Prevention of Postpartum Hemorrhage
Administer oxytocin 5-10 IU intramuscularly or slow intravenous immediately after delivery of the baby (at shoulder release or within the first minute after birth) to prevent postpartum hemorrhage. 1, 2
Active Management of Third Stage of Labor
The most effective strategy for preventing postpartum hemorrhage is active management of the third stage of labor, with oxytocin administration being the single most critical component. 1, 3
Oxytocin Administration (Option B - Correct Answer)
- Oxytocin 5-10 IU should be given intramuscularly or by slow intravenous injection immediately after delivery of the baby (at shoulder release or within the first minute after birth). 1, 2, 4, 3
- The FDA label specifies that 10 units (1 mL) can be given intramuscularly after delivery of the placenta for control of postpartum bleeding. 4
- Oxytocin is the first-line prophylactic drug regardless of route of delivery, with Grade A evidence supporting its effectiveness in reducing PPH incidence. 3, 5
- Active management with oxytocin reduces the risk of postpartum hemorrhage by 62% (relative risk 0.38,95% CI 0.32-0.46) compared to expectant management. 1
Delayed Cord Clamping (Option C - Not for PPH Prevention)
- Cutting and clamping the cord within 1-3 minutes does NOT prevent postpartum hemorrhage in the mother. 1
- Two randomized controlled trials found no difference in postpartum hemorrhage risk (blood loss >500 mL) between delayed cord clamping and immediate clamping (relative risk 0.89,95% CI 0.58-1.36). 1
- The International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians have removed immediate cord clamping from their recommendations for active management. 1
- The optimal approach combines delayed cord clamping (approximately 3 minutes) WITH oxytocin administration to benefit both infant (increased red cell mass) and mother (reduced bleeding). 1
Uterine Massage (Option A - Not Routinely Recommended for Prevention)
- Routine uterine massage is NOT systematically recommended for PPH prevention after vaginal delivery (Grade A evidence). 3
- Uterine massage should be performed as part of initial treatment once PPH is diagnosed, not as routine prevention. 2, 6, 3
- However, immediate uterine massage and bimanual compression are recommended alongside oxytocin when PPH occurs. 2, 6
Clinical Context: Nuchal Cord
The presence of umbilical cord around the neck does not change the standard approach to PPH prevention. 1
- This finding occurs in approximately 20-30% of deliveries and is not an independent risk factor for postpartum hemorrhage requiring modified management. [General Medicine Knowledge]
- Standard active management with oxytocin remains the appropriate preventive strategy. 1, 3
Complete Active Management Protocol
Beyond oxytocin administration, active management includes:
- Controlled cord traction after placental separation signs appear (recommended after cesarean delivery, Grade B; not systematically recommended after vaginal delivery, Grade A). 3
- Placental delivery should occur naturally with controlled cord traction, not through aggressive manual removal unless severe hemorrhage occurs. 1, 2
- Routine cord drainage and bladder voiding are not systematically recommended for PPH prevention. 3
Common Pitfalls to Avoid
- Do not delay oxytocin administration waiting for placental delivery—give it immediately after delivery of the baby. 1, 2
- Do not rely on immediate cord clamping as a PPH prevention strategy; this outdated practice has been removed from international guidelines. 1
- Do not perform routine manual removal of placenta except in cases of severe uncontrollable hemorrhage, as this increases infection risk without preventing PPH. 1, 2
- Do not use methylergonovine as first-line prevention if the patient has any hypertensive history, as it carries >10% risk of severe vasoconstriction. 2, 6