The duration of the third stage of labor is subject to the location of placental implantation

We evaluated the association between placental location and length of the third stage of labor in normal term singleton pregnancies. Two hundred consecutive singleton term live vaginal deliveries following uncomplicated pregnancies were included in a retrospective study. The mean maternal age was 27.5 +/- 5.2 years, and the mean parity was 2.2 +/- 1.4. Patients' charts were reviewed in order to determine the placental implantation site. Anterior location of the placenta was noted in 96 women (48%), posterior in 66 (33%), fundal in 26 (13%), and lateral in 12 (6%). The duration of the third stage was 9.5 +/- 5.5, 9.4 +/- 5.3, 12.8 +/- 9.5, and 7.6 +/- 3.5 min in anterior, posterior, fundal, and lateral groups, respectively (p < 0.05). The duration of the third stage of labor is statistically significantly longer, if the placenta is located in the fundal area of the uterus. Therefore, we believe that the placental location may be important in managing the third stage of labor.     

A double-blinded, randomized controlled trial of oxytocin at the beginning versus the end of the third stage of labor for prevention of postpartum hemorrhage

OBJECTIVE: The objective of this study was to compare the administration of oxytocin at the beginning and end of the third stage of labor for the prevention of postpartum hemorrhage. METHODS: Patients with documented singleton pregnancies were randomly assigned to two groups. The first received 10 units of oxytocin intramuscularly at delivery of the anterior shoulder of the fetus and an identical appearing placebo injection following delivery of the placenta. The second received the opposite medication sequence. The study was double blinded. Blood loss was measured by weighing all fluids collected, visual estimation, and serial blood counts. RESULTS: 27 women received oxytocin at the delivery of the fetal shoulder and 24 after the placenta. Oxytocin given after placenta delivery resulted in lower blood loss (345 vs. 400 ml, p = 0.28), lower collection bag weight (763 vs. 833 g, p = 0.55), lower change in HgB (-1.26 vs. -1.32 g, p = 0.86), lower DeltaHCT (-3.43 vs. -3.64%, p = 0.85), and a shorter third stage of labor duration (8.6 vs. 9.2 min, p = 0.75). The incidence of postpartum hemorrhage, defined as estimated blood loss >500 ml (0 vs. 14.8%) was significantly lowered with oxytocin following placental delivery (p = 0.049). CONCLUSIONS: In our study, postpartum hemorrhage was less frequent when oxytocin administration was delayed until after placenta delivery.     

第三产程中胎盘剥离过程的动态超声观察

目的　探讨第三产程中胎盘剥离的生理过程和适宜时间。方法　应用彩色超声诊断仪 ,观察第三产程中胎盘剥离过程的动态变化 ;以称重法计算产后 2h内的出血量。结果　第三产程中胎盘剥离过程可分为 4个时期 :潜伏期、收缩期、分离期、排出期 ;各期持续时间为 :潜伏期 (4 37±3 78)min ,收缩期 (1 4 8± 0 97)min ,分离期 (0 5 0± 0 0 0 )min ,排出期 (0 6 2± 0 2 3)min。约 85 %的产妇第三产程均在 10min以内结束 ,平均 6 94min。第三产程超过 10min者 ,阴道出血量显著增加 (P <0 0 1) ,发生各种并发症的危险性也相应增加。结论　为预防产后出血 ,第三产程以不超过 10min为宜。     

Intraumbilical vein injection of oxytocin and the third stage of labor: randomized double-blind placebo trial

The objective of this study was to determine whether intraumbilical injection of oxytocin shortens the third stage of labor. A randomized, double-blind, placebo-controlled trial was used to assess the effectiveness of an intraumbilical injection of oxytocin on the duration of the third stage. Following randomization, each of 79 women received 30 mL of saline ( N = 40) or 20 U of oxytocin in 30 mL of saline ( N = 39). The primary outcome of interest was the effect on the duration of the third stage. Secondary outcomes examined were change in hemoglobin and percentage of undelivered placenta after 15 minutes. There was no difference in the duration of the third stage between the two groups (7.8 +/- 6.1 min in the saline-only group versus 5.9 +/- 2.6 min in the oxytocin group). The change in hemoglobin was significantly lower in the oxytocin group (1.3 +/- 0.9 g/dL in the oxytocin group versus 1.8 +/- 0.9 g/dL in the saline-only group). The percentage of undelivered placentas beyond 15 minutes was significantly lower in the oxytocin group (0% in the oxytocin group versus 12.5% in the saline-only group). The study concluded that intraumbilical vein injection of oxytocin reduced the rate of placentas remaining undelivered beyond 15 minutes and subsequent blood loss.     

