Alloimmunity in pregnancy is the basis for two of the major complications of pregnancy in transfusion medicine: hemolytic disease of the fetus and newborn (HDFN), and fetal and neonatal alloimmune thrombocytopenia (FNAIT). Use of Rh(D) immune globulin has dramatically reduced the incidence of HDFN in Rh(D)-mismatched pregnancies. Treatment of HDFN may involve intrauterine transfusion, with fetal and neonatal survival rates of 70% to 90%. Treatments for FNAIT include immune globulin, steroids, or in severe cases, intrauterine platelet transfusions. Transfusion medicine is central to the management of pregnancy-associated complications such as postpartum hemorrhage, parvovirus B19 infection, hemoglobinopathies, and aplastic anemia.

OBJECTIVE The aim of this study is critically to review the available evidence regarding the use, efficacy and safety of tranexamic acid in the management of hemorrhage during pregnancy and for prevention and treatment of postpartum hemorrhage. RESEARCH DESIGN AND METHODS We performed a systematic search of electronic literature (PubMed, Embase, CINAHL, Scopus, Cochrane, DARE) to review all studies looking at the use of tranexamic acid during pregnancy and puerperium. We did a meta-analysis on three randomized controlled trials that evaluated reduction in blood loss in women undergoing cesarean sections with the use of tranexamic acid. RESULTS An electronic search yielded 34 articles, the studies dating from 1976 to 2010, five randomized controlled trials, seven observational studies, and twenty-two case reports. Meta-analysis showed that the estimate of the combined effect of tranexamic acid compared with placebo was a difference of 32.5 ml reduction in blood loss (95% CI -4.1-69.13; p = 0.08). Tranexamic acid was also used successfully to prevent and treat bleeding in observation studies and case reports. Pulmonary embolism was reported in two cases; however, the possible involvement of tranexamic acid in these thrombotic episodes could neither be confirmed nor excluded. CONCLUSIONS The clinical studies suggest that tranexamic acid reduces the amount of blood loss after delivery during cesarean sections and vaginal deliveries, and reduces the requirement for blood transfusion. Tranexamic acid seems to be safe and effective in the prevention and management of bleeding during pregnancy. Further investigation and larger clinical trials with better design and methodological quality are required to confirm these findings.

BACKGROUND Amnioinfusion aims to relieve umbilical cord compression during labour by infusing a liquid into the uterine cavity. OBJECTIVES The objective of this review was to assess the effects of prophylactic amnioinfusion for women in labour with oligohydramnios, but not fetal heart deceleration, compared with therapeutic amnioinfusion only if fetal heart rate decelerations or thick meconium-staining of the liquor occur. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012). SELECTION CRITERIA Randomised trials comparing prophylactic amnioinfusion in women in labour with oligohydramnios but not fetal heart rate deceleration in labour with therapeutic amnioinfusion. DATA COLLECTION AND ANALYSIS The authors assessed trial quality and extracted data. MAIN RESULTS One randomized trial of 116 women was included. No differences were found in the rate of caesarean section (risk ratio 1.29, 95% confidence interval 0.60 to 2.74). There were no differences in cord arterial pH, oxytocin augmentation, neonatal pneumonia or postpartum endometritis. Prophylactic amnioinfusion was associated with increased intrapartum fever (risk ratio 3.48, 95% confidence interval 1.21 to 10.05). AUTHORS' CONCLUSIONS There appears to be no advantage of prophylactic amnioinfusion over therapeutic amnioinfusion carried out only when fetal heart rate decelerations or thick meconium-staining of the liquor occur.

