J. Jpn. Acad. Midwif., Vol. 26, No. 2, 275-283, 2012
*1 St. Luke's College of Nursing, *2 Nagasaki University, *3 Research Center for Development of Nursing Practice, St. Luke's College of Nursing, *4 Doctoral Program, St. Luke's College of Nursing, *5 Omachi Municipal General Hospital, *6 Former Faculty of Nursing and Medical Care, Keio University
Received 2012; accepted 2012
Other
Japan Academy of Midwifery: 2012 evidence-based guidelines
for midwifery care during childbirth
Guidelines Committee: Japan Academy of Midwifery
Yaeko KATAOKA
*1, Hiromi ETO
*2, Mariko IIDA
*1Yukari YAJU
*3, Hiromi ASAI
*4, Ayaka SAKURAI
*5Yuriko TADOKORO
*6, Shigeko HORIUCHI
*1Abstract
The Japan Academy of Midwifery has developed the Evidence-Based Care During Childbirth Guideline for Midwives (2012 edition) containing care policies for healthy low risk women and newborns. In order to disseminate the guideline, contents of the guideline are introduced for midwives through the current paper. A total of twenty nine clinical questions were included in the guideline. For each clinical question, evidence statement, its explanations and references were prepared. Evidence-based and women-centered care would be promoted if midwives adopt care policy in the guideline at hospitals, clinics and independent midwives.
Key word: midwifery, guidelines, care policy, childbirth
Introduction
To ensure a safe and comfortable pregnancy and childbirth for all women is one of the most important topics in the national health plan called “Healthy Par-ents and Children 21” (Ministry of Health, Labour and Welfare, 2010). Their goal is to reduce the mortality rate of pregnant and delivering women by 50% by 2014. Development of evidence based guidelines that indicate the standard care is needed to establish the safety and quality of care because there is considerable diversity of the care policy among health care facilities and regions.
WHO published “Care in Normal Birth: A Practi-cal Guide” in 1996 that recommended effective care for low risk healthy pregnant women. In addition, in the UK the National Institute for Health and Clinical Excellence (2007) developed “Intrapartum care: Care of Healthy Women and Their Babies During Childbirth”, and
Clin-ical Practice Guidelines such as “Active Management of the Third Stage of Labour” (2009); The Society of Obstetricians and Gynaecologists of Canada developed: “Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks” (2008). Also in Japan, some guidelines were recently published: “Care Guideline for Comfort-able Pregnancy and Childbirth” in 2006, “Guidelines for Maternity Home Services” by the Japan Midwives As-sociation revised in 2009 and “Clinical Guidelines for Obstetrical Practice” published by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists in 2011 (Minakami, Hiramatsu, Koresawa, 2011). However, these guidelines are not enough for evidence-based practice and inform recommendations such as preventive care or non-phar-macological care that midwives provide women on dai-ly practice.
risk women and newborns. Highly urgent clinical ques-tions were selected based on the opinions of practicing midwives. The Cochrane Library, PubMed, the Nation-al Guidelines Clearing House for English articles and guidelines were used, and Ichu-shi Web and Minds for Japanese were used to search the research for relevant evidence. Based on this, evidence statements and rec-ommendations, discussion, abstract tables and refer-ences were prepared in the guideline. After obtaining public comments via the internet, the guideline was revised and then published. In order to disseminate the guideline, contents of the guideline are introduced for all Japanese midwives through the current paper.
Contents of the guideline
A total of twenty nine clinical questions were in-cluded in the guideline: induction of labor and monitor-ing the fetus (four questions); pain control (two ques-tions); acceleration of contractions (three quesques-tions); care for the second stage of labor (five questions); care for newborns (eight questions); care during and after the third stage of labor (three questions); and informed consent (four questions). Evidence-based statements are presented below.
CQ1. What about induction of labor post due date? For healthy women, there is no significant differ-ence in the outcomes of caesarean sections between a group where labor was induced and a group under ex-pectant management post due date, but the induction group was less likely to have perinatal mortality.
NICE guideline suggests that “decision making of induction of labor after 41 weeks” decreases the peri-natal mortality rate and this was the main result from a Cochrane systematic review. Meanwhile, expectant management is recommended for women without com-plications based on the results of delivery outcomes from an RCT, which found no significant difference in outcomes between a group where labor was induced and a group receiving expectant management.
