Third Stage of Labor:
Bleed Or Not To Bleed, That Is The Question
R. Oteri-Ahmadpour, D.O.
The third stage of labor is defined as the period of time between the delivery of the infant and the delivery of the placenta. A major complication associated with the third stage of labor is postpartum hemorrhage. Postpartum hemorrhage is defined as blood loss greater than 500 milliliters. There are many causes of postpartum hemorrhage, but a prolonged third stage of labor, whether due to uterine atony or other causes of retained placenta, account for the overwhelming majority. In the United States, postpartum hemorrhage is the third leading cause of death in women who carry a gestation for more than twenty weeks. Thromboembolic disorders and hypertensive disease rank first and second, respectively. Postpartum hemorrhage occurs in about four percent of vaginal deliveries in the United States. In less developed countries and in rural areas of the United States, maternal hemorrhage is even more of an issue. For example, in Zimbabwe hemorrhage is responsible for 25 percent of maternal deaths. Approximately 125,000 women per year die worldwide due to postpartum hemorrhage.
The third stage of labor usually lasts between 5 and 15 minutes. Management of the third stage of labor can be broken down into two broad categories; active management and expectant management. Expectant, or physiologic, management involves waiting for the typical signs of placental separation such as fundal rise, a gush of blood, and lengthening of the umbilical cord, then allowing the placenta to deliver spontaneously. Expectant management is the most common method in dealing with the third stage of labor in the United States and in most home deliveries. The following excerpt from a typical obstetric textbook used in the United States illustrates the preferred method for the third stage of labor in this country:
“Following the birth, one should watch for signs of placental separation, including lengthening of the umbilical cord, a gush of blood coming from the uterus, and the uterus becoming more globular and rising in the maternal abdomen. Once these signs are observed, with palpation of the fundus and pressure of the thumb just above the symphysis pubis, gentle traction may be placed on the umbilical cord, resulting in delivery of the placenta.”
The evidence seen in the literature, however, has supported active management of the third stage of labor for at least the last fifteen years, since the Bristol trial published in 1988. Active management of the third stage of labor usually consists of the administration of a uterotonic prior to the delivery of the placenta, clamping and cutting the umbilical cord immediately after the birth of the infant, and controlled cord traction with concurrent counterpressure to the uterus. Active management is performed in the United Kingdom, Canada and Australia. The two most widely cited studies regarding active management of the third stage of labor are the Bristol trial and the Hinchingbrooke trial.
The Hinchingbrooke trial was published in 1998. The hypothesis tested was that active management of the third stage of labor decreases the rate of primary postpartum hemorrhage as compared to expectant management. There were 1512 subjects, of which 764 were randomly assigned to expectant management and 748 to active management. Each group was then further randomly divided to upright or supine position groups to study the effect of posture on primary postpartum hemorrhage. Fully active management in this trial consisted of administering oxytocin plus ergometrine prophylactically just after the delivery of the anterior shoulder, clamping and cutting the umbilical cord immediately, and controlled cord traction to deliver the placenta. Fully expectant management consisted of no uterotonics, clamping and cutting the umbilical cord once pulsation had stopped, and delivery of the placenta by maternal effort within one hour. The primary outcome was primary postpartum hemorrhage, defined as blood loss greater than 500 milliliters. There were no statistically significant differences in the subjects within the two types of managements regarding socioeconomics, hematology, or median durations of first and second stages of labor.
The rate of primary postpartum hemorrhage in the expectant management group was 16.5, as compared with 6.8 in the active management group, a statistically significant difference. The relative risk was 2.4. There were also statistically significant differences between the groups with regards to postnatal hemoglobin of less than 10, blood transfusions, and use of iron tablets, with the active management group consistently doing better than the expectant management group.