BACKGROUND Clinical observations indicate that mothers commonly perceive a reduction in, or absence of, the baby's movements for some days preceding a baby's death. For this reason, fetal movement monitoring is advised by caregivers and used spontaneously by mothers to assess the baby's well-being. However, it is possible that the harmful effects of interventions may outweigh the benefits of such testing. Evidence of effectiveness of fetal movement screening to improve outcomes is limited, though indirect evidence suggests a potential benefit. A secondary question is whether any specific management response to perceived decreased fetal movements (DFM) improves clinical outcome. OBJECTIVES To determine, from the best available evidence, the effectiveness of various management strategies for DFM. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012) and bibliographies of included studies. SELECTION CRITERIA Randomised clinical trials comparing various management strategies for DFM, including delivery, expectant management, cardiotocography (visual and computerised), ultrasound examination including Doppler ultrasound, and fetal arousal tests (cardiotocographic or clinical). DATA COLLECTION AND ANALYSIS Two assessors evaluated potentially eligible trials for inclusion, and extracted data onto a purpose-designed form. Where DFM was one among a number of inclusion criteria for the trial, we contacted trial authors for information on outcomes specific to the DFM subgroups. MAIN RESULTS No randomised trials of management of DFM were found. Of 13 randomised trials of management strategies for pregnancies with risk factors for fetal compromise including DFM, data on the DFM subgroups could only be provided by the authors of one trial. The numbers were too small for meaningful analysis (there were 28 cases of DFM). AUTHORS' CONCLUSIONS There are insufficient data from randomised trials to guide practice regarding the management of DFM. Based on the results of other systematic reviews of management strategies for women whose babies are thought to be at risk of compromise for various reasons, the following strategies show promise and may be prioritised for further research: Doppler ultrasound studies, computerised cardiotocography, and fetal arousal to facilitate cardiotocography.For settings where electronic fetal assessment methods are not available, clinical fetal arousal tests should be investigated.

BACKGROUND: During caesarean section mothers can be in different positions. Theatre tables could be tilted laterally, upwards, downwards or flexed and wedges or cushions could be used. There is no consensus on the best positioning at present. OBJECTIVES: We assessed all available data on positioning of the mother to determine if there is an ideal position during caesarean section that would improve outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009), PubMed (1966 to 14 September 2009) and manually searched the references of retrieved articles. SELECTION CRITERIA: Randomised trials of woman undergoing caesarean section comparing different positions. DATA COLLECTION AND ANALYSIS: Two authors assessed eligibility, trial quality and extracted data. MAIN RESULTS: We identified 17 studies with a total of 683 woman included. We included nine studies and excluded eight studies. Included trials were of variably quality with small sample sizes. Most comparisons had data from single trials. This is a shortcoming and applicability of results is limited.The incidence of air embolism was not affected by head up versus horizontal position (risk ratio (RR) 0.91; 95% confidence interval (CI) 0.65 to 1.26). We found no change in hypotensive episodes when comparing left lateral tilt (RR 0.11; 95% CI 0.01 to 1.94), right lateral tilt (RR 1.25; 95% CI 0.39 to 3.99) and head down tilt (mean difference (MD)-3.00; 95% CI -8.38 to 2.38) with horizontal positions or full lateral tilt with 15-degree tilt (RR 1.20; 95% CI 0.80 to 1.79). Hypotensive episodes were decreased with manual displacers (RR 0.11; 95% CI 0.03 to 0.45), a right lumbar wedge compared to a right pelvic wedge (RR 1.64; 95% CI 1.07 to 2.53) and increased in right lateral tilt (RR 3.30; 95% CI 1.20 to 9.08) versus left lateral tilt.Position did not affect systolic blood pressure when comparing left lateral tilt (MD 2.70; 95% CI -1.47 to 6.87) or head down tilt (RR 1.07; 95% CI 0.81 to 1.42) to horizontal positions, or full lateral tilt with 15-degree tilt (MD -5.00; 95% CI -11.45 to 1.45). Manual displacers showed decreased fall in mean systolic blood pressure compared to left lateral tilt (MD -8.80; 95% CI -13.08 to -4.52).Position did not affect diastolic blood pressures when comparing left lateral tilt versus horizontal positions.(MD-1.90; 95% CI -5.28 to 1.48). The mean diastolic pressure was lower in head down tilt (MD -7.00; 95% CI -12.05 to -1.95) when compared to horizontal positions.There were no statistically significant changes in maternal pulse rate, five-minute Apgars, maternal blood pH or cord blood pH when comparing different positions. AUTHORS' CONCLUSIONS: There is limited evidence to support or clearly disprove the value of the use of tilting or flexing the table, the use of wedges and cushions or the use of mechanical displacers. Larger studies are needed.

