Question 58CORRECTWhen making a visit to the home of a postpartum woman one week afterbirth, the nurse should recognize that the woman would characteristically:
Get
answer to your question and much more Question 59WRONGFour hours after a difficult labor and birth, a primiparous woman refuses tofeed her baby, stating that she is too tired and just wants to sleep. The
nurseshould:Question 59 Explanation:Response 1 does not take into consideration the need for the newmother to be nurtured and have her needs met during the taking-instage. The behavior described is typical of this
stage and not areflection of ineffective attachment unless the behavior persists.Mothers need to reestablish their own well-being in order to effectivelycare for their baby. Get answer to your question and much more Question 60WRONGParents can facilitate the adjustment of their other children to a new baby by:
Meta-Analysis . 2018 Dec 19;12(12):CD011689. doi: 10.1002/14651858.CD011689.pub3. Argyro Papadopoulou, Rebecca Man, Nikolaos
Athanasopoulos, Aurelio Tobias, Malcolm J Price, Myfanwy J
Williams, Virginia Diaz, Julia Pasquale, Monica
Chamillard, Mariana Widmer, Özge Tunçalp, G Justus
Hofmeyr, Fernando Althabe, Ahmet Metin Gülmezoglu, Joshua P Vogel, Olufemi T Oladapo, Arri
Coomarasamy Affiliations - PMID: 30569545
- PMCID: PMC6388086
- DOI:
10.1002/14651858.CD011689.pub3
Free PMC article Meta-Analysis Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis Ioannis D
Gallos et al. Cochrane Database Syst Rev. 2018. Free PMC article
Abstract Background: Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic agents can prevent PPH, and are routinely recommended. The current World Health Organization (WHO) recommendation for preventing PPH is 10 IU (international units) of intramuscular or intravenous oxytocin. There are several uterotonic agents for preventing PPH but there is still
uncertainty about which agent is most effective with the least side effects. This is an update of a Cochrane Review which was first published in April 2018 and was updated to incorporate results from a recent large WHO trial. Objectives: To identify the most effective uterotonic agent(s) to prevent PPH with the least side effects, and generate a ranking according to their effectiveness and side-effect profile. Search methods: We searched the
Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (24 May 2018), and reference lists of retrieved studies. Selection criteria: All randomised controlled trials or cluster-randomised trials comparing the effectiveness and side effects of uterotonic agents with other uterotonic agents, placebo or no treatment for preventing PPH were eligible for inclusion.
Quasi-randomised trials were excluded. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. Data collection and analysis: At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. Secondary outcomes included blood loss and
related outcomes, morbidity outcomes, maternal well-being and satisfaction and side effects. Primary outcomes were also reported for pre-specified subgroups, stratifying by mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of administration. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available agents. Main results: The network meta-analysis included 196 trials
(135,559 women) involving seven uterotonic agents and placebo or no treatment, conducted across 53 countries (including high-, middle- and low-income countries). Most trials were performed in a hospital setting (187/196, 95.4%) with women undergoing a vaginal birth (71.5%, 140/196).Relative effects from the network meta-analysis suggested that all agents were effective for preventing PPH ≥ 500 mL when compared with placebo or no treatment. The three highest ranked uterotonic agents for
prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. Low-certainty evidence suggests that misoprostol, injectable prostaglandins, and
ergometrine may make little or no difference to this outcome compared with oxytocin.All agents except ergometrine and injectable prostaglandins were effective for preventing PPH ≥ 1000 mL when compared with placebo or no treatment. High-certainty evidence suggests that ergometrine plus oxytocin (RR 0.83, 95% CI 0.66 to 1.03) and misoprostol plus oxytocin (RR 0.88, 95% CI 0.70 to 1.11) make little or no difference in the outcome of PPH ≥ 1000 mL compared with oxytocin. Low-certainty evidence
suggests that ergometrine may make little or no difference to this outcome compared with oxytocin meanwhile the evidence on carbetocin was of very low certainty. High-certainty evidence suggests that misoprostol is less effective in preventing PPH ≥ 1000 mL when compared with oxytocin (RR 1.19, 95% CI 1.01 to 1.42). Despite the comparable relative treatment effects between all uterotonics (except misoprostol) and oxytocin, ergometrine plus oxytocin, misoprostol plus oxytocin combinations and
carbetocin were the highest ranked agents for PPH ≥ 1000 mL.Misoprostol plus oxytocin reduces the use of additional uterotonics (RR 0.56, 95% CI 0.42 to 0.73, high certainty) and probably also reduces the risk of blood transfusion (RR 0.51, 95% CI 0.37 to 0.70, moderate certainty) when compared with oxytocin. Carbetocin, injectable prostaglandins and ergometrine plus oxytocin may also reduce the use of additional uterotonics but the certainty of the evidence is low. No meaningful differences
