Aktive Leitung der Nachgeburtsperiode – Das Ende eines 50-jährigen Dogmas?

Zusammenfassung

Postpartale Blutungen (PPH) stehen weltweit an führender Stelle der Müttersterblichkeit. Zur Prävention der PPH wird seit mehr als 50 Jahren die aktive Leitung der Nachgeburtsperiode (Active Management of the Third Stage of Labour, AMTSL) propagiert und in aktuellen Leitlinien empfohlen.

Die 3 Schlüsselkomponente der AMTSL sind die prophylaktische Gabe von Oxytocin und das Abklemmen und Durchtrennen der Nabelschnur unmittelbar nach der Geburt des Kindes sowie der kontrollierte Zug an der Nabelschnur. Dieses Vorgehen hat das Risiko für eine schwere PPH um ca. 70% vermindert. Trotz der langen Tradition der AMTSL ist bisher unklar, welche der 3 Komponenten entscheidend zur Reduktion der PPH beiträgt. Evidenz-basiert aus Cochrane-Analysen und Metaanalysen ist, dass die prophylaktische Applikation von Oxytocin die Rate an PPH signifikant senkt. Gegenstand der Diskussion ist die optimale Dosis und der optimale Applikationsmodus von Oxytocin. Bis vor kurzem lagen keine randomisierten Studien zur Bedeutung des kon­trollierten Zugs an der Nabelschnur und des Zeitpunktes des Abklemmens der Nabelschnur im Rahmen der AMTSL vor.

Eine randomisierte Studie der WHO 2012 und die jüngste TRACOR-Studie (TRaction of the CORd) 2013 aus Frankreich zeigten, dass der kontrollierte Zug an der Nabelschnur zu keiner signifikanten Senkung des postpartalen Blutverlustes und der Rate an PPH führt.

Wie eine Cochrane-Analyse 2008 und eine jüng­ste randomisierte Studie aus Schweden ergaben, bestehen keine signifikanten Unterschiede in der Häufigkeit an PPH und schweren PPH zwischen dem frühen (<15 s) und dem verzögerten Abklemmen (> 1–3 min nach der Geburt) der Nabelschnur. Auch die Massage des Uterus nach der Geburt der Plazenta, dass Ablassen von plazentarem Nabelschnurblut oder die Applikation von Uterotonika in die Nabelschnur nach der Geburt des Kindes sind keine Evidenz-basierten Maßnahmen zur Prävention der PPH.

Die entscheidende und Evidenz-basierte Komponente der AMTSL ist die prophylaktische Gabe von Oxytocin nach Geburt der vorderen Schulter oder nach der Geburt des Kindes.

Künftige Leitlinien und Lehrbücher sollten diese neuen Erkenntnisse berücksichtigen.

Abstract

Post-partum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Since more than 50 years AMTSL has been proposed for the prevention of PPH and is still recommended in current guidelines. The 3 key components of AMTSL are the prophylactic administration of oxytocin, clamping and cutting of the umbilical cord immediately after delivery of the baby and controlled cord traction. AMTSL has proven to reduce the rate of severe PPH by 70%. Despite of the long tradition of AMTSL it is still unclear, which of the 3 components significantly contributes to the reduction in PPH.

Cochrane analyses and a recent metaanalysis gave strong evidence, that prophylactic oxytocin administration reduces the risk of PPH significantly, however, the optimal dose and mode of application is still a matter of debate.

Until a little while ago no randomized controlled studies exist regarding the significance of controlled cord traction and the time of cord clamping in AMTSL.

A randomized WHO trial 2012 and the 2013 published TRACOR (Traction of the CORd)-trial from France could clearly demonstrate that controlled cord traction is not associated with a significant reduction in postpartum blood loss and in the risk of severe PPH. A Cochrane analysis 2008 and a recent randomized trial from Sweden came to the conclusion, that there are no significant ­differences between early (< 15 s) and delayed (> 1–3 min) cord clamping in the reduction of PPH and severe PPH.

Uterine massage after delivery of the placenta, placental cord drainage and umbilical vein injection of uterotonics after delivery of the baby as part of AMTSL are not evidence-based methods.

It has taken 50 years since AMTSL was first described for it to become clear that prophylactic oxytocin is the most important and the only evidence-based component of AMTSL.

Future guidelines and textbooks should consider these new ­findings.

Schlüsselwörter

postpartale Blutung - aktive Leitung der Nach­geburtsperiode - prophylaktische Oxytocin-Gabe - kontrollierter Zug an der Nabelschnur - frühes versus verzögertes Abklemmen der Nabelschnur

Key words

postpartum haemorrhage - active management of the third stage of labour - prophylactic oxytocin ­administration - controlled cord traction - early versus delayed cord clamping

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