A double-blinded, randomized controlled trial of oxytocin at the beginning versus the end of the third stage of labor for prevention of postpartum hemorrhage. A randomized controlled trial of oxytocin administered at the end of the second stage of labor versus oxytocin administered at the end of the third stage of labor in the prevention of postpartum hemorrhage. A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage.
The objective of this study was to compare the administration of oxytocin at the beginning and end of the third stage of labor for the prevention of postpartum hemorrhage.
                Patients with documented singleton pregnancies were randomly assigned to two groups. The first received 10 units of oxytocin intramuscularly at delivery of the anterior shoulder of the fetus and an identical appearing placebo injection following delivery of the placenta. The second received the opposite medication sequence. The study was double blinded. Blood loss was measured by weighing all fluids collected, visual estimation, and serial blood counts.
                27 women received oxytocin at the delivery of the fetal shoulder and 24 after the placenta. Oxytocin given after placenta delivery resulted in lower blood loss (345 vs. 400 ml, p = 0.28), lower collection bag weight (763 vs. 833 g, p = 0.55), lower change in HgB (-1.26 vs. -1.32 g, p = 0.86), lower DeltaHCT (-3.43 vs. -3.64%, p = 0.85), and a shorter third stage of labor duration (8.6 vs. 9.2 min, p = 0.75). The incidence of postpartum hemorrhage, defined as estimated blood loss >500 ml (0 vs. 14.8%) was significantly lowered with oxytocin following placental delivery (p = 0.049).
                In our study, postpartum hemorrhage was less frequent when oxytocin administration was delayed until after placenta delivery.
                Copyright 2004 S. Karger AG, Basel The general objective was to determine the incidence of postpartum hemorrhage when oxytocin was administered at the end of the second stage of labor compared to when oxytocin was administered at the end of the third stage. The specific objectives were to determine the mean amount of blood loss, duration of the third stage of labor, need for additional uterotonics and blood transfusion, incidence of hypotension and retained placenta, and mean difference in hemoglobin levels. A randomized controlled trial was conducted in a tertiary care training hospital. 130 women with term, singleton, live pregnancies in cephalic presentation who delivered vaginally were included. Patients were randomly allocated to receive oxytocin after the second stage or after the third stage of labor. Oxytocin was administered as a continuous intravenous infusion. The placenta was delivered by controlled cord traction after placental separation. Blood loss was measured by weight, and the corresponding volume was computed. Relative risk was calculated. Incidence of postpartum hemorrhage, volume of blood loss, duration of the third stage of labor, need for additional uterotonics and blood transfusion, incidence of hypotension and retained placenta, and difference in hemoglobin levels were the main outcome measures. There was a decreased incidence of postpartum hemorrhage (39.66% vs. 48.61%, relative risk [RR] = 0.82, 95% confidence interval [CI] = 0.55-1.21) and less amount of blood loss (557.93 ml vs. 636.84 ml, p = 0.352) when oxytocin was administered at the end of the second stage of labor. There was less need for additional uterotonics (12.07% vs. 13.89%, RR = 0.87, 95% CI = 0.35-2.14), and blood transfusion (5.17% vs. 5.56%, RR = 0.87, 95% CI = 0.22-3.99). There was a smaller mean difference in hemoglobin (16.20 g/dl vs. 20.29 g/dl, p = 0.145). Mean duration of the third stage of labor were comparable (7.93 minutes vs. 7.96 minutes, p = 0.863). However, more patients developed hypotension (3.45% vs. 1.39%, RR = 2.48, 95% CI = 0.23-26.70). All results were not statistically significant. There was no incidence of retained placenta. There is a trend towards a reduction of the risk of postpartum hemorrhage when oxytocin is administered at the end of the second stage of labor. This is not accompanied by an increased risk for any morbidity. To determine if the timing of the administration of prophylactic oxytocin influences the incidence of postpartum hemorrhage caused by uterine atony, retained placenta, and third-stage duration.
                Parturients who presented for vaginal delivery were randomized in a double-blinded fashion to receive oxytocin, 20 units in a 500-mL crystalloid intravenous bolus, beginning upon delivery of either the fetal anterior shoulder or placenta. For all patients, the third stage of labor was managed with controlled cord traction until placental expulsion, followed by at least 15 seconds of fundal massage. Patients were excluded if they had a previous cesarean section, multiple gestation, antepartum hemorrhage, or bleeding disorder.
                A total of 1486 patients were enrolled: 745 in the before-placenta group and 741 in the after-placenta group. The groups were similar with respect to gestational age, fetal weight, labor duration, maternal age, parity, and ethnicity. The incidence of postpartum hemorrhage did not differ significantly between the two groups (5.4% vs 5.8%; crude OR, 0.92; 95% CI, 0.59 to 1.43). There were no significant differences between the two groups with respect to incidence of retained placenta (2.4% vs 1.6%; OR, 1.49; 95% CI, 0.72 to 3.08), or third-stage duration (7.7 minutes vs 8.1 minutes; P =.23).
                The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta.
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.