Description
This is part 4 of your evidence-based practice project (EBP).
In this assignment, you will refer back to assignment you completed in previous weeks, as this assignment will build upon it. You’ll be providing a solution to a clinical problem using the EBP process.
For this assignment, you will create a 13-16 slide PowerPoint, excluding the title and reference slides, covering the items below. This should be a high-level overview of what you’ve already discussed in your papers. Be sure to summarize your information (do not simply copy and paste).
Describe the select EBP problem
List the created PICOT question
“In pregnant women (Population), does the use of medication prior to labor (Intervention), compared with those without medications (Control), reduce the risk of postpartum hemorrhage (Outcome) within the first 12 weeks after childbirth (Time-frame)”
Provide a high-level overview of the articles you found, organizing them by design (i.e.; qualitative, quantitative, mixed methods)
Summarize the search strategy you used to locate the articles.
Search Strategy Correspondingly, addressing the PICOT question featured exploring research findings on the use medications as intervention for reducing the risk of postpartum hemorrhage in expecting mothers prior to labor. Specifically, The search strategy involved using key terms such as ‘Medication’, ‘Postpartum Hemorrhage’, ‘Labor’, and ‘Prevention’ to search for relevant articles in authoritative online research databases on nursing and healthcare, including CINAHL Plus with Full Text in EBSCO and Nursing and Allied Health Database in ProQuest. Initially, a broad search was conducted incorporating all the relevant keywords. Since the initial search yielded a substantial number of articles, the search was refined by carefully evaluating and screening the abstracts and text of the retrieved articles that led to the selection of three study articles.
Discuss what changes could be made as a result of these findings
Describe strategies and resources you would use to implement a change based on these findings
Describe areas of opportunity for future research and EBP related to your topic
Provide a conclusion and discussion of next steps
This should be a high-level overview of what you’ve already discussed in your papers. Be sure to summarize your information (do not simply copy and paste from previous papers). Your PowerPoint slides should be bullet points and/or images and not paragraphs of text. Descriptions and explanations will be written in the “speaker notes” section of the PowerPoint slides. In other words, use the “notes” section to write out what you would say if you were presenting the slides to a live audience.
You will be graded on presentation and layout. Be sure to not overcrowd your slides (follow the 7×7 Rule- No more than 7 bullet points per slide and no more than 7 words per bullet point). Finally, your background should be consistent throughout, and ensure your slides are readable. Do not use too many graphics either.
In addition, you must follow APA guidelines, providing a title slide, reference slide, and in-text citations.
Please review the rubric to ensure that your assignment meets criteria.
Assignment Resources
Gray, J. R., Grove, S. K. & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Elsevier Saunders. ISBN 978-0-323-37758-4
Chapters 1,2, 3
National Council of State Boards of Nursing, Inc. (2020).NCSBN regulatory guidelines and evidence-based quality indicators for nursing education programsLinks to an external site.. https://www.ncsbn.org/NCSBN-Regulatory-Guidelines-…
Please view NCSBN document on Evidence-Based Nursing education. Consider the integration of clinical evidence and best practices in nursing education. Review topics of interest regarding best practices in areas of nursing education.
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FPIN’s Clinical Inquiries
Preventing Postpartum Hemorrhage
Leila Mende, MD;Jestine MacDonald, MD;Dara Jolly, MD;and Jon
O. Neher, MD, Valley Family Medicine, Renton, Washington
Sarah Safranek, MLIS, University of Washington, Seattle, Washington
Clinical Question
What is the most effective medical therapy for
preventing postpartum hemorrhage after vaginal
delivery?
Evidence-Based Answer
Oxytocin plus misoprostol is more effective than
oxytocin alone in reducing postpartum hemorrhage after vaginal delivery. (Strength of Recommendation [SOR]:A, network meta-analysis
of a randomized controlled trial [RCT] and subsequent large RCT.) However, this combination
causes more nausea and vomiting than oxytocin
alone. Tranexamic acid plus oxytocin does not
significantly reduce the rate of postpartum hemorrhage compared with oxytocin alone. (SOR:B,
large RCT.) Overall, oxytocin is the medication of
choice for the prevention of postpartum hemorrhage because of the balance of high effectiveness
and low incidence of adverse effects. (SOR:C,
expert opinion.)
