Management of the Third Stage of Labor
ABSTRACT & COMMENTARY
Synopsis: Active management of the third stage of labor clearly reduces the rate of postpartum hemorrhage.
Source:Rogers J, et al. Lancet 1998;351:693-699.
To determine whether active or expectant management of the third stage of labor resulted in a lower rate of postpartum hemorrhage (PPH) defined as blood loss greater than 500 mL, Rogers and colleagues conducted a prospective, randomized trial in women at low risk for PPH. Women in the active management group (n = 748) received a combination of oxytocin and ergometrine as soon as possible after delivery of the anterior shoulder (within 2 minutes of birth), followed by immediate clamping and cutting of the cord and delivery of the placenta by cord traction or maternal effort. In contrast, mothers managed expectantly (n = 764) received no uterotonic drugs, no clamping of the cord until pulsations had ceased, and delivery of the placenta within one hour by maternal efforts. It was known that the rate of PPH for women at low risk was about 8% prior to the trial. Women in the active management group had a significantly lower rate of PPH when compared to women who were managed expectantly (6.8% vs 16.5%). Significant differences favoring active management were also noted in the number of women who had a hemoglobin level less than 10 g postpartum (28.4% vs 15.2%), the need for blood transfusion (2.6% vs 0.5%), and the use of iron tablets (28% vs 16.9%). Active management of labor was not associated with an increased rate of placenta entrapment, and mothers who received uterotonics had a significantly higher rate of nausea (11.5% vs 5.9%), vomiting (6.3% vs 2.2%), but not hypertension. No differences were noted in neonatal outcome including the need for phototherapy for jaundice. Rogers et al conclude that active management of the third stage of labor clearly reduces the rate of PPH.
COMMENT BY STEVEN G. GABBE, MD
Postpartum hemorrhage is most often due to uterine atony and is increased in association with prolonged labor, a multifetal gestation or macrosomic infant, high parity, and infection. Most obstetricians in the United States actively manage the third stage of labor, the period of delivery of the infant until delivery of the placenta, with immediate clamping of the cord, gentle traction on the cord, and administration of a dilute solution of oxytocin shortly after delivery of the placenta. Administration of oxytocin with the delivery of the anterior shoulder, as was done in this study, may be more effective in reducing PPH, although concern has been expressed that an unrecognized twin might be compromised by this approach. Given the widespread use of ultrasound during the antenatal and intrapartum periods, delivery of unrecognized twins is highly unlikely today.
In this study, Rogers et al used oxytocin plus ergometrine as the uterotonic for active management. Ergot alkaloids do increase the risk of hypertension. Ongoing research is examining the efficacy of oral misoprostol in the active management of the third stage of labor. In summary, as emphasized in an accompanying editorial by Keirse, active management of the third stage is preferred, because, for every 1000 women managed in this way, PPH can be prevented in 100, blood loss in excess of 1 L in 10, and blood transfusion in 20.
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