***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Objective To evaluate whether routine administration of sublingual misoprostol 600 μg after delivery reduces postpartum haemorrhage . Design R and omised double blind placebo controlled trial . Setting Primary health centre in Bissau , Guinea-Bissau , West Africa . Participants 661 women undergoing vaginal delivery . Intervention Misoprostol 600 μg or placebo administered sublingually immediately after delivery . Main outcome measures Postpartum haemorrhage , defined as a loss of ≥ 500 ml and decrease in haemoglobin concentration after delivery . Results The incidence of postpartum haemorrhage was not significantly different between the two groups , the relative risk being 0.89 ( 95 % confidence interval 0.76 to 1.04 ) in the misoprostol group compared with the placebo  group . Mean blood loss was 10.5 % ( −0.5 % to 20.4 % ) lower in the misoprostol group than in the control group . Severe postpartum haemorrhage of ≥ 1000 ml or ≥1500 ml occurred in 17 % ( 56 ) and 8 % ( 25 ) in the placebo group and 11 % ( 37 ) and 2 % ( 7 ) in the misoprostol group . Significantly fewer women in the misoprostol group experienced a loss of ≥1000 ml ( 0.66 , 0.45 to 0.98 ) or ≥ 1500 ml ( 0.28 , 0.12 to 0.64 ) . The decrease in haemoglobin concentration tended to be less in the misoprostol group , the mean difference between the two groups being 0.16 mmol/l ( −0.01 mmol/l to 0.32 mmol/l ) . Conclusion Sublingual misoprostol  reduces the frequency of severe postpartum haemorrhage Oxytocin has been the oxytocic of choice for Active Management of Third Stage of Labor ( AMTSL ) [ 1 ] . Misoprostol would be a suitable alternative in low re source setting s where drug delivery is hampered by storage and problems of parenteral administration . In patients who are vomiting , unable to take medications or under anesthesia , rectal administration may be associated with fewer side effects and ease of administration [2].The use of additional uterotonics is significantly higher with rectal 400 mcg misoprostol than with oxytocin [ 3 ] . It is possible that a higher dose of rectal misoprostol may be more effective in reducing blood loss . A prospect i ve , double-blind , r and omized pilot study was undertaken in the Post Graduate Institute of Medical Education and Research ( PGIMER ) , Ch and igarh , India to determine the effectiveness and safety of rectal administration of 600 mcg misoprostol compared to oxytocin as part of the AMTSL in women at low risk for PPH . The study was approved by the ethical committee of the Institute . Two hundred women in spontaneous labor were recruited , and a written informed consent was Postpartum hemorrhage is the leading cause of maternal mortality in India , accounting for 25 - --30 % of all maternal deaths [ 1 ] . A large number of deliveries still occur at home , especially in rural areas . Injectable uterotonics are not necessarily applicable to these setting s , as their effective use requires safe administration and special storage to maintain stability . In this prospect i ve double blind r and omized study conducted in 2005 - 06 at the Postgraduate Institute of Medical Education and Research ( PGIMER ) , Ch and igarh , India , 200 women at low risk of PPH were r and omized to receive either two tablets of misoprostol ( 400 mcg ) sublingually or 1ml of methylergometrine ( 200 mcg ) intramuscularly at the delivery of anterior shoulder of baby . Identical looking placebo tablets and injections were used . Primary and secondary outcomes measured are shown in Table 1 . The duration of third stage , mean blood loss and need for additional oxytocics was similar in Postpartum  hemorrhage ( PPH  ) is a major cause of maternal mortality and morbidity worldwide . Uterine massage is thought to stimulate uterine contraction possibly through stimulation of local prostagl and in release and thus to reduce hemorrhage . The objective of the r and omized trial reported here was to determine the effectiveness of intermittent uterine massage after delivery of the placenta to reduce postpartum blood loss and the need for additional uterotonics .  