Review
article
Uterine
massage
for
preventing
postpartum
hemorrhage
at
cesarean
delivery:
Which
evidence?
Gabriele
Saccone
a,
Claudia
Caissutti
b,
Andrea
Ciardulli
c,
Vincenzo
Berghella
c,*
aDepartmentofNeuroscience,ReproductiveSciencesandDentistry,SchoolofMedicine,UniversityofNaplesFedericoII,Naples,Italy b
DepartmentofExperimentalClinicalandMedicalScience,DISM,ClinicofObstetricsandGynecology,UniversityofUdine,Udine,Italy
c
DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,SidneyKimmelMedicalCollegeofThomasJeffersonUniversity, Philadelphia,PA,USA
ARTICLE INFO Articlehistory: Received13November2017 Accepted22February2018 Availableonlinexxx Keywords: Postpartumhemorrhage Maternaldeath Bleeding Cesareansection Maternalmortality ABSTRACT
Background:Cesareandeliverycouldbecomplicatedbypostpartumhemorrhage(PPH),thefirstcauseof
maternaldeath.
Objectives:Toevaluatetheefficacyofuterinemassageinpreventingpostpartumhemorrhageatcesarean
delivery.
Datasources:ElectronicdatabasesfromtheirinceptionuntilOctober2017.
Studyeligibilitycriteria,participants,andinterventions:WeincludedallRCTscomparinguterinemassage
aloneor aspart oftheactivemanagement oflaborbefore or afterdeliveryoftheplacenta,orboth,with
non-massageinthesettingofcesareandelivery.
Datacollectionandanalysis:TheprimaryoutcomewasPPH,definedasbloodloss>1000mL.Meta-analysis
wasperformedusingtherandomeffectsmodelofDerSimonianandLaird,toproducesummarytreatment
effectsintermsofmeandifference(MD)orrelativerisk(RR)with95%confidenceinterval(CI).
Results:Only3RCTscomparinguterinemassagevsnouterinemassagewerefound.Thequalityofthese3
trialsingeneralwasverylowwithhighorunclearriskofbias. Allofthemincludedonlywomeninthe setting
ofspontaneousvaginaldeliveryandnoneofthemincludedcesareandelivery,andthereforethe
meta-analysiswasnotfeasible.
Conclusions: There is not enough evidence todetermine if uterine massage prevents postpartum
hemorrhageatcesareandelivery.
©2018ElsevierB.V.Allrightsreserved.
Contents
Introduction ... 65
Materialsandmethods ... 65
Searchstrategy ... 65 Studyselection ... 65 Riskofbias ... 65 Outcomes... 65 Statisticalanalysis ... 65 Results ... 66
Studyselectionandstudycharacteristics ... 66
Synthesisofresults ... 66
*Correspondingauthorat:DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,ThomasJeffersonUniversity,833ChestnutStreet,FirstFloor, Philadelphia,PA19107,USA.
E-mailaddress:vincenzo.berghella@jefferson.edu(V.Berghella).
https://doi.org/10.1016/j.ejogrb.2018.02.023
0301-2115/ ©2018ElsevierB.V.Allrightsreserved.
EuropeanJournalofObstetrics&GynecologyandReproductiveBiology223(2018)64–67
ContentslistsavailableatScienceDirect
European
Journal
of
Obstetrics
&
Gynecology
and
Reproductive
Biology
Discussion... 66
Funding ... 67
Detailsofethicsapproval ... 67
Compliancewithethicalstandards ... 67
References ... 67
Introduction
The first causeof maternal death worldwideis postpartum hemorrhage(PPH),responsibleforanestimated127,000deaths annually. Failure of the uterus to contract adequately after childbirthisthemostcommoncauseofPPH.Intheabsenceof timelyandappropriateaction,awomancoulddiewithinafew hours[1].
Oneofthemostcommoncomplicationsofcesareandelivery (CD)isPPH,whichcanbelifethreatening[2–6].Inhigh-income countries,hemorrhageisreducedbyroutingactivemanagement ofthethirdstageoflabor,includingremovaloftheplacentaby controlledcordtraction,andbyusinguterotonicsafterdelivery, suchoxytocin,tostimulatecontraction oftheuterus[2],orby usingantifibrinolyticsagentsbeforeCD,mainlytranexamicacid (TXA)[3,4].
Assimpleandinexpensiveintervention,uterinemassage,by repetitive massaging or squeezing movements, afterdelivery of the placenta in the setting of CD can also promote contraction of the uterus. However itis not known whether itiseffective[6].