could be detected between all agents for maternal deaths or severe morbidity as these outcomes were rare in the included randomised trials where they were reported.The two combination regimens were associated with important side effects. When compared with oxytocin, misoprostol plus oxytocin combination increases the likelihood of vomiting (RR 2.11, 95% CI 1.39 to 3.18, high certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49, moderate certainty). Ergometrine plus oxytocin increases the
likelihood of vomiting (RR 2.93, 95% CI 2.08 to 4.13, moderate certainty) and may make little or no difference to the risk of hypertension, however absolute effects varied considerably and the certainty of the evidence was low for this outcome.Subgroup analyses did not reveal important subgroup differences by mode of birth (caesarean versus vaginal birth), setting (hospital versus community), risk of PPH (high versus low risk for PPH), dose of misoprostol (≥ 600 mcg versus < 600 mcg) and
regimen of oxytocin (bolus versus bolus plus infusion versus infusion only). Authors' conclusions: All agents were generally effective for preventing PPH when compared with placebo or no treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional desirable effects compared with the current standard oxytocin. The two combination regimens, however, are associated with significant side effects.
Carbetocin may be more effective than oxytocin for some outcomes without an increase in side effects. Conflict of interest statement Ioannis D Gallos (IDG): is a co‐applicant to the UK National Institute for Health Research HTA Project Award 14/139/17 entitled Uterotonic agents for preventing
postpartum haemorrhage: a network meta‐analysis and cost‐effectiveness analysis. He has been involved in one or more previous or ongoing trials related to the use of uterotonics for the prevention of PPH that were eligible for inclusion in this review. Ferring Pharmaceuticals and Novartis supplied carbetocin and oxytocin for these studies. IDG did not participate in any decisions regarding these trials (i.e. assessment for inclusion/exclusion, trial quality, data extraction) for the
purposes of this review (and will not for future updates) – these tasks were carried out by other members of the team who were not directly involved in the trials. Argyro Papadopoulou (AP): none known. Rebecca Man (RM): none known.
Nikolaos Athanasopoulos (NA): none known. Malcolm J Price (MJP): is a co‐applicant to the UK National Institute for Health Research HTA Project Award 14/139/17 entitled Uterotonic agents for preventing postpartum haemorrhage: a
network meta‐analysis and cost‐effectiveness analysis. Aurelio Tobias: none known. Myfanwy Williams (MJW): is employed by the University of Liverpool as a Research Associate at Cochrane Pregnancy and Childbirth. Her role is
supported by the World Health Organization. Virginia Diaz (VD): none known. Julia Pasquale (JP): none known. Monica Chamillard (MC): none known. Mariana Widmer (MW): has been involved in a trial related to the use of uterotonics for the prevention of PPH that is included in this review. Ferring Pharmaceuticals and Novartis supplied carbetocin and oxytocin for the trial and the study is supported by WHO/Merck for Mothers. MW did not
participate in any decisions regarding this trial (i.e. assessment for inclusion/exclusion, trial quality, data extraction) for the purposes of this review or future updates – these tasks were carried out by other members of the team who were not directly involved in the trial. Özge Tunçalp (OT): is a co‐applicant to the UK National Institute for Health Research
HTA Project Award 14/139/17 entitled Uterotonic agents for preventing postpartum haemorrhage: a network meta‐analysis and cost‐effectiveness analysis. G Justus Hofmeyr (GJH): has been and continues to be involved in a number of studies that may be eligible for inclusion in this review, but has not been (and will not participate in) data extraction
or quality assessment of the studies in which he was involved. GJH is a co‐investigator on the UK National Institute for Health Research HTA Project Award 14/139/17 entitled Uterotonic agents for preventing postpartum haemorrhage: a network meta‐analysis and cost‐effectiveness analysis. Neither he nor his institution receives funding from this grant. Fernando Althabe: none known. A Metin Gulmezoglu (AMG): was part of the central coordination unit of the large World Health Organization multicentre trial comparing carbetocin with oxytocin included in the review. He is a co‐applicant to the UK National Institute for Health Research HTA Project Award 14/139/17 entitled Uterotonic
drugs for preventing postpartum haemorrhage: a network meta‐analysis and cost‐effectiveness analysis. Joshua Vogel (JPV): led the updating of WHO recommendations on uterotonics for the prevention of postpartum haemorrhage based on this review. Olufemi T Oladapo (OTO): led the updating of WHO recommendations on uterotonics for the prevention of postpartum haemorrhage based on the findings of this review update. Arri Coomarasamy (AC): is the Chief Investigator of UK National Institute for Health Research HTA Project Award 14/139/17 entitled Uterotonic
agents for preventing postpartum haemorrhage: a network meta‐analysis and cost‐effectiveness analysis. He has been involved in one or more previous or ongoing trials related to the use of uterotonics for the prevention of PPH that were eligible for inclusion in this review. Ferring Pharmaceuticals and Novartis supplied carbetocin and oxytocin for these studies and another study is supported by WHO/Merck for Mothers. AC did not participate in any decisions regarding these trials (i.e.
