Bleeding after childbirth (postpartum haemorrhage) is the leading cause of maternal deaths in Sub-Saharan Africa and Egypt, and yet it is largely preventable. Possible causes of heavy bleeding directly following childbirth or within the first 24 hours are that the uterus fails to contract after delivery (uterine atony), a retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal tears.
In well-resourced settings haemorrhage is reduced by routine active management of delivery of the placenta, called the third stage of labour, using a drug to stimulate contraction of the uterus such as oxytocin. Uterine massage after delivery of the placenta can also promote contraction of the uterus. This involves placing a hand on the woman's lower abdomen and stimulating the uterus by repetitive massaging or squeezing movements.
This review included two controlled trials in which women were randomly assigned to receive uterine massage or no massage with active management of the third stage of labour, including the routine use of oxytocin.
In one trial involving 200 women, uterine massage was given every 10 minutes for 60 minutes after delivery of the placenta effectively reduced blood loss, and the need for additional uterotonics, by some 80%. The numbers of women losing more than 500 mL of blood were too small for meaningful comparison. Two women in the control group and none in the uterine massage group needed blood transfusions.
The second trial involved 1964 women who were assigned to receive oxytocin, uterine massage or both after delivery of the baby and before delivery of the placenta. There was no added benefit for uterine massage when oxytocin was used.
The results of this review are inconclusive. The methodological quality of the two included trials was high but it is possible that there were differences in the procedures used in the study sites. Disadvantages of uterine massage include the use of staff time, and discomfort caused to women. The findings should not change the recommended practice. It is likely that any reduction in blood loss was limited with the use of oxytocin in these trials. Uterine massage may also have increased apparent blood loss by pressing pooled blood out from the uterine cavity. There is a need for more trials, especially in settings where uterotonics are not available. Uterine massage could be a simple inexpensive intervention if proved effective.