Afterpains: A Comparison Between Active and Expectant Management of the Third Stage of Labor

Abstract: Background: Management of the third stage of labor, the period following the birth of the infant until delivery of the placenta, is crucial. Active management using synthetic oxytocin has been advocated to decrease blood loss. It has been suggested, but not studied, that oxytocin may increase afterpains. The aim of this study was to compare women’s experience of pain intensity when the third stage of labor was managed actively and expectantly and their experience of afterpains. Methods: A single‐blind, randomized, controlled trial was performed at two delivery units in Sweden in a population of healthy women with normal, singleton pregnancies, gestational age of 34 to 43 weeks, cephalic presentation, and expected vaginal delivery. Women (n = 1,802) were randomly allocated to either active management or expectant management of the third stage of labor. Afterpains were assessed by Visual Analog Scale (VAS) and the Pain‐o‐Meter (POM‐WDS) 2 hours after delivery of the placenta and the day after childbirth. Results: At 2 hours after childbirth, women in the actively managed group had lower VAS pain scores than expectantly managed women (p = 0.014). Afterpains were scored as more intense the day after, compared with 2 hours after, childbirth in both groups. Multiparas scored more intense afterpains, compared with primiparas, irrespective of management (p < 0.001). Conclusions: Active management of the third stage of labor does not provoke more intense afterpains than expectant management. (BIRTH 38:4 December 2011)     

A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage

OBJECTIVE: To determine if the timing of the administration of prophylactic oxytocin influences the incidence of postpartum hemorrhage caused by uterine atony, retained placenta, and third-stage duration. STUDY DESIGN: Parturients who presented for vaginal delivery were randomized in a double-blinded fashion to receive oxytocin, 20 units in a 500-mL crystalloid intravenous bolus, beginning upon delivery of either the fetal anterior shoulder or placenta. For all patients, the third stage of labor was managed with controlled cord traction until placental expulsion, followed by at least 15 seconds of fundal massage. Patients were excluded if they had a previous cesarean section, multiple gestation, antepartum hemorrhage, or bleeding disorder. RESULTS: A total of 1486 patients were enrolled: 745 in the before-placenta group and 741 in the after-placenta group. The groups were similar with respect to gestational age, fetal weight, labor duration, maternal age, parity, and ethnicity. The incidence of postpartum hemorrhage did not differ significantly between the two groups (5.4% vs 5.8%; crude OR, 0.92; 95% CI, 0.59 to 1.43). There were no significant differences between the two groups with respect to incidence of retained placenta (2.4% vs 1.6%; OR, 1.49; 95% CI, 0.72 to 3.08), or third-stage duration (7.7 minutes vs 8.1 minutes; P =.23). CONCLUSIONS: The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta.     

Study of the third stage of labor by color Doppler sonography

We wanted to evaluate whether improvement in ultrasound equipment in the last 5 years altered our perception of the phases of placental separation during the third stage of labor. We also investigated the influence of active management on the third stage of labor after sonographically verified placental separation. Between January and November 2001, the third stage of labor was examined in 55 women at 37-41 weeks of gestation by color Doppler sonography. The duration of blood flow between the myometrium and the placenta, the latent phase, the detachment phase, and the expulsion phase were measured and compared with the corresponding values of an earlier cohort of 57 patients investigated between November 1994 and August 1995. In the later cohort, both the duration of maternal blood flow and the detachment phase were significantly longer than in the earlier cohort (33 s +/- 48 s vs 0 s, P<0.0001 and 56 s+/-45 s vs 37 s+/-21 s, P<0.01, respectively), whereas the latent phase was significantly shorter (101 s+/-87 s vs 213 s+/-180 s, P<0.0001). There was no statistically significant difference in the length of the expulsion phase or the third stage of labor. The later cohort showed a statistically significantly more frequent multiphasic placental detachment ( P<0.05). Improvement in ultrasound equipment resulted in an earlier detection of the onset of placental separation, leading to a shorter latent phase and consecutively increased duration of the detachment phase, whereas the total duration of the third stage of labor remained unchanged. Furthermore, increased sensitivity of Doppler sonography led to a longer visualization of blood flow between the myometrium and the placenta in the normal third stage of labor.     