assessment for inclusion/exclusion, trial quality, data extraction) for the purposes of this review or future updates – these tasks have been carried out by other members of the team who were not directly involved in the trials. AC is a member of the Executive Board of Ammalife (UK registered charity 1120236). He does not receive any payment for this relationship. Figures
1 Study flow diagram.
2 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
4 Network Diagram for PPH ≥ 500 mL. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the
number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
5 Cumulative rankograms comparing each of the uterotonic agents for diarrhoea. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate the
SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
6 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for prevention of PPH ≥ 500 mL.
7 Cumulative rankograms comparing each of the uterotonic agents for prevention of PPH ≥ 500 mL. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each
ranking.We estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
8 Network Diagram for PPH ≥ 1000 mL. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the
number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
9 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for prevention of PPH ≥ 1000 mL.
10 Cumulative rankograms comparing each of the uterotonic agents for prevention of PPH ≥ 1000 mL. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each
ranking.We estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
11 Network Diagram for maternal death. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the
number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
12 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for prevention of maternal death.
13 Cumulative rankograms comparing each of the uterotonic agents for prevention of maternal death. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each
ranking.We estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
14 Network Diagram for severe maternal morbidity: intensive care admissions. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct
comparison and are drawn proportional to the number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
15 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for prevention of severe maternal morbidity: intensive care admissions.
16 Cumulative rankograms comparing each of the uterotonic agents for prevention of severe maternal morbidity: intensive care admissions. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis
the cumulative probability of each ranking. We estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
17 Network Diagram for additional uterotonics. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional
to the number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
18 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for additional uterotonics.
19 Cumulative rankograms comparing each of the uterotonic agents for additional uterotonics. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We
estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
20 Network Diagram for blood transfusion. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to
the number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
21 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for blood transfusion.
22 Cumulative rankograms comparing each of the uterotonic agents for blood transfusion. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We
estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
23 Network Diagram for mean blood loss (mL). The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to
the number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
24 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for mean blood loss (mL).
25 Cumulative rankograms comparing each of the uterotonic agents for mean blood loss (mL). Ranking indicates the cumulative probability of being the best, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate
the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
26 Network Diagram for change in haemoglobin measurements before and after birth (g/L). The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a
direct comparison and are drawn proportional to the number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
27 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for change in haemoglobin measurements before and after birth (g/L).
28 Cumulative rankograms comparing each of the uterotonic s for change in haemoglobin measurements before and after birth (g/L). Ranking indicates the cumulative probability of being the best, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative
probability of each ranking.We estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
29 Network Diagram for breastfeeding at discharge. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn
proportional to the number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
30 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for breastfeeding at discharge.
31 Cumulative rankograms comparing each of the uterotonic agents for breastfeeding at discharge. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each
ranking.We estimate the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
32 Network Diagram for nausea. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the number of
trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
33 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for nausea.
