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Masaje uterino para la prevención de la hemorragia posparto

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Antecedentes

La hemorragia posparto (HPP) (sangrado del tracto genital después del parto) es una causa principal de mortalidad y discapacidad materna, en particular en contextos de escasos recursos. En estos contextos, habitualmente los uterotónicos no están disponibles. Se necesitan técnicas sencillas y de bajo coste que se puedan aplicar en contextos de bajos recursos para prevenir y tratar la HPP. El masaje uterino se recomienda como parte del tratamiento activo habitual del alumbramiento. Sin embargo, no se sabe si es efectivo. Si muestra ser efectivo, el masaje uterino representaría una intervención sencilla con la posibilidad de tener un efecto importante sobre la HPP y la mortalidad materna en contextos de escasos recursos.

Objetivos

Determinar la efectividad del masaje uterino después del parto, y antes o después de la expulsión de la placenta, o ambos, para reducir la pérdida de sangre posparto, así como la morbilidad y mortalidad asociadas.

Métodos de búsqueda

Se realizaron búsquedas en el registro de ensayos del Grupo Cochrane de Embarazo y parto (Cochrane Pregnancy and Chilbirth Group) (30 de abril de 2013).

Criterios de selección

Todos los ensayos controlados aleatorizados publicados, no publicados y en curso que comparen el masaje uterino solo, o además de uterotónicos, antes o después de la expulsión de la placenta, o ambos, con ningún masaje.

Obtención y análisis de los datos

Dos investigadores, de forma independiente, consideraron la elegibilidad de los ensayos, evaluaron el riesgo de sesgo y extrajeron los datos mediante un formulario acordado. Se verificó la exactitud de los datos. El efecto del masaje uterino, comenzado antes o después de la expulsión de la placenta, se evaluó primero por separado y luego se combinó para un resultado general.

Resultados principales

Esta revisión incluyó dos ensayos controlados aleatorizados. El primer ensayo incluyó a 200 mujeres que se asignaron a recibir masaje uterino o ningún masaje después de la expulsión de la placenta, posterior al tratamiento activo del alumbramiento que incluye el uso de oxitocina. El número de mujeres con pérdida de sangre de más de 500 ml fue pequeño, sin diferencias estadísticamente significativas (razón de riesgos [RR] 0,52; intervalo de confianza [IC] del 95%: 0,16 a 1,67). Ningún grupo tuvo casos de placenta retenida. La pérdida de sangre media fue significativamente menor en el grupo de masaje uterino a los 30 minutos (diferencia de medias [DM] ‐41,60 ml; IC del 95%: ‐75,16 a ‐8,04) y a los 60 minutos después del ingreso al ensayo (DM ‐77,40 ml; IC del 95%: ‐118,71 a ‐36,09). La necesidad de uterotónicos adicionales se redujo significativamente en el grupo de masaje uterino (RR 0,20; IC del 95%: 0,08 a 0,50).

Para evaluar el uso del masaje uterino antes y después de la expulsión de la placenta, un ensayo reclutó a 1964 mujeres en Egipto y Sudáfrica. Las mujeres se asignaron a recibir oxitocina, masaje uterino o ambos después del parto del feto, pero antes de la expulsión de la placenta. No hubo un efecto beneficioso adicional del masaje uterino más oxitocina sobre la oxitocina sola con respecto a la pérdida de sangre mayor o igual a 500 ml (RR promedio 1,56; IC del 95%: 0,44 a 5,49; efectos aleatorios) o la necesidad de uso adicional de uterotónicos (RR 1,02; IC del 95%: 0,56 a 1,85).

Los dos ensayos se combinaron para examinar el efecto del masaje uterino comenzado antes o después de la expulsión de la placenta. Hubo heterogeneidad significativa con respecto a la pérdida de sangre de 500 ml o más después del ingreso al ensayo. El efecto promedio utilizando un modelo de efectos aleatorios no encontró diferencias estadísticamente significativas entre los grupos (RR promedio 1,14; IC del 95%: 0,39 a 3,32; efectos aleatorios).

