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952
Frolova et al
RESULTS
There were 7,121 consecutive term deliveries meeting
inclusion criteria in our cohort. Of these, 2,763 were
nulliparous and 4,358 were multiparous (Table 1).
Several baseline clinical characteristics differed by
parity. On average, nulliparous women were younger,
less likely to be obese, and had a higher incidence of
prolonged second stage of labor and chorioamnionitis. Nulliparous women were also more likely to have
Total Cohort
(N57,121)
Nulliparous Women
(n52,763)
Multiparous
Women (n54,358)
25.6765.86
602 (8.5)
23.0865.61
109 (3.9)
27.3065.42
493 (11.3)
4,601 (64.6)
1,602 (22.5)
548 (7.7)
38.8661.18
31.7767.21
3,759 (53.5)
201 (2.8)
80 (1.1)
1,085 (15.2)
630 (8.8)
4,598 (64.6)
335 (5.8)
326 (4.6)
7.2860.06
3,2226451
337 (4.7)
199 (2.8)
1,697 (61.4)
728 (26.3)
156 (5.6)
38.9361.20
30.8367.16
1,275 (46.5)
75 (2.7)
27 (1.0)
646 (23.4)
374 (13.5)
1,962 (71.0)
129 (4.8)
190 (6.9)
7.2660.06
3,1626440
89 (3.2)
147 (5.3)
2,904 (66.6)
874 (20.1)
392 (9.0)
38.8261.16
32.3667.18
2,484 (57.9)
126 (2.9)
53 (1.2)
439 (10.1)
256 (5.9)
2,636 (60.5)
206 (4.9)
136 (3.1)
7.2960.06
3,2606454
248 (5.7)
52 (1.2)
3,599 (50.6)
3,520 (49.4)
1,347 (48.8)
1,416 (51.2)
2,253 (51.7)
2,104 (48.3)
6,709 (94.2)
412 (5.8)
2,506 (90.7)
257 (9.3)
4,203 (96.4)
155 (3.6)
P*
,.001
,.001
,.001
,.001
,.001
,.001
.66
.35
,.001
,.001
,.001
.80
,.001
,.001
,.001
,.001
,.001
.028
,.001
Frolova et al
953
Vaginal Delivery
Combined (N57,121)
Nulliparous Women
(n52,763)
Multiparous Women
(n54,358)
P*
5.4665.4
4 (36)
0156
5.3765.1
4 (36)
074
5.5265.6
4 (36)
0156
.26
.60
9
13
28
9
13
28
10
14
28
13 minutes), and 99th percentile was 30 minutes (compared with 28 minutes). To address the risk of bias on
the calculations assessing risk for morbidity, we performed a sensitivity analysis excluding these patients.
The association between postpartum hemorrhage and
duration of the third stage did not change if these cases
of early placental extraction were removed from
analysis.
DISCUSSION
We found that the third stage of labor after a vaginal
delivery is shorter than historically described. In their
1991 study, Combs et al reported that 75% of
placentas were delivered by 10 minutes, whereas
90% of our contemporary obstetric cohort had
delivery of the placental by this time. Other recent
reports also support this finding.5,7 We posit that
active management of the third stage is the most
important contributor to this decreased duration.
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Frolova et al
Table 3. Postpartum Hemorrhage Among Elevated Third Stage of Labor After Vaginal Delivery
Outcome
Rate*
Postpartum hemorrhage
All
90th %tile (greater than 9 min)
95th %tile (greater than 13 min)
99th %tile (greater than 28 min)
Greater than 30 min
Transfusion
All
90th %tile (greater than 9 min)
95th %tile (greater than 13 min)
99th %tile (greater than 28 min)
Greater than 30 minutes
OR (95% CI)
626/7,121 (8.8)
93/705 (13.2)
57/356 (16.0)
20/68 (29.4)
15/44 (34.1)
1.68
2.08
4.43
5.47
(1.332.12)
(1.542.79)
(2.617.52)
(2.9210.3)
1.82
2.22
4.61
5.94
(1.432.31)
(1.643.01)
(2.687.93)
(3.1211.3)
61/7,121 (0.9)
7/705 (1.0)
2/356 (0.6)
1/68 (1.5)
1/44 (2.3)
1.18
0.64
1.74
2.72
(0.542.61)
(0.162.64)
(0.2412.7)
(0.3720.1)
1.18
0.62
1.66
2.83
(0.532.60)
(0.152.57)
(0.2312.2)
(0.3821.0)
Reference group for ORs includes all cases with third-stage durations below the indicated percentile.
Adjusted for parity, induction, prolonged first stage, prolonged second stage.
Frolova et al
955
extractions were performed before 30 minutes duration and were not associated with a postpartum hemorrhage. This suggests that although the current
analysis provides support for earlier intervention,
obstetric practitioners may already be moving in that
direction. Perhaps more important than manual
extraction of a placenta, we need to be prepared
for management of postpartum hemorrhage in the
setting of a third stage that begins to approach
20 minutes.
Some strengths of this study are its large sample
size and detailed data. This was a secondary analysis, which brings some inherent weaknesses such
as a predefined sample size and only previously
collected data, unable to be tailored to our specific
question. This study was also limited by exclusion
of preterm deliveries, which have previously been
shown to have a prolonged third stage of labor.6
Delayed postpartum hemorrhage (within the first
24 hours after delivery) may be underrepresented
in the cohort if it was not adequately recorded by
the physician in the electronic medical record.
Lastly, estimation of blood loss during deliveries
was by the delivering physician. Although visual
estimation of blood loss is the most commonly
clinically used method for estimating blood loss, it
has been shown to underestimate amount of blood
loss and thus our rate of postpartum hemorrhage may also be underestimated. However, it is
reassuring that recent work from our institution
showed that this estimate was correlated with
morbidity.14
In conclusion, we found that duration of the third
stage of labor is shorter in a modern obstetric cohort
relative to historically reported norms. Among term
vaginal deliveries, duration of the third stage of labor of
greater than 20 minutes is associated with increased risk
of postpartum hemorrhage. This suggests that heightened awareness and preparation for the increased risk
of postpartum hemorrhage should be considered earlier
in the third stage of labor.
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Frolova et al
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