The effects of sequential use of oxytocin and sublingual nitroglycerin in the cases of retained placenta

Objectives: To evaluate the effects of adding sublingual nitroglycerin to oxytocin, for delivery of retained placenta after vaginal delivery.

Method: The study was performed as a placebo controlled clinical trial on women who did not finish delivering placenta after 30 min of active management of the third stage of labor. In case group, 1 mg nitroglycerin and in the control group, placebo was prescribed sublingually.

Results: In total, 80 women finished the study. The number of manual removal of placenta did not show significant difference between the two groups [25 women (62.5%) in the case and 30 women (75%) in the control group, p?=?0.335]. There was no significant difference between the two groups according to duration of the third stage of labor, hemoglobin index, decline in HB index?>30% and maternal vital signs after treatment. There was no significant difference between the two groups according to adverse effects [eight women (20%) in the case group and four (10%) in the control group (p?=?0.348)].

Conclusion: The sequential use of oxytocin and sublingual nitroglycerin could not lead to delivery of more placentas and did not reduce the necessity of manual removal of placenta in comparison with placebo.     

Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor

AIM: To assess the effectiveness of oral misoprostol compared with methylergometrine in the prevention of primary post-partum hemorrhage during the third stage of labor. METHODS: This was a randomized controlled trial of 864 singleton low-risk pregnant women. The outcomes were total blood loss, duration of the third stage of labor and peripartal change in hematocrit. Comparisons were by the chi2-test and Student t-test. Relative risks were calculated for side-effects profile. A P-value of less than 0.05 was statistically significant. RESULTS: The biodata of all the participants were similar. The mean blood loss for the misoprostol and methylergometrine groups was 191.6 +/- 134.5 mL and 246.0 +/- 175.5 mL, respectively (95% CI: -79.3 to -39.5 mL). The mean duration of the third stage of labor was 19.6 +/- 2.4 min and 9.4 +/- 3.3 min in the misoprostol and methylergometrine groups, respectively (95% CI: 9.82-10.58 min). More subjects had blood loss >500 mL, 42 (9.7%) versus 6 (1.4%), and peripartal hematocrit change greater than 10%, 38 (8.8%) versus 5 (1.2%), in the methylergometrine group than in the misoprostol group, respectively. Also, more subjects received additional oxytocic in the methylergometrine group, compared to the misoprostol group (80 [18.5%] versus 33 [7.6%] patients, respectively). CONCLUSIONS: Orally administered misoprostol was more effective in reducing blood loss during the third stage of labor than intramuscular methylergometrine. However, there were more subjects in the misoprostol group in whom duration of the third stage of labor was greater than 15 min and who also had manual placental removal than in the methylergometrine group.     

Timing of manual placenta removal to prevent postpartum hemorrhage: is it time to act?

Objective: The length of the third stage of labor is an important risk factor for postpartum hemorrhage (PPH). Current practice recommends manual placenta removal, if not delivered spontaneously, within 30?min. The review reexamines the evidence to determine the optimal length of the third stage of labor.

Methods: A MEDLINE search that associated the length of the third stage of labor with the risk of PPH was undertaken.

Results: A retrospective cohort study revealed the risk of a PPH became significant at 10?min (odds ratio?=?2.1, 95% confidence interval: 1.6–2.6), and had doubled by 20?min (odds ratio?=?4.3, 95% confidence interval: 3.3–5.5). A receiver operator curve determined the optimal length of the third stage of labor to prevent PPH was 18?min. A follow up randomized controlled trial showed that hemodynamic compromise secondary to a PPH can be reduced with manual placenta removal at 10 compared to 15?min (6.4 versus 19.2%, p?=?0.001).