Evidence Summary
A systematic review and network meta-analysis
involving 137 RCTs (many multinational) and
87,466 women examined uterotonic medications
for the prevention of postpartum hemorrhage and
ranked their effectiveness.1 Trials examined oxytocin, ergometrine (not available in the United States;
similar to methylergonovine), misoprostol, and carbetocin (not available in the United States;similar
to oxytocin) as single agents and the combinations
of oxytocin plus misoprostol and oxytocin plus
ergometrine. Patients delivered by vaginal birth or
cesarean section. The medication was administered
prophylactically by a systemic route:sublingually,
subcutaneously, intramuscularly, rectally, orally,
via intravenous bolus, or intravenous infusion;
the timing of administration varied. These interventions were compared with other uterotonics,
placebo, or no treatment. Two medication combinations—misoprostol plus oxytocin and ergometrine plus oxytocin—were more effective than
standard oxytocin but had higher rates of nausea
and vomiting (Table 1).1 A subanalysis of data from
vaginal deliveries only (85 trials, N not provided)
yielded similar reductions in hemorrhages of 500
mL or greater compared with oxytocin alone (relative risk [RR] of oxytocin plus misoprostol = 0.74;
95% CI, 0.56 to 0.99;and RR of oxytocin plus ergometrine = 0.69;95% CI, 0.56 to 0.84). Most trials
(71%) had a high risk or unclear risk of bias.
A subsequent multicenter randomized trial in
England compared the effectiveness of intramuscular oxytocin, carbetocin, and Syntometrine (a
fixed combination of oxytocin and ergometrine)
in the prevention of primary postpartum hemorrhage after vaginal delivery.2 Researchers enrolled
5,929 normotensive pregnant women older than
18 years who were beyond 24 weeks’ gestation
with a singleton pregnancy and were in early labor
from six maternity units across England. Patients
were randomized to 10 IU of oxytocin, 100 mcg of
carbetocin, or 5 IU per 500 mcg of Syntometrine,
all administered intramuscularly after placental
expulsion. Patients receiving Syntometrine were
Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an
approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence
for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://w ww.cebm.net).
The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions
or writing answers for this series, go to https://w ww.fpin.org or email:questions@fpin.org.
This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.
A collection of FPIN’s Clinical Inquiries published in AFP is available at https://w ww.aafp.org/afp/fpin.
Author disclosure:No relevant financial relationships.
May 2023 ◆ Volume 107, Number 5
www.aafp.org/afp
American Family Physician 539
CLINICAL INQUIRIES
TABLE 1
Effects of Medical Interventions for Prevention of Postpartum Hemorrhage Compared With
Oxytocin Alone
Relative risk of specified outcome (95% CI)
Medications
Blood loss ≥ 500 mL*
Need for transfusion
Nausea
Vomiting
Misoprostol plus oxytocin
0.73 (0.60 to 0.90)
0.56 (0.40 to 0.80)
2.07 (1.12 to 3.82)
2.16 (1.37 to 3.39)
Ergometrine† plus oxytocin
0.69 (0.57 to 0.83)
0.81 (0.61 to 1.09)
2.27 (1.52 to 3.38)
3.10 (2.11 to 4.56)
Carbetocin†
0.72 (0.52 to 1.00)
0.64 (0.33 to 1.25)
0.94 (0.61 to 1.44)
0.89 (0.55 to 1.42)
*—This meta-analysis included studies with vaginal deliveries and cesarean sections. However, the outcome of blood loss of 500 mL or greater
defines postpartum hemorrhage only in vaginal deliveries.
†—Ergometrine and carbetocin are not available in the United States.
Information from reference 1.
significantly less likely to need additional uterotonics than
patients given oxytocin (odds ratio [OR] = 0.75;95% CI, 0.65
to 0.91; P =.002) or carbetocin (OR = 0.78;95% CI, 0.66 to
0.93; P = .004). The difference in hemorrhage between oxytocin and carbetocin was not statistically significant (19.5%
vs. 19.1%; P = .78). Syntometrine, compared with carbetocin
and oxytocin, resulted in more nausea (24%, 8%, and 8.9%,
respectively), vomiting (17.6%, 4.8%, and 4.9%, respectively),
hypertension (12.3%, 7.0%, and 7.1%, respectively), and trouble with infant bonding due to symptoms (8.4%, 2.9%, and
4.4%, respectively; P < .001 for all pairwise comparisons of
Syntometrine with oxytocin and carbetocin).
