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

Oxytocin 10 Units IM Within 5 Minutes of Baby Delivery

The most appropriate next step to prevent postpartum hemorrhage in this patient is oxytocin 10 units IM administered immediately after delivery of the baby (Option C). The presence of a nuchal cord does not alter the standard approach to PPH prevention 1.

Rationale for Oxytocin as First-Line Prevention

Oxytocin is the cornerstone intervention for PPH prevention and should be administered immediately after delivery of the anterior shoulder or immediately after birth of the baby, within 5 minutes of delivery 1, 2. This timing is critical because:

• Oxytocin prevents uterine atony before it develops, and delayed administration reduces effectiveness 1
• The intramuscular route (10 IU) is specifically recommended as the preferred medication and route for prevention of PPH in low-risk vaginal deliveries 2
• 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 Not the Other Options?

Uterine Massage (Option A)

• Uterine massage is part of active management but is secondary to oxytocin administration 3
• Massage is used as a treatment for established uterine atony, not as the primary prevention strategy 3
• The most common cause of PPH is uterine atony (>75% of cases), which is initially treated by uterine massage and uterotonic drugs such as oxytocin 3

Cord Clamping (Option B)

• While delayed cord clamping has benefits for the newborn, it is not a PPH prevention strategy 2
• Controlled cord traction is part of active management but occurs after oxytocin administration and after signs of placental separation 1
• The timing of cord clamping does not prevent maternal hemorrhage 2

Comprehensive Active Management Package

The complete active management of third stage of labor includes 1:

• Prophylactic oxytocin administration immediately after delivery (the cornerstone intervention)
• Controlled cord traction after signs of placental separation
• Uterine massage as needed

Dosing and Administration Details

For vaginal delivery, the recommended oxytocin regimen is 4, 2:

• 10 IU intramuscularly as the preferred route for low-risk vaginal deliveries 2
• Alternative: 5-10 IU IV bolus over 1-2 minutes 2
• Alternative: 20-40 IU in 1000 mL IV infusion at 150 mL/hour 2

Higher doses (up to 80 IU) are associated with 47% reduction in PPH compared to lower doses (10 IU), though the standard 10 IU IM remains the guideline-recommended dose for routine prevention 5, 6.

Special Consideration: Nuchal Cord

The presence of umbilical cord around the neck does not alter the standard approach to PPH prevention 1. Oxytocin administration should proceed immediately after the baby is delivered, regardless of nuchal cord presence.

Common Pitfalls to Avoid

• Do not delay oxytocin administration to perform cord clamping or wait for placental delivery—effectiveness decreases with delay 1
• Do not rely on uterine massage alone as primary prevention—it is adjunctive to pharmacologic prophylaxis 3
• Do not use methylergonovine as first-line if the patient has hypertension (contraindicated due to >10% risk of vasoconstriction and severe hypertension) 5, 7

If PPH Develops Despite Prevention

If bleeding occurs despite prophylactic oxytocin 5, 7:

• Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of birth (effectiveness decreases 10% for every 15-minute delay) 5, 7
• Initiate uterine massage and bimanual compression 7
• Consider second-line uterotonics (carboprost, methylergonovine if not hypertensive, or misoprostol) 8, 2
• Implement intrauterine balloon tamponade if medical management fails (90% success rate when properly placed) 5, 7