Original Article

Association of the Length of the Third Stage of Labor and Blood Loss Following Vaginal Delivery

Authors: Nader Z. Rabie, MD, Songthip Ounpraseuth, PhD, Dawn Hughes, MD, Patrick Lang, MD, Micah Wiegel, MD, Everett F. Magann, MD

Abstract

Objectives: The length of the third stage of labor is correlated with blood loss following a vaginal delivery. We aimed to accurately measure blood loss following a vaginal delivery and examine the relation between blood loss and length of the third stage of labor.

Methods: This was a prospective observational study of singleton pregnancies ≥24 weeks undergoing a vaginal delivery. Blood loss was meticulously measured and the length of the third stage of labor was recorded.

Results: The median blood loss of the 600 women was 125 mL (interquartile range 175) and the median length of the third stage of labor was 5 minutes (interquartile range 4). Total blood loss (P = 0.0263) and length of the third stage of labor (P = 0.0120) were greater in pregnancies ≥37 weeks versus <37 weeks. Women with a third stage of labor ≥15 minutes had a significantly greater risk of blood loss >500 mL (relative risk 5.8, 95% confidence interval 8.36–29.88).

Conclusions: The median blood loss following a vaginal delivery is 125 mL and the median length of the third stage of labor is 5 minutes. Total blood loss and the length of the third stage of labor are greater in pregnancies >37 weeks. Women with a third stage of labor >15 minutes are 15.8 times more likely to have total blood loss ≥500 mL. As such, it is prudent to consider manual extraction of the placenta at 15 minutes rather than 30 minutes to minimize the risk of excessive blood loss.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Pritchard JA. Changes in the blood volume during pregnancy and delivery. Anesthesiology 1965;26:393-399.
 
2. Clark SL, Yeh SY, Phelan JP, et al. Emergency hysterectomy for obstetric hemorrhage. Obstet Gynecol 1984;64:376-380.
 
3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol 2006;108:1039-1047.
 
4. World Health Organization. Trends in maternal mortality: 1990-2013. http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1. Published May 2014. Accessed December 28, 2017.
 
5. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e323-e333.
 
6. Lu MC, Korst LM, Fridman M, et al. Identifying women most likely to benefit from prevention strategies for postpartum hemorrhage. J Perinatol 2009;29:422-427.
 
7. Magann EF, Doherty DA, Briery CM, et al. Timing of placental delivery to prevent post-partum haemorrhage: lessons learned from an abandoned randomised clinical trial. Aust N Z J Obstet Gynaecol 2006;46:549-551.
 
8. Magann EF, Evans S, Chauhan SP, et al. The length of the third stage of labor and the risk of postpartum hemorrhage. Obstet Gynecol 2005;105:290-293.
 
9. Magann EF, Evans S, Hutchinson M, et al. Postpartum hemorrhage after cesarean delivery: an analysis of risk factors. South Med J 2005;98:681-685.
 
10. Magann EF, Evans S, Hutchinson M, et al. Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J 2005;98:419-422.
 
11. Naef RW, 3rd Chauhan SP, Chevalier SP, et al. Prediction of hemorrhage at cesarean delivery. Obstet Gynecol 1994;83:923-926.
 
12. Dombrowski MP, Bottoms SF, Saleh AA, et al. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995;172(4 Pt 1): 1279-1284.
 
13. Combs CA, Laros RK, Jr. Prolonged third stage of labor: morbidity and risk factors. Obstet Gynecol 1991;77:863-867.
 
14. Magann EF, Niederhauser A, Doherty DA, et al. Reducing hemodynamic compromise with placental removal at 10 versus 15 minutes: a randomized clinical trial. Am J Perinatol 2012;29:609-614.
 
15. Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006;113:919-924.
 
16. Dildy GA 3rd, Paine AR, George NC, et al. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol 2004;104:601-606.
 
17. Toledo P, McCarthy RJ, Burke CA, et al. The effect of live and web-based education on the accuracy of blood-loss estimation in simulated obstetric scenarios. Am J Obstet Gynecol 2010;202:400.e1-e5.
 
18. Edmonds JK, Hruschka D, Sibley LM. A comparison of excessive postpartum blood loss estimates among three subgroups of women attending births in Matlab, Bangladesh. J Midwifery Womens Health 2010;55:378-382.
 
19. Razvi K, Chua S, Arulkumaran S, et al. A comparison between visual estimation and laboratory determination of blood loss during the third stage of labour. Aust N Z J Obstet Gynaecol 1996;36:152-154.
 
20. Tibshirani R. Regression shrinkage and selection via the lasso: a retrospective. J R Stat Soc Ser B Stat Methodol 2011;73:273-282.
 
21. Cummings K, Doherty DA, Magann EF, et al. Timing of manual placenta removal to prevent postpartum hemorrhage: is it time to act? J Matern Fetal Neonatal Med 2016;29:3930-3933.
 
22. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004;159:702-706.
 
23. McNutt LA, Wu C, Xue X, et al. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol 2003;157:940-943.
 
24. Gulmezoglu AM, Villar J, Ngoc NT, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet 2001;358:689-695.
 
25. Newton M, Mosey LM, Egli GE, et al. Blood loss during and immediately after delivery. Obstet Gynecol 1961;17:9-18.