OBJECTIVE: To review maternal deaths and the dose-related effects of misoprostol on blood loss and pyrexia in randomized trials of misoprostol use for the prevention or treatment of postpartum haemorrhage. METHODS: We searched the Cochrane Controlled Trials Register and Pubmed, without language restrictions, for '(misoprostol AND postpartum) OR (misoprostol AND haemorrhage) OR (misoprostol AND hemorrhage)', and we evaluated reports identified through the Cochrane Pregnancy and Childbirth Group search strategy. Randomized trials comparing misoprostol with either placebo or another uterotonic to prevent or treat postpartum haemorrhage were checked for eligibility. Data were extracted, tabulated and analysed with Reviewer Manager (RevMan) 4.3 software. FINDINGS: We included 46 trials with more than 40,000 participants in the final analysis. Of 11 deaths reported in 5 trials, 8 occurred in women receiving >or= 600 microg of misoprostol (Peto odds ratio, OR: 2.49; 95% confidence interval, CI: 0.76-8.13). Severe morbidity, defined as the need for major surgery, admission to intensive care, organ failure or body temperature >or= 40 degrees C, was relatively infrequent. In prevention trials, severe morbidity was experienced by 16 of 10,281 women on misoprostol and by 16 of 10,292 women on conventional uterotonics; in treatment trials, it was experienced by 1 of 32 women on misoprostol and by 1 of 32 women on conventional uterotonics. Misoprostol recipients experienced more adverse events than placebo recipients: 8 of 2070 versus 5 of 2032, respectively, in prevention trials, and 5 of 196 versus 2 of 202, respectively, in treatment trials. Meta-analysis of direct and adjusted indirect comparisons of the results of randomized trials showed no evidence that 600 microg are more effective than 400 microg for preventing blood loss > 1000 ml (relative risk, RR: 1.02; 95% CI: 0.71-1.48). Pyrexia was more than twice as common among women who received > 600 microg rather than 400 microg of misoprostol (RR: 2.53; 95% CI: 1.78-3.60). CONCLUSION: Further research is needed to more accurately assess the potential beneficial and harmful effects of misoprostol and to determine the smallest dose that is effective and safe. In this review, 400 microg of misoprostol were found to be safer than > 600 microg and just as effective.

BACKGROUND Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates. OBJECTIVES To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 July 2012). SELECTION CRITERIA Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth. DATA COLLECTION AND ANALYSIS Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity. MAIN RESULTS We found no randomized trials of symphysiotomy. AUTHORS' CONCLUSIONS Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

BACKGROUND Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine. OBJECTIVES Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by:(1) routine practices and policies;(2) the provider's relationship to the hospital and to the woman; and (3) timing of onset. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012). SELECTION CRITERIA All published and unpublished randomised controlled trials comparing continuous support during labour with usual care. DATA COLLECTION AND ANALYSIS We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data. MAIN RESULTS Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support. AUTHORS' CONCLUSIONS Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

BACKGROUND Management of breech presentation is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV). ECV may reduce the number of breech presentations and caesarean sections, but there also have been reports of complications with the procedure. OBJECTIVES The objective of this review was to assess the effects of ECV at or near term on measures of pregnancy outcome. Methods of facilitating ECV, and ECV before term are reviewed separately. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Trials Register (7 August 2012). SELECTION CRITERIA Randomised trials of ECV at or near term (with or without tocolysis) compared with no attempt at ECV in women with breech presentation. DATA COLLECTION AND ANALYSIS Two review authors assessed eligibility and trial quality, and extracted the data. MAIN RESULTS We included seven studies. The pooled data from these studies show a statistically significant and clinically meaningful reduction in non-cephalic birth (seven trials, 1245 women; risk ratio (RR) 0.46, 95% confidence interval (CI) 0.31 to 0.66; and caesarean section (seven trials, 1245 women; RR 0.63, 95% CI 0.44 to 0.90) when ECV was attempted. There were no significant differences in the incidence of Apgar score ratings below seven at one minute (two trials, 108 women; RR 0.95, 95% CI 0.47 to 1.89) or five minutes (four trials, 368 women; RR 0.76, 95% CI 0.32 to 1.77), low umbilical artery pH levels (one trial, 52 women; RR 0.65, 95% CI 0.17 to 2.44), neonatal admission (one trial, 52 women; RR 0.36, 95% CI 0.04 to 3.24), perinatal death (six trials, 1053 women; RR 0.34, 95% CI 0.05 to 2.12), nor time from enrolment to delivery (2 trials, 256 women; weighted mean difference -0.25 days, 95% CI -2.81 to 2.31). AUTHORS' CONCLUSIONS Attempting cephalic version at term reduces the chance of non-cephalic births and caesarean section. There is not enough evidence from randomised trials to assess complications of external cephalic version at term. Large observational studies suggest that complications are rare.