Giacalone et al in another study, published in 2000, evaluated the clinical relevance of draining the blood out of the umbilical cord. This randomized trial consisted of 239 women receiving placental cord drainage plus cord traction and 238 women receiving expectant management. Neither group received uterotonics during the third stage of labor. It was found that there was no significant difference between the groups regarding manual removal of retained placenta or placental fragments. There was also no significant difference between the groups regarding postpartum hemoglobin levels. The number of women with a drop in hemoglobin of greater than 3 g/dL was statistically significantly lower in the cord drainage group as compared to the control group. The third stage of labor was significantly shorter in the cord drainage group compared to the control group. Prolonged third stage of labor (greater than 30 minutes) was seen in 2.1 percent of the drainage group as compared with 8 percent of the control group.
In 2001, Jackson et al published an article which compared oxytocin administration before and after placental delivery. Most physicians in the United States administer oxytocin after placental delivery due to fear that the uterus would “clamp down” and cause a retained placenta if oxytocin were to be given upon fetal delivery. In this blinded, randomized controlled trial, 745 women received oxytocin before the placenta was delivered and 741 received it after the placenta was delivered. Both groups, however, received controlled cord traction and fundal massage. In this study, there was no statistically significant difference between the groups regarding postpartum hemorrhage, drop in hemoglobin of greater than 2 g/dL, use of blood transfusion, duration of third stage of labor, or rate of retained placenta. The authors, therefore, concluded that the timing of the administration of a uterotonic during active management of the third stage of labor is irrelevant.
In September of 2001, the World Health Organization published an article in The Lancet regarding the use of misoprostol in the third stage of labor. In this multicenter randomized trial, 9264 women were assigned to receive 600 micrograms of misoprostol orally and 9266 were assigned to receive 10 units of oxytocin intravenously or intramuscularly. The primary outcomes measured were blood loss of greater than 1000 milliliters and use of additional uterotonics. The oxytocin group had a 3% rate of blood loss greater than 1000 milliliters. The misoprostol group had a 4% rate. This difference was statistically significant. Fifteen percent of the misoprostol group needed additional uterotonics versus eleven percent of the oxytocin group. This was also statistically significant. Thus, it was found that 10 units of oxytocin given intravenously or intramuscularly is preferable to 600 micrograms of misoprostol given orally.
Gerstenfeld and Wing published a study in the American Journal of Obstetrics and Gynecology in 2001 comparing rectal misoprostol and intravenous oxytocin. There were 201 women assigned to the misoprostol group and 199 assigned to the oxytocin group. In the misoprostol (study) group, women were given two 200 microgram tablets rectally plus two milliliters of saline injected into their bags of lactated ringers. In the oxytocin (control) group, the women were given 20 units of oxytocin intravenously plus two lactose tablets rectally. The primary outcomes measured were postpartum hemorrhage and the use of additional uterotonics. The incidence of postpartum hemorrhage was not statistically significantly different between the two groups, whether the amount of blood loss needed to be considered postpartum hemorrhage was 500 mL, 800 mL, or greater than one liter. There was, however, a statistically significant difference with regards to the use of additional uterotonics. In the study (misoprostol) group, 23 percent of women required the use of additional uterotonics, compared to 11 percent in the control (oxytocin) group.
Çalişkan et al published a randomized controlled trial regarding rectal misoprostol in the American Journal of Obstetrics and Gynecology in 2002. There were four groups. The first group received an intramuscular injection of saline, oxytocin 10 units intravenously, and misoprostol 400 micrograms rectally immediately following cord clamping, followed by 100 micrograms of misoprostol rectally at postpartum hours 4 and 8. The second group received an intramuscular injection of saline, an intravenous injection of saline, and misoprostol 400 micrograms rectally immediately following cord clamping, followed by 100 micrograms of misoprostol rectally at postpartum hours 4 and 8. The third group received an intramuscular injection of saline, oxytocin 10 units intravenously, and placebo rectally at cord clamping, followed by placebo rectally at postpartum hours 4 and 8. The last group received an intramuscular injection of methylergometrine, oxytocin 10 units intravenously, and rectal placebo at cord clamping, followed by rectal placebo at postpartum hours 4 and 8. It was found that there was a statistically significantly higher incidence of postpartum hemorrhage in the misoprostol only group as compared to the methylergometrine plus oxytocin group. There was no statistically significant difference in postpartum hemorrhage among the misoprostol only, the oxytocin only, or the oxytocin plus misoprostol groups. Statistically significantly more women needed blood transfusions in the misoprostol only group compared to the oxytocin plus misoprostol and the oxytocin plus methylergometine groups. Statistically significantly more women needed additional uterotonics in the misoprostol only group as compared to the misoprostol plus oxytocin and the oxytocin plus methylergometrine groups. Lastly, the length of the third stage of labor was statistically significantly longer in the misoprostol group as compared to all other groups.