34 Cumulative rankograms comparing each of the uterotonic agents for nausea. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate the
SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
35 Network Diagram for vomiting. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the number
of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
36 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for vomiting.
37 Cumulative rankograms comparing each of the uterotonic agents for vomiting. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate the
SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
38 Network Diagram for hypertension. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the
number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
39 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for hypertension.
40 Cumulative rankograms comparing each of the uterotonic agents for hypertension. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate
the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
41 Network Diagram for headache. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the number
of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
42 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for headache.
43 Cumulative rankograms comparing each of the uterotonic agents for headache. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate the
SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
44 Network Diagram for fever. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the number of
trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
45 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for fever.
46 Cumulative rankograms comparing each of the uterotonic agents for fever. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate the
SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
47 Network Diagram for shivering. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the number
of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
48 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for shivering.
49 Cumulative rankograms comparing each of the uterotonic agents for shivering. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate the
SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
50 Network Diagram for abdominal pain. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the
number of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
51 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for abdominal pain.
52 Cumulative rankograms comparing each of the uterotonic agents for abdominal pain. Ranking indicates the cumulative probability of being the best agent, the second best, the third best, etc. The x axis shows the relative ranking and the y‐axis the cumulative probability of each ranking.We estimate
the SUrface underneath this Cumulative RAnking line (SUCRA); the larger the SUCRA the higher its rank among all available agents.
53 Network Diagram for diarrhoea. The nodes represent an intervention and their size is proportional to the number of trials comparing this intervention to any other in the network. The lines connecting each pair of interventions represent a direct comparison and are drawn proportional to the number
of trials making each direct comparison. Numbers on the lines represent the number of trials and participants for each comparison. The colour of the line is green for high‐certainty evidence; light green for moderate‐certainty evidence; orange for low‐certainty evidence and red for very low‐certainty evidence. Multi‐arm trials contribute to more than one comparison.
54 Forest plot with relative risk ratios and 95% CIs from pairwise, indirect and network (combining direct and indirect) analyses for diarrhoea. Update of Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Gallos ID, Williams HM, Price MJ, Merriel A, Gee H, Lissauer D, Moorthy V, Tobias A, Deeks JJ, Widmer M, Tunçalp Ö, Gülmezoglu AM, Hofmeyr GJ, Coomarasamy A. Gallos ID, et
al. Cochrane Database Syst Rev. 2018 Apr 25;4(4):CD011689. doi: 10.1002/14651858.CD011689.pub2. Cochrane Database Syst Rev. 2018. PMID: 29693726 Free PMC article. Updated. Review.
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al. Cochrane Database Syst Rev. 2018 Apr 25;4(4):CD011689. doi: 10.1002/14651858.CD011689.pub2. Cochrane Database Syst Rev. 2018. PMID: 29693726 Free PMC article. Updated. Review. Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis. Parry Smith WR, Papadopoulou A, Thomas E, Tobias A, Price MJ, Meher S, Alfirevic Z, Weeks AD, Hofmeyr GJ, Gülmezoglu AM, Widmer M, Oladapo OT, Vogel JP, Althabe F, Coomarasamy
A, Gallos ID. Parry Smith WR, et al. Cochrane Database Syst Rev. 2020 Nov 24;11(11):CD012754. doi: 10.1002/14651858.CD012754.pub2. Cochrane Database Syst Rev. 2020. PMID: 33232518 Free PMC article. Uterotonic drugs to prevent postpartum haemorrhage: a network meta-analysis. Gallos I, Williams H, Price M, Pickering K, Merriel A, Tobias A, Lissauer D, Gee H, Tunçalp Ö, Gyte G, Moorthy V, Roberts T, Deeks J, Hofmeyr J, Gülmezoglu M, Coomarasamy A. Gallos
I, et al. Health Technol Assess. 2019 Feb;23(9):1-356. doi: 10.3310/hta23090. Health Technol Assess. 2019. PMID: 30821683 Free PMC article. Intravenous versus intramuscular prophylactic
