Evidence-based Labor Management: Third stage of labor (Part 5).

During the third stage of labor: oxytocin and tranexamic acid (TXA), or oxytocin and misoprostol, or oxytocin and methylergometrine, or carbetocin are recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 international units, IU) immediately after delivery of the neonate (either after anterior shoulder or whole body), and before delivery of the placenta is recommended. If oxytocin and TXA combination is chosen, intravenous TXA (1gram) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery are recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) both immediately after delivery of the neonate are recommended. If there is no IV access or in low resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2mg) and intravenous oxytocin (10 IU) both immediately after delivery of the neonate are recommended. Single dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for about 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage or nipple stimulation for prevention of postpartum hemorrhage. Repair of first and second degree laceration with continuous synthetic suture technique is recommended. No repair of first degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single dose second generation cephalosporin at the time of third or fourth degree laceration repair can be considered. Skin-to-skin after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.