Active Management of the Third Stage of Labor (AMTSL): What is NOT Recommended by WHO
Sustained uterine massage (option C) is not recommended as a routine component of AMTSL according to WHO guidelines.
Understanding Current WHO-Aligned AMTSL Components
The evolution of AMTSL recommendations has moved away from the original "bundle" approach. Based on the most recent evidence and guideline updates, the currently recommended components are:
Recommended Components
- Prophylactic uterotonic administration (oxytocin 10 IU IM/IV) immediately after delivery of the baby is the cornerstone of AMTSL 1, 2
- Delayed cord clamping (1-3 minutes after birth) is now recommended, representing a shift from earlier practices that advocated immediate clamping 3, 4
- Controlled cord traction remains recommended when feasible, though its benefit is primarily in reducing manual removal of placenta rather than preventing severe hemorrhage 5, 6
- Postpartum uterine tone assessment is a standard component of third stage monitoring 1
What is NOT Recommended: Sustained Uterine Massage
Sustained or continuous uterine massage is not part of routine AMTSL. The evidence shows that:
- Uterine massage after placental delivery should be done "according to local policy" rather than as a universal requirement 5
- The term "active management of the third stage of labor" as a combined intervention bundle is being phased out in favor of individualized "third stage care" 4
- Sustained massage is not listed among the core AMTSL components in current guidelines 1, 2
Key Evidence Points
The Shift in AMTSL Practice
The original AMTSL bundle included immediate cord clamping, which has been removed from recommendations by the International Confederation of Midwives and International Federation of Gynaecologists and Obstetricians 3. This demonstrates how AMTSL components have evolved based on evidence showing delayed clamping benefits neonatal outcomes without increasing maternal blood loss 3.
What Actually Prevents Postpartum Hemorrhage
The most critical intervention is prophylactic oxytocin administration, which reduces PPH risk significantly 2. The addition of controlled cord traction provides marginal benefit primarily in reducing manual placenta removal (RR 0.69,95% CI 0.57-0.83) rather than preventing severe hemorrhage 5.
Clinical Pitfalls to Avoid
- Do not perform sustained uterine massage routinely - this is not evidence-based and may cause maternal discomfort 4
- Do not use ergometrine in women with hypertension or respiratory conditions as it can cause bronchospasm and is contraindicated 3, 1
- Do not clamp the cord immediately - delayed clamping (1-3 minutes) is now standard unless there are specific maternal or fetal indications 3, 4