Conclusiones de los autores

Los resultados de esta revisión no son concluyentes y no se deben interpretar como una razón para cambiar la práctica actual. Debido a las limitaciones de los ensayos incluidos, se necesitan más ensayos con un número suficiente de mujeres para calcular los efectos del masaje uterino mantenido. Todas las mujeres comparadas en esta revisión recibieron oxitocina como parte del tratamiento activo del trabajo de parto. Estudios de investigación recientes indican que una vez que se ha administrado oxitocina, la reducción adicional de la pérdida de sangre posparto tiene un alcance limitado. Se necesitan ensayos de masaje uterino en contextos donde los uterotónicos no estén disponibles y que midan las experiencias de las mujeres con el procedimiento.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Resumen en términos sencillos

Masaje uterino para la prevención de la hemorragia posparto

El sangrado después del parto (hemorragia posparto) es la principal causa de muerte materna en África subsahariana y Egipto y, sin embargo, es en gran parte prevenible. Las posibles causas de hemorragia intensa inmediatamente después del parto o en el transcurso de las primeras 24 horas son la imposibilidad del útero de contraerse después del parto (atonía uterina), la placenta retenida, la rotura o inversión del útero y los desgarros cervicales, vaginales o perineales.

En los contextos con suficientes recursos, la hemorragia se reduce con el tratamiento activo habitual de la expulsión de la placenta, llamada etapa del alumbramiento, con el uso de un medicamento para estimular la contracción del útero como la oxitocina. El masaje uterino después de la expulsión de la placenta también puede estimular la contracción del útero. El masaje incluye colocar una mano sobre la parte baja del abdomen de la mujer y estimular el útero mediante movimientos repetitivos de masaje o presión.

Esta revisión incluyó dos ensayos controlados que asignaron al azar a las mujeres a recibir masaje uterino o ningún masaje con tratamiento activo de la etapa de alumbramiento, que incluye el uso habitual de oxitocina.

En un ensayo que incluyó a 200 mujeres, el masaje uterino proporcionado cada diez minutos durante 60 minutos después de la expulsión de la placenta redujo eficazmente la pérdida de sangre y la necesidad de uterotónicos adicionales en cerca del 80%. La cantidad de mujeres que perdió más de 500 ml de sangre fue demasiado pequeña para una comparación significativa. Dos mujeres del grupo control y ninguna del grupo de masaje uterino necesitaron transfusiones de sangre.

El segundo ensayo incluyó a 1964 mujeres que se asignaron a recibir oxitocina, masaje uterino, o ambos, después del parto del recién nacido y antes de la expulsión de la placenta. No hubo un efecto beneficioso añadido del masaje uterino cuando se utilizó oxitocina.

Los resultados de esta revisión no son concluyentes. La calidad metodológica de los dos ensayos incluidos fue alta, pero es posible que hubiera diferencias en los procedimientos utilizados en los centros de estudio. Las desventajas del masaje uterino incluyen el uso del tiempo del personal y el malestar ocasionado a las mujeres. Los hallazgos no deben cambiar la práctica recomendada. Es probable que cualquier reducción de la pérdida de sangre fuera limitada debido al uso de oxitocina en estos ensayos. El masaje uterino también podría haber aumentado la pérdida de sangre aparente al presionar la sangre retenida en el útero para expulsarla de la cavidad uterina. Se necesitan más ensayos, especialmente en contextos en los que los uterotónicos no están disponibles. El masaje uterino podría ser una intervención sencilla y de bajo coste si se demuestra que es efectiva.

Authors' conclusions

Implications for practice

The joint statement of ICM/FIGO 2004 on management of the third stage of labour, advises uterine massage after delivery of the placenta to prevent postpartum haemorrhage. The results of this review are inconclusive, and should not be interpreted as a reason to change current practice.

