Management of Third Stage of Labour
Core Components of Third Stage Management
- The World Health Organization strongly recommends active management of the third stage of labour, which includes administration of a prophylactic uterotonic agent, delayed cord clamping for approximately 60 seconds, and controlled cord traction to deliver the placenta 1
Placental Delivery Timing
- Spontaneous placental delivery should occur within 30 minutes of fetal expulsion, as retained placenta beyond 30 minutes increases postpartum haemorrhage risk 2
- Manual removal of placenta should not be performed routinely except in cases of severe, uncontrollable postpartum haemorrhage 2, 1
Tranexamic Acid for PPH Prevention
- The World Health Organization strongly recommends early administration of tranexamic acid 1 g IV over 10 minutes within 3 hours of birth for women with clinically diagnosed postpartum haemorrhage, in addition to standard uterotonic therapy 1, 3
- Tranexamic acid must be given within 3 hours of birth, as effectiveness decreases by approximately 10% for every 15 minutes of delay 1, 3, 4
- Tranexamic acid should not be given beyond 3 hours postpartum as it may be harmful 1, 3, 4
- A second 1 g dose of tranexamic acid can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 3
Indications for TXA
- Tranexamic acid should be administered in all cases of postpartum haemorrhage regardless of etiology, as it reduces bleeding-related mortality when given within 3 hours 1, 3
- The number needed to treat is 276 to prevent one bleeding-related death 2
Common Pitfalls to Avoid
- Manual removal of placenta should not be performed routinely before 30 minutes have elapsed, as this increases infection and haemorrhage risk 2, 1
- Methylergonovine should not be used in hypertensive patients due to risk of severe vasoconstriction and hypertensive crisis 1, 3, 4
- Tranexamic acid should not be administered beyond 3 hours postpartum as evidence suggests potential harm rather than benefit 1, 3, 4