Routine management of the third stage – oxytocin

Bibliographic reference Study type Evidence level Number of patients Patient characteristics Intervention Comparison Length of follow-up Outcome measures Effect size Source of funding Additional comments
Elbourne DR;Prendiville WJ;Carroli G;Wood J;McDonald S;

2005373
Systematic review - meta- analysisEvidence level: 1++30 trialsAll trials including pregnant women anticipating a vaginal delivery were considered, regardless of other aspects of third stage managementIntervention: Oxytocin given prophylactically for the third stage of labour, at whatever doseComparison: any otherFollow-up period: N/AOutcome Measures: Postpartum haemorrhage (PPH) (reported estimates of blood loss greater than or equal to 500mls)
Severe PPH (clinically estimated blood loss greater than or equal to 1000mls)
Mean blood loss (mls)
Maternal haemoglobin concentration (Hb) < 9gms/decilitre 24 to 48 hours postpartum
Blood transfusion
Iron tablets during the puerperium
Therapeutic uterotonics
Third stage > 20 minutes
Third stage > 40 minutes
Mean length of third stage (minutes)
Manual removal of the placenta
Subsequent surgical evacuation of retained products of conception
Diastolic blood pressure > 100mmHg between delivery of baby and discharge from the labour ward
Vomiting between delivery of baby and discharge from the labour ward
Nausea between delivery of baby and discharge from the labour ward
Headache between delivery of baby and discharge from the labour ward
Maternal pain during third stage of labour
Maternal dissatisfaction with third stage management
Secondary PPH (after 24 hours and before six we
Oxytocin vs no uterotonics (all trials)

PPH (clinically estimated blood loss > or = 500ml)
 6 trials
 3193 women
Relative Risk (Fixed) 95% CI
 0.50 [0.43, 0.59]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 4 trials
 2243 women
Relative Risk (Fixed) 95% CI
 0.61 [0.44, 0.87]

Mean blood loss (ml)
 4 trials
 1373 women
 Weighted Mean Difference (Fixed) 95% CI
  −101.93 [−134.89, −68.97]

Maternal haemoglobin concentration (Hb) < 9gms/deciltre 24 to 48 hours postpartum
 1 trial
 943 women
Relative Risk (Fixed) 95% CI
  0.63 [0.36, 1.09]

Blood transfusion
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 1.30 [0.50, 3.39]

Therapeutic uterontonics
 5 women
 2327 trials
Relative Risk (Fixed) 95% CI
0.50 [0.39, 0.64]

Mean length of third stage (mins)
 1 trial
 52 women
 Weighted Mean Difference (Fixed) 95% CI
 −1.80 [−5.55, 1.95]

Manual removal of the placenta
 4 trials
 2243 women
Relative Risk (Fixed) 95% CI
 1.17 [0.79, 1.73]

Nausea between delivery of the baby and discharge from the labour ward
 1 trial
 52 women
Relative Risk (Fixed) 95% CI
 0.29 [0.01, 6.74]

Oxytocin vs no uterotonics (randomised trials only)

PPH (clinically estimated blood loss > or = 500ml)
 4 trials
 2213 women
Relative Risk (Fixed) 95% CI
 0.61 [0.51, 0.72]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 3 trials
 1273 women
Relative Risk (Fixed) 95% CI
 0.72 [0.49, 1.05]

Mean blood loss (ml)
 3 trials
 1273 women
 Weighted Mean Difference (Fixed) 95% CI
  −109.12 [−151.93, −66.31]

Maternal haemoglobin concentration (Hb) <
9gms/deciltre 24 to 48 hours postpartum
 1 trial
 943 women
Relative Risk (Fixed) 95% CI
 0.63 [0.36, 1.09]

Blood transfusion
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 1.30 [0.50, 3.39]

Therapeutic uterontonics
 4 trials
 2227 women
Relative Risk (Fixed) 95% CI
 0.53 [0.41, 0.69]

Mean length of third stage (mins)
 1 trial
 52 women
 Weighted Mean Difference (Fixed) 95% CI
  −1.80 [−5.55, 1.95]