Implications for research

It is remarkable that a practice, which has been widespread for decades, has been subjected to so little formal research. Further research to determine the effectiveness of uterine massage should be a high priority, especially as it is an intervention that can be used in any setting, particularly where uterotonics are not available. Such trials should include an assessment of women's views. Due to the limitations of the included trials, trials with sufficient numbers to estimate the effects of sustained uterine massage with greater precision, particularly with respect to objective outcomes such as postpartum anaemia, are needed. In particular, trials of uterine massage in settings where uterotonics are not available are of great importance. Recent research suggests that once an oxytocic has been given, as was the case in the studies included in this review, there is limited scope for further reduction in postpartum blood loss (Widmer 2010). In settings with no access to uterotonics, the potential for uterine massage to reduce blood loss may differ from that when uterotonics are used. If shown to be effective, uterine massage would represent a simple intervention with the potential to have a major effect on postpartum haemorrhage and maternal mortality in under‐resourced settings.

Background

Postpartum haemorrhage (PPH) (excessive bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under‐resourced areas (Fawcus 1995). It is the leading cause of maternal mortality in Sub‐Saharan Africa (Lazarus 2005). The South African National Committee for the Confidential Enquiries into Maternal Deaths analysed 3406 reported maternal deaths for the years 2002 to 2004. Overall, 9.5% were due to PPH (NCCEMD 2006). In Egypt, in spite of the drop in maternal mortality ratio from 174/100,000 live births in 1992 to 1993 to 80/100,000 live births in the year 2000 (MOH 2000), PPH is still the leading cause and responsible for 34% of maternal deaths.

Deaths from PPH remain most common in areas where access to health services is poorest. In these settings, poor nutrition, malaria and anaemia may aggravate the effects of PPH. In well‐resourced settings with healthier populations and adequate health services, deaths from PPH are extremely rare, as effective methods are available to reduce and treat PPH. These include routine active management of the third stage of labour and facilities for resuscitation, blood transfusion and surgical interventions. In the 2002 to 2004 South African National Confidential Enquiry into Maternal Deaths, 83% of the 313 deaths from PPH were found to be 'clearly preventable' (NCCEMD 2006). For these reasons, strategies to reduce deaths from PPH have been a focus of attempts to achieve the Millennium Development Goal of reducing maternal mortality by 75% by 2015.

Primary PPH, heavy bleeding directly following childbirth or within 24 hours thereafter, is the most common type of PPH and can be caused by uterine atony, retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal lacerations. Uterine atony, when the uterus fails to contract after delivery, is the most important cause of primary PPH (WHO 2000). Methods leading to contraction of the uterus and correction of atony will reduce the amount of bleeding after delivery.

Recommendations for the prevention of PPH such as the joint statement of the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians (ICM/FIGO 2004) recommend routine massage of the uterus after delivery of the placenta. Uterine massage involves placing a hand on the woman's lower abdomen and stimulating the uterus by repetitive massaging or squeezing movements. Massage is thought to stimulate uterine contraction, possibly through stimulation of local prostaglandin release and thus to reduce haemorrhage. However, it is not done routinely after delivery in a systematic way. If shown to be effective, it would have important advantages as it is inexpensive and requires no access to medication or other specialised services, and could be used in any location in which women give birth. Disadvantages include the use of staff time, and discomfort caused to women. However, there is very little empirical research to evaluate the effectiveness of this method. There is therefore a need to evaluate systematically the effectiveness of uterine massage for preventing 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.

Methods

Criteria for considering studies for this review

Types of studies

All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or as part of the active management of labour (including uterotonics) before or after delivery of the placenta, or both, with non‐massage. We planned to exclude from the analyses quasi‐randomised trials (for example, those randomised by date of birth or hospital number). We planned to included studies reported only in abstract form if sufficient information to evaluate the trial was available. If not, they would be included in the 'Studies awaiting classification' category and be included in the analyses when published as full reports.

Types of participants

Women who have given birth vaginally or by caesarean section.

Types of interventions

  1. Uterine massage commencing after birth of the baby, before or after delivery of the placenta, or both, compared with no intervention or a 'dummy' procedure to mask allocation or with alternative methods or alternative forms of uterine massage, with or without other third stage co‐interventions.

