Third Stage of Labor, feat. Dr. Alyssa Hersh

Today we are joined by Dr. Alyssa Hersh, a resident at Oregon Health and Sciences University (OHSU) who is the lead author on a new Gray Journal (AJOG) review on the third stage of labor.

Check out the paper for all the good stuff, but here are the highlights of the podcast:

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• The third stage of labor occurs between fetal and placental delivery. It typically lasts 4-10 minutes, with complications starting to increase after 30 minutes.

• WThe ACOG definition of postpartum hemorrhage is blood loss ≥1,000 milliliters regardless of mode of delivery, or blood loss along with signs of excessive blood loss.

  • Remember the 4 T’s of etiologies of postpartum hemorrhage, including tone, tissue, trauma and thrombin.

• The original components of active management of the third stage of labor include:

  • Uterotonic, namely oxytocin;

  • Early cord clamping;

  • Controlled cord traction;

  • External uterine massage.

    • However, not all of these components are still evidence-based.

• There may be more effective uterotonic regimens than oxytocin alone for preventing postpartum hemorrhage.

• While TXA may be an effective adjunct to a uterotonic for prevention of postpartum hemorrhage, current evidence is conflicting and there is insufficient evidence to support its broad use at this time after all births.

• There is evidence supporting the use of controlled cord traction, particularly for reducing the need for manual extraction of the placenta.

  • External uterine massage is not effective for preventing postpartum hemorrhage.

• Early cord clamping has largely been replaced with delayed cord clamping due to the known benefits for both preterm and term infants.

• Cord milking may be harmful for very preterm neonates without sufficient data to support using it for neonates at higher gestational ages.