, shows that uterine massage is less effective than oxytocin in reducing blood loss after delivery and there was no additional beneﬁt when compared with of oxytocin alone.
Active Management of Third Stage of Labor (AMTSL): It is a clinical protocol, highly effective in preventing PPH. It consists of early intervention with amniotomy and oxytocin in order to increase the frequency and intensity of uterine contractions and one-to-one care  . The aim of AMTSL is to facilitate obstetric care in a busy labour ward and to reduce the high rate of caesarean sections  . However, active management decrease caesarean section and labour time very slightly as shown in a review  with 7 trials involving 5390 women and in  with 12 trials involving 7792 women. No other effects regarding assisted vaginal deliveries or maternal or neonatal morbidity were found. It is highly possible that some parts of the active management package are more effective than others and further evaluation would be needed to investigate this.
Non-Pneumatic Anti-Shock Garment (NASG): Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device that may help women survive delays in transport by compressing the lower body with nine articulated segments closed tightly around the legs, pelvis, and abdomen. Any vaginal or abdominal procedures or external uterine massage can be performed easily while NASG is put on. The majority of the pressure exerted by NASG is in the abdomen and pelvis thereby reducing immediately the blood flow once applied in obstetric hemorrhage  . The 54% reduced odds of maternal mortality and the significantly rapid shock recovery with no risk of safety issues suggest that as NASG can be used for quick shock reversal and as a first-aid device at the primary health care centers and ambulances level  . Both uterotonics and NASG should be considered in health systems (uterotonics to prevent and treat PPH and NASG for rapid shock reversal)
Uterine Balloon Tamponade: Obstetric Hemorrhage is one of the major causes of maternal mortality worldwide  . Recently, uterine balloon tamponade has been added to the guidelines for the management of PPH  . In this case, the balloon is inserted into the uterus and then inflated which help decrease or stop bleeding. There are different types of balloons available including the Bakri, Foley, Sengstaken-Blakemore, Rusch and condom catheter. A recent review in  confirms the effectiveness of uterine tamponade using intrauterine balloons in the management of PPH with minimal adverse effects. Overall, from the case reports, retrospective studies   and prospective studies   , 91.5% cases were successful where different balloons have been used.
Partograph: Partograph or Partogram is one of the most important tools to ensure timely management of obstructed labour  . It is a tool that graphically represents key events during labour usually in the form of a pre-printed paper. With the help of partograph, midwives and obstetricians are able to discover slow progress in labour, and hence, start appropriate interventions to prevent prolonged and obstructed labour  . WHO conducted a prospective multicenter study  to establish the effectiveness of composite WHO partograph in 35,484 women in South East Asia. This composite intervention reduced prolonged labour from 6.4% to 3.4% and the proportion of augmented labour from 20.7% to 9.1%. Emergency caesarean births decreased from 9.9% to 8.3% and intrapartum stillbirths from 0.5% to 0.3%. However, another review in  does not shows any firm evidence whether using a Partogram decrease or increase caesarean section rates or had any effect on other aspects of labour. Further trials are needed to identify the effect of partograph on the outcomes of labour in different settings.
Haematological Interventions for Treating DIC during Pregnancy: Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by intravascular blood clotting in the blood vessels and is the result of pathologic overstimulation of the coagulation system  . DIC can lead to organ dysfunction and bleeding because of depletion of platelets in pregnant women. In  the usefulness of haematological interventions was to be studied for treating DIC during pregnancy and postpartum but no RCT was found to be included in the review.
