What is the recommended management of the 3rd stage of labor?

Management of the Third Stage of Labor

Active management of the third stage of labor is recommended to reduce the risk of postpartum hemorrhage, with oxytocin as the uterotonic of choice.

Definition and Importance

• The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta 1
• Active management of the third stage significantly reduces the risk of postpartum hemorrhage, which is a common complication during this period 1

Recommended Components of Third Stage Management

Uterotonic Administration

• Administer 5-10 IU of oxytocin via slow IV or intramuscular injection at the time of shoulder release or immediately postpartum 2
• Oxytocin is indicated specifically to produce uterine contractions during the third stage of labor and to control postpartum bleeding or hemorrhage 3
• Intravenous administration of oxytocin provides immediate onset of action, while intramuscular administration takes effect within 2-5 minutes 4
• When oxytocin is the only intervention provided, intravenous administration reduces hemorrhage risk by 76% compared to intramuscular administration 4

Controlled Cord Traction

• Controlled cord traction (CCT) is an effective component of third stage management when performed by skilled birth attendants 5
• CCT reduces the risk of manual removal of the placenta, especially when ergometrine is used routinely in the third stage 5
• When combined with oxytocin prophylaxis, CCT reduces hemorrhage risk by 66% when oxytocin is administered intramuscularly 4
• CCT may reduce mean blood loss and shorten the duration of the third stage of labor 5

Additional Interventions

• Careful attention should be paid to minimizing trauma and actively managing the third stage of labor with uterotonics to enhance uterine contraction and promote placental separation 2
• Delayed cord clamping, early skin-to-skin contact, and controlled cord traction are supported by current evidence 1
• Avoid ergometrine in women with respiratory disease as it may cause bronchospasm, particularly in association with general anesthesia 2

Special Considerations

Women with Respiratory Disease

• For women with respiratory diseases, oxytocin is the uterotonic of choice for the active third stage of labor 2
• Ergometrine should be avoided in women with respiratory conditions as it may cause bronchospasm 2
• Prostaglandin F2α used to treat postpartum hemorrhage may cause bronchoconstriction and is not recommended in women with asthma 2

Women on Anticoagulation

• For women receiving anticoagulants at the time of delivery, careful attention should be paid to minimizing trauma and active management of the third stage of labor 2
• Active management with uterotonics enhances uterine contraction and promotes placental separation, reducing bleeding risk 2
• The primary physiologic mechanism to stem bleeding from the placental bed is sustained myometrial contraction leading to occlusion of uterine blood vessels, not the hemostatic system 2

Evolving Approach to Third Stage Management

• Recent evidence suggests moving away from the term "active management of the third stage of labor" as a combined intervention bundle 1
• Instead, "third stage care" is recommended, which promotes the implementation of evidence-based interventions that are safe and beneficial for both the woman and neonate 1
• The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine, oxytocin plus misoprostol, or carbetocin 1

Common Pitfalls and Caveats

• Uterine massage was associated with increased hemorrhage risk in some studies and should not be routinely performed 4
• Manual removal of the placenta should not be carried out to reduce the risk of postpartum hemorrhage outside specialized structures, except in the event of severe and uncontrollable postpartum hemorrhage 2
• In case of postpartum hemorrhage outside specialized structures, intravenous administration of 1g of tranexamic acid at most 1-3 hours after bleeding onset is recommended 2
• Significant practice differences exist between physicians and midwives in the management of the third stage, with physicians more likely to implement active management while midwives often prefer expectant approaches 6