It is preferable for women who are free of com-plications to be offered the chance to have expectant
labor would be based on the conditions of cervical rip-ening. Inducing labor is recommended after 42 weeks. CQ2. Is it effective for women to have membrane
sweep-ing to induce labor?
A membrane sweep is an effective option for induc-ing labor in women who are still pregnant at 40 weeks and before trying to pharmacological methods of labor induction. There is evidence that doing a membrane sweep for a nulliparous woman decreases her need for pharmacological induction and delivery at 41 weeks or after 42 weeks. There is no significant risk associated with having a caesarean section and there is no increased risk of infection for the mother or baby. A woman who has had a membrane sweeping does have a higher risk for bleeding, irregular contractions, and a great feeling of discomfort due to the internal examination.
As for the frequency of membrane sweeping some research suggests once is enough while other research supports the effectiveness of doing a membrane sweep more than once. Additional membrane sweeping may be offered if labor does not start spontaneously. A woman should be well-informed by her health care providers re-garding the purpose, method, and both the benefits and risks (such as pain or bleeding) of membrane sweeping.
According to the NICE guideline membrane sweep-ing is more important in the prevention of post-term pregnancy. Regardless, every woman should have the opportunity to make informed decisions about her care and treatment in partnership with her health care provid-ers.
CQ3. Is it effective to use nipple or breast stimulation to induce labor?
Nipple and breast stimulation is an effective meth-od of inducing labor for women with low-risk pregnan-cies. An analysis of trials comparing low-risk women who received breast stimulation to low-risk women who received no intervention found a significant reduction in the number of women who were not in labor within 72 hours as well as less reports of postpartum hemorrhage in the group that received intervention.
However one RCT, which focused on high-risk women, reported three cases of perinatal mortality in
Japan Academy of Midwifery: 2012 evidence-based guidelines for midwifery care during childbirth
and caesarean births.
A previous study of the RCT, systematic review, and the observed study have shown that it is sufficient to do intermittent Doppler auscultation in 30 minute intervals until the active phase and then every 5 to 15 minutes after the active phase during the first stage of labor. Continuous monitoring is needed if there is a pos-sibility of a high-risk delivery such as non-reassuring fetal status, bleeding before to delivery, induced labor, fever in the mother, or meconium stained liquor in the second stage of labor.
CQ7. What is the effectiveness of epidural anesthesia and its side effects?
The benefits of epidural anesthesia are that it man-ages labor pain and it is expected to shorten the first stage of labor. However, it is possible that epidural an-esthesia increases the need for an instrumental delivery. For women eager to have an epidural as pain con-trol they need to be fully informed of both the benefits and risks of the epidural. Delivery should take place in a way that risk can be managed.
CQ8. The effectiveness of water immersion during the first stage of labor.
There is no evidence that immersion in water ac-celerates labor, but it has been found to be is effective in relieving labor pain in the first stage of labor.
Evidence from the updated Cochrane systematic review suggests that immersion in water during the first stage of labor decreases the use of epidural or spinal an-algesia and that it is effective for relieving pain. Also, it does not affect mother/fetus outcomes or length of la-bor. Additionally, pain control was more effective only for women whose cervixes were dilated more than 5cm. From this evidence, immersion in water is one option during labor, but further research is needed to observe the effectiveness of foot baths, water birth, and safety during labor.
CQ9. The effectiveness of finger pressure and acupunc-ture for labor pain.
There is no evidence that acupressure for SP6 de-creases the use of pain control medication during labor. However, it is effective for pain relief when compared with just touch SP6.
NICE guideline and Lee’s research both report that the nipple and breast stimulation group and one death
in the group who used oxytocin. After doing a Cochrane systematic review, the sub-group analysis showed no significant reduction in the number of high-risk women with unfavorable cervixes who were not in labor within 72 hours.
Therefore it is effective for low-risk women to use nipple and breast stimulation to induce labor. However, it should not be used for high-risk women due to un-certain effectiveness and the reported cases of perina-tal morperina-tality. Further data is needed regarding safety, women’s satisfaction with this method, and feelings of discomfort.
CQ4. Is it effective to use acupressure or acupuncture to induce labor?
Currently there is no evidence that supports the ef-fectiveness of acupressure and acupuncture for inducing labor.The use of acupressure or acupuncture to induce labor is not recommended due to lack of information regarding its safety and effectiveness. Further studies need to be done on the effectiveness, safety, and the level of the women’s satisfaction with acupressure or acupuncture as a method of inducing labor.