Sonographic & Clinical Parameters in the Prediction of Retained Product of Conception (RPOC): Secondary PPH with possibly pain and fever is the most common clinical symptom of retained products of conception (RPOC), an incidence reported around 1% of all deliveries in the literature  . For the diagnosis of RPOC different clinical symptoms as well as sonographic assessment are used  . Once the diagnosis is done, evacuation of the RPOC is performed in approximately 70% of patients referred with secondary PPH  . Evacuation of the RPOC is usually a simple and a safe procedure. However, samples obtained after the primary evacuation of the uterus shows some false positive findings for gestational remains (28.9% if the diagnosis is based on sonography and 51.5% if it is based on clinical examination)  . In a prospective cohort 3-year audit  , the diagnostic accuracy of different clinical and sonographic parameters in the prediction and management of RPOC in the late postpartum period was assessed. The results confirm that sonography either alone or combined with color Doppler imaging provide statistically significant accuracy than the usual clinical parameters in the prediction of RPOC.
Ambulatory Monitoring of Blood Pressure (ABPM): One of the most common medical complications of pregnancy is hypertension. Accurate and timely measurement of blood pressure is important throughout the course of pregnancy. The effectiveness of conventional measurement of blood pressure has been questioned and cross-examined in recent years. Several efforts have been made to improve blood pressure measurement using ambulatory automated devices. These devices continuously and automatically measure blood pressure over a period of time while patients are busy doing their day to day activities. However, the authors in  find no RCTs to investigate the use of ABPM during pregnancy and hence it cannot be stated whether wearing a blood pressure monitoring device for 24 hours during pregnancy is effective in detecting hypertension.
Exercise for Preventing Pre-Eclampsia: In many cultures and societies it is believed that if women are not physically active during the later stage of her pregnancy, labour may be more difﬁcult  . Therefore, some studies (case-control studies) recommend physical exercise in order to reduce the risk of pre-eclampsia and gestational hypertension  . However, no effects of exercise or increased physical activity were found in the prevention of pre-eclampsia and its complications (review of 2 small, good quality trials with 45 women)  . There was insufficient data and hence, no reliable conclusions could be made. The extent and nature of physical activity during pregnancy should, therefore, be decided by the individual women in consultation with their physicians.
Preventing Hypotension during Spinal Anesthesia for Caesarean Section: Spinal anesthesia is commonly used for a caesarian section because it keeps the mother awake during birth and avoids the risks of general anesthesia. However, spinal anesthesia may cause hypotension which in its severe form is very risky for both the mother and baby  . In a systematic review in  , the authors studied the effects of prophylactic interventions for hypotension following spinal anesthesia for caesarean section. Crystalloids were found more effective than no fluids (relative risk 0.78, 95% CI 0.60 to 1.00) in one trial with 140 women while colloids were more effective than crystalloids (RR 0.68, 95% CI 0.52 to 0.89) in another 11 trials with 698 women. Similarly, in 7 trials with 470 women Ephedrine was significantly more effective than crystalloid. The review could not found any single method that could completely prevent hypotension. There was also insufficient data regarding the adverse effects.
Magnesium Sulphate: Pre-eclampsia is usually associated with raised blood pressure and proteinuria. Most women with pre-eclampsia give birth without problems. However, severe pre-eclampsia can cause problems like kidney failure, stroke, blood clotting and liver failure  . On the other hand, Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is rare but potentially life-threatening. Magnesium sulphate is the most promising drug which reduces the risk of eclampsia by more than 50%  . It should be available in all hospitals providing care for pregnant women with eclampsia and pre-eclampsia. It is more appropriate for low- resource settings due to its easy availability and inexpensiveness.
4.4. Pain Management
Immersion in Water in Pregnancy, Labour and Birth: The application of warm water immersion during pregnancy, labour and birth for relaxation and pain relief is being discussed since long  . It is usually easier for women to adjust her position in the water and to increase her comfort during labour and childbirth  . The warmth of the water may cause muscle relaxation and reduce anxiety, decreasing the release of catecholamine and motivate the release of endorphins  . However, some believe that immersion in water during labour and birth poses some risks to women or babies, for example, inhalation of water by the newborn and maternal or neonatal infections  . A review (8 RCTs with 2939 women) conducted in  , found that maternal pain and the use of epidural, spinal or paracervical analgesia is decreased with the application of water immersion during the ﬁrst stage of labour. Furthermore, the study found no adverse effects. However, no evidence could be found about the effects of water immersion in the third stage of labour.
