What is the recommended active management of the third stage of labor to prevent postpartum hemorrhage in a woman who has delivered six macrosomic infants?

Active Management of Third Stage of Labor to Prevent PPH in Women with History of Macrosomic Deliveries

Administer 5-10 IU of oxytocin via slow intravenous infusion or 10 IU intramuscularly immediately after delivery of the anterior shoulder or the entire baby, before placental delivery, to reduce postpartum hemorrhage risk in this high-risk patient. 1, 2, 3

Rationale for Oxytocin as First-Line Prevention

Women with a history of delivering six macrosomic infants face substantially elevated PPH risk due to uterine overdistension from repeated large babies, which impairs myometrial contractility. 2 The primary mechanism preventing hemorrhage after placental separation is sustained myometrial contraction that mechanically compresses and occludes uterine blood vessels at the placental implantation site—not the hemostatic system itself. 4 Oxytocin enhances this critical uterine contractility and promotes placental separation. 4

Optimal Oxytocin Administration Protocol

Timing and Dosing

• Administer oxytocin at the moment of anterior shoulder delivery or immediately after complete delivery of the infant, before the placenta delivers. 1, 2, 5
• Intravenous route: 5-10 IU given as slow IV infusion over 1-2 minutes to avoid hypotension and tachycardia. 1, 3
• Intramuscular route: 10 IU IM is equally effective and preferred when IV access is not established. 1, 6
• Continuous IV infusion alternative: 20-40 IU oxytocin in 1000 mL normal saline at 150 mL/hour is acceptable but not superior to bolus dosing for PPH prevention. 6

Route Selection Considerations

When oxytocin is the sole intervention, intravenous administration reduces hemorrhage risk by 76% compared to intramuscular administration. 7 However, when combined with controlled cord traction (discussed below), route of administration makes no difference in outcomes. 7

Complete Active Management Bundle

Controlled Cord Traction

Apply gentle controlled cord traction after signs of placental separation appear (uterine fundus rises, cord lengthens, gush of blood). 2, 5 This intervention is critical in this high-risk patient:

• When oxytocin prophylaxis is given intramuscularly, controlled cord traction reduces hemorrhage risk by an additional 66%. 7
• When oxytocin is given intravenously, controlled cord traction provides no additional benefit beyond the IV oxytocin alone. 7
• Among women receiving no oxytocin prophylaxis, controlled cord traction alone reduces hemorrhage risk by nearly 50%. 7

Delayed Cord Clamping

Delay cord clamping for approximately 60 seconds after delivery before cutting the cord. 2, 5 This practice benefits neonatal hematological outcomes without increasing maternal blood loss when combined with immediate oxytocin administration. 2, 5

Uterine Massage Controversy

Do not perform routine sustained uterine massage as part of standard third-stage management. 2 Current evidence shows uterine massage is associated with increased hemorrhage risk in both women receiving and not receiving oxytocin prophylaxis. 7 The World Health Organization does not recommend sustained uterine massage as a routine AMTSL component. 2

Medications to Avoid in This Patient

Ergot Alkaloids (Ergometrine/Methylergometrine)

Avoid ergometrine as first-line prophylaxis. 1, 6 While ergot alkaloids may reduce blood loss, they carry greater risk of:

• Maternal adverse effects including severe hypertension 6
• Increased need for manual placental removal 6
• Bronchospasm, particularly problematic if this patient has any respiratory comorbidities 1, 2

Ergometrine is contraindicated in patients with hypertension. 6

Prostaglandin F2α

Do not use prostaglandin F2α if this patient has any history of asthma or reactive airway disease, as it causes bronchoconstriction. 1, 2

Enhanced Prophylaxis Options for This High-Risk Patient

Tranexamic Acid Addition

Consider adding tranexamic acid 1 g IV immediately after delivery of the neonate in addition to oxytocin 10 IU IV. 5 This combination is recommended for PPH prevention in high-risk patients. 5 The WOMAN trial demonstrated that early tranexamic acid use (within 3 hours of bleeding onset) reduces maternal death due to bleeding. 2

Alternative Combination Regimens

If standard oxytocin alone seems insufficient given her extreme risk profile:

• Oxytocin 10 IU IV plus sublingual misoprostol 400 µg immediately after delivery provides enhanced prophylaxis. 5
• Carbetocin 100 µg IV bolus over 1 minute is an alternative single-dose uterotonic that may reduce need for additional uterotonics, though evidence is strongest for cesarean delivery. 6

Monitoring and Rescue Interventions

Blood Loss Assessment

Use clinical markers (maternal vital signs, symptoms, visual inspection of bleeding) rather than visual estimation alone to assess blood loss, as visual estimation is notoriously inaccurate. 6

If PPH Develops Despite Prophylaxis

• Administer tranexamic acid 1 g IV within 1-3 hours of bleeding onset if not already given prophylactically. 1, 2
• Give additional oxytocin as continuous IV infusion (20-40 IU in 1000 mL at 150 mL/hour). 6
• Consider second-line uterotonics: misoprostol 600-800 µg sublingual/rectal, or methylergometrine 0.2 mg IM (if no hypertension). 5, 6
• Uterine tamponade with balloon catheter can temporarily control active PPH unresponsive to medical therapy while preparing for definitive intervention. 6

Manual Placental Removal Caution

Do not perform manual removal of the placenta routinely to reduce PPH risk outside of severe, uncontrollable hemorrhage. 1, 2 If the placenta is retained beyond 30 minutes with active bleeding, consider intraumbilical injection of oxytocin 10-30 IU or misoprostol 800 µg as an alternative before proceeding to manual removal. 6

Critical Pitfalls to Avoid

• Do not give oxytocin as rapid IV bolus (faster than 1-2 minutes), as this causes hypotension and tachycardia. 1
• Do not delay oxytocin administration until after placental delivery; it must be given immediately after infant delivery. 1, 2, 5
• Do not rely on expectant management in this extremely high-risk patient with six prior macrosomic deliveries—active management is mandatory. 6, 8
• Do not use ergometrine if the patient has any hypertension or respiratory disease. 1, 6