International Journal of Gynecology and Obstetrics-India

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1 Interntionl Journl o Gyneology n Ostetris-Ini (Deemer-Jnury 2015);1(4):21-25 Interntionl Journl o Gyneology n Ostetris-Ini liinil rtile Prospetive rnomize tril o oxytoin ministrtion or tive mngement o the thir stge o lor Emire Oguz Orhn, Bern Dilz,*, Sezin Erturk Akskl, Siel Altıns, Slim Erky Sivs Stte Hospitl, Sivs, Turkey Deprtment o Ostetris n Gyneology, Etlik Zueye Hnim Women s Helth Tehing n Reserh Hospitl, Ankr, Turkey Deprtment o Ostetris n Gyneology, Hettepe University Kstmonu Meil Fulty, Ankr, Turkey Deprtment o Ostetris n Gyneology, Zeki Thir Burk Mternity n Tehing Hospitl, Ankr, Turkey r t i l e i n o Artile history: Reeive 13 August 2013 Reeive in revise orm 22 My 2014 Aepte 8 July 2014 Keywors: Ative mngement o thir stge o lor Lor ugmenttion Oxytoin Postprtum hemorrhge s t r t Ojetive: To etermine the most eiient route n timing o oxytoin ministrtion or tive mngement o the thir stge o lor. Methos: A prospetive rnomize stuy ws one t one enter in Ankr, Turkey, etween Jnury n Otoer Women with singleton pregnny (N37 weeks) who h live vginl irth were rnomly llote to our groups: iv-a (intrvenous oxytoin ter elivery o the etus), iv-b (when nterior shouler seen), im-a (intrmusulr oxytoin ter elivery), n im-b (when nterior shouler seen). Postprtum loo loss within the irst hour, hemogloin, hemtorit, n urtion o the thir stge were ompre. Results: A totl o 600 eligile women were reruite; 150 were ssigne to eh group. Postprtum loo loss, preprtum n postprtum hemogloin n hemtorit, n nee or itionl uterotonis were similr mong groups (P > 0.05). The urtion o the thir stge o lor n hnges in hemogloin n hemtorit were signiintly reue in group iv-b (P < 0.05). Among women not expose to oxytoin eore elivery, postprtum loo loss ws signiintly lower in group iv-b (P = 0.019). Lor ugmenttion ws relte to signiintly inrese postprtum loo loss in ll groups exept iv-a. Conlusion: Although postprtum loo loss ws similr in ll groups, erly intrvenous ministrtion seeme to hve eneiil eets. ClinilTrils.gov: NCT Interntionl Feertion o Gyneology n Ostetris. Pulishe y Elsevier Ireln Lt. All rights reserve. 1. Introution Postprtum hemorrhge (PPH) is responsile or one-qurter o ll mternl eths worlwie [1]. Aoring to the most reent survey, the mternl mortlity rte in Turkey is 28 per 100,000 live irths, n eths relte to intrprtum hemorrhge n PPH onstitute 24.9% o mternl eths [2]. PPH is ommonly eine s loo loss o 500 ml or more ter vginl elivery or o 1,000 ml or more ter esren elivery within the irst 24 hours post prtum. Ative mngement o the thir stge o lor (AMTSL) n help to prevent PPH n involves interventions tht ilitte uterine ontrtion n expulsion o the plent. Use o uterotoni rugs, ontrolle or trtion, ssessment o uterine tonus, n lte or lmping perorme 1 3 minutes ter elivery re the reommene omponents o AMTSL [3]. Oxytoin is the gol stnr uterotoni rug use in AMTSL [1]. A Cohrne review [4] showe tht, s ompre with no oxytoin, prophylti use o oxytoin s prt o AMTSL ereses the risk o loo loss exeeing 500 ml. The short hl-lie n verse eets o oxytoin et the hoie o route o ministrtion. Stuies inite tht the most eiient route o oxytoin ministrtion is slow * Corresponing uthor t: Deprtment o Ostetris