Pain Management for Women in Labour: Pharmacological and non-pharmacological interventions to manage pain in labour are classified into 3 categories  . What Works: Epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. CSE relieve pain more quickly than traditional or low-dose epidurals. Inhaled analgesia more likely cause vomiting, nausea and dizziness while epidural analgesia more likely result in hypotension, motor blockade, fever or urinary retention. What May Work: There is some evidence from single trials, which suggest that acupuncture, immersion in water, local anesthetic nerve blocks and massage may improve management of pain during labour, with few adverse effects. Insufﬁcient Evidence: No clear judgment can be made regarding the use of hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids for pain management in labour due to the lack of sufficient evidence. Most methods of non-pharmacological pain management appear to be safe with no adverse effects for mother and baby, however, their effectiveness is unclear, due to insufficient data.
Vacuum Extraction for Assisted Vaginal Delivery: Vacuum Extractor, an alternative to forceps delivery, is a metal or plastic cup which is attached to the baby's head to help guide him/her out of the birth canal and is used to assist pregnant women in vaginal delivery. Use of the vacuum extractor, when compared to forceps delivery, is associated with signiﬁcantly less maternal trauma (odds ratio 0.41, 95% CI 0.33 to 0.50) and with less general anesthesia as shown in  . It is also associated with more deliveries (odds ratio 1.69, 95% CI 1.31 to 2.19) and fewer caesarean sections. However neonatal cephalohematoma and retinal hemorrhage are increased in the vacuum extraction. The study shows that the vacuum extractor is signiﬁcantly less likely to perform a successful vaginal delivery than forceps. There may be a number of reasons for this. The most prominent could be errors in technique e.g. incorrect cup use or pulling in the wrong direction.
Elective Delivery in Diabetic Pregnant Women: 90% cases of diabetes complicating pregnancy are gestational diabetes with varying complications according to the type of diabetes and the intensity of the disease  . In pregnancies with pregestational diabetes, the major concerns during the third trimester are late fetal death, complications of premature delivery and birth trauma associated with fetal macrosomia  . A review (one trial with 200 insulin-requiring diabetic women) in  was conducted to assess the effect of elective delivery compared to expectant management in diabetic pregnant women. There was not enough evidence and hence no firm conclusion can be drawn.
4.6. Miscellaneous Approaches
Hospital Information System: Hospital information systems (HIS) are a useful tool for estimating and monitoring maternal mortality and severe maternal morbidity. They can be used to set health priorities and optimize the performance of health care facilities. Hospital records are rapidly available, and inexpensive to use, however, before using, its validity must be thoroughly assessed. Chantry et al in  analyzed the accuracy of hospital databases in four French teaching hospital discharge data in 2006-2007, covering 30,607 deliveries. They concluded that 95% of recording errors were in such a way that it could be easily corrected. The study suggests that hospital administrative database is reliable and accurate enough and that it could be used for monitoring purpose. Similarly, in  HIS data about 8620 women from the Municipal Secretariat of Health in Southeastern Brazil was analyzed for severe maternal mortality and morbidity. Prevalence of maternal morbidity was found to 37.8/1000 women, and that of mortality was 12/100,000 women. The authors confirm the usability and reliability of HIS in reporting maternal morbidity and mortality. Such type of information system can be used to improve our understanding and contribute to the enhancement of the quality of care provided to women during pregnancy, delivery and the postnatal period.
Routine Ultrasound in Late Pregnancy: Ultrasound is a sophisticated electronic technology in which a transducer (which emits ultrasound frequency) is moved across the area of the body to be examined. The pulses propagate through the tissues, where some are reflected back to the transducer, which are then processed by a computer where each echo is shown as an image on the screen. Ultrasound can be used in late pregnancy to assess the baby’s condition and abnormalities, which may not otherwise be evident. However routine late pregnancy ultrasound in low-risk populations was not associated with improvements in overall perinatal mortality and does not confer a benefit on mother or baby (8 trials including 27,024 women)  . Routine ultrasound in late pregnancy may slightly increase caesarean section rates, however, there is not sufficient evidence about long-term neonatal and childhood outcome.
