Timing alone doesn't influence the drug's  efficacy in preventing postpartum bleeding (strength of recommendation: B, randomized controlled trial [RCT] and prospective cohort studies)

Beste, Janalynn

Flake, Donna

Kahn, Scott

Meyer, Albert A.

University of Missouri: MOspace

CLINICAL INQUIRIES Evidence Based Answers from the Family Physicians Inquiries Network VOL 57, NO 12 / DECEMBER 2008 817www.jfponline.comFAST TRACK  Prophylactic oxytocin: Before or after placental delivery?Evidence-based answerEither is fi ne.  Timing alone doesn’t infl uence the drug’s effi cacy in preventing postpartum bleeding (strength of recommendation: B, randomized controlled trial [RCT] and prospective cohort studies). ❚ Evidence summaryThe prophylactic use of oxytocic drugs re-duces the risk of postpartum hemorrhage (PPH) by about 40% and has been widely adopted as a routine policy in the active management of the third stage of labor.1 A number of studies have evaluated the timing of oxytocin after delivery (TABLE). Which timing is best? It depends on the study A well-constructed double-blinded RCT found no signifi cant difference in the in-cidence of PPH when oxytocin was given after delivery of the anterior shoulder or the placenta.2 The study included 1486 patients; 745 received 20 units of oxy-tocin on delivery of the anterior shoul-der, and 741 received an identical dose of oxytocin on delivery of the placenta. The incidence of PPH was 5.4% for the anterior shoulder group and 5.8% for the placenta group (P=.72). Likewise, no signifi cant difference between the groups was noted in the proportion of women with estimated blood loss (EBL) ≥500 mL (7.5% vs 9.7%; P=.15). A much smaller double-blinded RCT found that PPH occurred signifi cantly less often when oxytocin was delayed until after delivery of the placenta.3 The study comprised 51 patients; 27 received 10 units of oxytocin on delivery of the an-terior shoulder and 24 received an iden-tical dose after delivery of the placenta. The incidence of PPH ≥500 mL was 0% when oxytocin was given after delivery of the placenta vs 14.8% when it was given on delivery of the anterior shoulder (P=.049). However, the study was limited by its size and potential inaccuracies in estimating blood loss. A prospective cohort study noted a signifi cant reduction in the risk of PPH when oxytocin was given after delivery of the anterior shoulder, compared with the placenta.4 In this study, 82 patients re-ceived 5 units of oxytocin on delivery of the anterior shoulder, and 52 received an identical dose after delivery of the placen-ta. The incidence of PPH ≥500 mL was 7.3% in the anterior shoulder group and 19.2% in the placenta group. However, the study was not blinded and was lim-ited by its small sample size. Two earlier studies, an RCT and a prospective cohort study, concluded that oxytocin is more effective in reduc-ing PPH when given before placental delivery (after delivery of the anterior shoulder and head, respectively).5,6 Nei-ther of these studies was blinded nor Oxytocin may be given either before or after the placenta is deliveredScott Kahn, MD Albert Meyer, MD Janalynn Beste, MDNew Hanover Regional Medical Center Residency in Family Medicine, Wilmington, NCDonna Flake, MSLS, MSASHealth Sciences Library, South East Area Health Education Center, Wilmington, NC817_JFP1208   817 11/17/08   1:28:37 PMCopyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.FAST TRACKCLINICAL INQUIRIES818 VOL 57, NO 12 / DECEMBER 2008  THE JOURNAL OF FAMILY PRACTICEcontrolled for nonpharmacologic inter-ventions, however. RecommendationsThe American College of Obstetricians and Gynecologists (ACOG) states that ongoing blood loss accompanied by de-creased uterine tone requires uterotonic agents as fi rst-line treatment for PPH.7 ACOG doesn’t make specifi c recommen-dations regarding the timing of oxytocin administration. The American Academy of Family Physicians (AAFP) recommends oxyto-cin as the uterotonic agent of choice for preventing PPH.8 The AAFP further ad-vocates active management of the third stage of labor to decrease PPH by admin-istering oxytocin as soon as possible af-ter delivery of the anterior shoulder and before delivery of the placenta.The World Health Organization (WHO) also recommends oxytocin as the uterotonic of choice.9 WHO advo-cates administration within 1 minute of delivery of the baby. ■References 1.  Prendiville W, Elbourne D, Chalmers I. The effects of routine oxytocic administration in the management of the third stage of labour: an overview of the evi-dence from controlled trials. Br J Obstet Gynaecol. 1988;95:3-16.  2.  Jackson KW Jr, Allbert JR, Schemmer GK, et al. A randomized, controlled trial comparing oxytocin ad-ministration before and after placental delivery in the prevention of postpartum hemorrhage. Am J Obstet Gynecol. 2001;185:873-877. 3.  Huh WK, Chelmow D, Malone F. A double-blinded, randomized controlled trial of oxytocin at the begin-ning versus the end of the third stage of labor for pre-vention of postpartum hemorrhage. Gynecol Obstet Invest. 2004;58:72-76. 4.  Fujimoto M, Takeuchi K, Sugimoto M et al. Preven-tion of postpartum hemorrhage by uterotonic agents: comparison of oxytocin and methylergometrine in the management of the third stage of labor. Acta Ob-stet Gynecol Scand. 2006;85:1310-1314. 5.  Khan GQ, John IS, Wani S, et al. Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial. Am J Obstet Gynecol. 1997;177:770-774.  6.  Soriano D, Dulitzki M, Schiff E, et al. A prospective co-hort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemor-rhage. Br J Obstet Gynaecol. 1996;103:1068-1073. 7.  American College of Obstetricians and Gynecolo-gists. Practice Bulletin Number 76, June 2006. Post-partum hemorrhage. Obstet Gynecol. 2006;76:1-9.  8.  Quinlan J, Bailey E, Dresang L, et al, for the Ad-vanced Life Support in Obstetrics Advisory Board. 2007-2008 Advanced Life Support in Obstetrics Course Syllabus. Leawood, Kan: American Academy of Family Physicians; 2006. 9.  Managing Complications in Pregnancy and Child-birth: A Guide for Midwives and Doctors. Geneva, Switzerland: World Health Organization, 2003. Avail-able at: www.who.int/reproductivehealth/impac/clinical_principles/normal_lobour_C57_C76.html. Accessed May 12, 2008. What studies say about the timing of oxytocin and PPH riskSTUDY TYPE (YEAR)OXYTOCIN GIVEN AFTEROUTCOMES (RISK OF PPH)DELIVERY OF ANTERIOR SHOULDER (N) DELIVERY OF PLACENTA (N)DBRCT (2001)2 745 741 No difference(OR=0.92; 95% CI, 0.59-1.43)DBRCT (2004)3 27 24 Incidence lower when given after delivery of placenta (P=.049)Cohort (2006)4 82 52 Incidence lower when given after delivery of anterior shoulder (OR=0.33; 95% CI, 0.11-0.98)RCT (1997)5 827 821 Incidence lower when given after delivery of anterior shoulder (OR=0.50; 95% CI, 0.34-0.73)Cohort (1996)6 524 (given after delivery of head)478 Incidence lower when given after delivery of head (OR=0.60; 95% CI, 0.41-0.87)CI, confi dence interval; DBRCT, double-blinded randomized controlled trial; OR, odds ratio; PPH, postpartum hemorrhage; RCT, randomized controlled trial. TABLEProphylactic use of oxytocic drugs reduces the risk of postpartum hemorrhage by about 40% 818_JFP1208   818 11/18/08   1:40:11 PM

Prophylactic oxytocin: Before or after placental delivery?

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