Eduardo V. Duquez, MD

Swedish First Hill FMR OB Fellow

John Peter Smith Family Medicine Residency

Preventing PPH: Evidence-

based management of

third stage of labor

My name is….

Learning objectives

Define active management of third stage of labor (AMTSL)

Develop an evidence-based approach for the third stage of

labor

Cord traction and clamping

Role of uterine massage

Prophylactic uterotonics

Timing of prophylactic uterotonics

Outline

Overviews of the following:

Cochrane reviews

Meta-analyses

No financial disclosures

Background

• Most significant cause of maternal death

worldwide

• 140k women/year

• 5-15% of all births, 2-3% in USA

• 4/1000 births with severe blood loss

• Rise in postpartum hemorrhage in US

Definitions

• vaginal birth:

• Mild: >500 mL

• Severe: >1000 mL

• Primary vs secondary

• Primary: 1st 24 hrs

• Secondary: after 24 hrs

Case

34yo G3P2 at 38+5, with uncomplicated pregnancy, history of 2 term

vaginal deliveries, presents in active labor, 8cm dilated, and

progresses to complete

Case

IS THIS THE BEST PRACTICE?

Third Stage of labor: the shorter the better?

AMTSLActive Management of Third Stage of Labor

Why the rush?

Active vs passive management

Early cord clamping and cutting

Active vs passive management

Controlled cord traction

Active vs passive management

Prophylactic uterotonic

Placenta: cord clamping

Early versus delayed/late

Focus: maternal outcomes

Placenta: cord clamping

Cochrane Review 2013, Mcdonald et al.

15 trials

3911 women/infant pairs

Placenta: cord clamping

OUTCOMES:

Mild PPH

Severe PPH

mean blood loss

pre and post delivery HgB

Take home point:

clamp now or later?

we can wait another minute

Placenta: cord drainage

Placenta: cord drainage

Cochrane Review, Soltani et al 2011

3 trials

1257 women

Placenta: cord drainage

blood loss

length of third stage of labour

Take home point:

to drain or not to drain?

provider preference

Placenta: cord traction

Controlled cord traction versus spontaneous expulsion

Placenta: cord traction

RCT, 4355 women, half control

Outcomes:

Mild PPH > 500 mL

Severe PPH > 1000mL

Duration

Manual removal of placenta

Women’s experience of third stage

Placenta: cord traction

Postpartum hemorrhage

Duration of third stage of labor

Uterine inversion

Cord rupture

Manual removal of placenta

Patient experience

Take home point:

to pull or not to pull?

no harm, some benefit

Uterine massage

Uterine Massage

Cochrane review, Hofmeyr et al, 2013, with 2 trials

Massage between infant and placental delivery:

No benefit

Massage after delivery of placenta:

Improved blood loss

Decreased need for additional uterotonics

Take home point:

Should I massage?

Maybe.

Prophylactic uterotonic

oxytocin

Uterotonics

oxytocin

misoprostol

ergonovine (i.e. methergine)

Uterotonic: oxytocin

10 IU IM

10-40 IU per 500-1000 mL solution

Oxytocin: timing

Cochrane Review,

Soltani et al,

2010

3 RCTs with 1671

participants

Oxytocin: Timing

Timing: before or after placenta removal

End points: mild and severe PPH, retained placenta, length of

third stage of labour, changes in HgB, incidence of maternal

hypotension

3 RCTs, 1671 women, IV oxytocin

No significant difference

Take home point:

Before or after placenta?

Whenever you or your RN

can start it.

Big take home points

Take home point:

clamp now or later?

we can wait another minute

Take home point:

to drain or not to drain?

provider preference

Take home point:

to pull or not to pull?

no harm, some benefit

Take home point:

Should I massage?

depends on when

Take home point:

Which uterotonic?

Oxytocin

Timing of uterotonic?

Whenever you or your RN

can start it.

