Umbilical vein injection for management of retained placenta
Umbilical vein injection of saline solution plus oxytocin appears to be effective in the management of retained placenta. Saline solution alone does not appear be more effective than expectant management. Brief training in giving injections into the umbilical vein may be necessary to implement this intervention.
RHL Commentary by Purwar MB
1. EVIDENCE SUMMARY
In the management of retained placenta, injection of saline (with or without oxytocics) into the umbilical vein was compared with expectant management, on the one hand, and with injection into umbilical vein of an alternative solution, on the other. Compared to expectant management, the injection of saline solution with oxytocin showed a reduction in the rate of manual removal of the placenta but the difference was marginally nonsignificant statistically (relative risk: 0.86; 95% confidence interval: 0.72 to 1.01). Compared to injection of saline solution alone, injection of saline solution with oxytocin showed a statistically significant reduction in the rate of manual removal of the placenta (RR: 0.79; 95% CI: 0.69 to 0.91). However, there was no difference between the two groups in terms of length of third stage of labour, blood loss, haemoglobin, need for blood transfusion, curettage, infection, hospital stay, fever, abdominal pain and oxytocin augmentation. Comparison of saline solution plus prostaglandin and saline solution plus oxytocin found no statistically significant differences for the above outcomes.
All randomized controlled trials that could be identified using the standard search strategy were included and appropriately analysed. However, I should like to draw the readers attention to my following concerns:
- The strategy for identifying controlled trials should have included contacting experts and regional institutions for help in identifying more trials.
- For certain parameters, such as postpartum haemorrhage, infection and length of the third stage of labour, summary measures (Relative Risks) are calculated on the basis of results of single studies.
- Data extraction and assessment of trial quality was done by two reviewers: the inter-observer reliability or agreement between the two reviewers should have been commented on by the authors.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Worldwide 585,000 women die every year as a result of pregnancy and childbirth and 99% of these deaths are occurring in the developing countries (1). About 25% of maternal deaths in Asian Countries are due to haemorrhage during pregnancy, birth or postpartum period. Of these almost 30% are contributed by postpartum haemorrhage. Further 15-20% of these (PPH) maternal deaths are due to retained placenta (2). Incidence of retained placenta is 0.8 – 1.2% of births (2). In modern practice manual removal of the placenta is used if there is failure to deliver the placenta half an hour after delivery of the newborn. Manual removal of the placenta carries a risk of trauma, haemorrhage, rhesus alloimmunization, postpartum infection and anaesthetic complications. In general, infrastructure such as operation theatre facilities and anaesthetists are not available at primary care levels. Therefore a less invasive and inexpensive form of management may be valuable to reduce the need for operative manual removal of retained placenta.
2.2. Feasibility of the intervention
The feasibility of the intervention may be considered from various aspects such as availability of trained health personnel, infrastructure and cost. Personnel assisting deliveries must be trained properly in the technique of giving saline (plus oxytocin) injections into the. In terms of efficacy, there is no evidence from the data reviewed for preferring prostaglandins over oxytocin. Furthermore, prostaglandins are likely to cost more than oxytocin in most developing countries. In India, 10 IU of oxytocin costs about US$ 0.25, which is affordable and the same is likely to be the case in most under-resourced settings. Provided that the health workers are trained in the technique it would be feasible to implement this intervention.
2.3. Applicability of the results of the Cochrane Review
All of the trials reviewed were conducted in developed countries, with the exception of one which was conducted in Latin America. The populations might differ in terms of the incidence of the problem but there are no biological reasons to expect a different effect of saline plus oxytocin in different ethnic groups.
2.4. Implementation of the intervention
The difficulties in implementing this intervention are related to the training of personnel in the technique of giving injections into the umbilical vein. Oxytocin and saline should be available in all primary and secondary care centres.
2.5. Research
Although it may be difficult to conduct, there is a need for a large community-based randomized controlled trial in developing countries on efficacy of saline plus oxytocin injection into the umbilical vein for the management of retained placenta. This trial should compare the following interventions: saline injection with oxytocin versus saline injection with prostaglandin, and perhaps with dose variation of oxytocin (e.g. 10 IU versus 20 IU).
Acknowledgements:Dr. Suresh Ughade, Biostatistician, Clinical Epidemiology Unit, Government Medical College Hospital, Nagpur, India; Dr. Sanjay Zodpey, Associate Professor, GMCH, Government Medical College Hospital, Nagpur, India.
References
- WHO and UNICEF. Revised 1990 estimates of maternal mortality WHO/FRH/MSM/96.1. 1996 .
- Daftary S.N. and Nanawati M.S. Management of Postpartum Haemorrhage. In : Principals and practice of Obstetrics and Gynaecology for Postgraduates. FOGSI Publication. Eds. Buckshee K, Patwardhan VB, and Soonawala R.P. Jaypee Brothers Medical Publishers, New Delhi:1996.
This document should be cited as: Purwar MB. Injection into umbilical vein for management of retained placenta: RHL commentary (last revised: 15 January 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.