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Original Research

Duration of the Third Stage of Labor and


Risk of Postpartum Hemorrhage
Antonina I. Frolova, MD, PhD, Molly J. Stout, MD, MSCI, Methodius G. Tuuli, MD, MPH,
Julia D. Lpez, MPH, LCSW, George A. Macones, MD, MSCE, and Alison G. Cahill, MD, MSCI
OBJECTIVE: To characterize the duration of the third
stage of labor and the association with postpartum
hemorrhage in a contemporary cohort.
METHODS: We performed a secondary analysis of
a cohort of 7,121 women who had a vaginal delivery at
or beyond 37 weeks 0 days of gestation at a single
tertiary care center from April 2010 to August 2014.
Active management of the third stage of labor was
routinely used during the study period. The mean,
median, interquartile range, 90th percentile, 95th percentile, and 99th percentile of the third stage of labor
duration were calculated. Odds ratios were calculated to
estimate the association between increased duration of
third stage of labor and incidence of postpartum hemorrhage.
RESULTS: The mean duration of the third stage of labor
among women who had a vaginal delivery was 5.46
(standard deviation 5.4) minutes and median duration
was 4 minutes. The 90th, 95th, and 99th percentiles were
defined by 9, 13, and 28 minutes, respectively. Women
with a third stage above the 90th percentile (n5705) had
an increased risk for postpartum hemorrhage compared
with a third stage below the 90th percentile (13.2% compared with 8.3%; adjusted odds ratio [OR] 1.82, 95%
confidence interval [CI] 1.432.31). When the 90th percentile was further subdivided into 5-minute increments,
risk for postpartum hemorrhage significantly increased
beginning at 2024 minutes compared with shorter
From the Department of Obstetrics and Gynecology, Washington University
School of Medicine, St. Louis, Missouri.
Dr. Cahill is supported by the Eunice Kennedy Shriver National Institute of
Child Health and Human Development (R01HD061619-01, Principal Investigator Cahill), which partially supported this work.
Corresponding author: Antonina I. Frolova, MD, PhD, Department of Obstetrics
and Gynecology, Washington University School of Medicine, 660 S Euclid
Avenue, Box 8064, St. Louis, MO 63110; e-mail: frolovaa@wudosis.wustl.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2016 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16

VOL. 127, NO. 5, MAY 2016

third-stage durations (15.9% compared with 8.5%;


adjusted OR 2.38, 95% CI 1.184.79). However, blood
transfusion was not associated with third-stage duration
(1.0% compared with 0.84% for third-stage duration
greater than 90th compared with 90th percentile or less,
adjusted OR 1.18, 95% CI 0.532.60).
CONCLUSION: Our data show that postpartum hemorrhage risk increases significantly when the third stage
of labor duration is 20 minutes or more, suggesting that
the definition of a prolonged third stage of labor being
30 minutes or more may be outdated.
(Obstet Gynecol 2016;127:9516)
DOI: 10.1097/AOG.0000000000001399

prolonged third stage of labor has traditionally


been defined as one lasting greater than 30 minutes.
This definition is based on a 1991 report that demonstrated risks of maternal morbidities, including postpartum hemorrhage and the need for blood transfusion,
began rising after duration of the third stage exceeded
30 minutes,1 yet both the modern obstetric population
and standard obstetric practice have evolved since publication of this study. One very significant change in
obstetric practice is the shift toward routine active management of the third stage after vaginal deliveries. This
involves administering an uterotonic agent, clamping
the cord early, and providing controlled cord traction
until the placenta is delivered. These active management strategies have consistently been shown to
decrease postpartum hemorrhage by 5070%.2
Active management has also been shown to
decrease the average duration of the third stage,
although this has not been studied as rigorously.3,4
Recent studies suggest the risk of postpartum hemorrhage may increase earlier than the commonly referenced 30 minutes with some suggesting that risk
increases as early as 1015 minutes after a vaginal
delivery.5,6 Together these data suggest that the definition of a prolonged third stage of labor in modern
obstetrics needs to be reexamined.

