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. 2016 Jan 27;2016(1):CD010845.
doi: 10.1002/14651858.CD010845.pub2.

Breastfeeding or nipple stimulation for reducing postpartum haemorrhage in the third stage of labour

Parvin Abedi  1 , Shayesteh Jahanfar, Farideh Namvar, Jasmine Lee
Affiliations

Breastfeeding or nipple stimulation for reducing postpartum haemorrhage in the third stage of labour

Parvin Abedi et al. Cochrane Database Syst Rev. .

Abstract

Background: Oxytocin and prostaglandin are hormones responsible for uterine contraction during the third stage of labour. Receptors in the uterine muscles are stimulated by exogenous or endogenous oxytocin leading to uterine contractions. Nipple stimulation or breastfeeding are stimuli that can lead to the secretion of oxytocin and consequent uterine contractions. Consequently, uterine contractions can reduce bleeding during the third stage of labour.

Objectives: To investigate the effects of breastfeeding or nipple stimulation on postpartum haemorrhage (PPH) during the third stage of labour.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 July 2015) and reference lists of retrieved studies.

Selection criteria: Randomised and quasi-randomised controlled trials comparing breast stimulation, breastfeeding or suckling for PPH in the third stage of labour were selected for this review.

Data collection and analysis: Two review authors independently assessed studies for inclusion in terms of risk of bias and independently extracted data. Disagreements were resolved by a third review author.

Main results: We included four trials (4608 women), but only two studies contributed data to the review's analyses (n = 4472). The studies contributing data were assessed as of high risk of bias overall. One of these studies was cluster-randomised and conducted in a low-income country and the other study was carried out in a high-income country. All four included studies assessed blood loss in the third stage of labour. Birth attendants estimated blood loss in two trials. The third trial assessed the hematocrit level on the second day postpartum to determine the effect of the bleeding. The fourth study measured PPH ≥ 500 mL. Nipple stimulation versus no treatmentOne study (4385 women) compared the effect of suckling versus no treatment. Blood loss was not measured in 114 women (59 in control group and 55 in suckling group). After excluding twin pregnancies, stillbirths and neonatal deaths, the main analyses for this trial were performed on 4227 vaginal deliveries. In terms of maternal death or severe morbidity, one maternal death occurred in the suckling group due to retained placenta (risk ratio (RR) 3.03, 95% confidence interval (CI) 0.12 to 74.26; one study, participants = 4227; very low quality evidence); severe morbidity was not mentioned. Severe PPH (≥ 1000 mL) was not reported in this study.The incidence of PPH (≥ 500 mL) was similar in the suckling and no treatment groups (RR 0.95, 95% CI 0.77 to 1.16; one study, participants = 4227; moderate quality). There were no group differences between nipple stimulation and no treatment regarding blood loss in the third stage of labour (mean difference (MD) 2.00, 95% CI -7.39 to 11.39; one study, participants = 4227; low quality). The rates of retained placenta were similar (RR 1.01, 95% CI 0.14 to 7.16; one study, participants = 4227; very low quality evidence), as were perinatal deaths (RR 1.06, 95% CI 0.57 to 1.98; one study, participants = 4271; low quality), and maternal readmission to hospital (RR 1.01, 95% CI 0.14 to 7.16; one study, participants = 4227; very low quality). We downgraded the evidence for this comparison for risk of bias concerns in the one included trial (inappropriate analyses for cluster design) and for imprecision (wide CIs crossing the line of no difference and, for some outcomes, few events).Many maternal secondary outcomes (including side effects) were not reported. Similarly, most neonatal secondary outcomes were not reported. Nipple stimulation versus oxytocinAnother study compared the effect of nipple stimulation (via a breast pump) with oxytocin. Eighty-seven women were recruited but only 85 women were analysed. Severe PPH ≥ 1000 mL and maternal death or severe morbidity were not reported.There was no clear effect of nipple stimulation on blood loss (MD 15.00, 95% CI -24.50 to 54.50; one study, participants = 85; low quality evidence), or on postnatal anaemia compared to the oxytocin group (MD -0.40, 95% CI -2.22 to 1.42; one study, participants = 85; low quality evidence). We downgraded evidence for this comparison due to risk of bias concerns in the one included trial (alternate allocation) and for imprecision (wide CIs crossing the line of no difference and small sample size).Many maternal secondary outcomes (including side effects) were not reported, and none of this review's neonatal secondary outcomes were reported.

