Active management of the third stage of labor

Medical practitioners.

Photo: Debbie Armbruster

Active management of the third stage of labor (AMTSL) is an evidence-based, low-cost intervention used to prevent postpartum hemorrhage. The Bristol1 and Hinchingbrooke randomized control trials provided conclusive evidence that AMTSL significantly reduces postpartum hemorrhage, decreases blood loss, and decreases the need for blood transfusions.

The current components of AMTSL include:2

  • Administration of a uterotonic agent (oxytocin is the drug of choice).
  • Controlled cord traction.
  • Uterine massage after delivery of the placenta.

In response to the growing evidence supporting the use of AMTSL for the prevention of PPH, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) issued a joint statement. The November 2003 joint statement promotes AMTSL to save mother’s lives. ICM and FIGO further state, “Every attendant at birth needs to have the knowledge, skills and critical judgment needed to carry out active management of the third stage of labour and access to needed supplies and equipment.”3

Evidence has also proven that oxytocin is the most effective uterotonic drug for prevention of PPH.4

1 Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of the third stage of labour. British Medical Journal. 1988; 297: 1295–1300.

2 The original research protocol in the Hinchingbrooke and Bristol trials included immediate cord-clamping. Whereas not equivocal, there is current research indicating that immediate cord clamping is not beneficial and may be detrimental to the newborn.

3 ICM and FIGO. Joint statement: management of the third stage of labour to prevent postpartum haemorrhage. [joint statement] 2003.

4 Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third stage of labour. The Cochrane Library. 2004;3:1–47.