Most Appropriate Next Step to Prevent PPH
Oxytocin 10 units IM within 5 minutes of baby delivery (Option C) is the most appropriate next step to prevent postpartum hemorrhage, regardless of the presence of a nuchal cord. 1, 2
Rationale for Oxytocin Administration
Oxytocin is the first-line prophylactic agent recommended by the American College of Obstetricians and Gynecologists for preventing postpartum hemorrhage and should be administered immediately after delivery of the anterior shoulder or immediately after birth of the baby. 2, 3
The recommended dose is 5-10 IU, given either intramuscularly or intravenously, with the intramuscular route (10 IU) specifically preferred for low-risk vaginal deliveries. 1, 2, 4
Timing is critical: Oxytocin must be administered within 5 minutes of delivery, ideally immediately after delivery of the anterior shoulder or the baby, because delayed administration reduces effectiveness and allows uterine atony to develop. 2
Why Not the Other Options?
Uterine Massage (Option A)
- Uterine massage is not recommended as a routine preventive measure after vaginal delivery for PPH prevention. 1
- Massage is reserved for treatment of PPH once it has occurred, not for primary prevention. 5
Cord Clamping (Option B)
- Cord clamping timing does not prevent maternal PPH. 1
- While delayed cord clamping (after 60 seconds) benefits the newborn by reducing intraventricular hemorrhage in premature infants and increasing hemoglobin levels in term infants, it has no impact on maternal hemorrhage prevention. 4
- The International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians have removed immediate cord clamping from their recommendations for active management of third stage. 1
Special Consideration: Nuchal Cord
- The presence of umbilical cord around the neck does not alter the standard approach to postpartum hemorrhage prevention. 2
- Oxytocin administration should proceed immediately after the baby is delivered, following the same protocol as any delivery. 2
Active Management Framework
Active management of the third stage of labor (which includes prophylactic oxytocin administration immediately after delivery) reduces the risk of PPH with a relative risk of 0.38 compared to expectant management. 1, 2
The complete active management package includes: prophylactic uterotonic administration (oxytocin) as the cornerstone intervention, followed by controlled cord traction after signs of placental separation. 2
This approach provides the greatest reduction in postpartum hemorrhage risk and is superior to expectant management in terms of maternal complications. 1
Common Pitfalls to Avoid
Do not delay oxytocin administration waiting to clamp the cord or massage the uterus—effectiveness decreases with every minute of delay. 2
Do not rely on uterine massage alone for prevention—it is not evidence-based as a preventive measure and should only be used therapeutically if bleeding occurs. 1, 5
Do not confuse neonatal benefits of delayed cord clamping with maternal PPH prevention—these are separate considerations with different evidence bases. 4