Third Stage of Labor

Aka: Third Stage of Labor, Stage Three of Labor, Active Management of the Third Stage of Labor

1. See Also
   1. Postpartum Hemorrhage
   2. Retained Placenta
2. Epidemiology
   1. Typical Third Stage of Labor lasts 8-9 minutes
   2. Median blood loss 574 ml
3. Complications: Most Unpredictable and Dangerous Stage
   1. Retained Placenta (1-2% Incidence)
   2. Primary Postpartum Hemorrhage (3-4% Incidence)
   3. Uterine Inversion
4. Management: Active (AMTSL)
   1. See Postpartum Hemorrhage
   2. Early Pitocin
      1. Pitocin given at anterior Shoulder delivery
         1. Contrast with Pitocin after placenta delivery
      2. Pitocin dose
         1. Pitocin 10 Units IM or
         2. Pitocin 20 units in 500 cc NS given as IV bolus
      3. Benefits
         1. Single most important measure to prevent Postpartum Hemorrhage
         2. Lower incidence Postpartum Hemorrhage
         3. Lower incidence Retained Placenta
         4. NNT 7 to prevent one Postpartum Hemorrhage >500 ml loss
      4. Risks
         1. No increased risk of Retained Placenta
         2. Risks compromise of undiagnosed second twin
            1. However, prenatal Ultrasound makes unlikely
      5. References
         1. Prendiville (2000) Cochrane Database Syst Rev
         2. Khan (1997) Am J Obstet Gynecol 177:770-4 [PubMed]
   3. Controlled cord traction to deliver placenta (Brandt-Andrews Maneuver)
      1. One hand applies firm traction on the Umbilical Cord
      2. Other hand applies suprapubic pressure
   4. Uterine massage after delivery of placenta
5. Management: Oxytocin alternatives not recommended
   1. Carbetocin (extended release Oxytocin)
      1. No benefit over standard Oxytocin
   2. Misoprostel (Cytotec)
      1. Less effective than Oxytocin, with more side effects (e.g. fever, Nausea, Diarrhea)
      2. Does not require injection and more effective than Placebo
   3. References
      1. Maughan (2006) Am Fam Physician 73:1025-8 [PubMed]