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Umbilical Oxytocin Does Not Reduce the Need for Manual Removal of Retained Placenta NEW YORK -- December 7, 2009 -- Umbilical oxytocin has no effect on the need for manual removal of retained placenta, according to a multicentre study published in an article that appears online (www.thelancet.com) and in an upcoming edition of The Lancet. Retained placenta complicates 0.1% to 2.0% of deliveries. The rate has increased in Europe since the 1920s and is now nearly 10 times that of resource-poor settings. It is thought that this might be due to increased induction rates as well as a greater availability of facilities for the procedure. Without prompt treatment, women are at high risk of haemorrhage. Current treatment, which requires a surgeon and an anaesthetist, has a case fatality rate of nearly 10% in rural communities. An effective, cheap, low technology treatment is urgently needed. A meta-analysis had suggested that umbilical injection of oxytocin, a low-cost solution, could increase placental expulsion without the need for a surgeon or anaesthetic. The Release Study aimed to assess the technique of umbilical vein oxytocin, which involves injection of oxytocin through an umbilical vein catheter to reach the placenta bed. At least 30 mL of solution needs to be injected through an umbilical vein catheter, a technique not previously studied, according to the article’s first author Andrew D. Weeks, MD, University of Liverpool and Liverpool Women’s Hospital, Liverpool, United Kingdom. In this randomised controlled trial, women who were not bleeding or in shock, and with a placenta retained for more than 30 minutes, were recruited from 13 sites in the United Kingdom, Uganda, and Pakistan. A total of 577 women were assigned to receive 30 mL saline containing either 50 IU oxytocin (n = 292) or 5 mL water (n = 285) injected into the placenta through an umbilical vein catheter. The primary outcome was the need for manual removal of the placenta. The authors detected no difference between the groups in the primary outcome: 61.3% in the oxytocin group and 62.1% in the placebo group required manual placenta removal. When combining the groups, the authors showed that the need for manual removal was higher in the United Kingdom (69%) than in Uganda (47%) or Pakistan (62%). Adverse events did not differ between the 2 groups. The authors say: “These findings [are in] accord with a review in which rates of retained placenta in the UK are seen to be rising with time and seem to be greater in high-resource settings than in low-resource settings. The reasons for this result are not clear, but it could represent the amount of exertion that is put into removal of the placenta by the attendants. In settings in which there are long waits for theatre and in which women are tolerant of pain, there can be many attempts at placental delivery with prolonged cord traction, grasping of vaginal portions of the placenta, and uterine massage. In the UK, by contrast, operating theatres with regional anaesthesia are easily accessible and so the woman does not need to undergo the discomfort of repeated attempts at placental delivery.” They conclude: “Findings from the Release Study have shown that umbilical vein oxytocin had no significant effect on the need for manual removal of the placenta or any other clinical outcome.” In an accompanying editorial, Bissallah Ekele, MD, University of Abuja, Abuja, Nigeria, and Imran Morhason-Bello, MD, University College Hospital, Ibadan, Nigeria, say: “The benefit of intra-umbilical oxytocin injection over manual removal of the placenta in terms of avoidable anaesthetic risks, lower chances of genital tract trauma, infection, uterine synaechia, and infertility might have informed its inclusion in the 2007 guidelines from the UK’s National Institute for Health and Clinical Excellence for the treatment of retained placenta. But with the strength of the evidence from Release, the guidelines might be revisited. WHO [World Health Organization] might also reconsider their recommendation that intra-umbilical vein injection of oxytocin with saline may be offered for the management of retained placenta, especially because the evidence was classified as weak. We do agree that the optimum period before manually removing the placenta remains to be determined.” SOURCE: The Lancet E-mail this page to a friend or colleague! To print, use this version