BACKGROUND Babies with breech presentation (bottom first) are at increased risk of complications during birth, and are often delivered by caesarean section. The chance of breech presentation persisting at the time of delivery, and the risk of caesarean section, can be reduced by external cephalic version (ECV - turning the baby by manual manipulation through the mother's abdomen). It is also possible that maternal posture may influence fetal position. Many postural techniques have been used to promote cephalic version. OBJECTIVES The objective of this review was to assess the effects of postural management of breech presentation on measures of pregnancy outcome. We evaluated procedures in which the mother rests with her pelvis elevated. These include the knee-chest position, and a supine position with the pelvis elevated with a wedge-shaped cushion. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 August 2012). SELECTION CRITERIA Randomised and quasi-randomised trials comparing postural management with pelvic elevation for breech presentation, with a control group. DATA COLLECTION AND ANALYSIS One or both review authors assessed eligibility and trial quality. MAIN RESULTS We have included six studies involving a total of 417 women. The rates for non-cephalic births, Cesarean section and Apgar scores below 7 at one minute, regardless of whether ECV was attempted or not, were similar between the intervention and control groups (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.84 to 1.15; RR 1.10; 95% CI 0.89 to 1.37; RR 0.88; 95% CI 0.50 to 1.55). AUTHORS' CONCLUSIONS There is insufficient evidence from well-controlled trials to support the use of postural management for breech presentation. The numbers of women studied to date remain relatively small. Further research is needed.

BACKGROUND Gestational hypertension and pre-eclampsia can cause fluid shifts. Pulmonary oedema and renal failure can result from these shifts. Fluid management is crucial in managing pre-eclampsia, especially in the context of pulmonary oedema and renal failure. Pulmonary artery catheterisation may be a method of effectively monitoring fluid status and thus aid in the management of renal failure and pulmonary oedema in the context of pre-eclampsia. OBJECTIVES To assess the safety and efficacy of pulmonary flow catheters in women with severe pre-eclampsia in preventing and managing of renal failure and pulmonary oedema or both. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2012). SELECTION CRITERIA Randomised trials evaluating the use of the pulmonary artery catheterisation in the management of pre-eclamptic and eclamptic antepartum, intrapartum and postpartum women. DATA COLLECTION AND ANALYSIS We did not identify any randomised controlled studies. MAIN RESULTS There are no included studies. AUTHORS' CONCLUSIONS There is currently no evidence from randomised controlled trials supporting the use of the pulmonary artery catheters. Fluid management in pre-eclampsia, especially in the context of preventing or managing renal failure and pulmonary oedema, remains an important issue. Randomised trials dealing with this intervention are needed, however, we do recognise the difficulty in performing randomised trials due to the invasive nature of the procedure and skills involved in inserting a pulmonary flow catheter.