CQ5. What is the efficacy of checking fetal heart rate when a woman is admitted for labor?
There is evidence that women admitted for labor who receive continuous electronic fetal monitoring (EFM) are more likely to have medical intervention such as instrumental vaginal birth, CS, analgesia, or continuous fetal blood sampling. On the other hand, there is evidence that there is no difference in the out-come for the baby or that CTG is better than intermittent auscultation.
Recently independent midwives are required to do CTG monitoring when they transfer woman to a hospi-tal in an emergency. CTG monitoring is recommended when a woman is admitted for labor to show fetal status. CQ6. The effectiveness of intermittent Doppler aus-cultation vs. continued monitoring during first or second stage of labor.
There is evidence that continuous EFM reduces the occurrence of neonatal seizure and that it has no impact on causing cerebral palsy. There is evidence that con-tinuous EFM increases the occurrence of instrumental
it is effective for pain relief when compared with just touch SP6. Chung reports that acupressure to LI4 and BL67 is an effective analgesia. Still, there is not enough evidence and further research is needed since there were only two previous studies done on this topic and they both had small sample size.
As for acupuncture, Cho’s systematic review com-pared labor pain scores between an electro-acupuncture group and a placebo group. Within the first 30 minutes of treatment the electro-acupuncture group showed sig-nificance in its effectiveness. Also NICE meta-analysis reports that treatment could be used to significantly de-crease the use of pain control medicine or epidural.
Acupuncture could be an effective analgesia, but a licensed acupuncture specialist is needed to work with the needles. Acupressure to SP6, LI4, and BL67 is con-sidered effective analgesia and it should be done if that is what the woman wants.
CQ10. Restriction of eating and drinking during labor. There is no significant difference in outcomes between women with eating and drinking restrictions during labor and those without restrictions. Eating and drinking during labor is necessary for physical strength, but some hospitals restrict food and drink due to the need for possible medical intervention.
NICE guideline reports that eating during labor may have biochemical benefits, but also that a woman is twice as likely to vomit before or while giving birth. A Cochrane systematic review of the NICE guideline reports there is no significance of merit or de-merit between the eating-drinking group and the restricted group. However, there is no significant difference in outcomes such as medical intervention, length of deliv-ery, vomiting, or neonatal prognosis. Thus, eating and drinking during labor should not be restricted or strongly recommended; rather it depends on the woman’s desire. Food that will not irritate the digestive system should be chosen. When it comes to prolonged labor and loss of energy, dietary intake is recommended.
CQ11. Effectiveness of “walking” to accelerate the first stage of labor.
It is possible that walking during the first stage of
“walked” and there is no evidence that recommends walking in order to accelerate delivery.
NICE guideline does not promote the effectiveness of walking before delivery; instead it reported similar results from an RCT that some women were uncomfort-able in a supine position compared to other positions. This study recommends moving and finding a comfort-able position for women during labor and that women should have support to move during labor.
CQ12. The effectiveness of preventing prolonged la-bor by using early routine amniotomy.
There is no evidence to support that doing an early amniotomy during a normally progressing labor will prevent a prolonged labor. A previous study of women who did not have aminiotomies showed that they were more likely to have abnormality of labor progression. However, this study included women with cervixes di-lated to 3 cm to birth and the adhibition was unclear so it was not appropriate in Japan.
CQ13. Effectiveness of enema to accelerate the in-progress first stage of labor.
There is no evidence that giving a woman an en-ema in the first stage of labor is effective in promoting labor. A Cochrane systematic review found no evidence of effectiveness in giving a woman an enema to pro-mote labor. Enemas are painful to women and should not be performed in order to promote labor. However, if a woman wants an enema to treat constipation, she should not be discouraged to have one.
CQ14. Effectiveness of finger pressure and acupunc-ture to accelerate labor.
In comparing a group of women who received puncture to a group of women who did not receive acu-puncture treatment, it was found that acuacu-puncture treat-ment during labor is effective in shortening the duration of labor. Also, these same results were shown in the study of women who received acupressure treatment.
Acupressure or acupuncture to SP6, LI4, and BL67 is expected to be one effective option for accelerating labor. They found no evidence due to small sample size; further study is needed with large sample sizes.
Japan Academy of Midwifery: 2012 evidence-based guidelines for midwifery care during childbirth
CQ15. Vulva sterilization.