The aim of this systematic review and meta-analysis of randomizedcontrolledtrials(RCTs)was toevaluatetheefficacy ofuterinemassageinpreventingPPHatCD.
Materialsandmethods Searchstrategy
Thisreviewwasperformedaccordingtoaprotocoldesigneda prioriand recommended for systematic review [7].Electronic databases (i.e. MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect,theCochraneLibraryat theCENTRALRegisterof ControlledTrials,Scielo)weresearchedfromtheirinceptionuntil October2017.Searchtermsusedwerethefollowingtextwords: “PPH,” “cesarean”, “caesarean”, “delivery”, “labor”, “labour”, “postpartum hemorrhage,” “bleeding,” “general anesthesia,” “morbidity,” “mortality,” “meta-analysis,” “metaanalysis,” “re-view,” “randomized,” “oxytocin,” “clinical trial,” “randomised,” “effectiveness,”“guidelines,”“bleeding,” “balloon”and “clinical trial.”No restrictionsfor languageor geographiclocationwere applied.In addition,thereferencelistsof allidentifiedarticles were examined to identify studies not captured by electronic searches.Theelectronicsearchandtheeligibilityofthestudies wereindependentlyassessedbytwoauthors(GS,CC).Differences werediscussedwithathirdreviewer(VB).
Studyselection
We included all published, unpublished and ongoing RCTs comparing uterine massage alone or as part of the active management of labor (including uterotonics) before or after deliveryoftheplacenta,orboth,withnon-massageinthesetting ofCD.QuasiRCTs(i.e.trialsinwhichallocationwasdoneonthe basis of a pseudo-random sequence, e.g. odd/even hospital numberordateofbirth,alternation)werenotincluded.Studies onuterinemassage in thesettingof spontaneousor operative vaginaldeliverywerealsoexcluded.
Riskofbias
Theriskofbiasineachincludedstudywasassessedbyusingthe criteriaoutlinedintheCochraneHandbookforSystematicReviewsof Interventions.Sevendomainsrelatedtoriskofbiaswereassessedin each includedtrialsince thereisevidencethat theseissues are associatedwithbiasedestimatesoftreatmenteffect:1)random sequence generation; 2) allocation concealment; 3)blinding of participantsandpersonnel;4)blindingofoutcomeassessment;5) incompleteoutcomedata;6)selectivereporting;and7)otherbias. Reviewauthors’judgmentswerecategorizedas“lowrisk”,“high risk”or“unclearrisk”ofbias[7].
Twoauthors(GS,CC)independentlyassessedinclusioncriteria, riskofbiasanddataextraction.Disagreementswereresolvedby discussionwithathirdreviewer(VB).
Outcomes
Allanalysesweredoneusinganintention-to-treatapproach, evaluatingwomenaccordingtothetreatmentgrouptowhichthey were randomly allocated in the original trials. Primary and secondaryoutcomesweredefinedbeforedataextraction.
TheprimaryoutcomewasPPH,definedasbloodloss>1000mL aftertrialentry.Thesecondaryoutcomeswerebloodloss>300, >500,>1500,>2000,and>2500mLaftertrialentry;meanblood loss after trial entry; mean time to placenta delivery; use of additionaluterotonics;useofotherprocedureformanagementof PPH;bloodtransfusion;andmaternaldeathorseveremorbidity.
Weplannedtoassesstheprimaryandsecondaryoutcomesin thefollowingsubgroupanalyses:
-Uterinemassagebeforeorafterdeliveryoftheplacenta -Withorwithoututerotonics(e.g.oxytocin)
-Withorwithoutcontrolledcordtraction
Wealsoplannedtoassesstheprimaryandsecondaryoutcomes inthefollowingsensitivityanalyses:
-Typeofuterinemassage -Trialquality
Statisticalanalysis
Thedataanalysiswascompletedindependentlybytwoauthors (GS,AC)usingReviewManagerv.5.3(TheNordicCochraneCentre, CochraneCollaboration,2014,Copenhagen,Denmark).The com-pleted analyses were then compared, and any difference was resolvedbydiscussionwithathirdreviewer(VB).
Data from each eligible study were extracted without modificationof originaldata ontocustom-made datacollection forms.Forcontinuousoutcomesmeansstandarddeviationwere extractedandimportedintoReviewManagerv.5.3.
Meta-analysiswasperformedusingtherandomeffectsmodelof DerSimonian andLaird,to producesummarytreatment effectsin termsofmeandifference(MD)orrelativerisk(RR)with95%confidence interval (CI). Heterogeneity was measured using I-squared (Higgins I2).