A double-blind noninferiority RCT (n = 29,645) conducted across 23 sites in 10 countries compared the effectiveness of carbetocin vs. oxytocin in preventing postpartum
hemorrhage.3 Researchers randomized patients to receive
carbetocin, 100 mcg intramuscularly, or oxytocin, 10 IU
intramuscularly, immediately after delivery of the infant.
The two primary outcomes were the rate of blood loss of at
least 500 mL or the need for additional uterotonic agents
and a rate of blood loss of at least 1,000 mL. Patients who
received carbetocin had a rate of postpartum hemorrhage
of at least 500 mL or a need for uterotonics similar to those
who received oxytocin (14.5% vs. 14.4%;RR = 1.01;95% CI,
0.95 to 1.06). The rates of postpartum hemorrhage of at least
1,000 mL were also similar (1.51% for carbetocin vs. 1.45%
for oxytocin;RR = 1.04;95% CI, 0.87 to 1.25).
A recent RCT from France randomized 4,079 women
delivering at 35 weeks’ gestation or later to 1 g of intravenous tranexamic acid infusion over two minutes or placebo
infusion in addition to a standard oxytocin injection upon
delivery of the infant’s anterior shoulder.4 The primary outcome was a postpartum hemorrhage of 500 mL or greater,
measured in a collection bag. Among the 3,891 patients who
delivered vaginally, the rate of postpartum hemorrhage was
540 American Family Physician
similar between the two groups (8.1% for tranexamic acid
vs. 9.8% for placebo;RR = 0.83;95% CI, 0.68 to 1.01;P = .07).
Recommendations From Others
In 2012, the World Health Organization advised using
uterotonics in the third stage of labor to prevent postpartum hemorrhage and specifically recommended oxytocin,
10 IU administered intravenously or intramuscularly (strong
recommendations, moderate-quality evidence).5 In 2017, the
American College of Obstetricians and Gynecologists recommended that all obstetric care facilities have guidelines
for the routine use of uterotonics, noting that oxytocin is “the
most effective medication with the fewest adverse effects.”6
Copyright © Family Physicians Inquiries Network. Used with
permission.
Address correspondence to Leila Mende, MD, at Leila_mende@
valleymed.org. Reprints are not available from the authors.
References
1. Gallos I, Williams H, Price M, et al. Uterotonic drugs to prevent postpartum haemorrhage:a network meta-analysis. Health Technol Assess.
2019;23(9):1-356.
2. van der Nelson H, O’Brien S, Burnard S, et al. Intramuscular oxytocin
versus Syntometrine versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth:a randomised double-blinded
clinical trial of effectiveness, side effects and quality of life. BJOG. 2021;
128(7):1 236-1246.
3. Widmer M, Piaggio G, Nguyen TMH, et al.;WHO CHAMPION Trial
Group. Heat-stable carbetocin versus oxytocin to prevent hemorrhage
after vaginal birth. N Engl J Med. 2018;379(8):743-752.
4. Sentilhes L, Winer N, Azria E, et al.;Groupe de Recherche en Obstétrique
et Gynécologie. Tranexamic acid for the prevention of blood loss after
vaginal delivery. N Engl J Med. 2018;379(8):731-742.
5. World Health Organization. WHO recommendations for the prevention
and treatment of postpartum haemorrhage. 2012. Accessed May 12,
2022. https://apps.who.int/iris/bitstream/handle/10665/75411/978924
1548502_eng.pdf
6. Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 183:
postpartum hemorrhage. Obstet Gynecol. 2017;1 30(4):e168-e186. ■
www.aafp.org/afp
Volume 107, Number 5 ◆ May 2023
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.