Conclusion: The time interval of 15?min may be a more appropriate time interval to recommend placental removal to prevent PPH.     

Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor

The use of umbilical vein injection of oxytocin was compared with traditional management of the third stage of labor. Pregnant women were randomized to receive intravenous oxytocin after the delivery of the placenta (n = 25) or oxytocin via the umbilical vein immediately after cord clamping (n = 25). Those who received umbilical vein oxytocin had a shorter third stage of labor (4.1 versus 9.4 minutes), less measured blood loss (135 versus 373 ml), and a lower drop in hematocrit (3.9% versus 6.2%). Intraumbilical vein oxytocin appears to be a useful alternative to traditional management of the third stage of labor.     

Randomized Controlled Trial of Rectal Misoprostol Versus Oxytocin in Third Stage Management

Objective: To compare rectal misoprostol with oxytocin for routine management of the third stage of labour.Study design: A total of 240 parturient women were randomized, at three University of Toronto teaching hospitals, to receive either rectal misoprostol (400 µg) after delivery of the infant or parenteral oxytocin (5 units IV or 10 units IM) with the delivery of the anterior shoulder, when possible, or 5 units IV or IM after the delivery of the placenta.The primary outcome measure was change in hemoglobin (Δ[Hgb]) from admission in early labour to day one postpartum.Setting: The labour ward of three University of Toronto teaching hospitals: St. Michaels, Toronto General, and Mount Sinai.Population: Labouring women either nulliparous or muciparous with no known risk for excessive third stage blood loss; vertex presentation; no previous Caesarean delivery; induced, spontaneous, or augmented labour.Results: No difference in Δ[Hgb] was observed between the two groups; the Δ[Hgb] in the oxytocin and misoprostol groups were 1.43 g/L (95% confidence interval [Cl], 1.2–1.6 g/L) and 1.59 g/L (95% Cl, 1.4–1.8 g/L) respectively (p = 0.35). Secondary outcome measures (excessive third stage bleeding, duration of third stage of labour, need for manual removal of the placenta or the need for additional oxytocics) did not differ between the two groups.Conclusion: Rectal misoprostol is of equivalent efficacy to parenteral oxytocin for the prevention of primary postpartum hemorrhage. Rectal misoprostol is an appropriate uterotonic agent for routine management of the third stage of labour.     

Uterine electric activity during the third stage of labor; a look into the physiology of a deserted stage

Abstract

Objective: To evaluate uterine activity during the third stage of labor and compare it to that observed in the second stage of labor.

Study design: Uterine electric activity was prospectively measured using electrical uterine myography (EUM) in 44 women with singleton pregnancy at term during the final 30?min of the second stage and throughout the third stage of labor. Results are reported using a scoring index of 1–5?mWS (micro-Watt-Second). Patients were stratified into two groups based on the duration of the third stage (<15?min and >=15?min)

Results: The mean durations of the second and third stages were 51.9?±?63.5 and 15.4?±?7.5?minutes, respectively. During the third stage, uterine activity (contractions peaks) was similar to that observed during the second stage of labor (3.43?±?0.64?mWS versus 3.42?±?0.57?mWS, p?=?0.8). No correlation was found between the duration of the third stage and EUM measurements during the third (p?=?0.9) or the second (p?=?0.2) stages of labor. No association was found between EUM measurements during the third stage and parity, maternal age, fetal weight, duration of labor, gestational age, gravity or BMI. The rate of oxytocin use during the second stage and EUM measurements during the second or third stage did not differ among women with short versus long duration of the third stage.

Conclusion: Uterine activity during the third stage is comparable and as intense as that occurring during the second stage. Third stage length cannot be predicted by contraction intensity during the second or third stage of labor.     

Rate of increase in oxytocin dose on the outcome of labor induction.

