In a woman in her 30s who had a prolonged (6–8 hour) vaginal delivery with a nuchal cord, which intervention is most appropriate to prevent postpartum hemorrhage: uterine massage immediately after birth, cord clamping, alternative cord clamping technique, or intramuscular oxytocin 10 mg?

Intramuscular Oxytocin is the Best Answer for Preventing Postpartum Hemorrhage

The correct answer is D) Oxytocin IM 10mg (though the standard dose is 10 IU, not 10mg—this is likely a transcription error in the question recall). Oxytocin administered intramuscularly immediately after delivery of the baby is the gold standard first-line intervention for preventing postpartum hemorrhage in all women, including those with prolonged labor and nuchal cord. 1, 2, 3

Why Oxytocin IM is the Correct Choice

Oxytocin is the uterotonic agent of choice for routine prophylaxis during active management of the third stage of labor. 1, 4, 3 The evidence strongly supports:

• Administration of 5-10 IU oxytocin via slow IV or intramuscular injection at the time of shoulder release or immediately postpartum reduces postpartum hemorrhage risk by approximately 60% 1, 3, 5

• Intramuscular dosing of 10 IU is equally effective as IV administration and is the preferred route when IV access is unavailable or for routine prophylaxis 1, 3

• Timing is critical: oxytocin must be given immediately after delivery of the anterior shoulder (or complete infant delivery) and before placental expulsion to maximize effectiveness 1, 5

Why the Other Options Are Incorrect

A) Uterine Massage Immediately After Birth

While uterine massage is part of postpartum hemorrhage treatment once bleeding occurs, the WHO does not recommend sustained uterine massage as a routine component of active management of the third stage of labor for prevention 1. Massage alone without uterotonic administration is insufficient prophylaxis 3, 5.

B & C) Cord Clamping Techniques

Delayed cord clamping (1-3 minutes) is recommended for neonatal benefits and should be combined with immediate oxytocin administration—but cord clamping itself does not prevent maternal postpartum hemorrhage 6, 1. The guideline explicitly states: "Delayed cord clamping should be combined with the administration of oxytocin immediately after delivery of the infant to reduce maternal blood loss" 6. Cord clamping is about optimizing neonatal outcomes, not preventing PPH.

Clinical Algorithm for This Scenario

For a woman in her 30s with prolonged labor and nuchal cord:

1. Immediately after delivery of the anterior shoulder (or complete infant): Administer oxytocin 10 IU intramuscularly 1, 2, 3

2. Delay cord clamping for 1-3 minutes to allow placental transfusion for neonatal benefit 6, 1

3. After cord clamping: Proceed with controlled cord traction to facilitate placental delivery 6

4. Monitor for bleeding: If postpartum hemorrhage develops despite prophylaxis, administer tranexamic acid 1g IV within 3 hours 1, 7

Common Pitfalls to Avoid

• Do not give oxytocin as a rapid IV bolus (faster than 1-2 minutes) because it can cause hypotension and tachycardia 1

• Do not delay oxytocin administration until after placental delivery—it must be given immediately after infant delivery for maximum effectiveness 1, 3

• Do not use ergometrine (methylergonovine) as first-line prophylaxis because although it may reduce blood loss, it carries higher risk of severe hypertension, increased need for manual placental removal, and bronchospasm 1, 7

• Do not rely on uterine massage alone without uterotonic administration for prevention 1, 3

Note on Dosing Terminology

The question states "10mg" but the correct dose is 10 IU (International Units), not milligrams. This is almost certainly a recall error, as oxytocin is always dosed in units, not weight 1, 2, 3. The FDA-approved indication specifies oxytocin for "control of postpartum bleeding or hemorrhage" with standard dosing of 10 IU IM 2.