Case

34yo G3P2 at 38+5, with uncomplicated pregnancy, history of 2 term

vaginal deliveries, presents in active labor, 8cm dilated, and

progresses to complete

Citations

Frolova, Antonina I. MD, PhD; Stout, Molly J. MD, MSCI; Tuuli, Methodius G. MD, MPH; López,

Julia D. MPH, LCSW; Macones, George A. MD, MSCE; Cahill, Alison G. MD, MSCI. Obstetrics &

Gynecology: May 2016 - Volume 127 - Issue 5 - p 951–956 doi: 10.1097/AOG.0000000000001399

Active management of third stage of labour: prevention/treatment of PPH. Leduc D., Senikas

V., Lalonde AB et al. JOGC October 2009. No. 235

McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping

of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic

Reviews 2013, Issue 7. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub3.

Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management

for women in the third stage of labour. Cochrane Database of Systematic Reviews 2015,

Issue 3. Art. No.: CD007412. DOI: 10.1002/14651858.CD007412.pub4.

Hofmeyr G, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum

haemorrhage. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006431.

DOI: 10.1002/14651858.CD006431.pub3

Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labour to

prevent postpartum haemorrhage. Cochrane Database of Systematic Reviews 2013, Issue 10.

Art. No.: CD001808. DOI: 10.1002/14651858.CD001808.pub2.

Citations

Postpartum misoprostol for preventing maternal mortality and morbidity (1), 15, July

2013. Editorial Group: Cochrane Pregnancy and Childbirth group. Mofmeyr, GJ; Gulmezoglu,

AM; Novikova, N; Lawrie, Theresa A

Soltani H, Hutchon DR, Poulose TA. Timing of prophylactic uterotonics for the third stage of

labour after vaginal birth. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.:

CD006173. DOI: 10.1002/14651858.CD006173.pub2.

Jackson K, Allbert J, Schemmer G, Elliot M, Humphrey A, Taylor J. A randomized controlled

trial comparing oxytocin administration before and after placental delivery in the prevention

of postpartum hemorrhage. American Journal of Obstetrics and Gynecology 2001;185(4):873-

7.

Effect of routine controlled cord traction as part of active management of third stage of

labour on PPH: multicenter randomized controlled trial (TRACOR). Deneux-Tharaux C.,

Sentilnes L., Maillard F., et al. BMJ 2013;346:f1541 doi: 10.1136/bmj.f1541

Cord clamping: Effect of timing of umbilical cord clamping of term infants on maternal and

neonatal outcomes. McDonald SJ, Middleton P, DOwswell T., Morris PS. July 11 2013.

Cochrane Library

Soltani H, Poulose TA, Hutchon DR. Placental cord drainage after vaginal delivery as part of

the management of the third stage of labour. Cochrane Database of Systematic Reviews 2011,

Issue 9. Art. No.: CD004665. DOI: 10.1002/14651858.CD004665.pub3.

Clip art and photo links: Blood dripping:

https://clipartfest.com/categories/view/bbaf3691a46333bac4162059166ff3ff9062e08a/blood-dripping-

clipart.html

Bottle: www.afsfood.co.uk%2Fimages%2Fproduct_images%2Faqua-twist-sport-and-flat-cap-500ml-water.jpg

Baby delivery: http://www.shoulderdystociainfo.com/shoulder_dystocia.htm

Cord clamp: https://www.whelpingsupplies.com.au/umbilical-cord-clamp-bulk-options.html

placenta: http://iheartguts.com/blogs/meet-the-guts/14652337-placenta-babys-first-roommate

Baby delivery steps: http://medilinks.blogspot.com/2011/06/complecations-of-third-stage-of-labour.html

IV bag: https://www.surgo.com/catalogpc.htm?CATEGORY=C-IV%20BAGS

30 min timer: https://rfclipart.com/30-minutes-blue-chronometer-icon-7337-vector-clipart.html

Umbilical cord clamping: http://www.9monthsin9monthsout.com/wp-

content/uploads/2011/06/UmbilicalCordClamp.jpg

Tug of war: http://www.tntbomb.com/tug-of-war-world-championships-in-our-backyard/

Oxytocin: http://www.paasp.net/attachments/Image/Oxytocin_big.png?template=generic

60 min stopwatch: https://www.shutterstock.com/search/60+seconds

Cord drainage: http://econintersect.com/wordpress/wp-content/uploads/2012/06/balloon-deflating2.jpg

Uterine massage: http://cdn2.hubspot.net/hubfs/317140/massage_abdomen_2.jpg

THANK YOU FOR LISTENING!