OBJECTIVE: To compare the efficacy and safety of arithmetic and geometric increases in oxytocin infusion dosage during induction of labor. METHODS: A total of 120 pregnant women requiring induction of labor at term were randomly assigned to receive oxytocin at dosages increasing arithmetically or geometrically. Maternal demographics, labor delivery data, and newborn outcomes were compared. The setting was the maternity unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. RESULTS: The mean maximum rates of oxytocin delivery needed to achieve adequate uterine contractions were similar in the 2 groups (24.66+/-8.34 mU/min vs. 26.38+/-8.77 mU/min, P=0.24). Labor duration was significantly shorter in the geometric progression group (496.33+/-54.77 min vs. 421.34+/-63.91 min, P<0.001). There were no differences in the rates of cesarean sections, vaginal deliveries, or uterine hyperstimulation, or in neonatal outcomes. CONCLUSION: A geometric rise in the rate of oxytocin infusion delivery reduced the duration of labor without affecting the rates of cesarean sections and uterine hyperstimulation, or newborn outcomes.     

Puerperal uterine inversion: a report of four cases

Acute puerperal uterine inversion is a life-threatening and unpredictable obstetric emergency. If overlooked, it could lead to a maternal death. Although the precise cause is unknown, it is postulated to be caused by the mismanagement of the third stage of labor with premature traction of the umbilical cord and fundal pressure before placental separation. At the Ipoh General Hospital in Malaysia there were 31 394 deliveries and four acute uterine inversions occurring from 1 January 2002 to 30 June 2005. The four patients were between 25 and 36 years of age and their parities were between two and three. When manual repositioning of the uterus failed, successful correction was accomplished by the O'Sullivan's hydrostatic method. One case had to undergo subtotal hysterectomy after repositioning because of massive hemorrhage secondary to placenta accreta. Early diagnosis, immediate treatment of shock, and replacement are essential.     

A randomized comparative study of prophylactic oxytocin versus ergometrine in the third stage of labor.

OBJECTIVE: To compare the effect of prophylactic use of oxytocin and ergometrine in management of the third stage of labor. METHODS: A prospective randomized study of 600 women assigned to receive either oxytocin or ergometrine in the third stage of labor. Outcome measures were the predelivery and 48-hour postdelivery hematocrit, duration of the third stage, specific side effects, and incidence of postpartum hemorrhage. Statistical analyses were done using the t test for continuous variables and chi2 test for categorical variables. The level of significance was set at P<0.05. RESULTS: There were no significant differences between the 2 groups in maternal age, gestational age, duration of third stage, birth weights, risk for retained placenta, manual removal of placenta, or need for additional oxytocics. Patients in the ergometrine group were at significant risk for nausea, vomiting, headaches, and elevated blood pressure (P=0.0001). CONCLUSION: Oxytocin is as effective as ergometrine at reducing the incidence of postpartum hemorrhage, but without the undesirable side effects of nausea, vomiting, and elevated blood pressure associated with ergometrine.     

Cesarean section intraoperative blood loss and mode of placental separation.

OBJECTIVE: To investigate whether manual removal of the placenta is associated with significant blood loss compared with spontaneous separation of the placenta during cesarean delivery. DESIGN: A randomized prospective study of 400 women with normal pregnancies undergoing cesarean delivery at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were randomly assigned to the study group, (manual placental removal, n=200) or the control group (spontaneous placental separation, n=200). Operative blood loss was assessed by the volumetric and gravimetric methods. Hemoglobin levels were evaluated the third postoperative day and patient's postoperative complications were recorded. RESULTS: The mean+/-S.D. amount of blood loss associated with manual and spontaneous removal of the placenta was 713+/-240 and 669+/-253 ml, respectively. This difference was statistically significant (P=0.04). There was a postoperative decrease in hemoglobin levels in both groups. Preoperative hemoglobin levels were 11.6+/-3 g/dl in the study group and 11.2+/-1.1 g/dl in the control group, and the difference was statistically significant (P=0.006). The postoperative hemoglobin levels at day 3 were 9.0+/-1.2 g/dl in the study group and 9.9+/-1.2 g/dl in the control group (P=0.003), also a statistically significant difference. The incidence of endometritis, wound infection, and need for blood transfusion was similar in the two groups. CONCLUSION: Manual delivery of the placenta was significantly associated with greater operative blood loss and greater decrease in postoperative hemoglobin levels, but with shorter operative time compared with spontaneous placental separation. No difference in postoperative complications was noted between the groups.     

