Angarita Ana M, Berghella Vincenzo
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
Am J Obstet Gynecol MFM. 2022 Sep;4(5):100661. doi: 10.1016/j.ajogmf.2022.100661. Epub 2022 May 7.
During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) 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 approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations 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 repairs can be considered. Skin-to-skin contact 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.
在第三产程中，推荐使用缩宫素与氨甲环酸、缩宫素与米索前列醇、缩宫素与甲基麦角新碱联合用药，或使用卡贝缩宫素预防阴道分娩后的产后出血。建议在新生儿娩出后（前肩娩出或全身娩出后）且胎盘娩出前立即静脉注射缩宫素（10 IU）。若选择缩宫素与氨甲环酸联合用药，建议在新生儿娩出后且胎盘娩出前静脉注射缩宫素（10 IU）的基础上，额外静脉注射氨甲环酸（1 g）。若选择缩宫素与米索前列醇联合用药，建议在新生儿娩出后立即静脉注射缩宫素（10 IU）的基础上，舌下含服米索前列醇（400 μg）。若无法建立静脉通路或处于资源匮乏地区，建议舌下含服米索前列醇（400 μg）并肌内注射缩宫素（10 IU）。若选择缩宫素与甲基麦角新碱联合用药，建议在新生儿娩出后立即肌内注射甲基麦角新碱（0.2 mg）并静脉注射缩宫素（10 IU）。建议在新生儿娩出后立即单剂量静脉注射或肌内注射卡贝缩宫素（100 μg）。建议采用控制性脐带牵引并延迟脐带钳夹约60秒。目前尚无足够证据支持或反驳脐带挤血、子宫按摩或乳头刺激预防产后出血的效果。建议采用连续合成缝线技术修复一度和二度裂伤。若能实现止血且外观正常，一度裂伤可不作修复。建议采用端端吻合或重叠连续合成缝线技术修复三度裂伤。建议采用连续缝合方式，用延迟可吸收的4-0或3-0聚乙醇酸缝线或铬制缝线修复四度裂伤。在修复三度或四度裂伤时可考虑使用单剂量第二代头孢菌素。建议产后进行皮肤接触。目前尚无足够证据支持或反驳产后常规采集脐带血气。建议进行公共脐带血库储存。