n Gyneology, Etlik Zueye HnimWomen s Helth Tehing n Reserh Hospitl, Yeni Etlik Street No. 55, Ankr, Turkey. Tel.: ; x: E-mil ress: silz@hotmil.om (B. Dilz). intrvenous inusion [3] or olus inusion given in 1 2 minutes [5]. Beuse rpi injetion o oxytoin hs een reporte to hve verse riovsulr eets (suh s thyri, hypotension, n eletroriogrphi hnges) n might use nuse, vomiting, hest pin, hehe, lushing, pulmonry eem, severe wter intoxition, n onvulsion, intrmusulr injetion is preerre in some settings [6,7]. The timing o oxytoin injetion lso iers: it my e ministere either on sight o the nterior shouler ter elivery o the he, or ter elivery o the neonte. The min im o the present stuy ws to etermine the most eiient route o oxytoin ministrtion y mesuring the urtion o the thir stge o lor n quntittive loo loss uring the irst hour ter elivery, n y ompring hemogloin n hemtorit hnges n the nee or itionl interventions mong women who unerwent either spontneous lor or reeive lor ugmenttion with oxytoin. A seonry im ws to investigte the timing o oxytoin ministrtion. 2. Mterils n methos The present prospetive rnomize stuy ws onute etween Jnury 1 n Otoer 31, 2010, t the Ministry o Helth Etlik Zueye Hnım Women s Helth Tehing n Reserh Hospitl, Ankr, Turkey. This enter is tertiry mternity hospitl with pproximtely 14,000 eliveries per yer. Institutionl pprovl /jp-journls

2 22 E. Oguz Orhn et l. / Interntionl Journl o Gyneology n Ostetris-Ini (Deemer-Jnury 2015);1(4):21-25 ws otine rom the hospitl s Trining Progrmming Bor,whih ts s n institutionl review or. All stuy prtiipnts signe inorme onsent. The stuy reruite women with singleton pregnny omore thn 37 weeks urtion who h norml live vginl elivery with ephli presenttion n were in tive lor. The exlusion riteri were: Fetl emise; multiple pregnny; known ogultion isorers; presenttion nomlies; plentl pthology; liver isese; thromoytopeni; hypertension or tking ntiogulnts; esren elivery, opertive elivery, or eep vginl ter; horiomnionitis; or evelopment o HELLP (hemolysis, elevte liver enzymes, low pltelet ount) synrome or isseminte intrvsulr ogultion eore elivery. Eligile prtiipnts were reruite n rnomly llote into our groups vi rnom numer tle. All prtiipnts reeive 10 IU o oxytoin (Postuitrin-Fort mpule, 5 IU; i.e. Ulgy, Istnul, Turkey). In group iv-a, oxytoin ws given intrvenously t 1 ml/min ter elivery o the etus n lmping o the or. In group iv-b, it ws given intrvenously t 1 ml/min when the nterior shouler ws seen ter the he ws elivere. In group im-a, it ws given intrmusulrly ter elivery o the etus. In group im-b, it ws given intrmusulrly when the nterior shouler ws seen ter the he ws elivere. The nurses who perorme the injetions were wre o group llotion. However, memers o the stuy tem who rrie out the mesurement o loo loss were mske to the llote groups. The prtiipnts were evlute y tking meil n ostetri history, n then unerwent generl n pelvi exmintions. Bloo smples were tken eore elivery to mesure hemogloin n hemtorit levels. Finings o the initil ostetri evlution n the ollow-up were reore vi prtogrm. The urtion o lor ugmenttion with oxytoin, i neee, ws reore. To investigte the eet o urtion o lor ugmenttion on postprtum loo loss within the irst hour, the mount o leeing ws ompre etween women who reeive inution or 4 hours or longer n those who reeive