Induction of labor with misoprostol in pregnancies with advanced maternal age

OBJECTIVE: The objective was to compare the efficacy and complications of intravaginal misoprostol application with oxytocin infusion for induction of labor in advanced aged pregnancies with a Bishop score of < 6. STUDY DESIGN: A hundred advanced aged (> or = 35 years) pregnant patients with a Bishop score of < 6 were randomized into two groups. The first group (50 patients) received 50 microg intravaginal misoprostol four times with 4 h intervals and the second group received oxytocin infusion for induction of labor starting from 2 mIU/min and was increased every 30 min with 2 mIU/min increments up to a maximum of 40 mIU/min. The time from induction to delivery, the route of delivery, fetal outcome, and maternal complications were recorded. Statistical analyses were performed using the Mann-Whitney U, Chi-squared and t tests to determine differences between the two groups. A p value < or = 0.05 was considered significant. RESULTS: Misoprostol was superior for induction of labor in advanced aged pregnancies with Bishop score of < 6, as the mean time from induction to delivery was 9.61 +/- 4.12 h and 11.46 +/- 4.86 h in the misoprostol and oxytocin groups respectively, with a significant difference between the groups (p = 0.04). The rate of vaginal delivery was higher in the misoprostol group (84.0%) than in the oxytocin group (80.0%), but the difference did not reach significance (p = 0.60). The rates of placental abruption and postpartum hemorrhage were similar in both groups and no cases of uterine rupture occurred. The 1- and 5-min mean Apgar scores were 6.98 +/- 1.17 to 9.08 +/- 0.99 and 6.88 +/- 1.81 to 9.00 +/- 1.35 in the misoprostol and oxytocin groups respectively, with no significant differences between the groups (p = 0.74, p = 0.83). No cases of asphyxia were present. The rate of admission to the neonatal intensive care unit was similar in both groups. CONCLUSION: Intravaginal misoprostol seems to be an alternative method to oxytocin in the induction of labor in advanced aged pregnant women with low Bishop scores, as it is efficacious, cheap, and easy to use. But large studies are necessary to clarify safety with regard to the rare complications such as uterine rupture.     

A Comparative Study of Oxytocin/Misoprostol/Methylergometrine for Active Management of the Third Stage of Labor

Objectives

To study oxytocin, misoprostol, and methylergometrine in active management of the third stage of labor and determine duration of the third stage of labor, blood loss, adverse effects, and need for additional uterotonics in each group.

Methods

Clinical trial of 300 women with healthy singleton pregnancy allocated into three groups to receive either: 10 IU intravenous oxytocin infusion, 600 μg sublingual misoprostol, or 200 μg intravenous methylergometrine. Primary outcome measure was blood loss in the third stage of labor; secondary measures were duration of the third stage, side effects, and complications.

Results

Subjects who received 600 μg of misoprostol had the least blood loss, followed by oxytocin, and methylergometrine. The shortest mean duration of the third stage was with misoprostol. Shivering and pyrexia were observed in misoprostol group, and raised blood pressure in methylergometrine group.

Conclusions

Misoprostol is as effective as oxytocin and both are more effective than methylergometrine in active management of the third stage of labor.     

Timing of placental delivery to prevent post-partum haemorrhage: lessons learned from an abandoned randomised clinical trial

It has been recognised that, if the length of the third stage of labour exceeds 30 min, then there is an increased risk of a post-partum haemorrhage. Recent information has suggested that 18 min is the optimal time for removal of the undelivered placenta to prevent a post-partum haemorrhage. A randomised trial comparing 20 vs. 30 min was stopped after an interim analysis because only eight of 1607 patients' placentas had not delivered by 20 min. A third stage of labour that exceeded 10 min was observed to be significantly correlated with an increased risk of post-partum haemorrhage.