May 1 2008
An intensive educational program for physicians and midwives involving 19 hospitals in Argentina and Uruguay dramatically reduced the rate of postpartum hemorrhage, according to researchers from the National Institutes of Health and other institutions.
Postpartum hemorrhage is excessive bleeding experienced by the mother after she gives birth. It results from failure of the uterus to contract after detachment of the placenta, or from ruptures or tears in the uterus and other tissues. The intensive educational program stressed giving the drug oxytocin to all women just after vaginal delivery, to contract the uterus and stop uterine bleeding.
The educational program also resulted in many fewer episiotomies being performed at the participating hospitals, especially among women delivering their first infant. An episiotomy is an incision in the skin between the vagina and anus. The procedure was thought to prevent tearing of the vagina during the birth process. Although many studies have shown that episiotomies are not beneficial, they are still performed in many hospitals worldwide.
"It can be difficult to change accepted medical practices," said Duane Alexander, M.D., director of the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). "This successful intervention offers an effective model that can be translated into education programs suitable for interventions throughout the United States and Latin America."
The report of the large randomized controlled trial appears in the May 1 New England Journal of Medicine.
The study was funded by the Global Network for Women's and Children's Health Research, a public-private partnership between the NICHD and the Bill and Melinda Gates Foundation. The NICHD Global Network for Women's and Children's Health Research supports studies seeking to improve treatments, procedures and preventive measures that will reduce death and disability in women, infants, and children in resource poor-countries. For information on the Global network for Women's and Children's Health Research, see http://www.nichd.nih.gov/research/supported/globalnetwork.cfm.
Additional funding for the study was provided by the National Institute of Diabetes and Digestive and Kidney Diseases.
The study's first author was Fernando Althabe, M.D., of the Institute of Clinical Effectiveness and Health Policy, in Buenos Aires, Argentina. The study also included researchers from the School of Public Health and Tropical Medicine at Tulane University, Louisiana; the Research Triangle Institute International, North Carolina; the University of North Carolina at Chapel Hill; the World Health Organization; and the NICHD.
To conduct the study, the researchers distributed questionnaires to birth attendants in 10 public maternity hospitals in Argentina and Uruguay. The birth attendants were asked to identify opinion leaders at their hospitals — physicians, midwives, and residents to whom the other birth attendants at the hospitals looked for professional guidance.
Three to six opinion leaders were selected from each hospital. They attended a five-day workshop on how to develop and carry out guidelines for physicians and midwives based on the best scientific evidence available. The guidelines focused on limiting the use of episiotomy at delivery, and the management of the third stage of labor — the period after birth of the baby, and before expulsion of the placenta.
At the workshop, the opinion leaders were instructed in how to find, evaluate and summarize the research findings on the management of the third stage of labor. Based on that evidence, they developed guidelines recommending administration of oxytocin to all women just after a vaginal birth. They also were taught techniques for stimulating expulsion of the placenta and for inducing the uterine contractions that stop uterine bleeding after detachment of the placenta.
The opinion leaders also developed evidence-based guidelines recommending against the routine use of episiotomy. The procedure poses such risks as blood loss, infection, and subsequent impairment of sexual functioning. The opinion leaders also were taught how to effectively communicate what they had learned at the workshop to their fellow birth attendants.
The remaining nine hospitals served as controls for the study. Birth attendants at those hospitals did not receive any instruction in labor management techniques or for communicating with their peers.
At the end of 18 months, the researchers compiled data on a total of 5,466 vaginal births. The researchers found that oxytocin use increased from 2.1 percent of births before the trial began to 83.6 percent at the 10 intervention (instruction) hospitals. By comparison, oxytocin use increased from 2.6 percent to 12.3 percent at the control hospitals.
Episiotomies decreased from 41.1 percent of births to 29.9 percent at hospitals receiving the staff instruction and increased slightly at control hospitals, from 43.5 percent to 44.5 percent.
The hospitals where the staff received the instruction also had a 45 percent reduction in postpartum hemorrhages of 500 milliliter (2 cups) or more and a 70 percent reduction on postpartum hemorrhage of 1000 milliliter (4 cups) or more.
After one year, oxytocin use remained high at the hospitals receiving the instruction (73.4 percent) and low in the control hospitals (7.1 percent.). Similarly, after a year, the episiotomy rate at hospitals receiving the instruction was 28.1 percent and 45.1 percent in the control hospitals.
Because the change in oxytocin use was much larger than the change in episiotomy use, the researchers suggested that getting health professionals to adopt a new practice may be easier than getting them to eliminate an established practice.
The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation.
http://www.nichd.nih.gov/.
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