Active management of third stage of labor

1. Dr. Meenakshi Sharma
MD Obs & Gynae, AIIMS
Senior Consultant Obs & Gynae
Yashoda Superspeciality Hospital

2. Hemorrhage 28.7%
Embolism 19.7%
P.I.H. 17.6%
Infection 13.1%
Cardiomyopathy 5.6%
Anesthesia compl 2.5%
Others 2.7%
 The commonest complication in at risk
pregnancy is PPH.
PPH: Post Partum Hemorrhage
Margaret C. Hogan et al., Lancet 2010
Int J Gynecol Obstet 2009,

3.  Primary PPH is defined as excessive
bleeding that occurs in the first 24 hours
after delivery
 Traditionally the definition of PPH has been
blood loss in excess of 500 mL after vaginal
delivery and in excess of 1000 mL after
abdominal delivery
 For clinical purposes, any blood loss that
has the potential to produce hemodynamic
instability should be considered PPH
WHO guidelines for the management of postpartum
hemorrhage and retained placenta

4.  The amount of blood loss required to
cause hemodynamic instability will
depend on the pre-existing condition
of the woman
 Hemodynamic compromise more
likely anaemia (e.g., iron deficiency,
thalassemia) or volume-contracted
states (e.g., dehydration, gestational
hypertension with proteinuria)
WHO guidelines for the management of postpartum
hemorrhage and retained placenta

5.  342,900 Maternal deaths worldwide ( 2008)
 Global MMR has decreased from 422 ( 1980) to
251(2008) per 100,000 live births
 PPH is the leading cause of maternal mortality
 The WHO statistics suggest that 25% of maternal
deaths are due to PPH, accounting for more than
100,000 maternal deaths per year
 PPH occurs in 5% of all deliveries
 The majority of these deaths occur within 4 hours
of delivery, which indicates that they are a
consequence of the third stage of labour
Margaret C. Hogan et al., Lancet 2010
Int J Gynecol Obstet 2009

6.  Tone - abnormalities of uterine
contraction
 Tissue - retained products of
conception
 Trauma - of the genital tract
 Thrombin - abnormalities of
coagulation
The most common cause of primary
PPH is uterine atony

7. Postpartum Haemorrhage
Predict Prepare
(Prophylaxis)
Manage
(Treatment)

8. Active management of the third stage
of labour should be offered to all
women during childbirth
 Administration of a uterotonic soon
after the birth of the baby;
 Clamping of the cord following the
observation of uterine contraction
 Delivery of the placenta by controlled
cord traction, followed by uterine
massage.
Int J Gynecol Obstet 2009

9. 0
10
20
30
Transfusion Prolonged Third
Stage
Therapeutic
Uterotonic
Low
Hemoglobin
Retained
Placenta
Percent
Active Management Physiological Management
McMormick, Sanghvi, Kinzie, McIntosh, IJGO2003

10.  Oxytocin
 Carboprost Tromethamine (15-Methyl
PGF2 alpha)
 Ergot alkaloids
(Ergometrine/Methylergometrine)
 Misoprostol

11. Clear practice implication in favour of
using oxytocin- in terms of reducing
PPH and the need for therapeutic
Oxytocics, when compared to using no
uterotonic
Cotter A, Ness A, Tolosa J. Prophylactic oxytocin for the third
stage of labour (Cochrane Review). In: The Cochrane Library,
Issue 1, 2006.

12.  Oxytocin is associated with fewer manual
removals and less raised blood pressure of
the placenta
 For all other outcomes definite conclusions
cannot be drawn
Cotter A, Prophylactic oxytocin for the third stage of labour
(Cochrane Review). In: The Cochrane Library, Issue 1, 2006.

13.  Carboprost low dose IM (125 µg) for AMTSL
 Carboprost high dose IM (250 µg) for High
risk cases & Management of PPH
 Mainly compared with Methylergometrine

14. Bhattacharya P (Late), Devi PK. Acta Obstet Gynecol Scand Suppl 145:13-15,
Blood Loss Duration 3rd Stage

15. 50
100
200
250
300
150
ml
283
Postpartum blood loss Blood loss at 2 hrs.
Control
100
Prostodin
27
Prostodin
163
Control
Duration of third stage
Control
11 min.
Prostodin
5 min.
Devi et al. Acta Obstet Gynecol Scand 1988;S145:7-8

16. 0
20
40
60
80
100
120
140
160
Blood loss (ml)
Prostodin
MEM
0
1
2
3
4
5
6
7
8
3rd stage (min.)
Prostodin
MEM
Anjaneyulu R, (Late) Devi PK et al. Acta Obstet Gynecol Scand Suppl 145:9-11, 1988
95.
2
154.9
3.5
6.1
Carboprost (125 µg) Vs
Methylergometrine

17. Goyal U., Chabra S. Obs. & Gynae Today , 1998
Group I: No uterotonic
Group II: Methylergometrine
Group III: Carboprost (125 µg)
Significant reduction in duration of 3rd stage and amount of
blood loss in group II and III (p< 0.01)
16% patients had rise in blood-pressure in group II
No major side effects in group III
Carboprost (125 µg) Vs
Methylergometrine