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Okunlola MA, Adekanle DA, et al. A double‐blind, randomized, placebo‐controlled trial of misoprostol and routine uterotonics for the prevention of postpartum hemorrhage. International Journal of Gynecology & Obstetrics 2011;112(2):107‐11. - PubMed
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Orji 2008 {published data only}- Orji E, Agwu F, Loto O, Olaleye O. A randomized comparative study of prophylactic oxytocin versus ergometrine in the third stage of labor. International Journal of Gynecology & Obstetrics 2008;101(2):129‐32. -
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Ortiz‐Gomez 2013 {published data only}- Ortiz‐Gomez JR, Morillas‐Ramirez F, Fornet‐Ruiz I, Palacio‐Abizanda FJ, Bermejo‐Albares L. [Clinical and pharmacological study of the efficacy of carbetocin in elective caesareans compared
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Owonikoko 2011 {published data only}
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Penaranda 2002 {published data only}-
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Rashid 2009 {published data only}- Rashid M, Clark A, Rashid MH. A randomised controlled trial comparing the efficacy of intramuscular syntometrine and intravenous syntocinon, in preventing
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Ray 2001 {published data only}- Chatterjee A. Misoprostol and the 3rd stage. XVI FIGO World Congress of Obstetrics & Gynecology; 2000 Sept
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Reddy 2001 {published data only}- Reddy R, Shenoy JV. Active management of third stage of labour. A comparative study in high risk patients for atonic postpartum haemorrhage.
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Reyes, Gonzalez 2011 {published data only}- Reyes OA, Gonzalez GM. Carbetocin versus oxytocin for prevention of postpartum hemorrhage in patients with severe preeclampsia: a double‐blind randomized controlled trial. Journal of Obstetrics and Gynaecology Canada: JOGC 2011;33(11):1099‐104. -
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Reyes 2011 {published data only}- Reyes OA. Carbetocin vs oxytocin for the prevention of postpartum hemorrhage in grand multiparous patients: A randomized controlled trial. [Spanish]. Clinica e investigacion en ginecologia y
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Rogers 1998 {published data only}- Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet 1998;351(9104):693‐9. -
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Sadiq 2011 {published data only}- Sadiq UG, Kwanashie O, Mairiga G, Gamaniel S, Isa H, Abdu A, et al. A randomised clinical trial comparing the efficacy of oxytocin injection and oral misoprostol tablet in the prevention of
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Samimi 2013 {published data only}- Samimi M, Imani‐Harsini A, Abedzadeh‐Kalahroudi M. Carbetocin vs. syntometrine in prevention of postpartum hemorrhage: a double blind randomized control trial. Iranian Red Crescent Medical Journal 2013;15(9):817‐22. -
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Sood 2012 {published data only}- Sood
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Supe 2016 {published data only}- Supe PA, Kore SJ, Nandanwar YS. A comparative study of efficacy of misoprostol with methyl ergometrine and carboprost in active management of third stage of labour. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 2016;5(5):1525‐31.
Surbek 1999 {published data only}- Surbek DV, Fehr PM, Hoesli I, Holzgreve W. Misoprostol for prevention of postpartum hemorrhage: a randomized controlled trial [abstract]. XVI FIGO World Congress of Obstetrics & Gynecology; 2000 Sept 3‐8; Washington DC, USA 2000;Book 1:33.
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Taheripanah 2018 {published data only}- Taheripanah R, Shoman A, Ali Karimzadeh M, Zamaniyan M, Malih N. Efficacy of oxytocin vs. Carbetocin in prevention of postpartum hemorrhage after cesarean section under general anesthesia: a prospective randomized clinical trial. Journal of Maternal‐Fetal
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Thilaganathan 1993 {published data only}- Thilaganathan B, Cutner A, Latimer J, Beard R. Management of the third stage of labour in women at low risk of postpartum haemorrhage.
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Tripti 2006 {published data only}- Tripti N, Manju E. Intramuscular PGF2 alpha 125 microg versus intravenous methyl ergometrine 0.2 mg in
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Ugwu 2014 {published data only}- Ugwu IA, Enabor OO, Adeyemi AB, Lawal OO, Oladokun A, Olayemi O. Sublingual misoprostol to decrease blood loss after caesarean delivery: a randomised controlled trial. Journal of Obstetrics and Gynaecology 2014;34(5):407‐11. -
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Zachariah 2006 {published data only}- Zachariah ES, Naidu M, Seshadri L. Oral misoprostol
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Ali 2012 {published data only}- Ali R, Hina F. Postpartum hemorrhage; comparison of efficacy of ergometrine with misoprostol in prophylaxis in cesarean section. Professional Medical Journal 2012;19(3):360‐4.