BACKGROUND Suspected fetal distress usually results in expedited delivery of a baby (often operatively). The potential harm to a mother and baby from operative delivery may not always be justified especially when fetal distress may be misdiagnosed. Even with a correct diagnosis it is not clear whether an operative or conservative approach is better. OBJECTIVES The objective of this review was to assess the effects of operative management for fetal distress on maternal and perinatal morbidity. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 February 2012). SELECTION CRITERIA Randomised trials of operative (caesarean section or expedited vaginal delivery) versus conservative management of suspected fetal distress. DATA COLLECTION AND ANALYSIS Trial quality assessment and data extraction were done by both review authors. MAIN RESULTS One study of 350 women was included. This trial was carried out in 1959. There was no difference in perinatal mortality (risk ratio 1.18, 95% confidence interval 0.56 to 2.48). AUTHORS' CONCLUSIONS There have been no contemporary trials of operative versus conservative management of suspected fetal distress. In settings without modern obstetric facilities, a policy of operative delivery in the event of meconium-stained liquor or fetal heart rate changes has not been shown to reduce perinatal mortality.

BACKGROUND The majority of women have spontaneous vaginal births, but some women need assistance in the second stage with delivery of the baby, using either the obstetric forceps or vacuum extraction. Rates of instrumental vaginal delivery range from 5% to 20% of all births in industrialised countries. The majority of instrumental vaginal deliveries are conducted in the delivery room, but in a small proportion (2% to 5%), a trial of instrumental vaginal delivery is conducted in theatre with preparations made for proceeding to caesarean section. OBJECTIVES To determine differences in maternal and neonatal morbidity between women who, due to anticipated difficulty, have trial of instrumental vaginal delivery in theatre and those who have immediate caesarean section for failure to progress in the second stage. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 June 2012). SELECTION CRITERIA Randomised controlled trials comparing trial of instrumental vaginal delivery (vacuum extraction or forceps) in operating theatre to immediate caesarean section for women with failure to progress in the second stage (active second stage more than 60 minutes in primigravidae). DATA COLLECTION AND ANALYSIS We identified no studies meeting our inclusion criteria. MAIN RESULTS No studies were included. AUTHORS' CONCLUSIONS There is no current evidence from randomised trials to influence practice.

BACKGROUND Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine. OBJECTIVES Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by:(1) routine practices and policies;(2) the provider's relationship to the hospital and to the woman; and (3) timing of onset. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012). SELECTION CRITERIA All published and unpublished randomised controlled trials comparing continuous support during labour with usual care. DATA COLLECTION AND ANALYSIS We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data. MAIN RESULTS Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support. AUTHORS' CONCLUSIONS Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

BACKGROUND Local anaesthetic nerve block is an important modality for pain management in labour. Pudendal and paracervical block (PCB) are most commonly performed local anaesthetic nerve blocks which have been used for decades. OBJECTIVES To establish the efficacy and safety of local anaesthetic nerve blocks for pain relief in labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012). SELECTION CRITERIA We included randomised controlled trials (RCTs) assessing pain management in labour with the use of local anaesthetic nerve blocks. We did not include results from quasi-RCTs. DATA COLLECTION AND ANALYSIS We designed a form to extract data. For eligible studies, two review authors extracted the data using the agreed form. We resolved discrepancies through discussion or, if required, we consulted a third person. We entered and analysed data using Review Manager software and checked for accuracy. MAIN RESULTS We found 41 trials for consideration of inclusion into this review. We included only 12 RCTs (1549 participants) of unclear quality. We excluded 29 studies (30 reports). The majority of excluded studies were not relevant to this review, and a few were not randomised.Local anaesthetic nerve block versus placebo or no treatment. We found that more women were satisfied with pain relief after local anaesthetic nerve block (in particular 2% lidocaine PCB) than after placebo (one study, 198 participants, risk ratio (RR) 32.31, 95% confidence interval (CI) 10.60 to 98.54). Local anaesthetic nerve block was associated with more side effects (one study, 200 participants, RR 29.0, 95% CI 1.75 to 479.61).Local anaesthetic nerve block (in particular, PCB) versus opioid Local anaesthetic nerve block (in particular, PCB) in comparison with opioid (in particular, intramuscular pethidine or fentanyl patient-controlled analgesia) was found to be more effective for pain relief (one study, 109 participants, RR 2.52, 95% CI 1.65 to 3.83) and was not associated with an increased rate of assisted vaginal birth (two studies, 129 participants, RR 1.02, 95% CI 0.56 to 1.87) or with an increased caesarean section rate (two studies, 129 participants, RR 0.23, 95% CI 0.03 to 1.87).Local anaesthetic nerve block versus non-opioid agents Satisfaction with pain relief and rate of caesarean sections were found to be the same in women receiving local anaesthetic nerve block and non-opioid agents (one study, 100 participants, RR 1.11, 95% CI 0.67 to 1.84; RR 2.0, 95% CI 0.19 to 21.36, respectively). More women who received non-opioid agent in comparison with women who received local anaesthetic nerve block required additional interventions for pain relief (one study, 100 participants, RR 0.06, 95% CI 0.02 to 0.25).Local anaesthetic nerve block using different anaesthetic agents There was no difference in pain relief satisfaction, assisted vaginal birth, caesarean section, side effects for mother, Apgar score or admission to the neonatal intensive care unit between different anaesthetic agents, e.g. bupivacaine, carbocaine, lidocaine, chloroprocaine. AUTHORS' CONCLUSIONS Local anaesthetic nerve blocks are more effective than placebo, opioid and non-opioid analgesia for pain management in labour based on RCTs of unclear quality and limited numbers. Side effects are more common after local anaesthetic nerve blocks in comparison with placebo. Different local anaesthetic agents used for pain relief provide similar satisfaction with pain relief. Further high-quality studies are needed to confirm the findings, to assess other outcomes and to compare local anaesthetic nerve blocks with various modalities for pain relief in labour.

