Management of the Third Stage of Labor
Recommended Components of Third Stage Management
- Administer 5-10 IU of oxytocin via slow IV or intramuscular injection at the time of shoulder release or immediately postpartum, as recommended by the American Society of Anesthesiologists 1
- Careful attention should be paid to minimizing trauma and actively managing the third stage of labor with uterotonics to enhance uterine contraction and promote placental separation, as suggested by the American College of Obstetricians and Gynecologists 2
Special Considerations
- For women with respiratory diseases, oxytocin is the uterotonic of choice for the active third stage of labor, according to the European Respiratory Society 3
- Ergometrine should be avoided in women with respiratory conditions as it may cause bronchospasm, as warned by the European Respiratory Society 3
- Prostaglandin F2α used to treat postpartum hemorrhage may cause bronchoconstriction and is not recommended in women with asthma, as advised by the European Respiratory Society 4
- For women receiving anticoagulants at the time of delivery, careful attention should be paid to minimizing trauma and active management of the third stage of labor, as recommended by the International Society on Thrombosis and Haemostasis 5
- Active management with uterotonics enhances uterine contraction and promotes placental separation, reducing bleeding risk, as explained by the American College of Obstetricians and Gynecologists 2
Common Pitfalls and Caveats
- Manual removal of the placenta should not be carried out to reduce the risk of postpartum hemorrhage outside specialized structures, except in the event of severe and uncontrollable postpartum hemorrhage, as cautioned by the American Society of Anesthesiologists 1
- In case of postpartum hemorrhage outside specialized structures, intravenous administration of 1g of tranexamic acid at most 1-3 hours after bleeding onset is recommended, as suggested by the World Health Organization 1
Uterotonic Agents in Obstetric Practice
Administration and Safety Considerations
- Careful titration of uterotonics is essential to avoid uterine hyperstimulation, as recommended by the American College of Obstetricians and Gynecologists 6
- Injudicious use of uterotonics to augment weak contractions is a risk factor for uterine rupture, according to the World Health Organization 7
- Oxytocin should be avoided in cases of cephalopelvic disproportion (CPD), as advised by the American College of Obstetricians and Gynecologists 6
- Careful attention should be paid to minimizing trauma when administering uterotonics to women receiving anticoagulants, as suggested by the American Society of Hematology 8
Active Management of the Third Stage of Labor (AMTSL) Recommendations
Understanding Current WHO-Aligned AMTSL Components
- The International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians recommend delayed cord clamping (1-3 minutes after birth) as part of AMTSL, which has been shown to benefit neonatal outcomes without increasing maternal blood loss 9, 10
- The World Health Organization does not recommend sustained uterine massage as a routine component of AMTSL, as the evidence does not support its universal requirement 9
Clinical Considerations
- The American College of Obstetricians and Gynecologists is not mentioned, however, the European Society of Cardiology is not relevant here, but the use of ergometrine is contraindicated in women with hypertension or respiratory conditions due to the risk of bronchospasm 11
Uterotonic Administration in the Third Stage of Labour
First-Line Uterotonic Agent
- Oxytocin is the uterotonic of choice for routine prophylaxis during active management of the third stage of labour, according to the British Medical Journal 12
Second-Line Uterotonic Options
- Ergometrine is contraindicated in women with hypertension or respiratory conditions due to risk of bronchospasm, as stated by the European Respiratory Journal 13
Integration with Delayed Cord Clamping
- The International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians recommend delayed cord clamping (1-3 minutes) combined with immediate oxytocin administration after delivery of the infant, as reported in the British Medical Journal 12, 14
Special Populations Requiring Modified Approach
- Women with respiratory diseases (asthma, cystic fibrosis, bronchiectasis) require specific uterotonic selection, with oxytocin being the uterotonic of choice, according to the European Respiratory Journal 13
- Ergometrine should be avoided entirely in women with respiratory diseases as it may cause bronchospasm, as stated by the European Respiratory Journal 13
Tranexamic Acid Consideration
- The World Health Organization updated recommendations to include the use of tranexamic acid (1g IV) for treatment of established postpartum hemorrhage within 1-3 hours of bleeding onset, based on evidence from The Lancet Global Health 15, 16
- The WOMAN trial demonstrated that early tranexamic acid use (within 3 hours) reduces maternal death due to bleeding, as reported in The Lancet Global Health 15, 16
Management of Prolonged Third Stage of Labor
Special Considerations
- Delay cord clamping for approximately 60 seconds after delivery before cutting the cord, as this practice benefits neonatal outcomes without increasing maternal blood loss when combined with immediate oxytocin administration, according to the British Medical Journal 17
Management in Special Populations
- For women with respiratory disease, such as asthma or COPD, oxytocin is the uterotonic of choice, and ergometrine is absolutely contraindicated due to the risk of bronchospasm, as recommended by the European Respiratory Journal 18
- For women with cardiovascular disease, such as peripartum cardiomyopathy or heart failure, a single intramuscular dose of oxytocin should be used for active management, and ergometrine is contraindicated, as suggested by the European Journal of Heart Failure 19
- For women with cardiovascular disease, consider a single IV dose of furosemide after delivery to counteract auto-transfusion from the contracted uterus and lower extremities, as recommended by the European Journal of Heart Failure 19
- For women on anticoagulation, pay careful attention to minimizing trauma during placental delivery and use active management with uterotonics to enhance uterine contraction, and restart anticoagulation only after postpartum bleeding has stopped and the epidural catheter has been removed, as suggested by the European Journal of Heart Failure 19
Active Management of the Third Stage of Labor with Prophylactic Oxytocin
Core Components of Third Stage Management
- Delay cord clamping for 1-3 minutes after birth to allow placental transfusion, which benefits neonatal hematological outcomes without increasing maternal blood loss when combined with immediate oxytocin administration 20
Special Population Considerations
- All women with BMI ≥30 should receive active management of the third stage due to increased risk of postpartum hemorrhage 21
- Establish early venous access during labor for women with BMI >40 21
Management of Postpartum Hemorrhage When It Occurs
- Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset if postpartum hemorrhage develops, as this reduces bleeding-related maternal mortality 22
- Do not perform manual removal of the placenta routinely to reduce PPH risk; this should only be done in cases of severe and uncontrollable postpartum hemorrhage 22
Active Management of the Third Stage of Labor in Women with Prior Macrosomic Deliveries
Oxytocin Prophylaxis
- Give 5–10 IU oxytocin by slow intravenous infusion (over 1–2 min) or 10 IU intramuscularly immediately after delivery of the anterior shoulder (or the whole infant) and before placental delivery to lower postpartum hemorrhage (PPH) risk in women with a history of multiple macrosomic births. 23
- Administer oxytocin at the moment the anterior shoulder is delivered (or immediately after complete infant delivery) and prior to placental expulsion. 23
- Intravenous dosing: 5–10 IU oxytocin given as a slow IV infusion over 1–2 minutes to avoid hypotension and tachycardia. 23
- Intramuscular dosing: 10 IU oxytocin IM is equally effective and is preferred when IV access is unavailable. 23
- Do not give oxytocin as a rapid IV bolus (faster than 1–2 minutes) because it can cause hypotension and tachycardia. 23
- Do not delay oxytocin administration until after placental delivery; it must be given immediately after infant delivery. 23
Medications to Avoid
- Ergometrine (ergot alkaloids) should not be used as first‑line prophylaxis because, although it may reduce blood loss, it carries a higher risk of severe hypertension, increased need for manual placental removal, and bronchospasm—especially in patients with respiratory comorbidities. 24
- Ergometrine is contraindicated in patients with hypertension. 24
- Prostaglandin F₂α must be avoided in any patient with a history of asthma or reactive airway disease because it can provoke bronchoconstriction. 24
Rescue and Adjunctive Interventions
- If PPH occurs despite prophylactic oxytocin, administer tranexamic acid 1 g IV within 1–3 hours of bleeding onset (if not already given prophylactically). 23
- When the placenta is retained beyond 30 minutes with active bleeding, consider intra‑umbilical injection of oxytocin 10–30 IU or misoprostol 800 µg before proceeding to manual removal; routine manual removal is not recommended. 23