The study was conducted in the labor ward of the Department of Obstetrics and Gynecology Assiut University Hospital during June and July 2005 . ( excerpt A r and omised , controlled trial of 1429 women was carried out to compare ' active ' management of the third stage of labour , using i.v . Ergometrine 0.5 mg , with a method of ' physiological ' management , in women at ' low risk ' to haemorrhage . In the " active " management group a higher incidence of the following complications was found:- manual removal of placenta ( p less than 0.0005 ) , problems such as nausea ( p less than 0.0005 ) , vomiting ( p less than 0.0005 ) , and severe after-birth pains ( p less than 0.02 ) , hypertension ( p less than 0.0001 ) and secondary postpartum haemorrhage ( p less than 0.02 ) . The incidence of postpartum haemorrhage ( blood loss greater than 500 ml ) and postnatal haemoglobins less than 10 gm/100 were higher in the ' physiological ' group ( p less than 0.0005 , p less than 0.002 ) . No difference was found in the need for blood transfusion in either group . The routine use of i.v . Ergometrine 0.5 mg during the third stage of labour in women at ' low risk ' to haemorrhage does not appear to be necessary and has many adverse effects . Further studies comparing different methods of ' physiological ' management are recommended in order to reduce to a minimum the incidence of postpartum haemorrhage and anaemia Objective To compare intravenous oxytocin administration ( Partocon ® 10 IU ) with saline solution in the management of postpartum haemorrhage in the third stage of labour BACKGROUND Misoprostol , an inexpensive , stable , orally active prostagl and in analogue , has been suggested for use in the prevention of postpartum haemorrhage . Potential side-effects , however , need to be quantified . OBJECTIVE To compare the rate of  postpartum shivering and pyrexia  following oral misoprostol 600 micrograms and placebo . DESIGN A double-blind placebo-controlled trial . Women in labour were r and omly allocated to receive either misoprostol 600 micrograms orally or placebo after delivery . Conventional oxytocics were given immediately if blood loss was thought to be more than usual . Side-effects were recorded . Postpartum blood loss in the first hour was measured by collection in a special flat plastic bedpan . SETTING The labour ward of an academic hospital in Johannesburg , with 7,000 deliveries per annum . MAIN OUTCOME MEASURES Shivering and pyrexia . RESULTS The groups were well matched . Misoprostol use was associated with more shivering ( 44 % versus 11 % , relative risk ( RR ) 4.03 , 95 % confidence interval ( CI ) 2.85 - 5.70 ) , pyrexia > or = 37.8 degrees C ( 38 % v. 6 % , RR 6.23 , CI 3.89 - 9.97 ) , 1-hour systolic blood pressure > or = 140 mmHg ( 33 % v. 25 % , RR 1.32 , CI 1.03 - 1.70 ) , and diastolic blood pressure > or = 90 mmHg ( 10.5 % v. 3.0 % , RR 3.44 , CI 1.67 - 7.11 ) . There were no other significant differences . The study was not design ed to be large enough to assess a difference in blood loss > or = 1,000 ml ( 9 % v. 9.7 % , RR 0.93 , CI 0.56 - 1.53 ) . Possible effects on blood loss may have been obscured by the lesser use of additional oxytocics in the misoprostol group ( 14 % v. 18 % , RR 0.78 , CI 0.54 - 1.13 ) . CONCLUSIONS This study has shown the association of postpartum oral misoprostol 600 micrograms with shivering , pyrexia and hypertension . The increased blood pressure , as for the trend towards increased abdominal pain , may be secondary to the uterotonic effect of misoprostol . Large r and omised trials are needed to assess the effectiveness of misoprostol in the prevention of postpartum haemorrhage , against which the disadvantages demonstrated here can be weighed OBJECTIVE --To compare the effects on fetal and maternal morbidity of routine active management of third stage of labour and expectant ( physiological ) management , in particular to determine whether active management reduced incidence of postpartum haemorrhage . DESIGN --R and omised trial of active versus physiological management . Women entered trial on admission to labour ward with allocation revealed just before vaginal delivery . Five months into trial high rate of postpartum