Management of the Third Stage of Labor and Prevention of Postpartum Hemorrhage

Both the WHO and ACOG recommend the use of prophylactic oxytocin as the first-line drug following delivery for prevention of postpartum hemorrhage.
There is no consensus, however, on the optimal dose or method of administration, with doses from 10-80 units given as IV infusion, and bolus doses of 2-5 units over one minute being reported.  Some studies have shown the lower range of doses to be effective, while others have shown reduction in blood loss, but not reduced need for transfusion with higher doses.   There do not appear to be increased adverse effects with higher doses of oxytocin infusion when compared to lower doses.

The 2012 WHO guidelines for active management of the third stage of labor recognize the need to balance hemorrhage prevention and the benefits of delayed cord clamping, which ACOG has also acknowledged in the Practice Bulletin on postpartum hemorrhage.

Based on review of the WHO guidelines, ACOG Practice Bulletin, and recent literature, the following is recommended for deliveries in GHS hospitals.

1. Delayed cord clamping should be practiced for most deliveries, allowing at least 30 to 60 seconds topass before clamping.  The cord should be clamped immediately if the newborn requires immediate resuscitation or if stabilization of the mother needs to take precedence.
2. At vaginal delivery, administer oxytocin 30 units in 500mL of normal saline given IV at the time of cord clamping.  This should be run in over 30 minutes.
3. If IV access is not available, oxytocin 20 units IM may be given as an alternative, also given at the time of cord clamping.  Misoprostol 600mcg PO or SL is an alternative if oxytocin is unavailable.
4. For cesarean deliveries, oxytocin 40 units in 1000mL to be started at cord clamping and infused over 30-60 minutes.
5. In both cases, the full dose should be given.
6. At vaginal delivery, controlled cord traction may be used to facilitate delivery of the placenta.  Uterine massage prior to placental delivery is not recommended, but should be performed following placental delivery.
7.  If a patient’s risk of postpartum hemorrhage is high, additional prophylactic oxytocin may be given in the first postpartum hours.
8. If active hemorrhage occurs, initiate the postpartum hemorrhage plan while continuing oxytocin administration.

References

• American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006 Oct. 108(4):1039-47.
•  Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev. 2013 Oct 30. CD001808.
• WHO recommendations on prevention and treatment of postpartum haemorrhage. 2012.
• Active versus expectant management for women in the third stage of labour. Begley CM, Gyte GM, Devane D, McGuire W, Weeks A Cochrane Database Syst Rev. 2015;
• Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Tita AT, Szychowski JM, Rouse DJ, Bean CM, Chapman V, Nothern A, Figueroa D, Quinn R, Andrews WW, Hauth JC . Obstet Gynecol. 2012;119(2 Pt 1):293.