and pain assessment is paramount in this process but these issues were not reported in the study. Overall, even though the evidence is extremely limited, uterine massage appears to have some benefits in terms of reducing mean maternal blood loss. This conclusion would be applicable in all settings.

4.2. IMPLEMENTATION OF THE INTERVENTION

This is a low-cost intervention in which would be easy to implement in under-resourced settings. However, programme managers and policy-makers would have to consider issues around staff time and availability. Considering the limitations of this study, the potential benefits of uterine massage should be weighed against potential pain and discomfort caused to the mother. It would be important to take into account how labouring women feel about uterine massage and apply it according to need with sensitivity and after their informed consent.

4.3. IMPLICATIONS FOR RESEARCH

In light of the limitations of this study, well designed large trials are needed to evaluate the effectiveness of uterine massage with and without the use of uterotonics. It would be beneficial to have a standard approach with particular attention to the following issues in the study design: women delivered vaginally or by caesarean section; comparisons with or without the use of routine uterotonics; uterine massage commenced before or after placental delivery;pattern, frequency and length of uterine massage. In addition to the incidence of PPH and other relevant clinical outcomes, it is of paramount importance to explore women’s experience of this intervention.

Sources of support: Sheffield Hallam University

References

  • Fawcus S, Mbizvo MT, Lindmark G, Nystrom L, Maternal mortality study group. Community based investigation of causes of maternal mortality in rural and urban Zimbabwe. Central African Journal of Medicine 1995;41:105–113.
  • Lazarus JV, Lalonde V. Reducing postpartum hemorrhage in Africa. International Journal of Gynecology & Obstetrics 2005;88:89–90.
  • Egyptian Ministry of Health and Population (EMOP). National Maternal Mortality Study. Cairo: Egyptian Ministry of Health and Population; 2000 (unpublished data).
  • Prendiville WJP, Elbourne D, McDonald SJ. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2000;Issue 3, Art. No.: CD000007; DOI: 10.1002/14651858.CD000007.
  • Begley CM, Devane D, Murphy DJ, Gyte GML, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews 2008;Issue 4, Art. No.: CD007412; DOI: 10.1002/14651858.CD007412.
  • World Health Organization. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: WHO; 2007.
  • International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO). Joint statement: management of the third stage of labour to prevent postpartum haemorrhage. Journal of Midwifery and Women’s Health 2004;49:76–7.
  • Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews 2008;Issue 3, Art. No.: CD006431; DOI: 10.1002/14651858.CD006431.pub2.

This document should be cited as: Soltani H. Uterine massage for preventing postpartum haemorrhage: RHL commentary (last revised: 1 April 2010). The WHO Reproductive Health Library; Geneva: World Health Organization.

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