haemorrhage in physiological group ( 16.5 % v 3.8 % ) prompted modification of protocol to exclude more women and allow those allocated to physiological group who needed some active management to be switched to fully active management . Sample size of 3900 was planned , but even after protocol modification a planned interim analysis after first 1500 deliveries showed continuing high postpartum haemorrhage rate in physiological group and study was stopped . SETTING --Maternity hospital . PARTICIPANTS --Of 4709 women delivered from 1 January 1986 to 31 January 1987 , 1695 were admitted to trial and allocated r and omly to physiological ( 849 ) or active ( 846 ) management . Reasons for exclusion were : refusal , antepartum haemorrhage , cardiac disease , breech presentation , multiple pregnancy , intrauterine death , and , after May 1986 , ritodrine given two hours before delivery , anticoagulant treatment , and any condition needing a particular management of third stage . INTERVENTIONS --All but six women allocated to active management actually received it , having prophylactic oxytocic , cord clamping before placental delivery , and cord traction ; whereas just under half those allocated to physiological management achieved it . A fifth of physiological group received prophylactic oxytocic , two fifths underwent cord traction and just over half clamping of the cord before placental delivery . ENDPOINT -- Reduction in incidence of postpartum haemorrhage from 7.5 % under physiological management to 5.0 % under active management . MEASUREMENTS AND MAIN RESULTS --Incidence of postpartum haemorrhage was 5.9 % in active management group and 17.9 % in physiological group ( odds ratio 3.13 ; 95 % confidence interval 2.3 to 4.2 ) , a contrast reflected in other indices of blood loss . In physiological group third stage was longer ( median 15 min v 5 min ) and more women needed therapeutic oxytocics ( 29.7 % v 6.4 % ) . Apgar scores at one and five minutes and incidence of neonatal respiratory problems were not significantly different between groups . Babies in physiological group weighed mean of 85 g more than those in active group . When women allocated to and receiving active management ( 840 ) were compared with those who actually received physiological management ( 403 ) active management still produced lower rate of postpartum haemorrhage ( odds ratio 2.4;95 % CI1.6 to 3.7 ) . CONCLUSIONS --Policy of active management practised in this trial reduces incidence of postpartum haemorrhage , shortens third stage , and results in reduced neonatal packed cell volume Objective To compare the effect of intramuscular Syntometrine and Syntocinon in the management of the third stage of labour BACKGROUND Maternal mortality rates in India are estimated at 560/100,000 live births and postpartum hemorrhage ( PPH ) accounts for 35 - 56 % of these deaths . Given that 50 % of births in rural India occur at home , oral Misoprostol administered by minimally trained midwives may be an effective uterotonic agent for preventing PPH when the use of other uterotonics is not feasible . While the import for testing the effectiveness of this intervention may be readily obvious , the elements essential for the conduct of a scientific study in rural areas served by indigenous health workers may not be as evident . METHODS We present the design as well as the preparation and development of an ongoing NICHD sponsored U.S.-Indian collaborative r and omized , placebo-controlled , clinical trial ( RCT ) conducted in four Primary Health Center areas of Belgaum District , Karnataka , India . The primary goal of the trial is to assess the effectiveness of Misoprostol 600 microg orally in reducing the incidence of acute PPH ( > or = 500 mL ) in women delivering at home or in neighboring sub-centers . 1600 pregnant women will be r and omized to receive Misoprostol or placebo immediately post-delivery of the infant . However , beyond testing the scientific merit of the RCT , this study also tests the feasibility of having indigenous midwives regularly using Misoprostol 
    Output:
    
Oxytocin is superior to misoprostol in hospitals .
Misoprostol substantially lowers PPH and severe PPH .