title: How Long Is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study.
abstract: OBJECTIVE
  The aim of our study was to determine the optimal time for manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion. Risk factors for postpartum blood transfusions were studied.
  
  
  METHODS
  Computerized data of all vaginal deliveries at our labor and delivery unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation up to 60 minutes into the third stage of labor were extracted for analysis. Patient demographics, obstetrical history, delivery course, and outcome were assessed as well as blood product requirements during the postpartum period. Receiver-operating curves (ROC) for prediction of blood transfusion during the third stage were calculated and risk factors were assessed.
  
  
  RESULTS
  31,226 vaginal deliveries occurred during the study period and 28,586 deliveries culminated with complete and spontaneous placental separation, 25,160 of which met inclusion criteria. Independent risk factors for blood transfusions were primiparity, longer second and third stage length, labor induction, and maternal intrapartum fever. ROC curves showed that the optimal cutoff for the prediction of blood transfusions was 17 minutes into the third stage of labor. Waiting more than 30 minutes for placental separation increases the risk for blood transfusion more than threefold.
  
  
  CONCLUSIONS
  A third stage longer than 17 minutes is associated with an increased risk for blood transfusion postpartum. After more than 30 minutes, the risk for blood transfusions increases more than threefold.
authors.affiliation: Department of Obstetrics and Gynecology, Lis Maternity Hospital Sourasky, Medical Center, Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel.
authors.forename: Shiri
authors.initials: S
authors.lastname: Shinar
authors.affiliation: Department of Obstetrics and Gynecology, Lis Maternity Hospital Sourasky, Medical Center, Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel.
authors.forename: Anat
authors.initials: A
authors.lastname: Schwartz
authors.affiliation: Department of Obstetrics and Gynecology, Lis Maternity Hospital Sourasky, Medical Center, Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel.
authors.forename: Sharon
authors.initials: S
authors.lastname: Maslovitz
authors.affiliation: Department of Obstetrics and Gynecology, Lis Maternity Hospital Sourasky, Medical Center, Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel.
authors.forename: Ariel
authors.initials: A
authors.lastname: Many
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D016022:Case-Control Studies; D036861:Delivery, Obstetric; D005260:Female; D005334:Fever / Q000453:epidemiology*; D006801:Humans; D007557:Israel / Q000453:epidemiology; D007749:Labor Stage, Third; D007751:Labor, Induced / Q000706:statistics & numerical data*; D016015:Logistic Models; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D010298:Parity; D018457:Placenta, Retained / Q000453:epidemiology*; D006473:Postpartum Hemorrhage / Q000453:epidemiology* / Q000628:therapy; D011247:Pregnancy; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors
keywords: blood; hemorrhage; postpartum; postpartum hemorrhage; third stage; transfusion