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951

The aim of this study was to characterize the


duration of the third stage of labor in a modern
obstetric cohort and examine the association between
increasing duration and postpartum hemorrhage.

MATERIALS AND METHODS


This was a secondary analysis of a cohort of all term
laboring women at Washington University Medical
Center in St. Louis, Missouri, between April 2010 and
August 2014. Washington University in St. Louis
Human Research Protection Office approved this
study. To be included in this study, patients were
required to be in labor (either spontaneous or
induced) at or beyond 37 weeks 0 days of gestation
by best obstetric estimate. Women with multifetal
gestations, preterm gestational ages at delivery, and
cesarean deliveries were excluded.
Our institution uses the standard practice of active
management of the third stage of labor; thus, it was
used during the entire study period. The umbilical
cord was clamped and cut immediately after the
neonate was delivered. A segment of cord was then
reclamped and cut for umbilical artery blood gas
measurements. Oxytocin administration was started
immediately after delivery of the neonate and the
umbilical cord clamping. The oxytocin was delivered
as either 30 units in 500 mL of lactated Ringers solution through an intravenous bolus or as 10 units
administered intramuscularly if the patient did not
have intravenous access. Placentas generally were
delivered by controlled cord traction with external
fundal massage performed. These were both begun
as soon as the cord was clamped and the cord gas
segment was removed or after cord blood was collected for banking. Our institution does not use standard delay of cord clamping for term deliveries.
However, if this practice was requested by a patient
and used at the time of delivery, the cord clamping
was delayed by approximately 3045 seconds and
traction was started as outlined previously. All women
then received an additional intravenous infusion of 30
units of oxytocin in 1,000 mL of lactated Ringers
solution administered over 8 hours.
Trained obstetric research nurses abstracted
detailed demographic information; obstetric, gynecologic, prenatal, medical, and surgical histories; antepartum history; and labor and delivery course. The
third stage of labor duration was calculated in minutes
as the time from neonatal delivery to placenta
delivery. Postpartum hemorrhage was defined as an
estimated blood loss of 500 mL or greater or if
patients had a postpartum hemorrhage within the first

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Third Stage of Labor

24 hours of delivery as documented by the treating


obstetrician.
Baseline characteristics of the cohort were estimated for the entire cohort and compared between
nulliparous and multiparous women using a twosample Students t test or Mann-Whitney U test for
continuous variables and x2 for categorical variables.
Descriptive analysis of the third stage of labor duration was characterized by calculating the mean,
median, interquartile range, 90th percentile, 95th percentile, and 99th percentile. Subsequently, these same
parameters were described stratified by parity. Incidence of postpartum hemorrhage was calculated and
compared by parity and then length of the third stage.
First, comparisons were made between those with
third-stage duration in the upper percentiles compared with those with shorter durations (upper 90th
percentile was compared with 90th percentile or less,
upper 95th percentile was compared with 95th percentile or less, upper 99th percentile was compared
with 99th percentile or less). Next, to further delineate
the threshold for increased postpartum hemorrhage
risk, third-stage length was stratified by 5-minute intervals. Rates of postpartum hemorrhage were compared between each 5-minute interval group and the
women who had shorter third-stage durations than
the indicated group. Odds ratios (ORs) and 95%
confidence intervals (CIs) were used to estimate the
association between postpartum hemorrhage and
third-stage duration. Multivariable logistic regression
was used to adjust for parity, prolonged first stage,
prolonged second stage, and induction of labor, factors previously shown to affect rates of postpartum
hemorrhage or duration of the third stage.1,7,8 Model
fit was assessed with the Hosmer-Lemeshow goodness
of fit test.9
An a priori sample size calculation was not
performed because the sample size was fixed and all
women in the cohort and who met our inclusion
criteria were included in these analyses. Statistical
significance was defined as a P value of ,.05. All
analyses were completed using STATA 12.0.

