II. Epidemiology
- Typical Third Stage of Labor lasts 8-9 minutes
- Median blood loss 574 ml
III. Complications: Most Unpredictable and Dangerous Stage
- Retained Placenta (1-2% Incidence)
- Primary Postpartum Hemorrhage (3-4% Incidence)
- Uterine Inversion
IV. Management: Active (AMTSL)
- See Postpartum Hemorrhage
- Early Pitocin
- Pitocin given at anterior Shoulder delivery
- Contrast with Pitocin after placenta delivery
- Pitocin dose
- Benefits
- Single most important measure to prevent Postpartum Hemorrhage
- Lower incidence Postpartum Hemorrhage
- Lower incidence Retained Placenta
- NNT 7 to prevent one Postpartum Hemorrhage >500 ml loss
- Risks
- No increased risk of Retained Placenta
- Risks compromise of undiagnosed second twin
- However, prenatal Ultrasound makes unlikely
- References
- Prendiville (2000) Cochrane Database Syst Rev
- Khan (1997) Am J Obstet Gynecol 177:770-4 [PubMed]
- Pitocin given at anterior Shoulder delivery
- Controlled cord traction to deliver placenta (Brandt-Andrews Maneuver)
- One hand applies firm traction on the Umbilical Cord
- Other hand applies suprapubic pressure
- Uterine massage after delivery of placenta
V. Management: Oxytocin alternatives not recommended
- Carbetocin (extended release Oxytocin)
- No benefit over standard Oxytocin
- Misoprostol (Cytotec)
- References