EVIDENCE-BASED ANSWER
Either is fine.
Timing alone doesn’t influence the drug’s efficacy in preventing postpartum bleeding (strength of recommendation: B, randomized controlled trial [RCT] and prospective cohort studies).
Evidence summary
The prophylactic use of oxytocic drugs reduces the risk of postpartum hemorrhage (PPH) by about 40% and has been widely adopted as a routine policy in the active management of the third stage of labor.1 A number of studies have evaluated the timing of oxytocin after delivery (TABLE).
TABLE
What studies say about the timing of oxytocin and PPH risk
| STUDY TYPE (YEAR) | OXYTOCIN GIVEN AFTER | OUTCOMES (RISK OF PPH) | |
|---|---|---|---|
| DELIVERY OF ANTERIOR SHOULDER (N) | DELIVERY OF PLACENTA (N) | ||
| DBRCT (2001)2 | 745 | 741 | No difference (OR=0.92; 95% CI, 0.59-1.43) |
| DBRCT (2004)3 | 27 | 24 | Incidence lower when given after delivery of placenta (P=.049) |
| Cohort (2006)4 | 82 | 52 | Incidence lower when given after delivery of anterior shoulder (OR=0.33; 95% CI, 0.11-0.98) |
| RCT (1997)5 | 827 | 821 | Incidence lower when given after delivery of anterior shoulder (OR=0.50; 95% CI, 0.34-0.73) |
| Cohort (1996)6 | 524 (given after delivery of head) | 478 | Incidence lower when given after delivery of head (OR=0.60; 95% CI, 0.41-0.87) |
| CI, confidence interval; DBRCT, double-blinded randomized controlled trial; OR, odds ratio; PPH, postpartum hemorrhage; RCT, randomized controlled trial. | |||
Which timing is best? It depends on the study
A well-constructed double-blinded RCT found no significant difference in the incidence of PPH when oxytocin was given after delivery of the anterior shoulder or the placenta.2 The study included 1486 patients; 745 received 20 units of oxytocin on delivery of the anterior shoulder, and 741 received an identical dose of oxytocin on delivery of the placenta. The incidence of PPH was 5.4% for the anterior shoulder group and 5.8% for the placenta group (P=.72). Likewise, no significant difference between the groups was noted in the proportion of women with estimated blood loss (EBL) ≥500 mL (7.5% vs 9.7%; P=.15).
A much smaller double-blinded RCT found that PPH occurred significantly less often when oxytocin was delayed until after delivery of the placenta.3 The study comprised 51 patients; 27 received 10 units of oxytocin on delivery of the anterior shoulder and 24 received an identical dose after delivery of the placenta. The incidence of PPH ≥500 mL was 0% when oxytocin was given after delivery of the placenta vs 14.8% when it was given on delivery of the anterior shoulder (P=.049). However, the study was limited by its size and potential inaccuracies in estimating blood loss.