Uterine massage for preventing postpartum haemorrhage

Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA

Published Online:

August 8, 2010

Bleeding from the genital tract after childbirth (postpartum haemorrhage) is a major cause of maternal mortality and disability in under-resourced areas with poor access to health services. It is the leading cause of maternal mortality in Sub-Saharan Africa and Egypt and yet is largely preventable. In these settings, poor nutrition, malaria and anaemia add to the health risk. Heavy bleeding directly following childbirth or within 24 hours is most common. Possible causes are the uterus failing to contract after delivery (uterine atony), a retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal lacerations.

In well-resourced settings haemorrhage is reduced by routine active management of delivery of the placenta, the third stage of labour.

Facilities for resuscitation, blood transfusion and surgical interventions are also available. The 2004 joint statement of the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians recommends routine massage of the uterus after delivery of the placenta to promote contraction. This involves placing a hand on the woman's lower abdomen and stimulating the uterus by repetitive massaging or squeezing movements to stimulate uterine contraction.

The present review included one controlled trial that randomly assigned 200 women to either uterine massage or no massage after active management of the third stage of labour, including the routine use of oxytocin.

Uterine massage given every 10 minutes for 60 minutes after birth effectively reduced blood loss, and the need for additional uterotonics, by some 80%. The number of women losing more than 500 ml of blood also appeared to be halved. Two women in the control group and none in the uterine massage group needed blood transfusions.

This one included study had a small sample size so the confidence intervals were wide. The chance of bias with respect to blood loss assessment was minimised by using objective direct measurement.

Disadvantages to massage include the use of staff time and discomfort to the women.

Abstract (click to read)

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, poor nutrition, malaria and anaemia may aggravate the effects of PPH. In addition to the standard known strategies to prevent and treat PPH, there is a need for simple, non-expensive techniques which can be applied in low-resourced settings to prevent or treat PPH.

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 (March 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2) and PubMed (1966 to June 2007).

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, to non-massage.

Data collection and analysis:

Both authors extracted the data independently using the agreed form.

Main results:

One randomised controlled trial in which 200 women were randomised to receive uterine massage or no massage after active management of the third stage of labour. The numbers of women with blood loss more than 500 ml was small, with wide confidence intervals and 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 less in the uterine massage group at 30 minutes (mean difference (MD) -41.60, 95% CI -75.16 to -8.04) and 60 minutes after enrolment (MD -77.40, 95% CI -118.71 to -36.09 ml) . The need for additional uterotonics was reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50). Two blood transfusions were administered in the control group.

Authors' conclusions:

The present review adds support to the 2004 joint statement of the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians on the management of the third stage of labour, that uterine massage after delivery of the placenta is advised to prevent PPH. However, due to the limitations of the one trial reviewed, trials with sufficient numbers to estimate the effects of sustained uterine massage with great precision, both with and in the absence of uterotonics, are needed.

This record should be cited as:

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

Assessed as up to date:

March 31, 2008

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Primary Review Group:

Pregnancy and Childbirth Group

Health topics:

Pregnancy & childbirth > Care during childbirth > Normal labour & birth

Complementary & alternative medicine > Pregnancy & childbirth > Care during childbirth

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Uterine massage for preventing postpartum haemorrhage

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