Potentialpublicationbiaseswereassessedstatisticallybyusing Begg’sandEgger’stests.
Themeta-analysiswasreportedfollowingthePreferred Report-ing Item for Systematic Reviews and Meta-analyses (PRISMA) statement[8].
Results
Studyselectionandstudycharacteristics
TheflowofstudyidentificationisshowninFig.1.Only3RCTs comparinguterine massagevs no uterinemassagewere found [9–11].Thequalityofthese3trialsingeneralwasverylowand
bothofthemhadhighorunclearriskofbiasinmostoftheseven Cochranedomainsrelatedtotheriskofbias(Fig.2AandB).Table1
showsthecharacteristicsoftheclinicaltrials.Allofthemincluded onlywomen inthesettingof spontaneousvaginaldeliveryand noneofthemincludedCD.
Synthesisofresults
NoneofthethreeRCTsmettheinclusioncriteriaandthereforea meta-analysiswasnotfeasible.
Discussion
The results of this review are inconclusive. Only three low quality RCTscomparing uterine massageversus no massageto reducetheriskofPPHwerefoundthroughasystematicreviewof the literature. None of them analyzed the efficacy of uterine massageinthesettingofcesareandelivery.Allofthemwerelow qualitytrials.
Hofmeyretal.inapriorCochranereviewanalyzedtheefficacy ofuterinemassagetopreventPPH [6].Theyincludedonlytwo trialsevaluatingtheefficacyofuterinemassageinthethirdstage oflaboraftervaginaldelivery.Theyconcludedthat thereis not
Fig.1.Flowdiagramofstudiesidentifiedinthesystematicreview.(Prismatemplate [PreferredReportingItemforSystematicReviewsandMeta-analyses]).
Fig.2. Assessmentofriskofbias.(A)Summaryofriskofbiasforeachtrial;Plussign: lowriskofbias;minussign:highriskofbias;questionmark:unclearriskofbias.(B)Risk ofbiasgraphabouteachriskofbiasitempresentedaspercentagesacrossallincluded studies.
enough evidence to support the use of uterine massage after cesareanorvaginaldelivery.
Different strategies have been published to prevent PPH in womenatcesarean[2–6].Prophylacticoxytocinatanydosehave been shown to decrease PPH and the need for therapeutic uterotonics compared to placebo alone [2]. Prophylactic TXA given before cesarean skin incision in women undergoing CD, underspinalorepiduralanesthesia,significantlydecreasesblood loss,includingpostpartumPPHandseverePPH,inadditiontothe standardprophylacticoxytocingivenafterdeliveryoftheneonate [3,4].Differentcesareantechniqueshavealsobeenstudiesinorder toreducebloodlossduringtheoperation.Forexampleexpansion oftheuterineincisionwithfingersinacephalad-caudaddirection is associated with better maternal outcomes and should be preferredtotransverseexpansionduringaCD[5].
Assimpleand inexpensiveintervention,uterinemassage,by repetitivemassagingorsqueezingmovements,afterdeliveryofthe placentainthesettingofCDcanalsohelptoreducetheriskofPPH. TheInternationalConfederationofMidwivesandtheInternational Federation of Gynecologists and Obstetricians (ICM/FIGO) both recommendedroutinemassageoftheuterusafterdeliveryofthe placenta[12].However,thereisverylittleempiricalresearchto evaluate the effectiveness of this method. So far, despite this techniquecanbeeasytodo,inexpensiveandlifesaving,noRCTs havebeenpublishedsofarandnoneareongoing.
In summary, there is not enough evidence to determine if uterine massage prevents postpartum hemorrhage at cesarean delivery.Giventhatthisinexpensiveandsimpleinterventionmay be life saving for women worldwide, especially in low-income countries, where uterotonics can be not available, a large, multicenter, well-designed randomized controlled trial should bea researchpriority.Ifshowntobeeffective,uterinemassage wouldrepresentaneasyinterventionwiththepotentialtohavea majoreffectonpostpartum hemorrhageandmaternalmortality worldwide.
Funding
Thisstudyhadnofundingsource Detailsofethicsapproval
Nonerequired
Compliancewithethicalstandards
*Disclosureofpotentialconflictsofinterest:Wedeclarethatwe havenoconflictofinterest.
*Researchinvolvinghumanparticipantsand/oranimals:no *Informedconsent:nonecessary
References
[1]WorldHealthOrganization(WHO).MaternalMortality.Availableat:http:// www.who.int/mediacentre/factsheets/fs348/en/(Accessed20.05.2017). [2]WesthoffG,CotterAM,TolosaJE.Prophylacticoxytocinforthethirdstageof
labourtoprevent postpartumhaemorrhage.CochraneDatabaseSystRev 2013;30(10):CD001808, doi:http://dx.doi.org/10.1002/14651858.CD001808. pub2.
