INTRODUCTION: This systematic review compared the effects of physiologic care or expectant management during the third stage of labor with oxytocin prophylaxis in preventing postpartum hemorrhage following physiologic birth.
METHODS: We searched MEDLINE, Embase, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials (to December 15, 2023), ClinicalTrials.gov (to July 8, 2024), and reference lists of eligible studies. We included randomized and nonrandomized studies of individuals who experienced physiologic birth or received minimal obstetric interventions. Two reviewers independently assessed eligibility and risk of bias. Random-effects meta-analyses were performed, and evidence certainty was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.
RESULTS: Three randomized controlled trials and 4 nonrandomized studies (N = 7; 7091 participants) were included, with 3 studies contributing data to the quantitative analyses. For individuals with physiologic birth, low-certainty evidence from one nonrandomized study (3436 participants) suggests that physiologic third-stage care results in a large reduction in the risk of blood loss greater than 1000 mL compared with oxytocin (relative risk [RR], 0.29; 95% CI, 0.09-0.92; 18 fewer per 1000; 95% CI, 22 fewer to 2 fewer). In contrast, evidence from one randomized controlled trial (1686 participants) indicates that expectant management likely results in a large increase in the risk of excessive blood loss greater than 1000 mL (RR, 1.87; 95% CI, 1.36-2.57; 21 more per 1000; 95% CI, 9 more to 39 more; moderate certainty) compared with oxytocin but may not increase the risk of transfusion (low certainty) and results in little to no difference in well-being or breastfeeding (high certainty).
DISCUSSION: Compared with oxytocin, physiologic third-stage care may result in a large reduction in the risk of excessive blood loss, whereas expectant management likely results in a large increase. Further research is needed to improve evidence certainty, focus on patient-important outcomes, and enhance generalizability.