18. 0
20
40
60
80
100
Blood loss (ml)
Prostodin
MEM
0
1
2
3
4
5
6
3rd stage (min.)
Prostodin
MEM
74.
8
93.
6
3.8
4
5.1
6
p<0.0001
Nagaria T, Ekka M. Obstet Gynecol India 56(4): 396-398,
September/October 2006

19. RCT methyl ergometrine 0.2 mg, misoprostol 400
mcg S/L and carboprost 125 mcg ( N-200
women)
 Median blood loss, blood loss >500ml, need of
additional oxytocics and drop in Hb were same in
all groups
 Significant side effect of shivering, pyerexia and
vomitting in misoprostol though self limiting
 Diarrhoea was common in carboprost and
hypertension in methyl ergometrine group
 Three women in methyl ergometrine group
required MRP
Vaid A, Dadhwal V, Mittal S, Arch Obstet Gynecol, 2009

20.  RCT Syntometrine Vs Carboprost 125 mcg
(N-112 women)
 Similar results in duration of third stage,
blood loss and need for blood transfusion
 Significant side effect of diarrhoea with
carboprost
Chua S, Aust N Z J Obstet Gynecol, 1995

21. Clinical evidences suggest CARBOPROST
when given postpartum will result in:
Powerful uterine contraction
• Immediate cessation of bleeding (88 – 98%)1,2
Adequate uterine retraction3
• Significantly reduced blood loss4
• Reduced need for blood transfusion/blood products4
• Obviates need for hysterectomy/surgical intervention2
Abdel-Aleem et al. Int J Gynecol Obstet 1993
Thiery & Parewijck. Z. Geburtsh U. Perinat. 1985
Arulkumaran S et al. The Management of Labour. Orient
Longman 2005 (2nd edn.):276
F. Boyoumeu et al. Eur J Obstet Gynecol Reprod Biol 2003

22. Sustained action for up to 7 hours
 Stimulates endogenous PGF2
 Does not require supplementation with
additional uterotonics
 Reduced risk of delayed/secondary
Abdel-Aleem et al. Int J Gynecol Obstet 1993
Thiery & Parewijck. Z. Geburtsh U. Perinat. 1985
Arulkumaran S et al. The Management of Labour. Orient Longman
2005 (2nd edn.):276
F. Boyoumeu et al. Eur J Obstet Gynecol Reprod Biol 2003

23.  No evidence was found relating to the priority
outcomes regarding blood loss
 Of 60 patients in the carboprost group, none
received a blood transfusion compared with 1
of 60 in the misoprostol group
 None of the patients in the carboprost group
reported shivering, compared with 5 in the
misoprostol group
WHO 2009

24.  Active management of third stage of labour
can prevent 60% of postpartum hemorrhage
 Overall there is little evidence of differential
effects of Oxytocin and ergot alkaloids
 Oxytocin is more safe as compare to ergot
alkaloids
 Misoprostol is inferior to Oxytocin in
prevention of PPH
 Pyrexia and shivering are common side
effects with Misoprostol

25.  Carboprost (125 µg) is more effective and
safe as compare to Methylergometrine
 Carboprost (125 µg) is well tolerated in
various clinical studies as compare to
Methylergometrine

26.  Prophylactic oxytocics should be offered routinely
in the management of the third stage of labour in
all women as they reduce the risk of PPH by about
60%.
 For women without risk factors for PPH delivering
vaginally, oxytocin (5 iu or 10 iu by intramuscular
injection) is the agent of choice for prophylaxis in
the third stage of labour.
 For women delivering by caesarean section,
oxytocin (5 iu by slowintravenous injection) should
be used
RCOG Guidelines: Prevention and Management of PPH, 2011

27.  Carboprost 0.25 mg by intramuscular
injection repeated at intervals of not less than
15 minutes to a maximum of 8 doses
(contraindicated in women with asthma)
 Direct intramyometrial injection of carboprost
0.5 mg (contraindicated in women with
asthma),
 Misoprostol 1000 micrograms rectally
RCOG Guidelines: Prevention and Management of PPH, 2011

28.  Two case series from the USA comprising 26
and 237 cases, respectively, reported success
in controlling hemorrhage, without resort to
surgical means in 85% and 95% of cases
 Two of the four failures in the smaller series
were associated with placenta accreta
Buttino L Jr, Garite TJ. Am J Perinatol 1986;86:241–3.
Oleen MA,Mariano JP. Am J Obstet Gynecol 1990;90:205–8.

29.  If bleeding occurs at LSCS or laparotomy
intra myometrial injection of carboprost
should be used
 It is also possible to inject intra myometrial
carboprost through the abdominal wall in
the absence of laparotomy
Buttino L Jr, Garite TJ. Am J Perinatol 1986;86:241–3.

31.  Oxytocin
 Methergine
 PGF2 
 Misoprostol
15-25o C
2-8o C (protect from light)
2-8o C
Long self life – Room temp
WHO guidelines for the management of Postpartum Hemorrhage and
retained placenta

32.  The pregnancy with comorbid conditions like
anaemia, PIH gestational diabetes are
considered to be AT RISK for PPH and thus
have to be prepared accordingly throughout.
 Thus increased importance of AMTSL in these
MMR: Maternal Mortality Rate