II. Epidemiology
- Typical Third Stage of Labor lasts 8-9 minutes
- Median blood loss 574 ml
III. Precautions
- The Third Stage of Labor is the most Unpredictable and Dangerous Stage (highest morbidity and mortality)
- Active Management of the Third Stage of Labor is standard of care to reduce the risk of Postpartum Hemorrhage
IV. Complications
- Retained Placenta (1-2% Incidence)
- Primary Postpartum Hemorrhage (3-4% Incidence)
- Uterine Inversion
V. Management: Active (AMTSL)
- See Postpartum Hemorrhage
- Early Oxytocin (Pitocin)
- Oxytocin given at anterior Shoulder delivery
- Contrast with Pitocin after placenta delivery
- Oxytocin dose
- Benefits
- Single most important measure to prevent Postpartum Hemorrhage
- Lower incidence Postpartum Hemorrhage
- Lower incidence Retained Placenta
- NNT 7 to prevent one Postpartum Hemorrhage >500 ml loss
- Risks
- No increased risk of Retained Placenta
- Risks compromise of undiagnosed second twin
- However, prenatal Ultrasound makes unlikely
- References
- Prendiville (2000) Cochrane Database Syst Rev
- Khan (1997) Am J Obstet Gynecol 177:770-4 [PubMed]
- Oxytocin given at anterior Shoulder delivery
- Controlled cord traction to deliver placenta (Brandt-Andrews Maneuver)
- One hand applies firm traction on the Umbilical Cord
- Other hand applies suprapubic pressure over the Uterus and toward the Umbilicus
- Other measures
- Uterine massage after delivery of placenta
VI. Management: Other Utertonic Medications (Oxytocin alternatives) are not recommended
-
Oxytocin combined with Methyl-ergonovine (Methergine) or Misoprostol (Cytotec)
- More effective than Oxytocin alone (prevents blood loss >500 ml)
- However, more adverse effects
- Gallos (2019) Health Technol Assess 23(9): 1-356 [PubMed]
- Carbetocin (extended release Oxytocin)
- No benefit over standard Oxytocin
- Misoprostol (Cytotec)
- References