inution or less thn 4 hours. A low-ose oxytoin protool ws use or ugmenttion o lor: oxytoin ws given t n initil ose o 2 mu/min n inrementlly inrese y 2 mu/min every 15 minutes until regulr ontrtions were otine [8]. None o the women reeive epiurl or nroti nlgesi, s speiie y the stuy protool. When require, meiolterl episiotomy ws perorme uner lol nesthesi. In line with hospitl poliy, the ler o ll women ws emptie eore elivery. A sterile lirte rpe (BRASS-V rpe, EKIN Turkey) ws ple unerneth the women to mesure loo loss immeitely ter elivery o the neonte. Two other omponents o AMTSL (or trtion n lte lmping) were not pplie to the women so tht the inepenent eet o route o oxytoin injetion on postprtum loo loss oul e nlyze. The or ws lmpe within 1 minute o elivery unless erly intervention or the neonte ws require. The urtion o the thir stge ws reore. For women who i not hve spontneous expulsion o the plent within 30 minutes, itionl oxytoin (10 mu) ws given. I there ws no susequent hnge, mnul removl o the plent ws perorme uner setion; these ses were reore. Women were ollowe up or 1 hour in the elivery room or mesurement o postprtum loo loss. For prtiipnts who h loo loss o more thn 500 ml or suen exessive hemorrhge, itionl oxytoin (10 mu)ws ministere; i the uterus ws oun to e toni, uterine mssge ws perorme. The women s vitl signs were reore t the en o the irst hour. I no urther tretment ws require, they were trnserre to the postprtum unit ter reoring the mount o loo in the lirte rpe. Hemogloin n hemtorit levels were reore t 24 hours postprtum. Any other interventions tht were require or verse eets tht ourre were reore. Totl loo loss ws use to lulte the stuy smple require. Unpulishe hospitl t inite tht the men loo loss in vginl elivery with stnr proeures ws pproximtely 300 ± 205 ml. A reution o 25% in the totl mount o loo loss ws epte s linilly signiint; smple size o 119 in eh group woul e require to etet suh ierene in loo loss. Assuming 20% ropout rte, 150 women were require in eh stuy group. Dt nlysis or sttistil evlution ws perorme vi SPSS version 15.0 (SPSS In, Chigo, IL, USA). The ierene in the mount o leeing ws ompre mong the groups y using inepenent smples t test n one-wy nlysis o vrine. When ierene ws oun mong the groups, Tukey honest signiint ierene n lest signiint ierene tests were use to etermine the groups tht showe the ierene. P < 0.05 ws onsiere sttistilly signiint. At this level o signiine, the smple size inluene ws 0.25, the α error 0.05, n the β error 80%. 3. Results O 724 women who were ssesse, 600 eligile women were reruite, with 150 ssigne to eh group. Among the our groups, there ws no signiint ierene in ge, grviity, prity, numer o spontneous ortions, numer o voluntry termintions, numer o live or stillorn hilren, weeks o pregnny, or irth weight (P > 0.05) (Tle 1). The eutionl level ws similr etween groups: 88 (58.7%) women in group iv-a, 86 (57.3%) in group iv-b, 90 (60.0%) in group im-a, n 99 (66.0%) in group im-b h omplete primry shool. The remining women h omplete high shool or university. Among the 600 prtiipnts, 32 (5.3%) h no prentl ollow-up. There ws no signiint ierene mong the groups in preprtum hemogloin n hemtorit vlues (P > 0.05) (Tle 1). Episiotomy ws perorme in 132 women (88.0%) in group iv-a, 140 (93.3%) in group iv-b, 143 (95.3%) in group