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

OBSTETRICS & GYNECOLOGY

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Table 1. Clinical and Labor Characteristics


Characteristic
Maternal age (y)
35 or older
Race
African American
Caucasian
Latina
Gestational age at delivery (wk)
BMI (kg/m2)
Obese (30 or greater)
GDM
Pre-GDM
Prostaglandin induction
Foley bulb induction
Oxytocin use
Prolonged 1st stage of labor
Prolonged 2nd stage of labor
Fetal arterial pH
Birth weight (g)
4,000 or greater
Chorioamnionitis
Neonatal sex
Male
Female
Mode of delivery
Vaginal
Operative vaginal

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

BMI, body mass index; GDM, gestational diabetes mellitus.


Data are mean6standard deviation or frequency (%).
Missing values: BMI, n590; prolonged first stage, n5209; prolonged second stage, n550; fetal arterial pH, n551; neonatal sex, n52.
* P values based on two sample Students t tests, Mann-Whitney U test for continuous variables, or x2 for categorical variables comparing
nulliparous and multiparous women.

an induction of labor, an augmentation of labor, or an


operative vaginal delivery.
There was no significant difference in duration of
the third stage of labor between vaginal and operative
vaginal deliveries (5.46 minutes compared with
5.44 minutes, P5.94). When further analyses were
performed with vaginal deliveries and operative vaginal deliveries combined, there was no significant difference in duration of the third stage for nulliparous
compared with multiparous women (Table 2). Within
the total cohort, 90% of women had a third stage
lasting 9 minutes or less, 95% had one lasting 13 minutes or less, and 99% of women completed placenta
delivery by 28 minutes.
Compared with multiparous women, nulliparous
women were more likely to experience a postpartum
hemorrhage (12.5% compared with 6.4%, P,.001).
Women with increasing duration of the third stage of
labor after vaginal delivery had increasing risk for
postpartum hemorrhage. Those with a third stage
greater than the 90th percentile (greater than 9 minutes)

VOL. 127, NO. 5, MAY 2016

compared with those with a third stage duration 90th


percentile or less (9 minutes or less) had an increased
risk for postpartum hemorrhage (13.2% compared with
8.3%; OR 1.68, 95% CI 1.332.12; Table 3). This association remained significant after adjusting for labor
induction, prolonged first or second stages, and parity
(adjusted OR 1.82, 95% CI 1.432.31; Table 3). To
further delineate the threshold for increased postpartum
hemorrhage risk, we stratified the third-stage duration
into 5-minute intervals (Fig. 1). This divided our cohort
into seven groups, five of which contained the women in
the top 90th percentile (greater than 9 minutes duration). A significant rise in postpartum hemorrhage risk
was noted starting at 20 minutes (15.9% at 2024 minutes
compared with 8.5% at less than 20 minutes, adjusted
OR 2.38, 95% CI 1.184.79; Fig. 1). This risk continued
to increase and patients with a third-stage duration of
30 minutes or greater had a postpartum hemorrhage risk
of 35.1%. There was no significant association between
the need for blood transfusion and duration of the third
stage of labor (1.0% compared with 0.84% for third-stage

Frolova et al

Third Stage of Labor

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953

Table 2. Descriptive Analysis of the Third Stage of Labor in Minutes by Parity


Measure
Mean6SD
Median (IQR)
Range
Percentile
90th
95th
99th

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

SD, standard deviation; IQR, interquartile range.


* Students t test or Wilcoxon rank-sum test as indicated, nulliparous compared with multiparous groups.
90th percentile, n5705; 95th percentile, n5356; 99th percentile, n568.

duration greater than 90th percentile compared with


90th percentile or less, adjusted OR 1.18, 95% CI
0.532.60; Table 3).
After vaginal delivery, 54 placentas (0.76%) were
manually extracted and 40 of these were extracted
before 30 minutes duration. Of the placentas that were
manually extracted before 30 minutes, 17 were not
associated with a postpartum hemorrhage. Because this
could introduce additional bias, as a result of premature
termination of the third stage, we performed two additional analyses. To evaluate the potential bias on the
length of the third stage, we made the assumption that
all 17 of the prematurely extracted placentas were left
in place until the classically recommended 30 minutes.
This assumption did not significantly alter the mean
duration of the third stage (5.51 minutes compared
with 5.46 minutes, P5.60). The 90th percentile was
slightly higher at 10 minutes (compared with 9 minutes), 95th percentile was 14 minutes (compared with

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.

