Management of the third stage of labor

Management of the third stage of labor has been an issue of discussion, concern, and continued debate for the past two decades. Despite the many strategies employed and the divergent approaches to care and philosophies espoused, there has not been a significant, consistent reduction in the postpartum hemorrhage rates reported in industrialized countries in recent times. This article explores the strategies that have been and are currently being used in an effort to reduce the risk of postpartum hemorrhage.     

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。     

Oral misoprostol in the third stage of labor.

OBJECTIVE: To compare the efficacy of intravenous ergometrine, intramuscular oxytocin, and oral misoprostol in the control of postpartum hemorrhage. METHODS: Mean blood loss, rates of blood loss between 500 and 1000 ml, hematocrit fall greater than 10%, and need for additional oxytocic agents and nature and rates of adverse effects were assessed in this prospective, randomized, controlled study. RESULTS: All outcomes were similar in the 3 groups. The main adverse effects in the misoprostol group were temperatures higher than 99 degrees F, which normalized within 2 h and shivering, which was mild and self-limiting. CONCLUSIONS: Oral misoprostol is as effective as conventional oxytocic agents in preventing postpartum hemorrhage and can be recommended for use in low-resource settings.     

Misoprostol use during the third stage of labor.

OBJECTIVES: To systematically review the efficacy of misoprostol compared with placebo or other uterotonics in preventing maternal morbidity associated with the third stage of labor. METHODS: We identified, retrieved, evaluated, abstracted data, and assessed the quality of all published studies (from January 1996 to May 2002) which assessed misoprostol's efficacy in minimizing uterine blood loss during the third stage of labor. Seventeen studies included 28170 subjects; of these, approximately one-half received misoprostol with the remainder receiving either a placebo or another uterotonic agent. An estimate of the odds ratio (OR) and risk difference for dichotomous outcomes was calculated using a random- and fixed-effects model. Continuous outcomes were pooled using a variance-weighted average of within-study difference in means. RESULTS: In assessing studies comparing misoprostol with placebo, those who received oral misoprostol had a decreased risk of needing additional uterotonics (OR 0.64, 95% confidence interval 0.46, 0.90). Compared with placebo, use of misoprostol was associated with an increased risk for shivering and pyrexia. In contrast, in studies comparing misoprostol with oxytocin, oxytocin was associated with significantly lower rates of postpartum hemorrhage, maternal shivering and pyrexia. In studies comparing misoprostol with Syntometrine, misoprostol was associated with higher rates of the need for additional uterotonic agent as well as shivering. CONCLUSIONS: Misoprostol was inferior to oxytocin and other uterotonics with regard to any of the third stage of labor outcomes assessed. However, when compared to placebo, misoprostol had a decreased risk of needing additional uterotonics. Thus, in less-developed countries where administration of parenteral uterotonic drugs may be problematic, misoprostol represents a reasonable agent for the management of the third stage of labor. Additional randomized clinical trials examining objective outcome measures (i.e. need for blood transfusion or 10% hemoglobin change) may further define benefits and risks of misoprostol use during the third stage of labor.     

Management of the third stage of labor with nipple stimulation

Nipple stimulation was found to be a safe alternative to oxytocin in the management of the third stage of labor.     

Misoprostol versus oxytocin in the third stage of labor.

OBJECTIVES: A double blind randomized controlled trial was performed at the tertiary hospital in Harare, Zimbabwe to compare oral misoprostol with intramuscular oxytocin in the management of third stage of labor. METHODS: A total of 499 women were randomized to receive either 400 microg misoprostol orally or 10 IU oxytocin intramuscularly. The incidences of postpartum hemorrhage and side effects were examined. RESULTS: The demographic and labor characteristics were comparable. Postpartum hemorrhage occurred in 15.2% of women given misoprostol and in 13.3% of those given oxytocin (P=0.534). Measured blood loss of more than 1000 ml occurred in 3.7% of the misoprostol group compared with 2% in the oxytocin group (P=0.237). There was no significant difference in the need for additional oxytocic drugs or blood transfusion in women given misoprostol (P values 0.137 and 0.600, respectively). Significant side effects of misoprostol were shivering [RR=1.32 (95% CI 1.11-1.58); P=0.002) and a rise in temperature [RR=2.02 (95% CI 1.75-2.33); P<0.001]. CONCLUSIONS: Oral misoprostol is as effective as intramuscular oxytocin in the prevention of PPH. Shivering and transient pyrexia were specific side effects of misoprostol. Misoprostol has potential in reducing the high incidence of PPH in developing countries.     

The length of the third stage of labor and the risk of postpartum hemorrhage

OBJECTIVE: To estimate whether the length of the third stage of labor is correlated with postpartum hemorrhage. METHODS: In this prospective observational study women delivering vaginally in a tertiary obstetric hospital were assessed for postpartum hemorrhage. All women were actively managed with the administration of oxytocin upon delivery of the anterior shoulder. Blood loss was measured at each delivery in collecting devices, and drapes and sheets were weighed to calculate the blood loss at each vaginal delivery. Postpartum hemorrhage was defined as more than 1,000 mL blood loss or hemodynamic instability related to blood loss requiring a blood transfusion. RESULTS: During a 24-month period there were 6,588 vaginal deliveries in a single tertiary obstetric hospital, and postpartum hemorrhage occurred in 335 of these (5.1%). The median length of the third stage of labor was similar in women having and those not having a postpartum hemorrhage. The risk of postpartum hemorrhage was significant at 10 minutes, odds ratio (OR) 2.1, 95% confidence interval (CI), 1.6-2.6; at 20 minutes, OR 4.3, 95% CI 3.3-5.5; and at 30 minutes OR 6.2, 95% CI 4.6-8.2. The best predictor for postpartum hemorrhage using receiver operating characteristic curves was 18 minutes. CONCLUSION: A third stage of labor longer than 18 minutes is associated with a significant risk of postpartum hemorrhage. After 30 minutes the odds of having postpartum hemorrhage are 6 times higher than before 30 minutes. LEVEL OF EVIDENCE: III.