im-a, n 148 (98.7%) in group im-b (P = 0.009). One vginl lertion ws reore in group iv-a. The urtion o the thir stge ws shorter in group iv-b thn in the other groups (P < 0.001) (Tle 1). The iniene o lor ugmenttion ws higher in group iv-a (56.0%) thn in the other groups (P < 0.001) (Tle 2). However, there ws no ierene in terms o the urtion o ugmenttion mong the our groups (P > 0.05) (Tle 2). The men postprtum loo loss i not ier signiintly etween groups (P = 0.134) (Tle 3). Although the iniene o postprtum loo loss o 600 ml or more ws 4.0% in oth intrvenous groups, n 6.0% in oth intrmusulr groups, the ierenes mong the groups were not signiint (P = 0.738) (Tle 3). No ierene ws oun mong the groups in preprtum or postprtum hemogloin n hemtorit vlues (P > 0.05). However, the hnges in hemogloin n hemtorit were smllest in group iv-b (P = n P = 0.018, respetively) (Tle 3). Regring the suset o women who reeive lor ugmenttion, there ws no signiint ierene in postprtum loo loss mong the our groups (P = 0.088) (Tle 4). However, mong the women who i not reeive lor ugmenttion, postprtum loo loss ws signiintly lower in group iv-b thn in the other three groups (P = 0.019) (Tle 4). When women who i n i not unergo inution in eh group were ompre, there ws no ierene in postprtum loo loss in group iv-a (P = 0.750). In the other three groups (iv-b, im-a, n im-b), however, postprtum loo loss ws higher mong those who reeive lor ugmenttion thn mong those who i not (P < 0.05) (Tle 4). In ll our groups, postprtum loo loss ws higher mong ptients who reeive lor ugmenttion with oxytoin or 4 hours or more thn mong those who reeive it or less thn 4 hours, n this ierene ws signiint in ll groups exept group im-b (Tle 5). Among women who reeive lor ugmenttion or less thn 4 hours, those in group iv-a h the lowest postprtum loo loss (P = 0.050) (Tle 5). In ll groups, postprtum loo loss ws higher in women who h n episiotomy thn in those who i not, ut this ierene ws only signiint within group iv-b (P = 0.011) (Tle 6). There ws no ierene mong the groups in itionl uterotoni use (P > 0.05).

3 E. Oguz Orhn et l. / Interntionl Journl o Gyneology n Ostetris-Ini (Deemer-Jnury 2015);1(4): Tle 1 Demogrphi n ostetri hrteristis o the our stuy groups. Chrteristi Age, y 25.8 ± ± ± ± Grviity 1.9 ± ± ± ± Prity 0.7 ± ± ± ± Numer o previous spontneous ortions 0.1 ± ± ± ± Numer o previous voluntry termintions o pregnny 0.1 ± ± ± ± Numer o previous stillirths 0.01 ± ± ± ± No. o hilren 0.7 ± ± ± ± Weeks o pregnny 39.2 ± ± ± ± Birth weight, g 3211 ± ± ± ± Hemogloin t mission, g/l 12.0 ± ± ± ± Hemtorit t mission, % 37.0 ± ± ± ± Durtion o 3r stge, min 12.6 ± ± ± ± e Vlues re given s men ± SD unless stte otherwise. Oxytoin given intrvenously when the or ws lmpe. Oxytoin given intrvenously when nterior shouler seen. Oxytoin given intrmusulrly when the or ws lmpe. Oxytoin given intrmusulrly when nterior shouler seen. versus the other groups. One ptient (0.7%) eh rom groups iv-a n iv-b n 2 (1.3%) rom group im-b require itionl oxytoin or retine plent. Overll, the numer o women requiring itionl postprtum uterotonis ws 6 (4.0%) in groups iv-a n iv-b, n 9 (6.0%) in groups im-a n im-b; this ierene ws not signiint (P > 0.05). Among the 600 prtiipnts, verse eets were seen in only one womn in group im-a who evelope uvulr eem. The prtiipnt ws given ortiosterois n ntihistmines. Respirtory istress ws not seen uring her ollow-up. None o the stuy prtiipnts require ny urther intervention, suh s lprotomy or postprtum hysteretomy. 