Hindawi
Evidence-Based Complementary and Alternative Medicine
Volume 2022, Article ID 9878482, 4 pages
https://doi.org/10.1155/2022/9878482
Research Article
The Effect of Oxytocin plus Carboprost Methylate in Preventing
Postpartum Hemorrhage in High-Risk Pregnancy and Its Effect on
Blood Pressure
Lin Wei, Haiping Yang, and Xiaoli Sun
Department of Obstetrics, Anhui Lujiang County People’s Hospital, Lujiang County, Lucheng, Anhui Province, China
Correspondence should be addressed to Xiaoli Sun; xichunfansunv@163.com
Received 28 March 2022; Revised 23 April 2022; Accepted 28 April 2022; Published 30 May 2022
Academic Editor: Zhaoqi Dong
Copyright © 2022 Lin Wei et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. This study aimed to explore and analyze the effectiveness of oxytocin plus carboprost methylate in preventing
postpartum hemorrhage in high-risk pregnancies and its effect on blood pressure. A total of 60 women with high-risk pregnancies
who gave birth in our hospital from January 2020 to May 2021 were recruited and assigned via random number table method (1 : 1)
to receive either oxytocin (control group) or oxytocin plus carboprost methylate (observation group). Outcome measures included hemorrhage and blood pressure. The bleeding volume of the women in the observation group (210.55 ± 45.98, 45.21 ± 9.27,
and 73.74 ± 12.18) was significantly less than that in the control group during delivery and 2h and 24h after the delivery
(276.91 ± 49.21, 72.98 ± 19.68, and 92.61 ± 15.67) (all P < 0.05). The observation group showed a significantly lower bleeding rate
(6.67%) than the control group (16.67%) (P < 0.05). The two groups showed similar diastolic and systolic blood pressures
(P > 0.05). Oxytocin plus carboprost methylate suppository effectively prevents postpartum hemorrhage in high-risk pregnancies,
significantly reduces the amount of postpartum hemorrhage in high-risk pregnancies, and has little effect on the blood pressure of
patients. Given its favorable treatment efficiency and high safety profile, this treatment protocol shows great potential for
clinical application.
1. Introduction
High-risk pregnancies refer to pregnancies that involve
increased health risks for the mother, the fetus, or both, with
a significantly higher maternal and neonatal morbidity and
mortality versus normal pregnancies [1]. Women with highrisk pregnancies are vulnerable to pregnancy complications
such as high blood pressure, gestational diabetes, and preterm labor, which necessitate intensive care to enhance the
health of the mother and the fetus [2]. Postpartum hemorrhage [3] is heavy vaginal bleeding (500 ml or more)
within 24 hours after delivery. It is a serious complication
during delivery and accounts for 25% of maternal deaths in
China [4, 5]. The main causes of postpartum hemorrhage
include uterine atony, detrimental placental profiles, perineal laceration, and coagulation dysfunction [6]. Studies
have found that high-risk pregnancies are associated with a
significantly higher postpartum hemorrhage rate compared
with normal pregnancies, and postpartum hemorrhage may
result in hemorrhagic shock, disseminated intravascular
coagulation, and even maternal death [7, 8]. Oxytocin [9] is a
peptide hormone secreted by the posterior pituitary and
synthesized by the paraventricular and supraoptic nuclei of
the hypothalamus [10]. It stimulates lactation, promotes the
contraction of uterine smooth muscle during delivery, and
lowers stress hormone levels such as adrenaline, thereby
lowering blood pressure [11, 12]. Carboprost methylate [13]
is a derivative of natural prostaglandin F2α and is widely
present in various tissues and body fluids. It increases the
frequency and amplitude of uterine contractions and enhances the contractility of uterine muscle, thereby promoting uterine contractions. At present, research has
reported that carboprost methylate suppository avoided
laborious treatment procedures and effectively reduced the
amount of postpartum hemorrhage with manageable safety
[14]. Therefore, by comparing the effectiveness of oxytocin
2
Evidence-Based Complementary and Alternative Medicine
mono-therapy versus combined therapy of oxytocin plus
carboprost methylate, this study was to explore and analyze
the effect of oxytocin combined with carboprost methylate in
preventing postpartum hemorrhage in high-risk pregnancies and its effect on blood pressure, so as to provide a basis
for clinical treatment. The research results are as follows.
2. Materials and Methods
2.1. Study Design and Participants. In this prospective, randomized, controlled study, 60 women with high-risk pregnancies who gave birth in our hospital from January 2020 to
May 2021 were selected and assigned via random number table
method to an observation group (n � 30). This project was
reviewed and approved by the Research Ethics Committees of
Anhui Lujiang County People’s Hospital, No. AH9647.
2.2. Inclusion and Exclusion Criteria
2.2.1. Inclusion Criteria. Patients who met the diagnostic
criteria for high-risk pregnancy in Obstetrics and Gynecology, with one or more high-risk factors for postpartum
hemorrhage [15], and who provided written informed
consent were included.
2.2.2. Exclusion Criteria. Patients with allergies to the drugs
used in this study with psychiatric diseases, with relevant
contraindications, and with hospital referral or withdrawal
of consent were excluded.
