Choice of uterotonic medication for managing the third stage of labor

PPH: postpartum hemorrhage.

* There is no consensus regarding the precise criteria that distinguish patients who are at low risk for PPH from those who are at higher risk. A patient can be considered low risk for PPH if they have a singleton gestation and a past history of ≤1 previous cesarean deliveries, ≤4 previous spontaneous vaginal deliveries, no bleeding diathesis, no PPH, no large fibroids, and no pregnancy complications that increase the risk for bleeding at delivery. Refer to UpToDate topic on overview of PPH. Another approach is to treat all patients as high risk for PPH using one of the drug regimens described above for patients not at low risk.

¶ Oxytocin: 10 to 40 units of oxytocin in 500 to 1000 mL of 0.9% saline, with the rate of infusion adjusted up to 500 mL/hour, until the uterus is contracted. The rate is then decreased (eg, 1 to 2.5 units/hour) as long as uterine tone is maintained and bleeding is not excessive.

Dosing:

• Oxytocin intravenous infusion: 10 to 40 units of oxytocin in 500 to 1000 mL of 0.9% saline, with the rate of infusion adjusted up to 500 mL/hour, until the uterus is contracted.
  • The infusion rate is then decreased (eg, 1 to 2.5 units/hour) as long as uterine tone is maintained and bleeding is not excessive.
• Misoprostol 200 to 400 mcg buccally or sublingually, single dose.
• Tranexamic acid 1 g intravenously over 10 minutes, single dose.
• Methylergometrine 0.2 mg intramuscularly, single dose.
• Oxytocin-ergometrine (combination drug oxytocin 5 units plus ergometrine 0.5 mg) intramuscularly, single dose. Not available in the United States.
• Carbetocin 100 mcg intravenously over 1 minute, single dose. Not available in the United States.

◊ The total oxytocin infusion time in patients with a normal uterine tone and volume of bleeding varies among providers; a minimum of 4 hours after birth is common.