Types of outcome measures

Primary outcomes

  1. Blood loss 500 mL or more after trial entry.

  2. Placenta delivered more than 30 minutes after birth.

Secondary outcomes

  1. Blood loss 1000 mL or more after trial entry.

  2. Mean blood loss after trial entry.

  3. Mean time to placental delivery.

  4. Use of additional uterotonics

  5. Use of other procedures for management of postpartum haemorrhage.

  6. Haemoglobin level after 12 to 24 hours less than 8 g/dL or blood transfusion.

  7. Blood transfusion.

  8. Maternal death or severe morbidity (organ failure, intensive care unit admission for more than 24 hours, major surgery).

  9. Women's experience including pain/discomfort.

  10. Caregiver's experience.

  11. Cost.

Only outcomes with available data appear in the analysis table. We planned that outcome data that we did not pre‐specify, but which were reported by the trial authors, would be labelled as such in the analysis but not used for the conclusions.

Search methods for identification of studies

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Trials Search Co‐ordinator (30 April 2013).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co‐ordinator and contains trials identified from:

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);

  2. weekly searches of MEDLINE;

  3. weekly searches of EMBASE;

  4. handsearches of 30 journals and the proceedings of major conferences;

  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co‐ordinator searches the register for each review using the topic list rather than keywords. 

We did not apply any language restrictions.

For additional searching performed for the previous version of the review, please seeAppendix 1

Data collection and analysis

For the methods used when assessing the trials identified in the previous version of this review, seeAppendix 2.

For this update we used the following methods when assessing the reports identified by the updated search.

Selection of studies

Two review authors independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any disagreement through discussion or, if required, we would have consulted a third person. In the case of trials involving the review authors, an independent person made the decision regarding inclusion of the study.

Data extraction and management

We designed a form to extract data. For eligible studies, two review authors extracted the data using the agreed form. We resolved discrepancies through discussion or, if required, we would have consulted a third person. We entered data into Review Manager software (RevMan 2011) and checked for accuracy.

When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

Assessment of risk of bias in included studies

Two review authors independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third assessor. In the case of trials involving the review authors, an independent person assessed for risk of bias.

(1) Random sequence generation (checking for possible selection bias)

We describe for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);

  • high risk of bias (any non‐random process, e.g. odd or even date of birth; hospital or clinic record number);

  • unclear risk of bias.   

(2) Allocation concealment (checking for possible selection bias)

We describe for each included study the method used to conceal allocation to interventions prior to assignment and assess whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);

  • high risk of bias (open random allocation; unsealed or non‐opaque envelopes, alternation; date of birth);

  • unclear risk of bias.   

(3.1) Blinding of participants and personnel (checking for possible performance bias)

We describe for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered studies to be at low risk of bias if they were blinded, or if we judged that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low, high or unclear risk of bias for participants;

  • low, high or unclear risk of bias for personnel.

(3.2) Blinding of outcome assessment (checking for possible detection bias)

We describe for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods used to blind outcome assessment as:

  • low, high or unclear risk of bias.

(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We describe for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We state whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes.  Where sufficient information was reported, or was supplied by the trial authors, we re‐included missing data in the analyses which we undertook.

We assessed methods as:

  • low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups);

  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomisation);

  • unclear risk of bias.

(5) Selective reporting (checking for reporting bias)

We describe for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it is clear that all of the study’s pre‐specified outcomes and all expected outcomes of interest to the review have been reported);

  • high risk of bias (where not all the study’s pre‐specified outcomes have been reported; one or more reported primary outcomes were not pre‐specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);

  • unclear risk of bias.

(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

We describe for each included study any important concerns we have about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;

  • high risk of other bias;

  • unclear whether there is risk of other bias.

(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the findings. We planned to explore the impact of the level of bias through undertaking sensitivity analyses ‐ seeSensitivity analysis

Measures of treatment effect

Dichotomous data

For dichotomous data, we presented results as summary risk ratio with 95% confidence intervals. 

Continuous data

For continuous data, we used the mean difference if outcomes were measured in the same way between trials. We would have used the standardised mean difference to combine trials that measured the same outcome, but used different methods.  

