What is the most appropriate next step to prevent postpartum hemorrhage (PPH) in a patient with a baby delivered with the umbilical cord (UC) around the neck?

Immediate Administration of Oxytocin 10 Units IM Within 5 Minutes of Baby Delivery

The most appropriate next step to prevent postpartum hemorrhage in this case is oxytocin 10 units IM administered immediately after delivery of the baby (Option C), regardless of the umbilical cord being around the neck. The presence of a nuchal cord does not alter standard PPH prevention protocols.

Evidence-Based Rationale

Primary Prevention Strategy

Oxytocin is the first-line prophylactic agent for preventing PPH and should be administered immediately after delivery of the anterior shoulder or immediately after birth of the baby 1, 2, 3, 4. The recommended dose is 5-10 IU, which can be given either intramuscularly or intravenously 1, 2, 5, 3.

• The intramuscular route (10 IU) is specifically recommended as the preferred medication and route for prevention of PPH in low-risk vaginal deliveries 3
• IV oxytocin is also acceptable but requires slower administration (over 1-2 minutes for bolus dosing) to avoid hemodynamic instability 5, 3
• IV administration may be more effective than IM for PPH prevention, though both routes are acceptable 6

Why Not the Other Options?

Uterine massage (Option A) is part of active management of the third stage but is not routinely recommended for PPH prevention after vaginal delivery 3, 7. Routine uterine massage does not reduce PPH incidence and should be reserved for treatment once bleeding occurs 7.

Cord clamping timing (Option B) does not prevent maternal PPH. While delayed cord clamping (≥60 seconds) benefits the neonate by reducing intraventricular hemorrhage in preterm infants and improving iron stores in term infants, it has no effect on maternal blood loss or PPH rates 8, 3. The timing of cord clamping is independent of PPH prevention strategies.

Active Management of Third Stage of Labor

The complete active management package includes 8, 3:

• Prophylactic uterotonic administration (oxytocin) immediately after delivery - this is the cornerstone intervention
• Controlled cord traction (after signs of placental separation)
• Early cord clamping (though this component has been removed from international recommendations as it provides no maternal benefit) 8

The administration of uterotonic drugs immediately after delivery is the mainstay of active management and provides the greatest reduction in PPH risk (relative risk 0.38 for PPH with active management versus expectant management) 8.

Timing Considerations

Oxytocin should be administered within 5 minutes of delivery, ideally immediately after delivery of the anterior shoulder or the baby 1, 2, 3. This timing is critical because:

• Early administration prevents uterine atony before it develops
• Delayed administration reduces effectiveness
• The drug takes effect within minutes to promote uterine contraction

Special Consideration for Nuchal Cord

The presence of umbilical cord around the neck is a common finding (occurring in approximately 20-30% of deliveries) and does not alter the standard approach to PPH prevention. Once the baby is delivered:

1. The nuchal cord is managed (either reduced or clamped and cut)
2. Standard PPH prophylaxis with oxytocin proceeds immediately
3. The cord status does not contraindicate or delay oxytocin administration

Clinical Pitfalls to Avoid

• Do not delay oxytocin administration to perform uterine massage first - the uterotonic is the priority 3, 7
• Do not wait for placental delivery before giving oxytocin - it should be given immediately after the baby is born 5, 3
• Do not give IV oxytocin as a rapid bolus without proper dilution and timing (should be over 1-2 minutes if given IV) to avoid hypotension 5, 3
• Do not confuse neonatal benefits of delayed cord clamping with maternal PPH prevention - these are separate considerations 8, 3