Generally, the third stage of labor starts with the delivery of the fetus and ends with the delivery of the placenta and its attached membranes. If there is any sign of complications during or after labor, the clinician will determine the risks and assess the situation. As a result, many authorities have named a fourth stage of labor that begins with the delivery of the placenta and lasts for several hours. The most common complication in the third and fourth stages of labor is postpartum hemorrhage (PPH). Although maternal mortality rates are coming down, PPH remains a leading cause of maternal mortality. In the United States, the maternal mortality rate is approximately seven to 10 women per 100,000 live births. National statistics suggest that approximately 8% of these deaths are caused by PPH. Misoprostol, sold under the brandname Cytotec among others, is a medication used to prevent and treat stomach ulcers, start labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. Misoprostol is used for the prevention of NSAID-induced gastric ulcers. It acts upon gastric parietal cells, inhibiting the secretion of gastric acid by G-protein coupled receptor-mediated inhibition of adenylate cyclase, which leads to decreased intracellular cyclic AMP levels and decreased proton pump activity at the apical surface of the parietal cell. Because other classes of drugs, especially H2-receptor antagonists and proton pump inhibitors, are more effective for the treatment of acute peptic ulcers, misoprostol is only indicated for use by people who are both taking NSAIDs and are at high risk for NSAID-induced ulcers, including the elderly and people with ulcer complications. Misoprostol is sometimes coprescribed with NSAIDs to prevent their common adverse effect of gastric ulceration (e.g. However, even in the treatment of NSAID-induced ulcers, omeprazole proved to be at least as effective as misoprostol, but was significantly better tolerated, so misoprostol should not be considered a first-line treatment. Misoprostol-induced diarrhea and the need for multiple daily doses (typically four) are the main issues impairing compliance with therapy. It causes uterine contractions and the ripening (effacement or thinning) of the cervix. Medical abortion has the advantage of being less invasive, and more autonomous, self-directed, and discreet.
Barbieri is Editor in Chief, OBG Management; Chair, Obstetrics and Gynecology, Brigham and Women’s Hospital; and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts. Barbieri reports no financial relationships relevant to this article. For women who experience a postpartum hemorrhage, and already have received oxytocin as part of routine obstetric care, prioritize the use of parenteral uterotonics, including oxytocin, methylergonovine, and carboprost tromethamine, and avoid the use of rectal misoprostol Uterine atony is failure of the uterus to contract following delivery and is a common cause of postpartum hemorrhage. The options for treating hemorrhage due to this cause are uterotonic agents, including additional oxytocin, carboprost tromethamine, methylergonovine, and misoprostol. Prioritizing the optimal therapy given the circumstances is imperative to maternal safety. In the United States, the preferred uterotonic for this preventive effort is oxytocin—a low-cost, highly effective agent that typically is administered as an intravenous (IV) infusion or intramuscular (IM) injection. Unfortunately, even with the universal administration of oxytocin in the third stage of labor, PPH occurs in about 3% of vaginal deliveries. A key decision in treating a PPH due to uterine atony is treatment with an optimal uterotonic. 1000 ml cesarean section 15% Vital Sign change -or-HR equal to or greater than 110, BP equal to or less than 85/45 O2 Sat less than 95%, pallor, delayed capillary refill, or decreased urine output. can indicate Decreased urine output, decreased BP and tachycardia may be late signs of compromise REFERENCES: 1. 2. Burtelow M, Riley E, Druzin M, Fontaine M, Viele M, Goodnough LT. How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Massive Transfusion Practices Around the Globe and a Suggestion for Common Massive Transfusion Protocol. The use of recombinant factor VIIa in A Textbook of Post Partum Hemorrhage (ed C. A Critical Review on the Use of Recombinant Factor VIIa in Life-Threatening Obstetric Postpartum Hemorrhage. Thromboembolic adverse events after use of recombinant human coagulation factor VIIa. Franchini M, Franchi M, Bergamini V, Salvagno GL, Montagnana M, Lippi G. O'Connell KA, Wood JJ, Wise RP, Lozier JN, Braun MM.
East London Hospital Complex and University of the Witwatersrand, PB X9047, East London 5201, South Africa.b. Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland. Attempts to reduce deaths from postpartum haemorrhage have been complicated by the fact that many deaths occur in out-of-hospital settings or too quickly for the patient to be transferred to a health facility. Furthermore, prevention and treatment have depended primarily on injectable uterotonics, which are seldom available for births outside the health system. For these reasons, the use of misoprostol to prevent or treat postpartum haemorrhage has attracted considerable attention. Misoprostol, an inexpensive and stable prostaglandin E1 analogue, has been shown to stimulate uterine contractility in early pregnancy Administration of this drug on a wide scale at the community level to prevent and treat postpartum haemorrhage is of major public health importance. The first of many randomized trials of the use of misoprostol in the third stage of labour was conducted in 1995. The oral route of administration is the fastest but also the one associated with the shortest duration of action. Severe postpartum hemorrhage, the most common serious complication of delivery, traditionally is managed by blood transfusion or surgery. Oral misoprostol has been advocated as an effective and acceptable therapy. Its most common adverse effects are shivering and pyrexia. In certain circumstances, rectally administered misoprostol can be lifesaving. The use of this administration route is increasing worldwide, but the pharmacologic characteristics of rectal misoprostol may not be equivalent to those of oral misoprostol. Khan and El-Refaey studied the pharmacokinetics and side effects of misoprostol administered rectally during the third stage of labor. To assess the absorption of misoprostol, they studied 20 women in spontaneous labor of a singleton term fetus at a teaching hospital in London. The mothers were older than 18 years and had no contraindications to prostaglandin therapy.
Studies of rectally-administered misoprostol were excluded because of uncertain absorption via the rectal route. In one small trial in which misoprostol at a dose. Misoprostol is a water-soluble drug and is quickly absorbed after sublingual, oral, vaginal, and rectal use. The most common method of administering misoprostol for PPH is rectally. The dose usually ranges from 800 to 1,000 mcg.