Unit of analysis issues

Cluster‐randomised trials

We did not identify any cluster‐randomised trials for inclusion. In future updates, if we identify cluster‐randomised trials we will include them in the analyses along with individually‐randomised trials. We will adjust their standard errors using the methods described in the Handbook using an estimate of the intracluster correlation co‐efficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster‐randomised trials and individually‐randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely.

We will also acknowledge heterogeneity in the randomisation unit and perform a subgroup analysis to investigate the effects of the randomisation unit.

Dealing with missing data

For included studies, we noted levels of attrition. In future updates we will explore the impact of including studies with high levels of missing data (>10%) in the overall assessment of treatment effect by using sensitivity analysis.

For all outcomes, we carried out analyses, as far as possible, on an intention‐to‐treat basis, i.e. we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial was the number randomised minus any participants whose outcomes were known to be missing.

Assessment of heterogeneity

We assessed statistical heterogeneity in each meta‐analysis using the T², I² and Chi² statistics. We regarded heterogeneity as substantial if the T² was greater than zero and either an I² was greater than 30% or there was a low P value (less than 0.10) in the Chi² test for heterogeneity.

Assessment of reporting biases

If there had been 10 or more studies in the meta‐analysis we planned to investigate reporting biases (such as publication bias) using funnel plots. We would have assessed funnel plot asymmetry visually, and used formal tests for funnel plot asymmetry. For continuous outcomes, we would have used the test proposed by Egger 1997, and for dichotomous outcomes, we would have used the test proposed by Harbord 2006. If asymmetry was detected in any of these tests or was suggested by a visual assessment, we planned to perform exploratory analyses to investigate it.

Data synthesis

We carried out statistical analysis using the Review Manager software (RevMan 2011). We used fixed‐effect meta‐analysis for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect: i.e. where trials were examining the same intervention, and the trials’ populations and methods were judged sufficiently similar. If there was clinical heterogeneity sufficient to expect that the underlying treatment effects differed between trials, or if substantial statistical heterogeneity was detected, we used random‐effects meta‐analysis to produce an overall summary if an average treatment effect across trials was considered clinically meaningful. The random‐effects summary is treated as the average range of possible treatment effects and we discuss the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful, we would not have combined trials.

Where we used random‐effects analyses, the results are presented as the average treatment effect with its 95% confidence interval, and the estimates of  T² and I².

Subgroup analysis and investigation of heterogeneity

In future updates, when adequate data are available, we will analyse data in the following subgroups.

  1. Uterine massage commencing before or after delivery of the placenta.

  2. With or without routine uterotonics.

  3. With or without controlled cord traction.

We will include all outcomes in the sub‐group analysis.

We will assess subgroup differences by interaction tests available within RevMan (RevMan 2011). We will report the results of subgroup analyses quoting the χ2 statistic and P value, and the interaction test I² value.

Sensitivity analysis

In future updates of this review, as more data become available, we will use sensitivity analysis to explore aspects of the trials that might affect the results. These will include:

  1. type of uterine massage;

  2. type of co‐interventions;

  3. trial quality.

Results

Description of studies

Two trials are included in this review. Abdel‐Aleem 2006 is a small randomised trial conducted in a teaching hospital located in a developing country (Egypt). The other study (Abdel‐Aleem 2010) is a larger trial from the same group conducted in teaching hospitals in Egypt and South Africa. For the purposes of this review, the data for each site for the latter trial are presented separately due to heterogeneity between sites. In our analyses, the data are included as Abdel‐Aleem 2010 Egypt and Abdel‐Aleem 2010 S Africa. In both trials, women were randomly allocated to receive uterine massage or no massage after active management of the third stage of labour, including the routine use of oxytocin 10 units. Uterine massage was commenced before (Abdel‐Aleem 2010 Egypt; Abdel‐Aleem 2010 S Africa) or after delivery of the placenta (Abdel‐Aleem 2006). The first trial (Abdel‐Aleem 2006) recruited 200 women assigned at random to receive uterine massage or no massage after delivery of the placenta, in addition to active management of the third stage of labour. The second trial (Abdel‐Aleem 2010 Egypt; Abdel‐Aleem 2010 S Africa) included 1964 women, assigned randomly to receive one of three interventions after delivery of the baby and before delivery of the placenta. These interventions were oxytocin (10 IU), uterine massage, or both. In this review we include only the oxytocin versus both oxytocin and uterine massage groups (i.e. uterine massage versus no uterine massage with oxytocin as a co‐intervention in both groups).

