Comparison Of Sublingual Misoprostol And Intramuscular Oxytocin In Management Of 3Rd Stage Of Labour In Kenyatta National Hospital

Abstract

Introduction: Third stage of labor is defined as the part of labor from the birth of the baby until the placenta (afterbirth) and fetal membranes are delivered. (1).Signs of third stage of labor includes, gush of fresh blood, and cord lengthening, globular and firm uterus and rise of the uterus anteriorly. Everyday 800 women die from pregnancy or child birth related complications around the world, of these deaths most of them occur in developing countries. In 2013 for example 289,000 women died during and following pregnancy and child birth.(2).Of the global causes of maternal mortality;27% is attributed to severe bleeding after delivery,28% to pre-existing conditions,14% to pregnancy induced high blood pressure,8% to complications following abortion,11% to infections,9% by obstructed labor and other causes,3% to blood clots and embolism.(2).PPH is defined as blood loss of more than 500mls following vaginal delivery or more than 1000mls following cesarean section delivery. A loss of these amounts within the first 24hrs of delivery is referred to as primary PPH, whereas such an amount of blood loss occurring after 24hrs is termed as secondary PPH.WHO recommends the use of oxytocin 10i.u intramuscular in prevention of PPH. On the other hand, sublingual misoprostol is affordable, rapidly absorbed, efficacious and doesn’t require refrigeration. There is little data on the effectiveness of misoprostol in comparison to oxytocin for prevention or management of third stage of labor in our set up. Objective: To compare sublingual misoprostol 600 ug with intramuscular oxytocin 10 i.u. in management of 3rd stage of labor in low-risk vaginal birth at KNH. Design: This study was an open blind randomized clinical trial. Setting: Labor ward at Kenyatta National Hospital. Sample size: 144 mothers who met the inclusion criteria were sampled out for inclusion in the study. Methods: open blind randomized clinical trial was used at Kenyatta National Hospital from May 2016 through July 2016, 72 women were administered 10i.u oxytocin intramuscular while 72 women were given sublingual misoprostol 600mcg after the delivery of the anterior shoulder. The time taken to deliver the placenta was recorded, the amount of blood loss was estimated and the need for additional uterotonics was compared. Data management: Data analysis was conducted using STATA version 12 (College Station, Texas. US). Initial descriptive analysis of patients was conducted according to treatment group to determine success of randomization. Continuous variables including age, were summarized using means and standard deviation and comparisons between the treatment arms was conducted using Student’s t-test. The categorical variables e.g. education level were analyzed by calculating Page xii of 65 frequencies and percentages followed by comparisons of frequency distributions conducted using Pearson’s chi square test. Main outcome measure: The primary outcome was the mean duration of third stage of labor. The mean duration (SD) of third stage was calculated in the two groups and based on tests of normality of residuals either a Student’s t-test (normal distribution) or a Mann-Whitney test (skewed distribution) used for comparisons. The two secondary outcomes namely proportion of additional uterotonics used and proportion of excessive blood loss were determined through recording the respective variables into binary variables and calculating the corresponding percentages. Comparison of these outcomes and treatments were conducted using chi-square test. The magnitude of effect was presented as odds ratios and 95% confidence intervals derived from logistic regression models. For all analysis statistical significance was determined using a cut-off value of 0.05.