There is no evidence of using benzalkonium chlo-ride or Chlorhexidine for vulva sterilization.One con-trolled study from the UK compared using cetrimide/ chlorhexidine to using just tap water for perineal clean-ing durclean-ing labor. The study found no significance be-tween the number of women who developed fever, used antibiotics, had perineal infection, and intention of peri-neal tear. Also, there was no significant difference in the outcomes of the babies. Therefore, this study’s evidence indicates that using cetrimide/chlorhexidine is no more effective than tap water for perineal cleaning.
CQ16. Position in the second stage of labor.
There are benefits and risks of each position, but there is no specific evidence that the supine position is more beneficial for women.
There is high-level evidence that, when compared to spine position, upright position significantly reduced labor duration; the occurrence of vaginal instrumental birth; and it decreased episiotomy, pain and the inci-dence of fetal heart rate abnormalities.
On the other hand, a high percentage of women us-ing the up-right position had second-degree perineal tear and blood loss of over 500ml. There is no significant dif-ference in third or fourth degree perineal tear for women in the upright position compared to women in the supine position. A woman should be informed about both the benefits and risks of each position and she should be able to choose the position.
There is no specific evidence for position other than spine position is beneficial. Also there is no evi-dence for safeness. If there is a possibility of an abnor-mal labor then the spine position was recommended. CQ17. Effectiveness of fundal pressure during the
second stage of labour.
There is no evidence available on the effects of manual fundal pressure. Fundal pressure by an insufflat-able belt during the second stage of labour does not ap-pear to shorten the second stage of labor.
Several reports suggest that fundal pressure is as-sociated with maternal and neonatal complications such as uterine rupture, neonatal fractures and brain damage. Also anal sphincter damage has been reported. In the “Clinical Guidelines for Obstetrical Practice”, they
rec-ommended complementary use of fundal pressure for vacuum extraction or forceps but with caution. Fundal pressure during the second stage of labor is not recom-mended for normal delivery.
CQ18. Effectiveness of perineal massage during the second stage of labor.
There is no evidence that perineal massage is ef-fective in reducing the incidence of perineal tears or episiotomies. The only significant difference was that third-degree tears occurred less frequently in the group using perineal massage.
Another RCT compared using perineal massage to applying warm compresses to the perineum, massaging the perineum with oil, and not touching the perineal un-til the baby’s head crowns during second stage of labor. This RCT found no significant difference in the inci-dence of perineal tear or episiotomy between the study groups. In addition, the women in the group who used perineal massage were the most willing to stop the in-tervention, yet there was still no significant difference in the incidence of third-degree perineal tear in the mas-sage group compared to the other groups.
Since there was no evidence that perineal massage prevents perineal tears, perineal massage should not be performed by health care professionals during the sec-ond stage of labor.
CQ19. The effectiveness of applying warm compress-es to the perineum in order to prevent perineal tear during the second stage of labor.
There was no evidence that applying warm com-presses to the perineum is effective for preventing perineal trauma. However, there was evidence that the group using the warm compresses experienced less peri-neal pain in post-delivery day one and two than the other group.
NICE guideline indicates from a cohort study that perineal trauma occurs less frequently when a warm compress is applied to the perineum. In an RCT intended for nulliparas, the women in the warm compress group were less likely to have third-degree perineal tears com-pared to the women in the control group.
However, NICE evaluated one US RCT and found that there was no significant difference in the incidence of perineal trauma between the groups applying warm
crowned during the second stage of labor.
Since different studies show conflicting informa-tion there is no evidence that supports applying warm compresses to the perineum in order to prevent perineal tear. However, no outcomes of harm occurred and it was found to decrease pain during labor and post-delivery day one and two; warm compress to the perineum can be one option.
CQ20. Hand position during the birth of a baby. There was no evidence of the effectiveness of two different methods of perineal management used to pre-vent perineal tears during delivery in the lateral position. In the NICE guideline, there was limited high-level evidence that women allocated to a ‘hands on’ perineal management group reported less pain at ten days after delivery compared to those women allocated to a ‘hand poised’ group. Also, in the ‘hand poised’ group, a smaller percentage of episiotomies were conducted in the ‘hand poised’ group compared to the ‘hands on’ group. There was no difference in the incidence of perineal trauma between the two groups and both methods of perineal management could be useful. There was no significant difference in the other RCT.
However, the three studies used for the NICE guideline did not take delivery position into consider-ation during analyses and the RCT only considered the lateral position. Not to mention, the incidence of peri-neal injury differed by race.