For further details of the included studies, seeCharacteristics of included studies.

Risk of bias in included studies

See table of Characteristics of included studies, particularly the 'Methods' section.

The sequence generation and allocation concealment for both trials was rated as 'low risk of bias' and there was a low proportion of losses to follow‐up (losses to follow‐up occurred only in the South African arm of the second trial (Abdel‐Aleem 2010 S Africa)). There was no blinding of participants and caregivers, which raises the possibility of biased assessment of outcomes. Because the primary outcome assessment was dependent on objective measurement of blood loss, the risk of bias was considered low. The methodological quality of both included trials was high.

Effects of interventions

Analysis 1. Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth

There was substantial heterogeneity with respect to the proportion of women with blood loss greater than or equal to 500 mL (Analysis 1.1). The average effect found no statistically significant difference between groups (average risk ratio (RR) 1.56, 95% confidence interval (CI) 0.44, 5.49; random‐effects). Retained placenta for more than 30 minutes occurred only in the South African cohort (Abdel‐Aleem 2010 S Africa), and was not significantly different between groups (RR 0.79, 95% CI 0.33 to 1.88) (Analysis 1.2). Haemoglobin levels after 12 to 24 hours were measured only in the South African cohort (Abdel‐Aleem 2010 S Africa), and there were no statistically significant differences in haemoglobin less than 8 g/dL (RR 0.63, 95% CI 0.21 to 1.88) (Analysis 1.9) or need for additional use of uterotonics (RR 1.02, 95% CI 0.56 to 1.85) (Analysis 1.3). There were four blood transfusions in each group (too few for statistical analysis) (Analysis 1.4).

Analysis 2. Uterine massage after placental delivery versus no massage: vaginal birth

In the first trial (Abdel‐Aleem 2006), the mean blood loss was less in the uterine massage group at 30 (mean difference (MD) ‐41.60 mL, 95% CI ‐75.16 to ‐8.04 (Analysis 2.4)) and 60 minutes after trial entry (MD ‐77.40 mL, 95% CI ‐118.71 to ‐36.09 (Analysis 2.5)). The need for additional uterotonics was reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50 (Analysis 2.6)). Two blood transfusions were administered in the control group (Analysis 2.8).

The numbers of women with blood loss more than 500 mL was small, with no statistically significant difference (RR 0.52, 95% CI 0.16 to 1.67) (Analysis 2.1). There were no cases of retained placenta in either group.

Analysis 3. Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth

Concerning the effect of uterine massage commenced either before or after delivery of the placenta, we included the results of both included studies (Abdel‐Aleem 2006; Abdel‐Aleem 2010 Egypt; Abdel‐Aleem 2010 S Africa).There was substantial heterogeneity with respect to the blood loss 500 mL or more after trial entry. The average effect using a random‐effects model found no statistically significant differences between groups (average RR 1.14, 95% CI 0.39 to 3.32; random‐effects, I² = 77% (Analysis 3.1)). The use of additional uterotonics was not statistically different between the groups (RR 0.52, 95% CI 0.15, 1.81; random‐effects, I² = 78% (Analysis 3.3)).

Discussion

One small trial found evidence of reduced blood loss with uterine massage after placental delivery. However, overall, the trials do not provide compelling evidence of the effectiveness of uterine massage.

