Administration of uterotonic drugs before and after placental delivery as part of the management of the third stage of labour following vaginal birth

Active management of the third stage of labour has been shown to reduce the risk of postpartum haemorrhage. It usually involves clamping and cutting the cord, administration of uterotonic drugs and controlled cord traction (inserting pressure on the uterus and pulling the cord mainly with the sign of placental separation). Although active management has been shown to reduce the risk of postpartum haemorrhage, it may have an impact on the well-being of the mother and baby in terms of the amount of blood that has been transfused to the baby before the separation of the placenta. The optimum timing of uterotonic administration (before or after placental expulsion) can have a major role in this process and it has not been systematically investigated previously. This review of three trials (1671 participants) found that routine administration of oxytocin with the anterior shoulder compared with use of oxytocin after delivery of the placenta did not have any influence on the amount of bleeding postpartum or retained placenta. The route of administration of oxytocin in two of the three included studies was through intravenous infusion. Cord management at delivery was consistent with double clamping and immediate cutting after delivery of the baby. Application of controlled cord traction was slightly different among the included studies. In two of the studies, the placenta was delivered with controlled cord traction when signs of placental separation were present. Fundal pressure on the uterus was used in one study from the beginning to ensure continued uterine contraction. Oxytocin was the only uterotonic assessed. There were no assessments of any impact on neonatal health. More well designed studies using consistent approaches in this area of the management of the third stage of labour are required.

Authors' conclusions: 

Administration of oxytocin before and after the expulsion of placenta did not have any significant influence on many clinically important outcomes such as the incidence of postpartum haemorrhage, rate of placental retention and the length of the third stage of labour. However, the number of available studies were limited. The only uterotonic drug used was oxytocin, mainly through intravenous infusion, therefore its extrapolation to other routes of administration should be interpreted cautiously. More studies are required to examine other maternal and neonatal outcomes using consistent approaches.

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Background: 

Administration of the uterotonic drugs is one of the main components of the active management of the third stage of labour. The timing of uterotonics varies considerably across the globe and it may have significant implications on the well-being of the mothers and their babies.

Objectives: 

To assess the effect of the timing of administration of prophylactic uterotonics (before compared to after placental delivery) on the outcomes related to the third stage of labour.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009).

Selection criteria: 

Randomised controlled trials examining the timing of prophylactic uterotonic drugs in the third stage of labour.

Data collection and analysis: 

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked

Main results: 

We included three trials involving 1671 participants; oxytocin was the only uterotonic drug that was used. The dose and route of administration of oxytocin varied among the included studies. Administration of oxytocin before and after the expulsion of placenta does not significantly influence the incidence of postpartum haemorrhage (blood loss greater than 500 ml) (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.62 to 1.04; n = 1667, three trials); retained placenta (RR 1.54, 95% CI 0.76 to 3.11; n = 1667, three trials); length of third stage of labour (minutes) (mean difference (MD) -0.30, 95% CI -0.95 to 0.36; n = 1667, three trials); postpartum blood loss (ml) (MD 22.32, 95% CI -58.21 to 102.86; n = 181, two trials); changes in haemoglobin (g/dL) (MD 0.06, 95% CI -0.60 to 0.72; n = 51, one trial); blood transfusion (RR 0.79, 95% CI 0.23 to 2.73; n = 1667, three trials); the use of additional uterotonics (RR 1.10, 95% CI 0.80 to 1.52; n = 1667, three trials); the incidence of maternal hypotension (RR 2.48, 95% CI 0.23 to 26.70; n = 130, one trial) and the incidence of severe postpartum haemorrhage (blood loss 1000 ml or more) (RR 0.98, 95% CI 0.48 to 1.98; n = 130, one trial). No data on other maternal or neonatal outcome measures were available.

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