BACKGROUND Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long-acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. OBJECTIVES To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. SELECTION CRITERIA Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. MAIN RESULTS We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). There were no statistically significant differences between carbetocin and oxytocin in terms of risk of any PPH (blood loss greater than 500 ml) or in risk of severe PPH (blood loss greater than 1000 ml). Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD)-48.84 ml; 95% CI -94.82 to -2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost-effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. AUTHORS' CONCLUSIONS For women who undergo caesarean section, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of postpartum haemorrhage. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost-effectiveness of carbetocin as a uterotonic agent.

BACKGROUND Advance community distribution of misoprostol for preventing or treating postpartum haemorrhage (PPH) has become an attractive strategy to expand uterotonic coverage to places where conventional uterotonic use is not feasible. However, the value and safety of this strategy remain contentious. OBJECTIVES To assess the effectiveness and safety of a strategy of advance misoprostol distribution for PPH prevention and treatment in non-facility births. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (5 October 2011). We did not apply any language restrictions. SELECTION CRITERIA Randomised or quasi-randomised controlled trials of advance misoprostol distribution to lay health workers or pregnant women compared with usual care for PPH prevention or treatment in non-facility births. We excluded studies without any form of random design. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility for inclusion. MAIN RESULTS The search strategies identified three studies. None of the studies met the inclusion criteria. AUTHORS' CONCLUSIONS There is no evidence from randomised or quasi-randomised trials on the benefits or risks of a strategy of advance misoprostol distribution for PPH prevention or treatment in non-facility births. In view of the increasing interest to scale up this strategy, there is an urgent need for large and well-designed randomised trials to evaluate its comparative benefits and risks.

BACKGROUND There is a general agreement that oxytocin given either through the intramuscular or intravenous route is effective in reducing postpartum blood loss. However, it is unclear whether the subtle differences between the mode of action of these routes have any effect on maternal and infant outcomes. OBJECTIVES To determine the comparative effectiveness and safety of oxytocin administered intramuscularly or intravenously for prophylactic management of the third stage of labour after vaginal birth. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011). SELECTION CRITERIA Randomised trials comparing intramuscular with intravenous oxytocin for prophylactic management of the third stage of labour after vaginal birth. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors planned to independently assess trials for inclusion, assess risk of bias and extract data. MAIN RESULTS The search strategies identified no trials for consideration but we identified one ongoing study. AUTHORS' CONCLUSIONS There is no evidence from randomised trials to evaluate the comparative benefits and risks of intramuscular and intravenous oxytocin when given to prevent excessive blood loss after vaginal birth. Randomised trials with adequate design and sample sizes are needed to assess whether the route of prophylactic oxytocin after vaginal birth affects maternal or infant outcomes. Such trials should be large enough to detect clinically important differences in major side effects reported in observational studies and also to consider the acceptability of the intervention to mothers and providers as important outcomes.