The heterogeneity between trials and sites is cause for cautious interpretation of the results of this review. The heterogeneity raises the possibility that differences in trial procedures between sites may affect the results. For example, it is possible that uterine massage may express blood from the uterine cavity, while in the control group pooled blood in the uterine cavity is not measured, leading to a relative under‐estimation of blood loss. This could mask a beneficial effect of uterine massage. This effect is suggested by the fact that in the South African site (Abdel‐Aleem 2010 S Africa), measured blood loss was significantly more in the uterine massage group, yet there was a trend to higher haemoglobin levels at 12 to 24 hours. In view of these uncertainties, the results of this review should be regarded as inconclusive.

The data reviewed included only women who had received routine uterotonics. In this situation, it is likely that their uteri were optimally contracted, and the potential for further benefit from uterine massage was limited.

These results should therefore not be extrapolated to settings where routine uterotonics are not used or not available.

There were no data on women's experience of discomfort during the procedure.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.
Figuras y tablas -
Analysis 1.1

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.
Figuras y tablas -
Analysis 1.2

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 3 Use of additional uterotonics.
Figuras y tablas -
Analysis 1.3

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 3 Use of additional uterotonics.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 4 Blood transfusion.
Figuras y tablas -
Analysis 1.4

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 4 Blood transfusion.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 5 Need for manual removal of placenta.
Figuras y tablas -
Analysis 1.5

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 5 Need for manual removal of placenta.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 6 Blood loss > 1000 mL.
Figuras y tablas -
Analysis 1.6

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 6 Blood loss > 1000 mL.

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 9 Haemoglobin < 8 g/dL.
Figuras y tablas -
Analysis 1.9

Comparison 1 Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth, Outcome 9 Haemoglobin < 8 g/dL.

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.
Figuras y tablas -
Analysis 2.1

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.
Figuras y tablas -
Analysis 2.2

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 4 Mean blood loss in 30 minutes after trial entry.
Figuras y tablas -
Analysis 2.4

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 4 Mean blood loss in 30 minutes after trial entry.

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 5 Mean blood loss in 60 minutes after delivery (mL).
Figuras y tablas -
Analysis 2.5

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 5 Mean blood loss in 60 minutes after delivery (mL).

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 6 Use of additional uterotonics.
Figuras y tablas -
Analysis 2.6

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 6 Use of additional uterotonics.

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 8 Blood transfusion.
Figuras y tablas -
Analysis 2.8

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 8 Blood transfusion.

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 9 Maternal death or severe morbidity.
Figuras y tablas -
Analysis 2.9

Comparison 2 Uterine massage after placental delivery versus no massage: vaginal birth, Outcome 9 Maternal death or severe morbidity.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.
Figuras y tablas -
Analysis 3.1

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 1 Blood loss 500 mL or more after trial entry.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.
Figuras y tablas -
Analysis 3.2

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 2 Placenta delivered more than 30 minutes after birth.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 3 Use of additional uterotonics.
Figuras y tablas -
Analysis 3.3

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 3 Use of additional uterotonics.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 4 Blood transfusion.
Figuras y tablas -
Analysis 3.4

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 4 Blood transfusion.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 5 Need for manual removal of placenta.
Figuras y tablas -
Analysis 3.5

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 5 Need for manual removal of placenta.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 6 Blood loss > 1000 mL.
Figuras y tablas -
Analysis 3.6

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 6 Blood loss > 1000 mL.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 7 Mean blood loss at 30 minutes.
Figuras y tablas -
Analysis 3.7

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 7 Mean blood loss at 30 minutes.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 8 Mean blood loss at 60 minutes.
Figuras y tablas -
Analysis 3.8

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 8 Mean blood loss at 60 minutes.

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 9 Haemoglobin < 8 g/dL.
Figuras y tablas -
Analysis 3.9

Comparison 3 Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth, Outcome 9 Haemoglobin < 8 g/dL.