Therefore, there is no significant difference be-tween two groups who were in lateral position. How-ever, further study is needed to take other factors into consideration such as labor positions, race, and delivery environment. Since no study has been conducted in Ja-pan, further study is needed.
CQ21. Routine vs. restricted use of episiotomy. There is evidence that restrictive use of episiotomy is more beneficial to women when compared to those women in the routine episiotomy group.
The results of one systematic review showed that 75% of women had episiotomies in the routine group while 28% of women in the restrictive group had otomies. Obviously there was lower incidence of
episi-vere perineal trauma who needed suturing or who ex-perienced the complication of dysraphism in restrictive group. There was no significant difference in the out-comes of vaginoperineal trauma, dyspareunia, urinary incontinence, perineum pain, or asphyxia of newborn. Therefore, restrictive use of episiotomy is more benefi-cial to both women and babies.
NICE guideline only recommends restrictive use of episiotomy when it is needed for an instrumental deliv-ery or for fetal abnormality, but not for routine use.
In conclusion, episiotomy is not needed for all women. Rather, restrictive use is recommended when it is medically necessary during low-risk delivery in Ja-pan.
CQ22. Effectiveness of taking hands and knees po-sition for correcting fetus’s abnormal rotation during progressing labor.
There is no obvious evidence that the hands and knees position fixes the abnormal rotation of the fetus or that it is effective in relieving the back pain that comes from abnormal rotation.
There have been a few research studies on the ef-fectiveness of the hands and knees position for abnor-mal rotation, but only one study was used for NICE guideline and a Cochrane systematic review. According to this study, there was no significance in the number of babies fixed as occipitoposterior to position occipi-toanterior presentation. However, there is a tendency to correct the fetus’s abnormal rotation. In addition, this position was effective for relieving back pain and many women wanted to use the hands and knee position in her next delivery. No harm to mother or fetus has been reported due to being in the hands and knees position. CQ23. Resuscitation of babies with meconium-stained
liquor.
There is no high quality evidence that routine suc-tioning of the nasopharynx and tracheal intubation can improve outcomes for a baby with meconium staining who is in good condition.
There is no evidence that suctioning the baby’s shoulders and trunk before it’s birth decreases the risk of meconium aspiration. There is no evidence to
sup-Japan Academy of Midwifery: 2012 evidence-based guidelines for midwifery care during childbirth
port the suctioning of the nasopharynx before the birth either. There is no need for routine suctioning whether or not there is meconium-stained liquor. If there is any abnormality in the baby, advance life support would be needed. Resuscitation of the baby should follow Con-sensus 2010 and a healthcare professional trained in advance life support should always be readily available for births.
CQ24. Timing of cord clamping (early cord clamping vs. delayed cord clamping).
There is evidence that delayed cord clamping de-creases the occurrence of iron deficiency anemia in ba-bies. However, it increases neonatal hyperbilirubinemia. NICE guideline has reported that delayed cord clamping decreases the occurrence of anemia in new-borns and increases neonatal hyperbilirubinemia. There is no clear evidence of long-term outcomes so further study on the timing of cord clamping as well as benefits and risks for mother and baby are needed.
Updated Cochrane systematic review reports that in comparison to early clamping, a delay of around 2-3 minutes provides additional blood to babies and im-proves their iron levels. It is also clinically beneficial for babies in low income countries because it does not increase the risk of post-partum hemorrhage. However, there is an increased risk of jaundice in the babies and the need to be treated by phototherapy.
Neonates are physiologically polycythemia. The baby’s blood volume is affected by the timing of the cord clamping. A baby’s usual blood volume is 70ml per kg of the body weight when cord clamping is done im-mediately; 85ml per kg after 1min; and 90ml per kg in 3min. Thus, a baby is more likely to be polycythemia when cord clamping is delayed.
From the Japanese version of the guideline Con-sensus 2010, Japanese babies bilirubin levels are higher compared to other races which leads to higher gene mu-tations of UGT2B related to jaundice. So it is possible that the increase in incidence of jaundice in newborns increases the need for phototherapy in Japan, but further studies of mothers and babies are needed.
CQ25. Mother and infant skin-to-skin contact right after delivery.
There is evidence that skin-to-skin contact (SSC)
promotes bonding, breast feeding, and a better chance of the baby being in stable condition.
