What is the management for a patient with a prolonged 3rd stage of labor?

Management of Prolonged Third Stage of Labor

Active management of the third stage should be implemented immediately, with oxytocin 10 IU intramuscularly or intravenously as the first-line uterotonic, combined with controlled cord traction once signs of placental separation appear; if the placenta is not delivered within 30 minutes despite these measures, manual removal should be performed. 1, 2, 3

Immediate Active Management Protocol

All women should receive active management of the third stage of labor to prevent postpartum hemorrhage, regardless of risk factors. 1, 2, 3

Uterotonic Administration

• Administer oxytocin 10 IU intramuscularly immediately after delivery of the anterior shoulder or within 1 minute of delivery of the infant. 1, 2, 3
• Alternatively, oxytocin can be given as 10 IU slow IV bolus over 1-2 minutes, or as 20 IU diluted in 500-1000 mL normal saline infused at 150 mL/hour. 2, 3
• Oxytocin works by enhancing sustained myometrial contractions that mechanically compress and occlude uterine blood vessels at the placental implantation site, which is the primary mechanism to control bleeding—not the hemostatic system. 4

Controlled Cord Traction

• Perform controlled cord traction once signs of placental separation are evident (uterine fundus rises, cord lengthens, gush of blood). 1, 5, 6
• Controlled cord traction reduces hemorrhage risk by 50-66% when combined with oxytocin prophylaxis. 7
• Apply steady, gentle traction on the umbilical cord while providing counter-traction on the uterus above the symphysis pubis (Brandt-Andrews maneuver). 5

Delayed Cord Clamping

• Delay cord clamping for approximately 60 seconds after delivery before cutting the cord. 8, 1, 6
• This practice benefits neonatal outcomes without increasing maternal blood loss when combined with immediate oxytocin administration. 8, 1

Defining Prolonged Third Stage

• The third stage is considered prolonged if the placenta has not delivered within 30 minutes of infant delivery despite active management. 3
• Traditional teaching allowed 30-45 minutes before intervention, but there is no evidence that waiting beyond 30 minutes in the presence of bleeding reduces PPH risk. 3

Management of Prolonged Third Stage

Before Manual Removal (If No Active Bleeding)

• Ensure adequate uterotonic coverage is maintained with ongoing oxytocin infusion (20-40 IU in 1000 mL at 150 mL/hour). 3
• Verify bladder is empty, as a full bladder can impede placental separation. 5
• Consider intraumbilical injection of oxytocin (10-30 IU) or misoprostol (800 mcg) as an alternative intervention before proceeding to manual removal. 3

Manual Removal Indications

• Proceed to manual removal if the placenta is retained beyond 30 minutes with active bleeding or signs of hemodynamic instability. 1, 3
• Manual removal should not be performed routinely outside specialized structures except in cases of severe, uncontrollable postpartum hemorrhage. 1
• Ensure adequate analgesia/anesthesia (epidural extension or IV sedation) before attempting manual removal. 8

Manual Removal Technique

• Maintain strict aseptic technique with sterile gloves and preparation. 5
• Follow the umbilical cord to the placental edge with one hand inserted into the uterine cavity. 5
• Use the ulnar border of the hand to create a plane of cleavage between the placenta and uterine wall. 5
• Remove the placenta in its entirety and inspect for completeness. 5
• Perform uterine exploration to ensure no retained fragments remain. 5

Special Populations Requiring Modified Approach

Women with Respiratory Disease (Asthma, COPD, Cystic Fibrosis)

• Oxytocin is the uterotonic of choice; ergometrine is absolutely contraindicated due to risk of bronchospasm, particularly with general anesthesia. 8, 1
• Prostaglandin F2α should also be avoided as it may cause bronchoconstriction. 8, 1

Women with Cardiovascular Disease (Peripartum Cardiomyopathy, Heart Failure)

• Use a single intramuscular dose of oxytocin for active management; ergometrine is contraindicated. 8
• Avoid fluid overload during third stage management with continuous monitoring and urinary catheter drainage. 8
• Consider a single IV dose of furosemide after delivery to counteract auto-transfusion from the contracted uterus and lower extremities. 8
• Shorten the second stage with assisted delivery (forceps/vacuum) to reduce maternal exertion before the third stage. 8

Women on Anticoagulation

• Pay careful attention to minimizing trauma during placental delivery and use active management with uterotonics to enhance uterine contraction. 1
• Restart anticoagulation only after postpartum bleeding has stopped and epidural catheter has been removed. 8

Management of Postpartum Hemorrhage During Third Stage

If Hemorrhage Develops

• Administer tranexamic acid 1 g IV within 1-3 hours of bleeding onset in addition to ongoing uterotonic therapy. 1, 6
• Early tranexamic acid use (within 3 hours) reduces maternal death due to bleeding. 1

Second-Line Uterotonics

• If oxytocin alone is insufficient, add methylergometrine 0.2 mg IM (unless contraindicated by hypertension or respiratory disease). 1, 6, 3
• Alternatively, add misoprostol 400-800 mcg sublingually, orally, or rectally. 6, 3
• Carbetocin 100 mcg IV bolus is an alternative single-dose option. 6, 3

Escalation to Surgical Intervention

• If medical management fails, proceed to uterine tamponade (balloon catheter), compression sutures (B-Lynch), uterine artery ligation, internal iliac artery ligation, or hysterectomy as indicated. 3

Common Pitfalls and Caveats

• Do not perform routine uterine massage after placental delivery, as evidence shows it is associated with increased hemorrhage risk rather than benefit. 1, 7
• Avoid injudicious use of oxytocin to augment weak contractions during labor, as this is a risk factor for uterine rupture. 1, 4
• Do not use IV oxytocin as a rapid bolus during cesarean section, as this increases risk of hypotension; slow administration over 1-2 minutes is safer. 3
• Ergometrine causes more adverse maternal effects and increases the need for manual placental removal compared to oxytocin, making it second-line. 3
• Ensure IV access is secured before delivery, as intravenous oxytocin is more effective than intramuscular when it is the only intervention provided (76% risk reduction). 7
• When oxytocin is given intravenously, controlled cord traction confers no additional benefit; however, when oxytocin is given intramuscularly, controlled cord traction reduces hemorrhage risk by 66%. 7