Authors' conclusions: None of the included studies reported one of this review's primary outcomes: severe PPH ≥ 1000 mL. Only one study reported on maternal death or severe morbidity. There were limited secondary outcome data for maternal outcomes and very few secondary outcome data for neonatal outcomes.There was no clear differences between nipple stimulation (suckling) versus no treatment in relation to maternal death, the incidence of PPH (≥ 500 mL), blood loss in the third stage of labour, retained placenta, perinatal deaths or maternal readmission to hospital. Whilst these data are based on a single study with a reasonable sample size, the quality of these data are mostly low or very low.There is insufficient evidence to evaluate the effect of nipple stimulation for reducing postpartum haemorrhage during the third stage of labour and more evidence from high-quality studies is needed. Further high-quality studies should recruit adequate sample sizes, assess the impact of nipple stimulation compared to uterotonic agents such as syntometrine and oxytocin, and report on important outcomes such as those listed in this review.

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Conflict of interest statement

Parvin Abedi: none known

Shayesteh Jahanfar: none known

Farideh Namvar: none known

Jasmine Lee: none known

Figures

1
1
Study flow diagram.
2
2
Methodological quality summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Nipple stimulation (suckling) versus no treatment, Outcome 1 Maternal death.
1.2
1.2. Analysis
Comparison 1 Nipple stimulation (suckling) versus no treatment, Outcome 2 Frequency of PPH ≥ 500 mL.
1.3
1.3. Analysis
Comparison 1 Nipple stimulation (suckling) versus no treatment, Outcome 3 Amount of blood loss.
1.4
1.4. Analysis
Comparison 1 Nipple stimulation (suckling) versus no treatment, Outcome 4 Retained placenta.
1.5
1.5. Analysis
Comparison 1 Nipple stimulation (suckling) versus no treatment, Outcome 5 Perinatal death.
1.6
1.6. Analysis
Comparison 1 Nipple stimulation (suckling) versus no treatment, Outcome 6 Maternal admission to hospital.
2.1
2.1. Analysis
Comparison 2 Nipple stimulation (breast pump) versus oxytocin, Outcome 1 Amount blood loss.
2.2
2.2. Analysis
Comparison 2 Nipple stimulation (breast pump) versus oxytocin, Outcome 2 Postnatal anaemia.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010845

References

References to studies included in this review

Badhwar 1991 {published data only}
    1. 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 and Obstetrics 1991;36 Suppl:16.
Bullough 1989 {published data only}
    1. Bullough CHW. Breast suckling or nipple stimulation: prevention of postpartum haemorrhage?. European Journal of Obstetrics & Gynecology and Reproductive Biology 1996;69:39.
    1. Bullough CHW, Msuku RS, Karonde L. Early suckling and postpartum haemorrhage: controlled trial in deliveries by traditional birth attendants. Lancet 1989;2:522‐5. - PubMed
Irons 1994 {published data only}
    1. Irons DW, Sriskandabalan P, Bullough CHW. A simple alternative to parenteral oxytocics for the third stage of labor. International Journal of Gynecology & Obstetrics 1994;46:15‐8. - PubMed
Kim 1986 {published data only}
    1. Kim YM, Tejani N, Chayen B, Verma UL. Management of the third stage of labor with nipple stimulation. Journal of Reproductive Medicine 1986;31:1033‐4. - PubMed

References to studies awaiting assessment

Narenji 2012 {published data only}
    1. Narenji F. Comparison the effect of intramuscular injection of oxytocin and nipple stimulation on the third stage of delivery length and bleeding. IRCT Iranian Registry of Clinical Trials (www.irct.ir) [accessed 16 July 2015] 2012.
    1. Narenji F, Bahmani Z, Mirzaie R. Comparison of the effect of oxytocin IM injection and nipple stimulation on bleeding and length of third stage of deliver. Complementary Medicine Journal of Faculty of Nursing & Midwifery 2012; Vol. 2, issue 1:119‐25.