4. Disussion The present stuy showe tht the urtion o the thir stge o lor ws shortest in the group reeiving intrvenous oxytoin ter elivery o the etl nterior shouler. Postprtum loo loss, Tle 2 Distriution o ptients who reeive lor ugmenttion n omprison o inution urtion. Lor ugmenttion Inution No 66 (44.0) 94 (62.7) 95 (63.3) 98 (65.3) Yes 84 (56.0) 56 (37.3) 55 (36.7) 52 (34.7) Durtion o inution, min ± ± ± ± e Vlues re given s numer (perentge) or men ± SD, unless stte otherwise. Oxytoin given intrvenously when the or ws lmpe. Oxytoin given intrvenously when nterior shouler seen. Oxytoin given intrmusulrly when the or ws lmpe. Oxytoin given intrmusulrly when nterior shouler seen. versus the other three groups. Tle 3 Comprison o leeing, n hemogloin n hemtorit levels in the stuy groups. Vrile PPBL, ml ± ( ) ± ( ) ± ( ) ± (35 800) PPBL N600 ml 6 (4.0) 6 (4.0) 9 (6.0) 9 (6.0) Hemogloin t mission, g/l 120 ± ± ± ± Postprtum hemogloin, g/l 109 ± ± ± ± Hemtorit t mission, % 37.1 ± ± ± ± Postprtum hemtorit, % 33.2 ± ± ± ± Chnge in hemogloin, g/l 11.6 ± ± ± ± Chnge in hemtorit, % 3.9 ± ± ± ± Vlues re given s men ± SD (rnge), numer (perentge), or men ± SD, unless stte otherwise. versus the other three groups.

4 24 E. Oguz Orhn et l. / Interntionl Journl o Gyneology n Ostetris-Ini (Deemer-Jnury 2015);1(4):21-25 Tle 4 Comprison o PPBL y iniene o lor ugmenttion. Augmenttion o lor PPBL in women with no inution, ml ± ± ± ± PPBL in women with inution, ml ± ± ± ± (within group) Vlues re given s men ± SD unless stte otherwise. versus the other three groups. iniene o high postprtum loo loss ( 600 ml), n hemogloin n hemtorit levels t mission n ter elivery were similr in ll groups. However, signiint ierenes were reore in hnges in hemogloin n hemtorit vlues, whih were lower mong women who reeive intrvenous oxytoin ter elivery o the etl he (P = n P = 0.018, respetively). Postprtum loo loss ws lso slightly lower in this group thn in the other groups, ut the ierene ws not signiint (P > 0.05). Moreover, ny ierenes h no linil impt, euse the iniene o postprtum hemorrhge ws similr in ll groups. The UK Ntionl Institute or Helth n Cre Exellene guieline or intrprtum re [9] reommens the ministrtion o 10 IU o intrmusulr oxytoin uring the thir stge o lor. In 2012, WHO pulishe new guieline or the prevention n tretment o PPH in whih oxytoin (10 IU) is the reommene uterotoni rug in the thir stge o lor, ut the route o ministrtion is optionl [4]. The Soiety o Ostetriins n Gyneologists o Cn reommens intrmusulr ministrtion o oxytoin (10 IU) ter elivery o the nterior shouler [10]. Fujimoto et l. [11] reporte signiintly erese postprtum leeing risk in group who reeive oxytoin ter elivery o the nterior shouler. By ontrst, Huh et l. [12] stte tht postprtum loo loss ws less n the thir stge ws shorter when oxytoin (10 IU intrmusulr) ws ministere ter elivery o the plent thn when it ws ministere ter elivery o the etl nterior shouler. Jkson et l. [13] ministere 20 IU o oxytoin in rystlloi solution y intrvenous olus upon elivery o either the etl nterior shouler or plent, n oun no signiint ierene etween the two groups with respet