Association between the duration of the third stage of labor and postpartum hemorrhage

To determine the association between the duration of the third stage of labor and postpartum hemorrhage (PPH), and to identify an appropriate time threshold for performing manual removal of the placenta (MROP).

A retrospective cohort study was conducted in women who underwent vaginal delivery with an uncomplicated third stage of labor. Data were retrieved from a digital obstetric database, including consecutive records of singleton pregnancies delivered vaginally at ≥24 weeks of gestation. Cases with excessive bleeding or emergency placental removal before completion of the third stage were excluded.

During a 13-year study period, 13 653 cases were eligible for analysis, comprising 13 509 cases managed expectantly and 54 undergoing MROP. The median duration of the third stage was 5 min, and <1% of cases exceeded 40 min. The duration of the third stage was an independent risk factor for increased blood loss (523 ± 376 vs. 239 ± 161 mL after and before 30 min, respectively; P < 0.001), higher PPH rates, and greater need for blood transfusion. When the third stage exceeded 30 min, MROP resulted in significantly greater median blood loss compared with expectant management (500 vs. 400 mL, P = 0.018) and a higher rate of PPH (62.96% vs. 38.58%, P < 0.001), whereas the duration of the third stage was significantly shortened (38 vs. 50 min, P < 0.001).

Blood loss increased with prolonged third-stage duration, with a markedly higher risk of PPH after 30 min. In cases with an uncomplicated third stage, expectant management is preferable within the first 30 min. Beyond this point, either expectant management or MROP may be considered on an individualized basis, with appropriate preparedness for PPH.