Oxytocin Administration is the Most Appropriate Next Step
The most appropriate next step to prevent postpartum hemorrhage after delivery of a baby with a nuchal cord is administration of oxytocin 10 IU intramuscularly within 5 minutes of delivery, ideally immediately after birth of the baby. 1, 2
Why Oxytocin is the Correct Answer
The presence of an umbilical cord around the neck does not alter the standard approach to PPH prevention—oxytocin administration should proceed immediately after the baby is delivered. 1, 3
Evidence-Based Rationale
Oxytocin is the first-line prophylactic agent recommended by the American College of Obstetricians and Gynecologists for preventing postpartum hemorrhage, with a recommended dose of 5-10 IU given either intramuscularly or intravenously immediately after delivery. 1
The intramuscular route (10 IU) is specifically recommended as the preferred medication and route for prevention of PPH in low-risk vaginal deliveries. 1, 4
Timing is critical: Oxytocin should 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—delayed administration reduces effectiveness. 1, 4
The 2014 CNGOF/SFAR guidelines stipulate that "it is recommended to administer 5 to 10 IU of oxytocin, slow IV or intramuscular infusion, at the time of shoulder release or immediate postpartum so as to reduce incidence of postpartum haemorrhage." 2
Why the Other Options Are Incorrect
Uterine Massage (Option A)
- Routine uterine massage after delivery is not systematically recommended for PPH prevention and is not evidence-based as part of active management. 5, 6
- While uterine massage is part of PPH treatment once bleeding occurs, it is not the primary preventive intervention. 5
Cord Clamping (Option B)
- The timing of cord clamping has no significant effect on reducing PPH or severe PPH. 6
- A 2012 WHO trial and the 2013 TRACOR trial demonstrated that controlled cord traction is not associated with a significant reduction in postpartum blood loss or risk of severe PPH. 6
- Delayed cord clamping (60 seconds to 3 minutes) is actually recommended for neonatal benefits, not maternal PPH prevention. 3, 4
Active Management of Third Stage
Prophylactic oxytocin administration is the cornerstone intervention and provides the greatest reduction in PPH risk (relative risk 0.38 for PPH with active management versus expectant management). 1
After 50 years of research, it has become clear that prophylactic oxytocin is the most important and the only evidence-based component of active management of the third stage of labor. 6
Oxytocin reduces PPH-1 rates (blood loss ≥500 mL) from 5.5% to 2.6% (RR: 0.49; 95% CI: 0.27-0.88) and reduces blood loss by approximately 45 mL compared to no prophylaxis. 7
Clinical Implementation
Administer oxytocin 10 IU intramuscularly immediately after delivery of the baby—this can be given after delivery of the anterior shoulder or immediately postpartum. 1, 4
Alternative route: Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL at 150 mL per hour) is an acceptable alternative, or an IV bolus of 5-10 IU given over 1-2 minutes. 4, 8
The nuchal cord should be managed by slipping it over the baby's head if loose, or clamping and cutting if tight, but this does not delay oxytocin administration for PPH prevention. 3