to the iniene o PPH, rte o retine plent, or urtion o the thir stge. Grotegut et l. [14] emonstrte tht mssive leeing seonry to uterine tony ws signiintly higher mong women who were expose to oxytoin uring lor thn in ontrol group. In retrospetive stuy, Phillip et l. [15] oun tht women unergoing lor inution h higher rtes o postprtum leeing. Golerg et l. [16] reporte orreltion etween PPH n the urtion n mount o oxytoin exposure in retrospetive stuy. In the present stuy, mong women who were not expose to oxytoin eore elivery, postprtum loo loss ws signiintly lower in group iv-b thn in the other groups; mong those who reeive oxytoin or lor inution, however, there ws no signiint ierene in postprtum loo loss mong the groups. When these susets o women were ompre within the groups, postprtum loo loss ws higher mong ptients who reeive oxytoin or lor inution in ll groups exept group iv-a. These results highlight the negtive impt o lor inution on postprtum loo loss, lthough none o Tle 5 Comprison o PPBL y urtion o inution mong ptients who unerwent lor inution. Durtion o inution (n = 84) (n = 56) (n = 55) (n = 52) e PPBL in women who reeive lor ugmenttion or 4 h, ml ± ± ± ± PPBL in women who reeive lor ugmenttion or 4 h, ml ± ± ± ± (within group) Vlues re given s men ± SD unless stte otherwise. Tle 6 Comprison o PPBL y iniene o episiotomy. Episiotomy PPBL in women who i not unergo episiotomy, ml ± ± ± ± PPBL in women who unerwent episiotomy, ml ± ± ± ± (within group) Vlues re given s men loo loss ± SD unless stte otherwise.

5 E. Oguz Orhn et l. / Interntionl Journl o Gyneology n Ostetris-Ini (Deemer-Jnury 2015);1(4): the hnges h linil implition. In ll groups, postprtum loo loss ws higher mong ptients who reeive lor ugmenttion or more thn 4 hours thn mong those ptients reeiving it or less thn 4 hours. This implies possile negtive impt o longer lor ugmenttion. A stuy ompring the eet o erly repir o episiotomy on postprtum loo loss with tht o repir ter spontneous plentl expulsion [17] oun no signiint ierene etween the groups. By ontrst, Bksu et l. [18] reporte signiintly greter erese in hemogloin n hemtorit in ll episiotomy groups s ompre with women who i not hve episiotomy (P < 0.05). The present stuy showe no sttistilly signiint ierene in postprtum loo loss etween groups or women who i n i not reeive episiotomy (P > 0.05). However, when women who i n i not reeive episiotomy were ompre within groups, postprtum loo loss ws signiintly lower in ptients who i not hve n episiotomy in group iv-b. Although loo loss seeme to e lower in women who i not reeive episiotomy in the other groups, no signiint ierenes were reore. The present stuy hs some limittions. Beuse no ptients reeive the other two omponents o AMTSL (lte lmping n or trtion), the results re limite to evlution o only the oxytoin omponent o AMTSL. Thereore, the results my not e uplite mong ptients who reeive ll three omponents o AMTSL. In ition, the stuy ws onute t tertiry re hospitl, whih restrits generliztion o the results to helth servies on ierent levels. In summry, the present stuy oun tht the moe n timing o oxytoin ministrtion i not hve ny signiint eet on postprtum loo loss. Although intrvenous ministrtion espeilly ter elivery o the etl he might seem vorle, the oserve eets were linilly insigniint n h no mrke impt on