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acupuncture in the third stage of labour [Dit Bedeutung der Akupunktur in der Plazentarperiode]. Deutsche Zeitschrift fur Akupunktur 2000;43:264‐8.
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Badhwar 1991 {published data only}- Badhwar L, Singh K, Sethi N, Gupta I, Aggarwal N. The value of nipple stimulation in the management of third stage of labour. International Journal of Gynecology & Obstetrics 1991;36 Suppl:16.
Bai 2014 {published data only}- Bai J, Sun Q, Zhai H. A comparison of oxytocin and carboprost
tromethamine in the prevention of postpartum hemorrhage in high‐risk patients undergoing cesarean delivery. Experimental and Therapeutic Medicine 2014;7(1):46‐50. - PMC -
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Baig 2015 {published data only}- Baig FS, Shahzad N, Khurshid HN, Malik A. Postpartum haemorrhage; comparison of intra umbilical and intra venous injection of oxytocin on blood loss in third stage of labour. Professional Medical
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Balki 2006 {published data only}- Balki M, Ronayne M, Davies S, Fallah S, Kingdom J, Windrim R, et al. Minimum oxytocin dose requirement after cesarean delivery for labor arrest. Obstetrics & Gynecology 2006;107(1):45‐50. -
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Banovska 2013 {published data only}
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Barbaro 1961 {published data only}- Barbaro CA, Smith GO. Clinical trial of SE505 ‐ a new oxytocic mixture.
Australian and New Zealand Journal of Obstetrics and Gynaecology 1961;1:147‐50.
Baumgarten 1983 {published data only}- Baumgarten K, Schmidt J, Horvat A, Neumann M, Cerwenka R, Gruber W, et al. Uterine motility after post‐partum application of sulprostone and other oxytocics. European Journal of Obstetrics & Gynecology and Reproductive Biology 1983;16:181‐92. -
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Bhattacharya 1988 {published data only}- Bhattacharya P, Devi PK, Jain S, Kanthamani CR, Raghavan KS. Prophylactic use of 15(S)15 methyl PGF2alpha by intramuscular route for control of postpartum bleeding ‐ a comparative trial
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Bhavana 2013 {published data only}- Bhavana G, Mittal S. Evaluation of efficacy of prophylactic injection tranexamic acid in decreasing blood loss before and after caesarean section. BJOG: an international journal of
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Bider 1991 {published data only}- Bider D, Menashe Y, Dulitzky M, Mashiach S, Ben‐Rafael Z. Oxytocin or saline injected intra‐umbilically did not influence the third stage of labor. Acta Obstetricia et Gynecologica Scandinavica 1991;70:321‐3. - PubMed
Bider 1992 {published data only}- Bider D, Ben‐Rafael Z, Dulitzky M, Menashe Y, Mashiach S, Barkai G. Effect of intraumbilical prostaglandin F2alpha injection on the third stage of labor. Journal of Reproductive Medicine 1992;37(4):317‐9. -
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Bisri 2011 {published data only}- Bisri Y, Redjeki IS, Himendra A. The comparative of effect of bolus‐infusion oxytocine with infusion oxytocine on blood pressure, heart rate, and uterine contraction of women undergoing elective
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Blum 2010 {published data only}- Blum J, Winikoff B, Raghavan S, Dabash R, Ramadan MC, Dilbaz B, et al. Treatment of post‐partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a
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Daly 1999 {published data only}- Daly S, Andolina K, Tolosa JE, Roberts N, Wapner R. A randomized controlled trial of misoprostol versus oxytocin in preventing postpartum blood loss. American Journal of Obstetrics and Gynecology
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Dao 2009 {published data only}- Dao B, Blum J, Barrera G, Cherine Ramadan M, Dabash R, Darwish E, et al. Side effect profiles for misoprostol and oxytocin in the treatment of postpartum hemorrhage. International Journal of Gynecology & Obstetrics 2009;107(Suppl 2):S150.