BACKGROUND Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side effects. Carbetocin, a long-acting oxytocin agonist, appears to be a promising agent for the prevention of PPH. OBJECTIVES To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library 2011, Issue 1 of 4), MEDLINE (1966 to 1 March 2011) and EMBASE (1974 to 1 March 2011). We checked references of articles and communicated with authors and pharmaceutical industry contacts. SELECTION CRITERIA Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. MAIN RESULTS We included 11 studies (2635 women) in the review. Six trials compared carbetocin with oxytocin; four of these were conducted for women undergoing caesarean deliveries, one was for women following vaginal deliveries and one did not state the mode of delivery clearly. The carbetocin was administered as 100 µg intravenous dosage across the trials, while oxytocin was administered intravenously but at varied dosages. Four trials compared intramuscular carbetocin and intramuscular syntometrine for women undergoing vaginal deliveries. Three of the trials were on women with no risk factor for PPH, while one trial was on women with risk factors for PPH. One trial compared the use of intravenous carbetocin with placebo. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics (risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44 to 0.88; four trials, 1173 women) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Compared to oxytocin, carbetocin was associated with a reduced need for uterine massage following both caesarean delivery (RR 0.54; 95% CI 0.37 to 0.79; two trials, 739 women) and vaginal delivery (RR 0.70; 95% CI 0.51 to 0.94; one trial, 160 women). Pooled data also showed that carbetocin resulted in a lower risk of PPH compared to oxytocin in women who underwent caesarean delivery (RR 0.55; 95% CI 0.31 to 0.95; three trials, 820 women). This is, however, limited by the number of studies and risk of bias in the studies. Comparison between carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin compared to syntometrine (mean difference (MD)-48.84 ml; 95% CI -94.82 to -2.85; four trials, 1030 women). There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40; four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). The incidence of postpartum hypertension was also significantly lower in women who received carbetocin compared to those who received syntometrine. Cost-effectiveness of carbetocin was investigated by one study published as an abstract, with limited data. AUTHORS' CONCLUSIONS There is evidence to suggest that 100 µg of intravenous carbetocin is more effective than oxytocin for preventing PPH in women undergoing caesarean deliveries, but more studies are needed to validate this finding. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for women who have vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed to analyse the cost-effectiveness of carbetocin as a uterotonic agent.

Cord drainage in the third stage of labour involves unclamping the previously clamped and divided umbilical cord and allowing the blood from the placenta to drain freely into an appropriate receptacle. The objective of this review was to assess the specific effects of placental cord drainage on the third stage of labour following vaginal birth, with or without prophylactic use of uterotonics in the management of the third stage of labour. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2010). Randomised controlled trials comparing placental cord draining with no placental cord drainage as part of the management of the third stage of labour. Two review authors independently assessed the quality of trials and extracted data. This was then verified by the third review author who then entered the agreed outcomes to the review. Three studies involving 1257 women met our inclusion criteria. Cord drainage reduced the length of the third stage of labour (mean difference (MD)-2.85 minutes, 95% confidence interval (CI)-4.04 to -1.66; three trials, 1257 women (heterogeneity: T² = 0.87; Chi²P=17.19, I² = 88%)) and reduced the average amount of blood loss (MD -77.00 ml, 95% CI -113.73 to -40.27; one trial, 200 women).No incidence of retained placenta at 30 minutes after birth was observed in the included studies, therefore, it was not possible to compare this outcome. The differences between the cord drainage and the control group were not statistically significant for postpartum haemorrhage or manual removal of the placenta. None of the included studies reported fetomaternal transfusion outcomes and there were no data relating to maternal pain or discomfort during the third stage of labour. There was a small reduction in the length of the third stage of labour and also in the amount of blood loss when cord drainage was applied compared with no cord drainage. The clinical importance of such observed statistically significant reductions, is open to debate. There is no clear difference in the need for manual removal of placenta, blood transfusion or the risk of postpartum haemorrhage. Due to small trials with medium risk of bias, the results should be interpreted with caution.