Wearable Cardiac Defibrillator in PPCM: In last trimester of pregnancy, women usually show a rare type of cardiomyopathy called peripartum cardiomyopathy (PPCM)  . Wearable Cardiac Defibrillator (WCD) automatically monitors the patient’s electrocardiograms and also records total wear time and can deliver a biphasic deﬁbrillation pulse if ventricular tachycardia or ventricular ﬁbrillation is detected  . The outcomes of women with PPCM versus non-ischemic dilated cardiomyopathy (NIDCM) in non-pregnant similarly aged women referred for a WCD were explored and compared in  . The analysis was done on 107 patients with PPCM and 159 patients with NIDCM. The average use duration of the WCD was 124 ± 123 days (median 86.5 days) for the PPCM patients, and 96 ± 83 days (median 76.0 days) for the NIDCM patients. The outcomes show a mortality rate of 2.8% in PPCM patients which is lower than previously published results. Early PPCM ventricular improvements were high and 26% of women showed improvement within 3 months of WCD referral. WCD therapy may reduce sudden cardiac risk in PPCM and need further prospective studies for detailed assessment.
Treatments for Iron-Deﬁciency Anemia in Pregnancy: Anemia in pregnancy is deﬁned by the World Health Organization as a hemoglobin value below 11 g/dl  . The common causes of anemia include iron deﬁciency, folate deﬁciency, vitamin B12 deﬁciency, bone marrow suppression, malaria, chronic blood loss and underlying malignancies  . During pregnancy, there is an increase in both red blood cells and plasma volume due to the needs of the growing fetus which results in a reduction of the concentration of hemoglobin in the blood  . Severe anemia can be very harmful to mothers and babies, but the risks of mild and moderate anemia are controversial. It is still unknown whether treating mild or moderate anemia have any adverse effect on pregnant women. For this purpose, the effects of different treatments for iron-deﬁciency anemia is assessed in a review  with 17 small and low-quality trials involving 2578 women. Only one trial with 125 women showed a reduction in anemia with oral iron (relative risk 0.38; 95% CI 0.26 to 0.55). There was not enough data on the effects of treatment according to the severity of anemia and also on adverse effects. Although the intramuscular and intravenous routes showed better results than the oral route, with no assessment of clinical outcomes and adverse effects.
There are a number of health technologies and techniques which are relatively simple to develop and safe to apply and it has no adverse effects. These includes different type of high-fidelity simulations and training programs, educational and awareness programs for women and communities, decision support tools and Hospital Information Systems. Governments, hospitals and care providers should make policies about the development and implementation of such type of programs. Similarly, technologies like Active management of the third Stage of Labour, Magnesium Sulphate, Uterine Balloon Tamponade, Wearable Cardiac Defibrillator and Non-Pneu- matic Anti-Shock Garment (NASG) should be core components of every maternity care unit as it shows promising results with no serious adverse effects. Besides that, high-quality RCTs are still needed to assess the effectiveness and exact role of Interventional radiology, Ambulatory Monitoring of Blood Pressure, Vacuum Extraction, Immersion in Water, Mechanical Methods for induction of labour, Haematological interventions, Transcutaneous Electro Stimulation and Partographs in the prevention and reduction of maternal mortality.
Further research is recommended to assess and establish the role of health technologies in reducing maternal mortality. Technology-based solutions can fill the gap in health resources, knowledge and expertise when provided by appropriate care provider with proper skills and with community support. Health and technology researchers must be motivated to continue improving existing solutions and finding a new one for problems that endanger women and their babies while at the same time governments, care providers and private health organizations must be forced and convinced to apply available technological approaches.
Conflicts of Interest
The authors declare no conflicts of interest.
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