The Role of Skin-to-Skin Contact and Breastfeeding in Postpartum Hemorrhage

Monday, 30 October 2017: 3:45 PM

Wedad M. Almutairi, PhD
School of Nursing, School of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia
Susan Ludington, PhD, MS, BS
Nursing School, Frances Payne Bolton School of Nursing at Case Western Reserve University, CLEVELAND, OH, USA
Mary T. Quinn Griffin, PhD, BS
School of nursing, Frances Payne Bolton School of Nursing at Case Western Reserve University, CLEVELAND, OH, USA
Chris Burant, PhD
Frances Payne Bolton School of Nursing at Case Western Reserve University, CLEVELAND, OH, USA

Background The postpartum hemorrhage (PPH) rate increased by 27.5% from 1995-2004, and the increase occurred in 19.1% of all hospitals. The incidence of severe PPH doubled from 2001/2002 to 2011/2012. Prevention of PPH focuses on medical and pharmacological methods that constitute “active management of third stage of labor,” used to prevent PPH by enhancing uterine contractility and shortening the 3rd stage of labor. The primary non-pharmacologic sustained uterine massage intervention to prevent PPH is poorly validated and no longer recommended (World Health Organization, 2012). Other non-pharmacologic interventions to prevent PPH have been sparsely reported in medical literature, but skin-to-skin contact (SSC) between mother and newborn and breastfeeding (BF) immediately or shortly after birth are becoming commonly practiced in the U.S. and have been identified as possible psychophysiological interventions to reduce PPH but lack evidence based on U.S. practices.

The purposes of the retrospective chart review were to 1) determine and compare the incidence of PPH, estimated blood loss, and duration of the 3rd stage of labor in women with PPH and had SSC only, or BF only, or SSC + BF, or no SSC/no BF within the first two hours post-birth, and 2) to determine and compare the estimated blood loss and duration of the 3rd stage of labor in women without PPH who had SSC only, BF only, SSC + BF, or No SSC/ No BF within the first two hours post-birth from 2009 – 2015 at a university-based tertiary care maternity unit in Midwest, USA.

Method: The retrospective comparative chart review was conducted using 265 medical records of two groups of women: women with PPH (ICD9-666.1 or CD10-072.1 codes) and those without PPH (no codes, called non-PPH group). Data for each group were divided into 4 subgroups (SSC only, BF only, SSC+BF, No SSC/ No BF).

Sampling and sample: Purposive sampling yielded 265 electronic medical records. Eligible data sets were available in 154 charts.

Instrument: An investigator developed Data Collection Sheet was used to manually record data related to 50 demographic and medical variables.

The BF only subgroup was not included in inferential analyses because sample size was too small (n=6) in both PPH and Non-PPH groups.

Analysis: Two separate one-way ANOVAs for the PPH group and the non-PPH group were run identify the differences between subgroups for each group. A two-way ANOVA (PPH and non-PPH groups by SSC, SSC+BF, and No SSC/No BF subgroups) was used to determine interactions and power of effects for estimated blood loss and duration of 3rd stage. The BF only subgroup was not included in inferential analyses because sample size was too small (n=6) in both PPH and Non-PPH groups.

Results: A total of 79 (51.3%) charts represented women with PPH and 75 (48.7%) women without PPH. Women in both groups (PPH, non-PPH) were a mean27.50 years, 68% were African-American, 27.9% were White, and 1.3% were other races. In the PPH group, 11 (13.9%) had SSC only, 4 (5.1%) had BF only, 29 (36.7%) had SSC +BF, and 35 (44.3%) had no SSC/no BF.

PPH Incidence. PPH incidence increased from 3.54% in 2009 to 7.10% in 2015.

Estimated Blood Loss. The mean estimated blood loss in women with PPH who had a) SSC only was 836.00 mls (b) BF only was 933.30mls c) SSC+BF was 728.00 mls and d) no SSC/no BF was 1149.20 mls. The one-way ANOVA for estimated amount of blood loss showed significant difference between the subgroups in PPH group; a Bonferroni Post Hoc revealed a higher estimated blood loss in the No SSC/No BF subgroup than in the SSC+BF subgroup. The mean estimated blood loss in women without PPH who had a) SSC only was 131.00 mls (SD=37.61), b) BF only was 183.33 mls (S. TD=28.87), c) SSC + BF was 210.00 mls (SD=78.12), and d) no SSC/no BF was 228.00 mls (SD=81.03) – yielding a significant one-way ANOVA with a Bonferroni Post-Hoc showing higher blood loss in the No SSC/No BF subgroup than in the SSC only subgroup.

The two-way ANOVA revealed a statistically significant interaction between groups (PPH, without PPH) and subgroups (SSC, SSC+BF, No SSC/ No BF) on estimated blood loss. The observed power of the effects of groups on estimated blood loss = 100% with effect size of 0.35; the observed power of the effects of subgroups on estimated blood loss = 79.2% with effect size of 0.06, and the observed power of the effects of the interactions between groups and subgroups = 67.4% with effect size of 0.05, indicating that subgroups treatments had an influence on blood loss, with SSC + BF subgroup having the biggest effect on blood loss in women with PPH.

Duration of 3rd Stage. The mean duration of the 3rd stage of labor for women with PPH who had SSC only was 11.9 minutes, BF only was 18.25 minutes, SSC+BF was 11.6 minutes, no SSC/no BF was 18.32 minutes. The mean duration of 3rd stage of labor for women without PPH was 5.86 minutes for SSC only, 7.33 minutes for BF only, 6 minutes for SSC+BF, and 2 minutes for no SSC/no BF subgroups. A two-way ANOVA (PPH and non-PPH groups by SSC, SSC+BF, and No SSC/No BF subgroups) was performed on duration of 3rd stage after running two separate one-way ANOVAs for the PPH and the without-PPH groups; both were non-significant. The interaction between groups (PPH, without-PPH) was significant, showing a longer duration of 3rd stage in women with PPH than in women without-PPH.

Conclusion In women with PPH the combination of SSC + BF had a larger effect on decreasing estimated blood loss than No SSC/No BF did. For women without PPH, SSC only decreased estimated blood loss and had a larger impact on decreasing estimated blood loss than no SSC/no BF. Women with PPH benefitted more in decreasing estimated blood loss from SSC + BF than women without PPH. Women with PPH had longer durations of 3rd stage of labor than women without PPH. In summary, SSC+BF have different effects in women with PPH than in women without PPH, SSC + BF was the most promising intervention to decrease amount of blood loss and duration of 3rd stage of labor in women with PPH.

Significance: The study’s data can be used to inform and facilitate application of low-cost interventions (SSC, BF) to manage 3rd stage of labor to minimize estimated blood loss and duration of 3rd stage of labor in women who at risk for PPH. The data also support a large clinical trial with all four subgroups to provide evidence as to which non-pharmacologic intervention can be expected to decrease the incidence of PPH as well as to decrease estimated blood loss and duration of 3rd stage of labor. Use of non-pharmacologic nursing interventions such as those tested here may stop the increase in PPH incidence and severity.

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