OBJECTIVE The aim of this study is critically to review the available evidence regarding the use, efficacy and safety of tranexamic acid in the management of hemorrhage during pregnancy and for prevention and treatment of postpartum hemorrhage. RESEARCH DESIGN AND METHODS We performed a systematic search of electronic literature (PubMed, Embase, CINAHL, Scopus, Cochrane, DARE) to review all studies looking at the use of tranexamic acid during pregnancy and puerperium. We did a meta-analysis on three randomized controlled trials that evaluated reduction in blood loss in women undergoing cesarean sections with the use of tranexamic acid. RESULTS An electronic search yielded 34 articles, the studies dating from 1976 to 2010, five randomized controlled trials, seven observational studies, and twenty-two case reports. Meta-analysis showed that the estimate of the combined effect of tranexamic acid compared with placebo was a difference of 32.5 ml reduction in blood loss (95% CI -4.1-69.13; p = 0.08). Tranexamic acid was also used successfully to prevent and treat bleeding in observation studies and case reports. Pulmonary embolism was reported in two cases; however, the possible involvement of tranexamic acid in these thrombotic episodes could neither be confirmed nor excluded. CONCLUSIONS The clinical studies suggest that tranexamic acid reduces the amount of blood loss after delivery during cesarean sections and vaginal deliveries, and reduces the requirement for blood transfusion. Tranexamic acid seems to be safe and effective in the prevention and management of bleeding during pregnancy. Further investigation and larger clinical trials with better design and methodological quality are required to confirm these findings.

BACKGROUND: Administration of the uterotonic drugs is one of the main components of the active management of the third stage of labour. The timing of uterotonics varies considerably across the globe and it may have significant implications on the well-being of the mothers and their babies. OBJECTIVES: To assess the effect of the timing of administration of prophylactic uterotonics (before compared to after placental delivery) on the outcomes related to the third stage of labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009). SELECTION CRITERIA: Randomised controlled trials examining the timing of prophylactic uterotonic drugs in the third stage of labour. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked MAIN RESULTS: We included three trials involving 1671 participants; oxytocin was the only uterotonic drug that was used. The dose and route of administration of oxytocin varied among the included studies. Administration of oxytocin before and after the expulsion of placenta does not significantly influence the incidence of postpartum haemorrhage (blood loss greater than 500 ml)(risk ratio (RR) 0.81, 95% confidence interval (CI) 0.62 to 1.04; n = 1667, three trials); retained placenta (RR 1.54, 95% CI 0.76 to 3.11; n = 1667, three trials); length of third stage of labour (minutes)(mean difference (MD)-0.30, 95% CI -0.95 to 0.36; n = 1667, three trials); postpartum blood loss (ml)(MD 22.32, 95% CI -58.21 to 102.86; n = 181, two trials); changes in haemoglobin (g/dL)(MD 0.06, 95% CI -0.60 to 0.72; n = 51, one trial); blood transfusion (RR 0.79, 95% CI 0.23 to 2.73; n = 1667, three trials); the use of additional uterotonics (RR 1.10, 95% CI 0.80 to 1.52; n = 1667, three trials); the incidence of maternal hypotension (RR 2.48, 95% CI 0.23 to 26.70; n = 130, one trial) and the incidence of severe postpartum haemorrhage (blood loss 1000 ml or more)(RR 0.98, 95% CI 0.48 to 1.98; n = 130, one trial). No data on other maternal or neonatal outcome measures were available. AUTHORS' CONCLUSIONS: Administration of oxytocin before and after the expulsion of placenta did not have any significant influence on many clinically important outcomes such as the incidence of postpartum haemorrhage, rate of placental retention and the length of the third stage of labour. However, the number of available studies were limited. The only uterotonic drug used was oxytocin, mainly through intravenous infusion, therefore its extrapolation to other routes of administration should be interpreted cautiously. More studies are required to examine other maternal and neonatal outcomes using consistent approaches.