Manual removal of the placenta
 3 trials
 1273 women
Relative Risk (Fixed) 95% CI
 1.67 [0.82, 3.41]

Nausea between delivery of the baby and discharge from the labour ward
 1 trial
 52 women
Relative Risk (Fixed) 95% CI
 0.29 [0.01, 6.74]

Oxytocin vs no uterotonics (active management only)

PPH (clinically estimated blood loss > or = 500ml)
 1 trial
 970 women
Relative Risk (Fixed) 95% CI
 0.29 [0.21, 0.41]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 1 trial
 970 women
Relative Risk (Fixed) 95% CI
 0.33 [0.14, 0.77]

Manual removal of the placenta
 1 trial
 970 women
Relative Risk (Fixed) 95% CI
 0.99 [0.62, 1.59]

Oxytocin vs no uterotonics (expectant management only)

PPH (clinically estimated blood loss > or = 500ml)
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 0.61 [0.51, 0.73]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 0.73 [0.49, 1.07]

Mean blood loss (ml)
 2 trials
 1221 women
 Weighted Mean Difference (Fixed) 95% CI
  −83.58 [−118.02, −49.14]

Maternal haemoglobin concentration (Hb) < 9gms/deciltre 24 to 48 hours postpartum
 1 trial
 943 women
Relative Risk (Fixed) 95% CI
 0.63 [0.36, 1.09]

Blood transfusion
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 1.30 [0.50, 3.39]

Therapeutic uterontonics
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 0.66 [0.48, 0.90]

Manual removal of the placenta
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 1.67 [0.82, 3.41]

Oxytocin vs no uterotonics (given before placental delivery)

PPH (clinically estimated blood loss > or = 500ml)
 5 trials
 2253 women
Relative Risk (Fixed) 95% CI
 0.50 [0.42, 0.58]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 4 trials
 2243 women
Relative Risk (Fixed) 95% CI
 0.61 [0.44, 0.87]

Mean blood loss (ml)
 3 trials
 1273 women
 Weighted Mean Difference (Fixed) 95% CI
  −109.12 [−151.93, −66.31]

Maternal haemoglobin concentration (Hb) < 9gms/deciltre 24 to 48 hours postpartum
 1 trial
 943 women
Relative Risk (Fixed) 95% CI
 0.63 [0.36, 1.09]

Blood transfusion
 2 trials
 1221 women
Relative Risk (Fixed) 95% CI
 1.30 [0.50, 3.39]

Therapeutic uterontonics
 3 trials
 1273 women
Relative Risk (Fixed) 95% CI
 0.64 [0.47, 0.87]

Mean length of third stage (mins)
 1 trial
 52 women
 Weighted Mean Difference (Fixed) 95% CI
  −1.80 [−5.55, 1.95]

Manual removal of the placenta
 4 trial
 2243 women
Relative Risk (Fixed) 95% CI
 1.17 [0.79, 1.73]

Nausea between delivery of the baby and discharge from the labour ward
 1trial
 52 women
Relative Risk (Fixed) 95% CI
 0.29 [0.01, 6.74]

Oxytocin vs no uterotonics (given after placental delivery)

PPH (clinically estimated blood loss > or = 500ml)
 1 trial
 940 women
Relative Risk (Fixed) 95% CI
 0.60 [0.32, 1.12]

Mean blood loss (ml)
 1 trial
 100 women
 Weighted Mean Difference (Fixed) 95% CI
 12.00 [−102.30, 126.30]

Therapeutic uterontonics
 2 trials
 1054 women
Relative Risk (Fixed) 95% CI
 0.32 [0.20, 0.50]

Oxytocin vs ergot alkaloids (all trials)

PPH (clinically estimated blood loss > or = 500ml)
 5 trials
 2719 women
Relative Risk (Fixed) 95% CI
 0.90 [0.70, 1.16]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 3 trials
 1746 women
Relative Risk (Fixed) 95% CI
 0.99 [0.56, 1.74]

