Oxytocin 10 Units IM Within 5 Minutes of Baby Delivery
The most appropriate next step to prevent postpartum hemorrhage after delivering a baby with a nuchal cord is immediate administration of oxytocin 5-10 IU intramuscularly or intravenously within 5 minutes of delivery. 1, 2
Rationale for Oxytocin as First-Line Prevention
Oxytocin is the first-line prophylactic agent for preventing PPH regardless of delivery route or presence of nuchal cord, and should be administered immediately after delivery of the anterior shoulder or immediately after birth of the baby. 1, 3
The intramuscular route with 10 IU is specifically recommended as the preferred medication and route for prevention of PPH in low-risk vaginal deliveries. 3
Active management of the third stage of labor with prophylactic oxytocin provides the greatest reduction in PPH risk (relative risk 0.38 compared to expectant management). 1
Why the Other Options Are Insufficient Alone
Uterine Massage (Option A)
- Uterine massage alone is NOT systematically recommended for routine PPH prevention after vaginal delivery. 4
- Massage is a component of treatment AFTER PPH has occurred, not primary prevention. 4
- The evidence shows massage should be combined with oxytocin administration, not used as a standalone preventive measure. 5
Cord Clamping (Option B)
- Cord clamping timing does not prevent maternal PPH—it affects neonatal outcomes (reduced intraventricular hemorrhage in preterm infants, increased jaundice risk in term infants). 3
- Delayed cord clamping by 60 seconds benefits the newborn but has no established role in preventing maternal hemorrhage. 3
Critical Timing Considerations
Oxytocin must be administered within 5 minutes of delivery, ideally immediately after delivery of the anterior shoulder or the baby, to prevent uterine atony before it develops. 1
Delayed administration reduces effectiveness—this is why immediate prophylactic administration is superior to waiting to treat established bleeding. 1
Nuchal Cord Does Not Change Standard Management
The presence of umbilical cord around the neck does not alter the standard approach to PPH prevention, and oxytocin administration should proceed immediately after the baby is delivered. 1
The nuchal cord is a red herring in this question—it does not contraindicate or modify the standard active management protocol. 1
Dosing and Administration Details
The recommended dose is 5-10 IU, given either intramuscularly or intravenously (slowly over 1-2 minutes if IV). 2, 3
For vaginal delivery, 10 IU IM is the preferred route and dose. 3
An acceptable alternative is IV infusion of 20-40 IU in 1000 mL at 150 mL/hour, but this is less practical for immediate prophylaxis. 3
Common Pitfall to Avoid
Do not wait to see if bleeding occurs before administering oxytocin—prophylactic administration is far more effective than treatment of established PPH. 1, 6
The most common cause of early PPH is uterine atony (>75% of cases), which is prevented by immediate oxytocin administration causing sustained uterine contraction. 7