Additional references

Aflaifel 2012
    1. Aflaifel N, Weeks AD. Active management of the third stage of labour, oxytocin is all you need. BMJ 2012;345:1‐2. [DOI: 10.1136/bmj.e4546] - DOI - PubMed
Alexandrova 1980
    1. Alexandrova M, Soloff MS. Oxytocin receptors and parturition. I. Control of oxytocin receptor concentration in the rat myometrium at term. Endocrinology 1980;106(3):730‐5. - PubMed
Andolina 1999
    1. Andolina K, Daly S, Roberts N, Tolosa J, Wapner R. Objective measurement of blood loss at delivery: is it more than a guess?. American Journal of Obstetrics and Gynecology 1999;180:S69.
Arenson 2007
    1. Arenson J, Drake P. Maternal and Newborn Health. Jones & Bartlett Learning, 2006.
Begley 2015
    1. Begley CM, Gyte GM, Declan D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews 2015, Issue 3. [DOI: 10.1002/14651858.CD007412.pub4] - DOI - PubMed
Brandt 1933
    1. Brandt M. The mechanism and management of the third stage of labor. American Journal of Obstetrics and Gynecology 1933;25:662‐7.
Carroli 2008
    1. Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum haemorrhage: a systematic review. Best Practice & Obstetrics and Gynecology 2008;22(6):999‐1012. [DOI: 10.1016/j.bpobgyn.2008.08.004] - DOI - PubMed
Christensson 1989
    1. Christensson K, Nilsson BA, Stock S, Matthiesen AS, Uvnäs‐Moberg K. Effect of nipple stimulation on uterine activity and on plasma levels of oxytocin in full term, healthy, pregnant women. Acta Obstetricia et Gynecologica Scandinavica 1989;68(3):205‐10. - PubMed
CMQCC 2010
    1. Maternity Quality Care Collaborative. OB Hemorrhage Care Guidelines: Checklist Format V.1.4. Retrieved from http://www.cmqcc.org/resources/ob_hemorrhage/ob_hemorrhage_care_guidelin... 2010.
Coad 2011
    1. Coad J, Melvyn D. Anatomy and Physiology for Midwives. 3rd Edition. Churchill Livingstone, 2011.
Creanga 2015
    1. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy‐Related Mortality in the United States, 2006–2010. Obstetrics and Gynecology 2015;125:5‐12. [DOI: 10.1097/AOG.0000000000000564] - DOI - PubMed
Dewey 2001
    1. Dewey KG. Maternal and fetal stress are associated with impaired lactogenesis in human. Journal of Nutrition 2001;131(11):3012S‐5S. - PubMed
Elbourne 1995
    1. Elbourne D. Care in the third stage of labour. In: Robinson S, Thomson AM editor(s). Midwives, Research and Childbirth. Vol. 4, London: Chapman & Hall, 1995:192‐207.
Festin 2003
    1. Festin MR, Lumbiganon P, Tolosa JE, Finney KA, Ba‐Thike K, Chipato T, et al. International survey on variations in practice of the management of the third stage of labour. Bulletin of the World Health Organization 2003;81(4):286‐91. - PMC - PubMed
Finley 1986
    1. Finley BE, Amico J, Castillo M, Seitchik J. Oxytocin and prolactin responses associated with nipple stimulation contraction stress tests. Obstetrics and Gynecology 1986;67(6):836‐9. - PubMed
Fuchs 1991
    1. Fuchs AR, Romero R, Keefe D, Parra M, Oyarzun E, Behnke E. Oxytocin secretion and human parturition: pulse frequency and duration increase during spontaneous labor in women. American Journal of Obstetrics and Gynecology 1991;165(5 Pt 1):1515‐23. - PubMed
Gimpl 2001
    1. Gimpl G, Fahrenholz F. The oxytocin receptor system: structure, function and regulation. Physiological Reviews 2001;81(2):629‐83. - PubMed
Gyte 1994
    1. Gyte GM. Evaluation of the meta‐analyses on the effects, on both mother and baby, of the various components of active’ management of the third stage of labour. Midwifery 1994;10(4):183‐99. - PubMed
Gülmezoglu 2012
    1. Gülmezoglu AM, Lumbiganon P, Landoulsi S, Widmer M, Abdel‐Aleem H, Festin M, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non‐inferiority trial. Lancet 2012;379(9827):1721‐7. [DOI: 10.1016/S0140-6736(12)60206-2] - DOI - PubMed
Hatjis 1989
