What is the WHO guideline for management of the third stage of labour to prevent postpartum hemorrhage?

WHO Guideline for Management of Third Stage of Labour

The WHO strongly recommends active management of the third stage of labour, which includes administration of a prophylactic uterotonic agent (preferably 10 IU oxytocin IV or IM) immediately after delivery of the baby, delayed cord clamping for approximately 60 seconds, and controlled cord traction to deliver the placenta. 1, 2

Core Components of Third Stage Management

Prophylactic Uterotonic Administration

Oxytocin 10 IU should be administered intravenously or intramuscularly immediately after delivery of the anterior shoulder or complete delivery of the baby, before placental delivery. 2, 3

• The IV route is more effective than IM for PPH prevention 1
• This single intervention is the most important and effective component of active management 4
• Oxytocin reduces PPH ≥ 500 mL compared with placebo (high-certainty evidence) 3

Alternative uterotonic regimens with superior efficacy include:

• Ergometrine plus oxytocin (reduces PPH ≥ 500 mL compared to oxytocin alone, RR 0.76; high-certainty evidence) 3
• Misoprostol 400 μg sublingual plus oxytocin 10 IU (probably reduces PPH ≥ 500 mL compared to oxytocin alone, RR 0.70; moderate-certainty evidence) 2, 3
• Carbetocin 100 μg IV or IM (similar effectiveness to oxytocin with fewer side effects) 2, 3

Cord Management

Delayed cord clamping for approximately 60 seconds is recommended to improve neonatal outcomes while not increasing maternal bleeding risk 2

Controlled cord traction should be applied during placental delivery when feasible 5, 2

• This involves applying gentle traction on the umbilical cord while providing counter-traction on the uterus 5
• Reduces time to placental delivery without increasing complications 5

Placental Delivery Timing

Spontaneous placental delivery should occur within 30 minutes of fetal expulsion. 6

• Retained placenta beyond 30 minutes increases PPH risk (RR 5.94) 6
• Manual removal of placenta should NOT be performed routinely except in cases of severe, uncontrollable PPH 6, 1

Tranexamic Acid for PPH Prevention

The WHO strongly recommends early administration of tranexamic acid 1 g IV over 10 minutes within 3 hours of birth for women with clinically diagnosed PPH, in addition to standard uterotonic therapy. 1, 7

Critical Timing Considerations

• TXA must be given within 3 hours of birth 1, 7, 8
• Effectiveness decreases by approximately 10% for every 15 minutes of delay 1, 7, 8
• TXA should NOT be given beyond 3 hours postpartum as it may be harmful 1, 7, 8
• A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 7

Indications for TXA

TXA should be administered in ALL cases of PPH regardless of etiology (uterine atony, genital tract trauma, retained tissue) 1, 7

• Reduces bleeding-related mortality when given within 3 hours (RR 0.81) 6
• Number needed to treat is 276 to prevent one bleeding-related death 6

Immediate Skin-to-Skin Contact

Early skin-to-skin contact between mother and newborn immediately after delivery is recommended 2

• Promotes bonding and breastfeeding initiation 2
• Does not interfere with third stage management 5

Common Pitfalls to Avoid

Do not delay oxytocin administration – it should be given immediately after delivery of the anterior shoulder or baby, not after placental delivery 2, 4

Do not routinely perform manual removal of placenta before 30 minutes have elapsed, as this increases infection and hemorrhage risk 6, 1

Do not use methylergonovine in hypertensive patients due to risk of severe vasoconstriction and hypertensive crisis 1, 7, 8

Do not administer TXA beyond 3 hours postpartum as evidence suggests potential harm rather than benefit 1, 7, 8

Avoid routine episiotomy as it increases blood loss and risk of severe perineal trauma without reducing PPH 4

Setting-Specific Considerations

Low-Resource Settings Without IV Access

If IV access is unavailable, use sublingual misoprostol 400 μg plus intramuscular oxytocin 10 IU 2

• Misoprostol alone (400-600 μg) is an acceptable alternative when oxytocin is unavailable 2, 3
• Rectal misoprostol 800-1000 μg can be used for treatment of active hemorrhage unresponsive to oxytocin 8

Hospital vs. Community Settings

The same active management principles apply in both hospital and community settings 3

• Oxytocin remains first-line regardless of setting 3, 4
• Ensure availability of uterotonic agents and trained personnel in all birth settings 1