What uterotonic is used for active management of the third stage, and what are the alternatives?

Oxytocin is the first-line uterotonic (e.g. 5 IU IV slowly or 10 IU IM after delivery of the baby) - effective with few side effects.

Alternatives/additions: ergometrine (or Syntometrine, oxytocin+ergometrine; avoid ergometrine in hypertension/pre-eclampsia), misoprostol (a prostaglandin, useful where oxytocin/refrigeration is unavailable), and carboprost for refractory atony.

Clinical relevance. Choosing the right uterotonic (oxytocin first; avoid ergometrine in hypertension; misoprostol where no cold chain) optimises PPH prevention.

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Uterotonics for the third stage

Oxytocin is the preferred prophylactic uterotonic, with several alternatives.

First-line: oxytocin

• Oxytocin 5 IU IV (slowly) or 10 IU IM after delivery of the baby (or after the anterior shoulder).
• Effective, with few side effects; the recommended agent.
• Requires cold-chain storage.

Alternatives/additions

• Ergometrine (or Syntometrine = oxytocin + ergometrine) - more sustained contraction, but causes nausea/vomiting and raises BP - avoid in hypertension/pre-eclampsia and cardiac disease.
• Misoprostol (oral/sublingual prostaglandin E1) - heat-stable, useful where oxytocin/refrigeration is unavailable (e.g. home births, low-resource settings); side effects: fever, shivering.
• Carboprost (PGF2-alpha) - for refractory atony (avoid in asthma); tranexamic acid is an adjunct for treating PPH.