Mean blood loss (ml)
 2 trials
 1273 women
 Weighted Mean Difference (Fixed) 95% CI
  −29.12 [−59.36, 1.13]

Blood transfusion
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 3.74 [0.34, 40.64]

Therapeutic uterontonics
 2 trials
 1208 women
Relative Risk (Fixed) 95% CI
 1.02 [0.67, 1.55]

Third stage > 20 minutes
 1 trial
 473 women
Relative Risk (Fixed) 95% CI
 Not estimable

Third stage > 40 minutes
 1 trial
 383 women
Relative Risk (Fixed) 95% CI
 Not estimable

Mean length of third stage (mins)
 1 trial
 1049 women
 Weighted Mean Difference (Fixed) 95% CI
 −0.80 [−1.65, 0.05]

Manual removal of the placenta
 3 trials
 1746 women
Relative Risk (Fixed) 95% CI
 0.57 [0.41, 0.79]

Diastolic blood pressure > 100 mm Hg between delivery of the baby and discharge from the labour ward
 1 trial
 150 women
Relative Risk (Fixed) 95% CI
 0.53 [0.19, 1.52]

Oxytocin vs ergot alkaloids (randomised trials only)

PPH (clinically estimated blood loss > or = 500ml)
 3 trials
 1660 women
Relative Risk (Fixed) 95% CI
 1.03 [0.73, 1.47]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 2 trials
 697 women
Relative Risk (Fixed) 95% CI

 1.09 [0.45, 2.66]

Mean blood loss (ml)
 1 trial
 224 women
 Weighted Mean Difference (Fixed) 95% CI
 23.00 [−91.86, 137.86]

Blood transfusion
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 3.74 [0.34, 40.64]

Therapeutic uterontonics
 2 trials
 1208 women
Relative Risk (Fixed) 95% CI
 1.02 [0.67, 1.55]

Third stage > 20 minutes
 1 trial
 473 women
Relative Risk (Fixed) 95% CI
 Not estimable

 Third stage > 40 minutes
 1 trial
 473 women
Relative Risk (Fixed) 95% CI
 Not estimable

 Manual removal of the placenta
 2 trials
 697 women
Relative Risk (Fixed) 95% CI
 0.71 [0.49, 1.03]

Oxytocin vs ergot alkaloids (active management only)

No outcomes currently reported

Oxytocin vs ergot alkaloids (expectant management only)

PPH (clinically estimated blood loss > or = 500ml)
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 0.87 [0.59, 1.28]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 1.09 [0.45, 2.66]
Mean blood loss (ml)
 1 trial
 224 women
 Weighted Mean Difference (Fixed) 95% CI
 23.00 [−91.86, 137.86]

Blood transfusion
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 3.74 [0.34, 40.64]

Therapeutic uterontonics
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 1.25 [0.67, 2.31]

Manual removal of the placenta
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 0.94 [0.09, 10.16]

Oxytocin vs ergot alkaloids (given before placental delivery)

PPH (clinically estimated blood loss > or = 500ml)
 4 trials
 1756 women
Relative Risk (Fixed) 95% CI
 0.83 [0.64, 1.08]

Severe PPH (clinically estimated blood loss > or = 1000ml)
 3 trials
 1746 women
Relative Risk (Fixed) 95% CI
 0.99 [0.56, 1.74]

 Mean blood loss (ml)
 2 trials
 1273 women
 Weighted Mean Difference (Fixed) 95% CI
 −29.12 [−59.36, 1.13]

Blood transfusion
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 3.74 [0.34, 40.64]

Therapeutic uterontonics
 1 trial
 224 women
Relative Risk (Fixed) 95% CI
 1.25 [0.67, 2.31]

Third stage > 20 minutes
 1 trial
 473 women
Relative Risk (Fixed) 95% CI
 Not estimable

Third stage > 40 minutes
 1 trial
 473 women
Relative Risk (Fixed) 95% CI
 Not estimable

Mean length of third stage (mins)
 1 trial
 1049 women
 Weighted Mean Difference (Fixed) 95% CI
 −0.80 [−1.65, 0.05]