[3]SimonazziG,BisulliM,SacconeG,MoroE,MarshallA,BerghellaV.Tranexamic acid for preventing postpartum blood loss after cesarean delivery: a systematicreviewandmeta-analysisofrandomizedcontrolledtrials.Acta Obstet Gynecol Scand 2016;95(January (1))28–37, doi:http://dx.doi.org/ 10.1111/aogs.12798Epub2015Nov12.Review..
[4]SimonazziG,SacconeG,BerghellaV.Evidenceontheuseoftranexamicacidat cesareandelivery.ActaObstetGynecolScand2016;95(July(7))837,doi:http:// dx.doi.org/10.1111/aogs.12889Epub2016Mar23.
[5]XodoS,SacconeG,CromiA,OzcanP,SpagnoloE,BerghellaV.Cephalad-caudad versustransversebluntexpansionofthe lowtransverseuterineincision duringcesareandelivery.EurJObstetGynecolReprodBiol2016;202(July)75– 80, doi:http://dx.doi.org/10.1016/j.ejogrb.2016.04.035 Epub 2016 Apr 30. Review..
[6]HofmeyrGJ,Abdel-AleemH,Abdel-AleemMA.Uterinemassageforpreventing postpartum haemorrhage. Cochrane Database Syst Rev 2013;1(July (7)) CD006431,doi:http://dx.doi.org/10.1002/14651858pub3.Review.
[7]Cochranehandbookforsystematicreviewsofinterventions,version5.1.0 (updateMarch).HigginsJPT,GreenS,editors.TheCochraneCollaboration 2011;2011Availableat:handbook.cochrane.org(Accessed20.05.2017). [8]MoherD, LiberatiA,TetzlaffJ,AltmanDG. Preferredreportingitemsfor
systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol2009;62:1006–12.
[9]Abdel-AleemH,HofmeyrGJ,ShokryM,El-SonoosyE.Uterinemassageand postpartumbloodloss.IntJGynaecolObstet2006;93(June(3))238–9Epub 2006May6.
[10]Abdel-AleemH, SingataM,Abdel-AleemM,MshweshweN,Williams X, HofmeyrGJ.Uterinemassagetoreducepostpartumhemorrhageaftervaginal delivery.IntJGynaecolObstet2010;111(October(1)):32–6,doi:http://dx.doi. org/10.1016/j.ijgo.2010.04.036.
[11]ChenM,ChangQ,DuanT,HeJ,ZhangL,LiuX.Uterinemassagetoreduce blood loss aftervaginal delivery: a randomized controlledtrial. Obstet Gynecol2013;122(August(2Pt1)):290–5,doi:http://dx.doi.org/10.1097/AOG. 0b013e3182999085.
[12]ICM/FIGO. International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO). Joint statement: managementofthethirdstageoflabourtopreventpost-partum haemor-rhage.JMidwifWomen’sHealth2004;2004(49):76–7.
Table1
Characteristicsofthetrialsonuterinemassage.
Abdel-Aleem,2006[9] Abdel-Aleem,2010[10] Chen,2013[11]
Studylocation Egypt Egypt China
Samplesizea
200(98/102) 1964(643/652/659) 2340(1170/1170) Inclusioncriteria Singletonundergoingspontaneousvaginaldelivery Singletonundergoingspontaneousvaginal
delivery
Singletonundergoingspontaneousvaginal delivery
Exclusioncriteria Cesareandelivery,malpresentation Cesareandelivery,malpresentation Cesareandelivery,malpresentation Intervention
group
Uterinemassageevery10minfor60minpromptly afterplacentaldelivery
Uterinemassagefor30minpromptlyafter placentaldelivery
Uterinemassagefor30minpromptlyafter placentaldelivery
Useofoxytocinb
Oxytocin10UIMimmediatelyaftercordclamping Oxytocin10UIMimmediatelyafterdelivery oftheshoulder
Oxytocin10UIMimmediatelyafterdelivery oftheshoulder
Additional manovreb
Controlledcordtraction Controlledcordtraction Notstated
Nvaginaldelivery 100% 100% 100%
Ncesarean delivery
0% 0% 0%
Primaryoutcome Meanbloodloss Bloodloss>300mL Bloodloss>400mL
aDataarepresentedasnumberintheuterinemassagegroupvsnumberinthecontrolgroup. b
Inbothgroup.