Davies 2005 {published data only}
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Amornpetchakul 2017 {published data only}- Amornpetchakul P, Lertbunnaphong T, Boriboonhiransarn D, Leetheeragul J, Sirisomboon R, Jiraprasertwong R. Efficacy of intravenous 100 mcg carbetocin versus intravenous 5 units oxytocin for prevention of immediate postpartum hemorrhage after normal vagina delivery among high risk pregnancies;
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Draycott 2014 {published data only}- NCT02216383. Intramuscular oxytocics: a comparison study of intramuscular carbetocin, syntocinon and syntometrine for the third stage of labour following vaginal birth (IMox). clinicaltrials.gov/ct2/show/NCT02216383 (first received 15 August 2014).
Gomez 2011 {published data only}- ACTRN12610000550000. Comparison of the effectiveness of carbetocin vs oxytocin in managing the third stage of labor in a group of women with risk factors for postpartum hemorrhage. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335628 (first received
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Goudar 2016 {published data only}- CTRI/2016/06/006996. Effect of carbetocin RTS vs oxytocin for preventing postpartum hemorrhage on post‐delivery hemoglobin: a randomized controlled trial. ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=10619 (first received 6 June 2016).
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Kalahroudi 2010b {published data only}- IRCT201008212854N5. Comparison of the effect of rectal misoprostol and syntometrin in prevention of post partum hemorrhage. en.search.irct.ir/view/3932 (first received 9 September 2010).
Maged 2018 {published data only}- NCT03556852. Carbetocin versus rectal
misoprostol for management of third stage of labor in women at low risk of postpartum hemorrhage. clinicaltrials.gov/ct2/show/NCT03556852 (first received 14 June 2018).
Moradi 2010 {published data only}- IRCT138812223548N1. Comparison of misoprostol and oxytocin in reduction of postpartum hemorrhage. en.search.irct.ir/view/2616 (first received 29 May 2010).
Sweed 2014 {published data only}- NCT02083107. Comparison between rectal and sublingual misoprostol before caesarian section to reduce intra & post‐operative blood loss.
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Thakur 2015 {published data only}- CTRI/2015/06/005918. Efficacy of oxytocin, misoprostol, 15‐methylprostaglandinF2alpha and methylergometrine in active management of third stage of labor.
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Miscellaneous
What is a measure for preventing late postpartum hemorrhage?
The nurse knows that a measure for preventing late postpartum hemorrhage is to a. administer broad-spectrum antibiotics. b. inspect the placenta after delivery. c. manually remove the placenta. d. pull on the umbilical cord to hasten the delivery of the placenta. ANS: B
When evaluating a postpartum woman's perineal care technique the nurse would?
When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: 4. Responses 1, 2, and 3 are all appropriate measures.
What is early postpartum hemorrhage?
The newest definition of early postpoartum hemorrhage is cumulative blood loss >1000 mL with signs of hypovolemia within the first 24 hours after the birth process. Hemorrhage after 24 hours is considered late postpartum hemorrhage. A woman delivered a 9-lb, 10-oz baby 1 hour ago.
What does a postpartum nurse do?
A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: 1. Every 30 minutes during the first hour and then every hour for the next two hours.
Which measure would be least effective in preventing pp hemorrhage?
Which measure would be least effective in preventing postpartum hemorrhage? Question 9 Explanation: The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.
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Postpartum Hemorrhage Practice Exam (EM)*.
Which measurement best describes postpartum hemorrhage?
Postpartum hemorrhage (PPH) is commonly defined as blood loss exceeding 500 mL following vaginal birth and 1000 mL following cesarean.
Which of the following complications is most likely responsible for a postpartum hemorrhage?
The most common causes of PPH are: Uterine atony: Uterine atony (or uterine tone) refers to a soft and weak uterus after delivery. This is when your uterine muscles don't contract enough to clamp the placental blood vessels shut. This leads to a steady loss of blood after delivery.
Which is the most common cause for excessive blood loss after childbirth?
Uterine atony.
This is the most common cause of PPH. It happens when the muscles in your uterus don't contract (tighten) well after birth. Uterine contractions after birth help stop bleeding from the place in the uterus where the placenta breaks away.
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