Manual removal of the placenta
 3 trials
 1746 women
Relative Risk (Fixed) 95% CI
 0.57 [0.41, 0.79]

Diastolic blood pressure > 100 mm Hg between delivery of the baby and discharge from the labour ward
 1 trial
 150 women
Relative Risk (Fixed) 95% CI
 0.53 [0.19, 1.52]

Oxytocin vs ergot alkaloids (given after placental delivery)

PPH (clinically estimated blood loss > or = 500ml)
 1 trial
 963 women
Relative Risk (Fixed) 95% CI
 1.75 [0.77, 3.96]

Therapeutic uterontonics
 1 trial
 984 women
Relative Risk (Fixed) 95% CI
 0.89 [0.50, 1.56]

Oxytocin+ergot alkaloids (Syntometrine) vs ergot alkaloids alone (all trials)

PPH (clinically estimated blood loss > or = 500ml)
 5 trials
 2891 women
Relative Risk (Fixed) 95% CI
 1.29 [0.90, 1.84]

Severe PPH (clinically estimated blood loss > or = 1000ml)

 1 trial
 1120 women
Relative Risk (Fixed) 95% CI
 1.67 [0.40, 6.94]

Blood transfusion
 1 trial
 1120 women
Relative Risk (Fixed) 95% CI
 0.71 [0.23, 2.24]

Third stage > 20 minutes
 3 trials
 2281 women
Relative Risk (Fixed) 95% CI
 0.89 [0.67, 1.19]

Manual removal of the placenta
 2 trials
 1927 women
Relative Risk (Fixed) 95% CI
 1.02 [0.48, 2.20]

Oxytocin+ergot alkaloids (Syntometrine) vs ergot alkaloids alone (randomised trials)

PPH (clinically estimated blood loss > or = 500ml)
 2 trials
 1161 women
Relative Risk (Fixed) 95% CI
 0.44 [0.20, 0.94]

Third stage > 20 minutes
 1 trial
 354 women
Relative Risk (Fixed) 95% CI
 3.21 [0.34, 30.57]

Oxytocin+ergot alkaloids (Syntometrine) vs ergot alkaloids alone (active management)

PPH (clinically estimated blood loss > or = 500ml)
 1 trial
 416 women
Relative Risk (Fixed) 95% CI
 0.22 [0.03, 1.85]

Third stage > 20 minutes
 1 trial
 416 women
Relative Risk (Fixed) 95% CI
 6.54 [0.79, 53.87]

Manual removal of the placenta
 1 trial
 416 women
Relative Risk (Fixed) 95% CI
 4.36 [0.49, 38.70]

Oxytocin+ergot alkaloids (Syntometrine) vs ergot alkaloids alone (expectant management)

No outcomes currently reported

Oxytocin+ergot alkaloids (Syntometrine) vs ergot alkaloids alone (given before placental delivery)

PPH (clinically estimated blood loss > or = 500ml)
 5 trials
 2891 women
Relative Risk (Fixed) 95% CI
 1.29 [0.90, 1.84]

Severe PPH (clinically estimated blood loss > or = 1000ml)

 1 trial
 1120 women
Relative Risk (Fixed) 95% CI
 1.67 [0.40, 6.94]

Blood transfusion
 1 trial
 1120 women
Relative Risk (Fixed) 95% CI
 0.71 [0.23, 2.24]

Third stage > 20 minutes
 3 trials
 2281 women
Relative Risk (Fixed) 95% CI
 0.89 [0.67, 1.19]

Manual removal of the placenta
 2 trials
 1927 women
Relative Risk (Fixed) 95% CI
 1.02 [0.48, 2.20]

Oxytocin+ergot alkaloids (Syntometrine) vs ergot alkaloids alone (given after placental delivery)

No outcomes currently reported
Nil

From: Evidence tables

Cover of Intrapartum Care
Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth.
NICE Clinical Guidelines, No. 55.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2007 Sep.
Copyright © 2007, National Collaborating Centre for Women’s and Children’s Health.

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