postprtum loo loss. The present results nnot e generlize n wrrnt veriition y uture stuies mong lrger ptient groups in ierent level helth ilities. Conlit o interest The uthors hve no onlits o interest. Reerenes [1] Worl Helth Orgniztion. The Worl helth report: 2005: Mke every mother n hil ount. Aville rom en.p. Pulishe Aesse Mrh 24, [2] Hettepe University, Institute o Popultion Stuies. Turkey Ntionl Mternl Mortlity Stuy Aville rom nkr. Pulishe Aesse Mrh 24, [3] Worl Helth Orgniztion. WHO reommentions or the prevention n tretment o postprtum hemorrhge. Aville rom itstrem/10665/75411/1/ _eng.p. Pulishe Aesse Mrh 24, [4] Westho G, Cotter AM, Tolos JE. Prophylti oxytoin or the thir stge o lour to prevent postprtum hemorrhge. Cohrne Dtse Syst Rev 2013;10:CD [5] Dvies GA, Tessier JL, Woomn MC, Lipson A, Hhn PM. Mternl hemoynmis ter oxytoin olus ompre with inusion in the thir stge o lor: A rnomize ontrolle tril. Ostet Gyneol 2005;105(2): [6] Bhtthry S, Ghosh S, Ry D, Mllik S, Lh A. Oxytoin ministrtion uring esren elivery: Rnomize ontrolle tril to ompre intrvenous olus with intrvenous inusion regimen. J Anesthesiol Clin Phrmol. 2013;29(1):32 5. [7] Gizzo S, Ptrelli TS, Gngi SD, Crrozzini M, Sri C, Zmon A, et l. Whih uterotoni is etter to prevent the postprtum hemorrhge? Ltest news in terms o linil eiy, sie eets, n ontrinitions: systemti review. Repro Si. 2013;20(9): [8] ACOG Committee on Prtie Bulletins Ostetris. ACOG Prtie Bulletin No. 107: Inution o lor. Ostet Gyneol. 2009;114(2 Pt 1): [9] Ntionl Institute or Helth n Clinil Exellene. Intrprtum re: re o helthy women n their ies uring hilirth. NICE linil guieline 55. Aville rom Pulishe Septemer Aesse Mrh 24, [10] The Soiety o Ostetriins n Gyneologists o Cn. SOGC Clinil Prtie Guieline: No Ative Mngement o the Thir Stge o Lour: Prevention n Tretment o Postprtum Hemorrhge. Aville rom sog.org/wp-ontent/uplos/2013/01/gui235cpg0910.p. Pulishe Otoer Aesse Mrh 24, [11] Fujimoto M, Tkeuhi K, Sugimoto M, Mruo T. Prevention o postprtum hemorrhge y uterotoni gents: Comprison o oxytoin n methylergometrine in the mngement o the thir stge o lor. At Ostet Gyneol Sn. 2006;85(11): [12] Huh WK, Chelmow D, Mlone FD. A oule-line, rnomize ontrolle tril o oxytoin t the eginning versus the en o the thir stge o lor or prevention o postprtum hemorrhge. Gyneol Ostet Investig. 2004;58(2): [13] Jkson Jr KW, Allert JR, Shemmer GK, Elliot M, Humphrey A, Tylor J. A rnomize ontrolle tril ompring oxytoin ministrtion eore n ter plentl elivery in the prevention o postprtum hemorrhge. Am J Ostet Gyneol. 2001;185(4): [14] Grotegut CA, Pgli MJ, Johnson LN, Thmes B, Jmes AH. Oxytoin exposure uring lor mong women with postprtumhemorrhge seonry to uterine tony. Am J Ostet Gyneol. 2011;204(1):56.e1 6. [15] Phillip H, Flether H, Rei M. The impt o inue lour on postprtum loo loss. J Ostet Gyneol. 2004;24(1):12 5. [16] Golerg CC, Kllenv MA, MCury CM, Miller HS. Eet o intrprtum use o oxytoin on estimte loo loss n hemtorit hnge t vginl elivery. Am J Perintol. 1996;13(6): [17] Ozegirmeni O, Erky S, Ylv S, Dilz B, Altins S, Herl A. Does erly repir o episiotomy erese postprtum loo loss: A rnomize linil tril. J Mtern Fetl Neontl Me. 2010;23(4): [18] Bksu B, Dvs I, Akyol A, Ozgul J, Ezen F. Eet o timing o episiotomy repir on periprtum loo loss. Gyneol Ostet Investig. 2008;65(3):