From the Guidelines
The third stage of labor management algorithm should prioritize active management with oxytocin to minimize blood loss and reduce the risk of postpartum hemorrhage, as supported by the most recent and highest quality study 1. The management of the third stage of labor is crucial to prevent postpartum hemorrhage and ensure a safe delivery.
- Active management involves administering oxytocin 10 units intramuscularly or 20-40 units in 1000mL of IV fluid at 125-250 mL/hour after the baby is delivered.
- Waiting for signs of placental separation, such as cord lengthening, small gush of blood, and the uterus becoming globular and firmer, is essential before applying gentle controlled cord traction with counter-pressure on the uterus above the pubic symphysis.
- Never pulling on the cord without counter-pressure is critical to avoid uterine inversion.
- If the placenta does not deliver within 30 minutes despite active management, it constitutes retained placenta requiring manual removal under appropriate anesthesia, as suggested by the study 1.
- After placental delivery, examining it for completeness, massaging the uterus to ensure it remains contracted, and assessing for excessive bleeding are vital steps.
- Continuing oxytocin infusion for 2-4 hours after delivery is also recommended to minimize the risk of postpartum hemorrhage. This active management approach significantly reduces postpartum hemorrhage risk compared to expectant management by promoting uterine contraction, expediting placental separation, and ensuring complete placental removal, as supported by the study 1.
- Additionally, the use of tranexamic acid has been shown to be effective in reducing blood loss and bleeding-related mortality in patients with postpartum hemorrhage, as demonstrated in the study 1.
- However, the interpretation of this study is limited by the high mortality reported in the placebo group, which may not be representative of developed countries.
- In general, the management of the third stage of labor should be individualized and based on the patient's specific needs and risk factors, as emphasized in the study 1.
- A multidisciplinary approach and shared decision-making are essential in making decisions about delivery plans and anesthetic options for women receiving anticoagulants, as highlighted in the study 1.
- The study 1 also suggests that active management of the third stage of labor may be considered using oxytocin without ergotamine in women with lung disease.
From the FDA Drug Label
Postpartum Oxytocin Injection, USP (synthetic) is indicated to produce uterine contractions during the third stage of labor and to control postpartum bleeding or hemorrhage. The uterotonic effect of methylergonovine maleate is utilized after delivery to assist involution and decrease hemorrhage, shortening the third stage of labor.
The management algorithm for the third stage of labor involves the use of uterotonic agents such as oxytocin or methylergonovine to:
- Produce uterine contractions
- Control postpartum bleeding or hemorrhage
- Assist involution and decrease hemorrhage, shortening the third stage of labor 2 3
From the Research
Management Algorithm for the Third Stage of Labor
The third stage of labor is a critical period that requires effective management to prevent postpartum hemorrhage and promote maternal and neonatal health. The following steps outline the management algorithm for the third stage of labor:
- Administration of a uterotonic agent, such as oxytocin, ergometrine, carbetocin, or misoprostol, to prevent postpartum hemorrhage 4, 5, 6, 7
- Controlled cord traction, which should only be performed by skilled birth attendants, to facilitate placental separation and delivery 4, 5, 7
- Delayed cord clamping, which enables transfusion of blood to the neonate and is recommended rather than early clamping 4, 5, 7
- Early skin-to-skin contact, which promotes maternal and neonatal health 4, 5
- Repair of lacerations, which should be performed using a continuous synthetic suture technique 5
Uterotonic Agents
The choice of uterotonic agent depends on various factors, including patient comorbidities, costs, and availability of resources and staff. The following uterotonic agents are recommended:
- Oxytocin, which is the most commonly used uterotonic agent and can be administered intravenously or intramuscularly 4, 5, 6, 8, 7
- Carbetocin, which is a long-acting uterotonic agent that can be administered intravenously or intramuscularly 4, 5, 7
- Ergometrine, which can be administered intravenously or intramuscularly, but is less commonly used due to its side effects 4, 6, 7
- Misoprostol, which can be administered sublingually or intramuscularly, but is less commonly used due to its side effects 4, 5, 7
Dose and Route of Administration
The dose and route of administration of uterotonic agents vary depending on the agent and patient factors. The following doses and routes of administration are recommended: