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Third Stage of Labor

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

  • See Also
  1. Spontaneous Vaginal Delivery
  2. Postpartum Hemorrhage
  3. Retained Placenta
  • Epidemiology
  1. Typical Third Stage of Labor lasts 8-9 minutes
  2. Median blood loss 574 ml
  • Precautions
  1. The Third Stage of Labor is the most Unpredictable and Dangerous Stage (highest morbidity and mortality)
  2. Active Management of the Third Stage of Labor is standard of care to reduce the risk of Postpartum Hemorrhage
  • Complications
  1. Retained Placenta (1-2% Incidence)
  2. Primary Postpartum Hemorrhage (3-4% Incidence)
  3. Uterine Inversion
  • Management
  • Active (AMTSL)
  1. See Postpartum Hemorrhage
  2. Early Oxytocin (Pitocin)
    1. Oxytocin given at anterior Shoulder delivery
      1. Contrast with Pitocin after placenta delivery
    2. Oxytocin 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 over the Uterus and toward the Umbilicus
  4. Other measures
    1. Uterine massage after delivery of placenta
  • Management
  • Other Utertonic Medications (Oxytocin alternatives) are not recommended
  1. Oxytocin combined with methylergonovine (Methergine) or Misoprostol (Cytotec)
    1. More effective than Oxytocin alone (prevents blood loss >500 ml)
    2. However, more adverse effects
    3. Gallos (2019) Health Technol Assess 23(9): 1-356 [PubMed]
  2. Carbetocin (extended release Oxytocin)
    1. No benefit over standard Oxytocin
  3. Misoprostol (Cytotec)
    1. Less effective than Oxytocin, with more side effects (e.g. fever, Nausea, Diarrhea)
    2. Combination with Oxytocin is more effective (see above), but with greater adverse effects
    3. Does not require injection and more effective than Placebo
  4. References
    1. Maughan (2006) Am Fam Physician 73:1025-8 [PubMed]
  • References
  1. McKenna (2024) Am Fam Physician 109(6): 525-32 [PubMed]