Comparison 1. Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Blood loss 500 mL or more after trial entry Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 Routine active management of 3rd stage of labour

2

1291

Risk Ratio (M‐H, Random, 95% CI)

1.56 [0.44, 5.49]

2 Placenta delivered more than 30 minutes after birth Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Routine active management of 3rd stage of labour

2

1289

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.33, 1.88]

3 Use of additional uterotonics Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Routine use of uterotonics

2

1260

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.56, 1.85]

4 Blood transfusion Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Routine use of uterotonics

2

1257

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.26, 3.58]

5 Need for manual removal of placenta Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

5.1 Routine use of uterotonics

2

1289

Risk Ratio (M‐H, Random, 95% CI)

1.77 [0.18, 17.62]

6 Blood loss > 1000 mL Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Routine use of uterotonics

2

1291

Risk Ratio (M‐H, Fixed, 95% CI)

2.96 [0.31, 28.35]

7 Mean blood loss at 30 minutes

0

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8 Mean blood loss at 60 minutes

0

0

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

9 Haemoglobin < 8 g/dL Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

9.1 Routine use of uterotonics

1

382

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.21, 1.88]

10 maternal mortality

0

0

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figuras y tablas -
Comparison 1. Uterine massage commenced before placental delivery versus no uterine massage: vaginal birth
Comparison 2. Uterine massage after placental delivery versus no massage: vaginal birth

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Blood loss 500 mL or more after trial entry Show forest plot

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.52 [0.16, 1.67]

1.1 Routine uterotonic used

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.52 [0.16, 1.67]

2 Placenta delivered more than 30 minutes after birth Show forest plot

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.1 Routine uterotonic used

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Blood loss 1000 mL or more after trial entry

0

0

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Mean blood loss in 30 minutes after trial entry Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

4.1 Routine uterotonics used

1

200

Mean Difference (IV, Fixed, 95% CI)

‐41.60 [‐75.16, ‐8.04]

5 Mean blood loss in 60 minutes after delivery (mL) Show forest plot

1

200

Mean Difference (IV, Fixed, 95% CI)

‐77.40 [‐118.71, ‐36.09]

5.1 Routine uterotonics used

1

200

Mean Difference (IV, Fixed, 95% CI)

‐77.40 [‐118.71, ‐36.09]

6 Use of additional uterotonics Show forest plot

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.20 [0.08, 0.50]

6.1 Routine uterotonics used

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.20 [0.08, 0.50]

7 Haemoglobin level after 12 to 24 hours less than 8 g/dL

0

0

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8 Blood transfusion Show forest plot

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8.1 Routine uterotonics used

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9 Maternal death or severe morbidity Show forest plot

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9.1 Routine uterotonics used

1

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figuras y tablas -
Comparison 2. Uterine massage after placental delivery versus no massage: vaginal birth
Comparison 3. Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Blood loss 500 mL or more after trial entry Show forest plot

3

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 Routine use of uterotonics

3

1491

Risk Ratio (M‐H, Random, 95% CI)

1.14 [0.39, 3.32]

2 Placenta delivered more than 30 minutes after birth Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Routine use of uterotonics

3

1489

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.33, 1.88]

3 Use of additional uterotonics Show forest plot

3

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

3.1 Routine use of uterotonics

3

1460

Risk Ratio (M‐H, Random, 95% CI)

0.52 [0.15, 1.81]

4 Blood transfusion Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Routine use of uterotonics

3

1457

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.26, 3.58]

5 Need for manual removal of placenta Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

5.1 Routine use of uterotonics

2

1289

Risk Ratio (M‐H, Random, 95% CI)

1.77 [0.18, 17.62]

6 Blood loss > 1000 mL Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Routine use of uterotonics

2

1291

Risk Ratio (M‐H, Fixed, 95% CI)

2.96 [0.31, 28.35]

7 Mean blood loss at 30 minutes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7.1 Routine use of uterotonics

1

200

Mean Difference (IV, Fixed, 95% CI)

‐41.60 [‐75.16, ‐8.04]

8 Mean blood loss at 60 minutes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 Routine use of uterotonics

1

200

Mean Difference (IV, Fixed, 95% CI)

‐77.40 [‐118.71, ‐36.09]

9 Haemoglobin < 8 g/dL Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

9.1 Routine use of uterotonics

1

382

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.21, 1.88]

10 maternal mortality

0

0

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

10.1 Routine use of uterotonics

0

0

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figuras y tablas -
Comparison 3. Uterine massage commenced before or after placental delivery versus no uterine massage: vaginal birth