    1. Hatjis CG, Morris M, Rose JC, Kofinas AD, Penry M, Swain M. Oxytocin, vasopressin, and prolactin response associated with nipple stimulation. Southern Medical Journal 1989;82(2):193‐6. - PubMed
Higgins 2011
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
ICM/FIGO 2006
    1. ICM/FIGO. Prevention and treatment of postpartum haemorrhage. http://www.figo.org/projects/prevent/PPH 2006.
Kavanagh 2005
    1. Kavanagh J, Kelly AJ, Thomas J. Breast stimulation for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews 2005, Issue 3. [DOI: 10.1002/14651858.CD003392.pub2] - DOI - PMC - PubMed
Khushk 2002
    1. Khushk IA, Baig LA. Maternal mortality in Pakistan: no room for complacency. Journal of College of Physicians and Surgeons Pakistan 2002;12:511‐2.
Koh 2009
    1. Koh E, Devendra K, Tan LK. B‐Lynch suture for the treatment of uterine atony. Singapore Medical Journal 2009;50(7):693‐7. - PubMed
Mashini 1987
    1. Mashini IS, Devoe LD, McKenzie JS, Hadi HA, Sherline DM. Comparison of uterine activity induced by nipple stimulation and oxytocin. Obstetrics and Gynecology 1987;69:74‐8. - PubMed
Maughan 2006
    1. Maughan KL, Heim SW, Galazka SS. Preventing postpartum hemorrhage: managing the third stage of labor. American Family Physician 2006;73(6):1025‐8. - PubMed
McDonald 2007
    1. McDonald S. Management of the third stage of labor. Journal of Midwifery and Women’s Health 2007;52(3):254‐61. - PubMed
Phaneuf 1998
    1. Phaneuf S, Asbóth G, Carrasco MP, Liñares BR, Kimura T, Harris A, et al. Desensitisation of oxytocin receptors in human myometrium. Human Reproduction Update 1998;4(5):625‐33. - PubMed
POPPHI 2008
    1. Prevention of Postpartum Hemorrhage Initiative (POPPHI). Fact sheets: Uterotonic drugs for the prevention and treatment of postpartum hemorrhagia. Seattle: PATH. http://www.path.org/publications/files/MCHN_popphi_pph_fs_uterotonic.pdf (accessed 2013) 2008.
Prendiville 1989
    1. Prendiville WJ, Elbourne DR. Care during the third stage of labour. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:1145‐69.
Prendiville 1996
    1. Prendiville WJ. The prevention of post partum haemorrhage: optimising routine management of the third stage of labour. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1996;69(1):19‐24. - PubMed
Razvi 2008
    1. Razvi K, Chua S, Arulkumaran S, Ratnam SS. A comparison between visual estimation and laboratory determination of blood loss during the third stage of labour. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008;36(2):152‐4. - PubMed
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Ridley 2002
    1. Ridley S, Smith G, Batchelor A. Core Cases in Critical Care. Cambridge University Press, 2002.
Soltani 2008
    1. Soltani H. Global implications of evidence based practice: management of the third stage of labour. Midwifery 2008;24:138‐42. - PubMed
UNICEF 2002
    1. Anonymous. Facts for Life. 3rd Edition. New York: United Nations Children's Fund/UNICEF, 2002.
WHO 1998
    1. World Health Organization. Evidence for the Ten Steps to Successful Breastfeeding. Geneva: WHO, 1998.
WHO 2007
    1. World Health Organization. WHO Recommendations for the Prevention of Postpartum Haemorrhage. Geneva: WHO, 2007. - PMC - PubMed
WHO 2012
    1. World Health Organization. Maternal Mortality. Geneva: WHO, 2012.
WHO 2014
    1. World Health Organization. Maternal mortality fact sheet No. 348. (http://apps.who.int/iris/bitstream/10665/112318/1/WHO_RHR_14.06_eng.pdf?..., accessed 5 February 2015 2015.

References to other published versions of this review

Abedi 2013
    1. Abedi P, Jahanfar S, Namvar F. Nipple stimulation or breastfeeding for preventing postpartum haemorrhage in the third stage of labour. Cochrane Database of Systematic Reviews 2013, Issue 11. [DOI: 10.1002/14651858.CD010845] - DOI - PMC - PubMed

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