In SSC, in order to keep a baby (who is in good condition) warm, the baby should be dried off and cov-ered with a warm and dry blanket or towel while main-taining SSC with the mother. SSC is recommended in the Cochrane systematic review and other systematic reviews for its effectiveness in increasing breastfeeding, bonding, and the stable condition of baby.
Oxygen desaturation was reported in the SSC group; however, the methods of observation were not compared. There was also a report of a sudden change in some of the babies’ conditions during SSC. When con-ducting SSC, full and careful informed consent must be given to the family and observation by a health care pro-fessional trained in advanced neonatal life support and the use monitoring equipment is recommended.
A neonate’s saturation of oxygen is usually unsta-ble immediately after birth. The Japanese NCPR guide-lines of Consensus 2010 and Dawson’s report note that a baby’s saturation will be stable within 10 minutes. Sup-plemental oxygen can be interrupted when saturation is likely to be increased even if it’s not over 95%, but as in 60% in 1 minute, 70% in 3 minutes, 80% in 5 minutes, and 90% in 10 minutes as lower limit.
The timing and duration of SSC was different in each study so it is not clear which method is the most effective. However, evidence-based guidelines for com-fortable pregnancy and delivery suggest doing SSC im-mediately after birth and to continue doing it for one hour without separating the mother and baby. Also, in the evidence-based kangaroo care guidelines, SSC is recommended immediately after birth and it is recom-mended to continue as long as possible. The recommen-dations are different in each guideline so further study on timing, duration, and safety of SSC is needed. CQ26. Perineal repair.
There is no evidence about suturing first or second-degree perineal tears. A small RCT recommends sutur-ing except when there is a clear case of trauma. Another RCT compared a suturing group with a non-suturing group using the REEDA score which measures healing. Six weeks after delivery, 84% of the women in the su-turing group completely healed while 44% of the
wom-of trauma was not conducted (70% wom-of trauma was sec-ond-degree perineal tear). No other studies, evidence, or methods have been found.
CQ27. Management of the third stage of labor. Active management in the third stage of labor is a method to provide women uterotonic support. In ac-tive management the cord is cut after the baby is born, then cord traction is applied to remove the placenta to prevent postpartum hemorrhage. By contrast expectant management supports the body’s natural process. The cord is cut after the umbilical cord pulse stops and the placenta expels as a natural process resulting from uter-ine contractions.
From the updated Cochrane systematic review, ac-tive management is effecac-tive for reducing hemorrhage over 1000ml. However, since it has side effects such as elevated diastolic blood pressure and increased vomit-ing, whether or not to use active management is depen-dent on the facility resources. If women at low risk for hemorrhage are in facilities where the emergency con-veyance system is maintained, expectant management could be adopted. However, we still must train ourselves for emergency situations such as serious hemorrhage. CQ28. What, when and how the prophylactic
utero-tonic is administrated?
Giving uterotonics to women who are at risk for hemorrhage is effective for preventing haemorrhage. Effective use of a uterotonic could significantly reduce the haemorrhage over 1000ml or use of uterotonic re-peatdly. The dosage of the uterotonic is 5 or 10 units of oxytocin depending on the risk. Because using an ergot alkaloid as a uterotonic increased the number of manu-ally removed placentas and elevated the blood pressure, the use of oxytocin is more preferable. In Japan it was found that there were no significant differences for ef-fects and side efef-fects regarding the timing of adminis-tration, so timing could be either before placenta deliv-ery or after placenta delivdeliv-ery. For the injection method, there was not enough evidence indicating effectiveness for either an intramuscular injection or the intravenous injection. In addition, we need to follow the obstetrics guidelines for critical bleeding when the patient has a
prevent hemorrhage.
There is no evidence of uterine massage being ef-fective for preventing hemorrhage. Uterine massage was not any more effective with or without using oxytocin.
When comparing uterine massage along with using oxytocin for hemorrhage, 2 to 3.5 times more women were over 500ml of hemorrhage in the uterine massage group and 1.5 to 3 times more women needed additional oxytocin. Performing uterine massage after using oxyto-cin also had no effect on the women. Half of the women who received uterine massage also reported feeling pain or discomfort.
Therefore, if risk is expected and there is a need to prevent hemorrhage, oxytocin is recommended rather than doing uterine massage. If oxytocin is used, uter-ine massage should not be performed as there is no evi-dence that it is effective in preventing hemorrhage and some women have reported that it is painful.
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