What is the optimal management for a term, non‑compromised infant and mother immediately after delivery, including delayed cord clamping for 30–60 seconds, oxytocin (10 IU in 1 L normal saline) infusion at 10–20 mU per minute, allowing additional cord drainage for 30–60 seconds before controlled placental traction, newborn skin‑to‑skin contact with standard assessments, and strategies to prevent postpartum hemorrhage?

Optimal Third-Stage Management After Delivery

Delay cord clamping for 30–60 seconds, administer 5–10 IU oxytocin by slow IV infusion (over 1–2 minutes) or 10 IU IM immediately after delivery of the anterior shoulder or infant, then perform controlled cord traction after signs of placental separation—this protocol maximizes neonatal iron stores and hemoglobin while reducing postpartum hemorrhage risk without increasing maternal bleeding. 1, 2, 3

Step 1: Delayed Cord Clamping (30–60 seconds)

• Clamp the cord at 30–60 seconds after delivery for vigorous term and late-preterm infants (≥34 weeks) who do not require resuscitation. 1, 3
• Position the infant on the mother's abdomen or at/below the level of the placenta (0–10 cm lower) during this interval to optimize placental transfusion. 1
• This timing increases hemoglobin by approximately 1.2 g/dL, hematocrit by 3.4%, and improves iron stores for up to 6 months without significantly increasing polycythemia or phototherapy needs. 1, 3
• Do NOT extend clamping beyond 60 seconds routinely—delays to 120 seconds nearly double the risk of hyperbilirubinemia requiring phototherapy (RR 1.93) and increase polycythemia without additional iron benefit. 1

Critical Exception:

• If the infant requires immediate resuscitation (apnea, gasping, poor tone), clamp the cord immediately (<30 seconds) and begin positive-pressure ventilation without delay—resuscitation always takes priority over delayed clamping. 1

Step 2: Oxytocin Administration (Immediate, During Delayed Clamping Window)

• Administer oxytocin immediately after delivery of the anterior shoulder or the whole infant, during the 30–60 second delayed clamping window, and before placental delivery. 2
• Dosing options:
  • IV route (preferred if access available): 5–10 IU oxytocin as a slow IV infusion over 1–2 minutes—never as a rapid bolus, which causes hypotension and tachycardia. 2
  • IM route: 10 IU oxytocin IM if IV access is unavailable or impractical. 2
• Oxytocin is the only evidence-based component of active third-stage management that significantly reduces postpartum hemorrhage (PPH). 4
• Combining delayed cord clamping with immediate oxytocin administration reduces maternal blood loss without increasing PPH risk. 5, 1

Medications to Avoid:

• Do NOT use ergometrine as first-line prophylaxis—it increases the risk of severe hypertension, manual placental removal, and bronchospasm (absolutely contraindicated in patients with hypertension or respiratory disease). 2
• Avoid prostaglandin F₂α in patients with asthma or reactive airway disease—it can provoke bronchoconstriction. 2

Step 3: Cord Drainage (Optional, Low-Priority)

• Cord drainage (allowing blood to drain from the cut cord into the infant after clamping) is NOT evidence-based and does not reduce PPH or improve neonatal outcomes. 4
• If you choose to allow cord drainage, limit it to 30–60 seconds maximum after the initial 30–60 second delayed clamping period, but recognize this adds no proven benefit. 5

Step 4: Controlled Cord Traction (After Placental Separation)

• Perform controlled cord traction only after signs of placental separation appear (uterine fundus rises, cord lengthens, gush of blood). 6
• Controlled cord traction does NOT reduce PPH or blood loss compared with expectant management when oxytocin is given, but it may shorten the third stage slightly. 4
• Do NOT perform manual placental removal routinely—reserve this for severe, uncontrollable PPH only. 2

Step 5: Neonatal Care During Delayed Clamping

• Place the infant skin-to-skin on the mother's chest or abdomen during the 30–60 second delay. 1, 6
• Perform standard Apgar scoring at 1 and 5 minutes and initiate routine newborn assessments after cord clamping. 7
• Monitor all infants for jaundice in the first 24–48 hours, as delayed clamping increases the risk of hyperbilirubinemia requiring phototherapy by approximately 70 additional cases per 1,000 infants. 1

Step 6: Postpartum Hemorrhage Prevention & Rescue

• If PPH occurs despite prophylactic oxytocin, administer tranexamic acid 1 g IV within 1–3 hours of bleeding onset. 2, 6
• Do NOT perform sustained uterine massage routinely—it is not evidence-based for PPH prevention. 2
• Ensure mechanisms are in place to monitor and treat neonatal jaundice before adopting delayed cord clamping protocols. 3

Common Pitfalls to Avoid

• Never give oxytocin as a rapid IV bolus—always infuse over 1–2 minutes to prevent hypotension. 2
• Never delay oxytocin until after placental delivery—it must be given immediately after infant delivery. 2
• Never extend cord clamping beyond 60 seconds in routine practice—this increases jaundice and polycythemia without benefit. 1
• Never use ergometrine in patients with hypertension or respiratory disease. 2
• Never prioritize delayed clamping over immediate resuscitation—if the infant is non-vigorous, clamp immediately and start PPV. 1

Oxytocin Infusion Rate (If Continuous Infusion Needed)

• For ongoing uterine atony or PPH treatment (not routine prophylaxis), infuse oxytocin at 10–20 mU/min (equivalent to 10–20 IU in 1 L normal saline at 60–120 mL/hr). 5
• This rate is for treatment of established atony, not for the initial prophylactic bolus described above. 5

Summary Algorithm

1. Assess infant at birth: Vigorous → proceed to delayed clamping; non-vigorous → clamp immediately and resuscitate. 1
2. Delay cord clamping 30–60 seconds with infant on mother's abdomen. 1, 3
3. Give oxytocin 5–10 IU slow IV (over 1–2 min) or 10 IU IM during the delayed clamping window. 2
4. Clamp and cut cord at 30–60 seconds. 1
5. Perform controlled cord traction after placental separation. 6, 4
6. Monitor infant for jaundice; treat PPH with tranexamic acid if needed. 1, 2