The Cochrane Library published a review regarding active versus expectant management of the third stage of labor in 2003. They determined that active management resulted in a significantly decreased risk of maternal blood loss, postpartum hemorrhage of greater than 500 milliliters, and prolonged third stage of labor. Active management, however, also resulted in a higher risk of nausea, vomiting, and elevated blood pressure in the mother, and no problems to the infant. Another Cochrane Review addressed the prophylactic use of oxytocin in the third stage of labor. This review found that prophylactic oxytocin resulted in a significantly decreased risk of postpartum hemorrhage greater than 500 milliliters and therapeutic uterotonic use. They also determined that there was little evidence of additional benefit in adding ergometrine to oxytocin versus ergometrine alone. They found a non-significantly increased risk of manual removal of the placenta when prophylactic oxytocin was given. The Cochrane Library also reviewed the use of prostaglandins to prevent postpartum hemorrhage. They found that 600 micrograms of oral misoprostol was associated with a statistically significantly increased risk of blood loss greater than 1000 milliliters as compared to other conventional injected uterotonics.
In summary, it appears that active management of the third stage of labor is superior to expectant management. This is only the case, however, in labors that are performed in hospitals. Active management of the third stage would be nearly impossible in most home deliveries, and, therefore, in many third world countries where home deliveries are the norm. Thus, it would be prudent for more physicians in the United States to apply active management of the third stage of labor to their deliveries.
1. Çalişkan E, Meydanli M, Dilbaz B, Aykan B, Sönmezer M, Haberal A. Is rectal misoprostol really effective in the treatment of third stage of labor? A randomized controlled trial. Am J Obstet Gynecol 2002; 187: 1038-45.
2. Combs CA, Larol RK. Prolonged third stage of labor: morbidity and risk factors. Obstet Gynecol 1991; 77: 863-67.
3. Danforth’s Obstetrics and Gynecology, 8th edition. 1999; page 101.
4. Dombroski MP, Bottoms SF, Saleh AAA, Hurd WW, Romero R. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995; 172: 1279-84.
5. Elbourne DR, Prendville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third stage of labor (Cochrane Review). The Cochrane Library, Issue 2, 2003.
6. Gerstenfeld TS, Wing DA. Rectal misoprostol versus intravenous oxytocin for the prevention of postpartum hemorrhage after vaginal delivery. Am J Obstet Gynecol 2001; 185: 878-82.
7. Gialcone PL, Vignal J, Daures JP, Boulot P, Hedon B, Laffargue F. A randomised evaluation of two techniques of management of the third stage of labour in women at low risk of postpartum haemorrhage. BJOG 2000; 107:396-400.
8. Gülmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for prevention of postpartum haemorrhage (Cochrane Review). The Cochrane Library, Issue 2, 2003.
9. Gülmezoglu AM, Villar J, Ngoc TNN, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet 2001; 358: 689-95.
10. Jackson KW, Albert JR, Schemmer GK, et al. A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage. Am J Obstet Gynecol 2001; 185: 873-7.
11. Outlook. Preventing postpartum hemorrhage: managing the third stage of labor. Outlook Vol 19, Number 3.
12. Prendville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour (Cochrane Review). The Cochrane Library, Issue 2, 2003.
13. Rogers J, Wood J, McCandlish R. et al. Active versus expectant management of third stage of labour; the Hinchingbrooke randomised controlled trial. Lancet 1998; 351: 693-99.
14. Silverman F. Management of the third stage of labor. Up To Date Online 11.1.