2.3. Methods. Both groups were admitted to our hospital
before delivery. The women in the control group received 20
U of oxytocin (Beijing Saisheng Pharmaceutical Co., Ltd.,
National Pharmacopoeia H11020363) through intramuscular injection immediately after delivery. A similar administration regimen of oxytocin was introduced to those in
the observation group.
Except for oxytocin administration, the women in the
observation group one also received carboprost methylate
suppository (Northeast Pharmaceutical Group Shenyang
No.1 Pharmaceutical Co., Ltd. State Drug Quantiėer
H10800006). The midwife placed the carboprost methylate
suppository in 1/3 part of the anterior vaginal wall and kept
it there for 2 min until the suppository dissolved to avoid a
decrease in the efficacy of the suppository as it might be
displaced by the blood flow. If bleeding persisted, the drug
was administered through the anus.
2.4. Evaluation Criteria
(1) The blood loss in the two groups of patients during
delivery, 2 hours after the delivery, and 24 hours after
the delivery was recorded. The volume of blood in
the blood collector and in the gauze after delivery
was recorded separately using a combination of the
volumetric method and area method. The volume of
gauze blood was estimated according to the wet area
of gauze blood, and the actual amount of bleeding at
delivery was calculated as the sum of the two. The
postpartum bleeding volume at 2 h and 24 h was
recorded by weighing the weight of the mattress, and
the actual bleeding volume was accurately calculated
and compared between groups.
(2) The number of bleeding cases within 2 hours and 24
hours after the delivery was recorded, and the
bleeding rates were calculated for comparison.
(3) The blood pressure of the two groups of women before
and after treatment was recorded, and the systolic
blood pressure and diastolic blood pressure of the two
groups of women before and after the treatment were
continuously monitored and compared.
2.5. Statistical Analysis. All data analyses were performed
with SPSS22.0 software. Enumeration data are expressed as
[n (%)] and analyzed using the chi-square test, and measurement data are expressed as (mean ± SD) and analyzed
using the t-test. Differences were considered statistically
significant at P < 0.05.
3. Results
3.1. General Data. The women in the observation group
were aged 21–42 years, with a mean age of 28.53 ± 5.32 years,
and the gestational week was 34-42 weeks, with a mean of
39.08 ± 2.18 weeks. The women in the control group were
aged 19–37 years, with a mean age of 28.64 ± 4.54 years, and
the gestational week was 34–42 weeks, with a mean of
39.23 ± 1.99 weeks. There were no significant differences in
general data between the two groups (Table 1).
3.2. Bleeding
3.2.1. Bleeding Volume. The bleeding volume of the women
in the observation group (210.55 ± 45.98, 45.21 ± 9.27, and
73.74 ± 12.18) was significantly less than that in the control
group during delivery and 2 h and 24 h after the delivery
(276.91 ± 49.21, 72.98 ± 19.68, and 92.61 ± 15.67) (all
P < 0.05) (Table 2).
3.2.2. Number of Bleeding Cases. The bleeding rate of the
observation group (6.67%) was significantly lower than that
of the control group (16.67%) (P < 0.05) (Table 3).
3.3. Blood Pressure. The differences in diastolic and systolic
blood pressure in the observation group (85.87 ± 8.01,
122.12 ± 10.65/89.17 ± 6.12, 127.62 ± 11.28) and the control
group (85.02 ± 7.98, 123.61 ± 10.17/89.68 ± 6.58, 126.88 ±
11.61) before and after treatment were not statistically
significant (P > 0.05) (Table 4).
4. Discussion
The morbidity and mortality of pregnant women and
newborns in high-risk pregnancies are significantly higher
than those in normal pregnancies. Therefore, pregnancy
Evidence-Based Complementary and Alternative Medicine
3
Table 1: Comparison of general data of the two groups of patients (x ± s).
Groups
Observation group
Control group
t
P
n
30
30
Age
28.53 ± 5.32
28.64 ± 4.54
0.086
0.932
Gestational age
39.08 ± 2.18
39.23 ± 1.99
0.278
0.782
Table 2: Comparison of bleeding volume between two groups of patients (x ± s).
Groups
Observation group
Control group
t
P
n
30
30
—
—
Intraoperative blood loss
210.55 ± 45.98
303.91 ± 49.21
7.593
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