Give a uterotonic routinely during the third stage of labor

By which route and at what dosage, then?

The most common oxytocin regimens following delivery are

• 10 to 20 units in 1 L of fluid, administered at 100–150 mL/h by continuous infusion
• 5 to 10 units in an IV bolus
• 10 units as an intramuscular injection. The 2 trials summarized above both used an IV bolus of oxytocin. In the United States, however, common practice is to administer a continuous infusion after delivery.

In 1 trial, Davies and colleagues compared methods of administration by randomizing 201 women postpartum to receive an IV bolus of 10 units of oxytocin or continuous infusion of 10 units of oxytocin in 500 mL of saline.⁵ Women treated with the IV bolus had, on average, less blood loss (358 mL) than those treated with IV infusion (424 mL) (P=.029).

In the Davies study, bolus oxytocin was not associated with adverse hemodynamic effects in the mother. Additional studies are warranted to clarify whether the benefit of an IV bolus is potentially superior to that of continuous infusion.

Laissez-faire isn’t acceptable

Some clinicians exhibit an interesting disconnect between knowledge and practice when they discuss how they manage the third stage of labor. Almost all acknowledge that clinical trials demonstrate that active management of the third stage of labor reduces maternal blood loss. In practice, however, they report a laissez-faire approach to the third stage: They either administer a uterotonic only if bleeding is excessive or do not have a standardized approach to administering oxytocin postpartum.

We continue to work on “truing-up” patterns of practice in light of strong clinical evidence. To that end, it’s time to uniformly adopt a policy of administering oxytocin during the third stage of labor.