Fig. 1. Postpartum hemorrhage by


third stage duration in minutes.
*P,.05. Postpartum hemorrhage
(PPH) rate in each percentile category
presented as percent (n/N). Reference
groups are all cases with third-stage
duration shorter than the indicated
time interval. aOR, adjusted for
induction, prolonged first stage, prolonged second stage. OR, odds ratio;
CI, confidence interval. Bold indicates
statistically significant results.
Frolova. Third Stage of Labor. Obstet
Gynecol 2016.

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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)

Adjusted 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)

OR, odds ratio; CI, confidence interval.


Bold indicates statistically significant result.
* Rate presented as number of events within indicated percentile, n/N (%).

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.

Although most trials looking at active management of


the third stage aimed to determine its effects on postpartum hemorrhage, some also documented a significant decrease in third-stage duration.2 Therefore, in
the setting of modern active third-stage management
after a vaginal delivery, the definition of prolonged
third stage and recommendations for intervention timing should be reconsidered.
The exact threshold for abnormal length of the
third stage is unclear. The 95th percentile is often used
statistically as the upper limit of normal. Based on our
data, this cutpoint would suggest an abnormally
prolonged third stage if it lasts greater than 13 minutes.
However, arbitrary cutpoints based on population
percentiles do not consider clinical sequelae. An
alternative method would be to base the definition
on risk of maternal morbidity, which is how the 30minute upper limit was originally designated.1 These
data show that the risk for postpartum hemorrhage
nearly doubles by the time third-stage duration reaches 20 minutes. Additionally, the proportion of
women experiencing a postpartum hemorrhage rose
steadily with increasing third-stage duration, from
8.5% among those with a stage of 9 minutes or less
to 15.9% at 2024 minutes and as high at 35.1% when
the third stage was 30 minutes or greater. At 20 minutes, the risk for postpartum hemorrhage was almost
doubled compared with those who delivered the placenta within the first 9 minutes (durations encompassing the lower 90%).
Some epidemiologic studies have suggested that
although rates of maternal death resulting from postpartum hemorrhage have been steadily dropping, the
rate of postpartum hemorrhage in high-resource

VOL. 127, NO. 5, MAY 2016

countries has been slowly increasing.10 The etiology


of this rise is unclear. Another study previously used
a receiver operator curve to determine the best duration cutoff to predict a postpartum hemorrhage in the
setting of active management of the third stage.5 The
study reported 18 minutes to be the duration most
predictive of an impending postpartum hemorrhage
with a specificity of 90%. However, the sensitivity was
31% and area under the curve was 0.60, indicating
very poor predictability of the model and confirming
that although prolonged duration of the third stage is
associated with increased risk for postpartum hemorrhage, there are likely other contributory factors in its
etiology. Alternatively, population changes may be
responsible for the rise, as we have seen increases in
maternal obesity and age, which are known risk factors of postpartum hemorrhage.10,11 These trends
serve as reminders that despite our vast improvements
in postpartum hemorrhage prevention and treatment,
it continues to be a significant source of maternal
morbidity and mortality that requires educated health
care providers who are able to prevent, recognize, and
treat postpartum hemorrhage.
There are limited data to guide interventions for
a prolonged third stage of labor. Manual extraction
of the placenta is commonly performed; however,
there is no evidence to suggest whether this intervention decreases volume of blood loss. In fact, in
the setting of cesarean deliveries, manual extraction
was repeatedly shown to be associated with higher
estimated blood loss and increased rates of endometritis.12,13 We noted that although rates of manual
placental extraction after a vaginal delivery remain
low in our cohort (0.76%), a high proportion of these

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Third Stage of Labor

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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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