What is the recommended approach for active management of the third stage of labor to reduce postpartum hemorrhage and other complications in all women?

Active Management of the Third Stage of Labor

All women should receive active management of the third stage of labor with prophylactic oxytocin 5-10 IU administered via slow IV or intramuscular injection immediately after delivery of the anterior shoulder or immediately postpartum to reduce postpartum hemorrhage. 1, 2

Core Components of Third Stage Management

Uterotonic Administration (Essential)

• Oxytocin 10 IU is the first-line uterotonic agent for routine prophylaxis during the third stage of labor, administered either as slow IV bolus or intramuscularly at the time of shoulder release or immediately after delivery 1, 3, 4

• This intervention reduces the risk of postpartum hemorrhage >500 mL by approximately 47% compared to placebo (RR 0.53) and decreases the need for therapeutic uterotonics by 44% (RR 0.56) 3

• Oxytocin is superior to ergot alkaloids (ergometrine/methylergonovine) for preventing PPH >500 mL (RR 0.76) and causes significantly fewer side effects, particularly nausea and vomiting 3

• The FDA-approved indication for oxytocin specifically includes producing uterine contractions during the third stage of labor and controlling postpartum bleeding or hemorrhage 2

Delayed Cord Clamping (Recommended)

• Delay cord clamping for 1-3 minutes after birth to allow placental transfusion, which benefits neonatal hematological outcomes without increasing maternal blood loss when combined with immediate oxytocin administration 5, 1, 6

• This practice should be integrated with immediate oxytocin administration—the uterotonic enhances placental transfusion by hastening blood transfer to the infant before the cord is clamped 5

Controlled Cord Traction (Conditional)

• Controlled cord traction should only be performed by skilled birth attendants and provides minimal additional benefit in preventing retained placenta beyond uterotonic administration 4

• This component is less critical than uterotonic administration and delayed cord clamping 7

What NOT to Do

Avoid Routine Interventions Without Evidence

• Do not perform manual removal of the placenta routinely to reduce PPH risk; this should only be done in cases of severe and uncontrollable postpartum hemorrhage 5, 1

• Do not perform sustained uterine massage as a routine component—the WHO does not recommend this as evidence does not support universal requirement 1

• Do not clamp the cord immediately, as this eliminates the opportunity for beneficial placental transfusion 6

Special Population Considerations

Women with Obesity (BMI ≥30)

• All women with BMI ≥30 should receive active management of the third stage due to increased risk of postpartum hemorrhage 5

• Establish early venous access during labor for women with BMI >40 5

Women with Respiratory Disease

• Oxytocin remains the uterotonic of choice for women with asthma, COPD, cystic fibrosis, or bronchiectasis 1

• Absolutely avoid ergometrine in these patients as it may cause bronchospasm 1, 8

• Prostaglandin F2α should not be used for PPH treatment as it causes bronchoconstriction 1

Women with Cardiovascular Disease

• Use a single intramuscular dose of oxytocin 10 IU for active management 1

• Ergometrine is contraindicated due to vasoconstrictive effects 1, 8

Women on Anticoagulation

• Pay careful attention to minimizing trauma during placental delivery 1

• Use active management with uterotonics to enhance uterine contraction and promote placental separation, which reduces bleeding risk 1

Management of Postpartum Hemorrhage When It Occurs

Tranexamic Acid for Established PPH

• Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset if postpartum hemorrhage develops, as this reduces bleeding-related maternal mortality 5, 1

• The WOMAN trial demonstrated that early tranexamic acid use (within 3 hours) reduces maternal death due to bleeding 1

Alternative Uterotonics (When Oxytocin Unavailable or Ineffective)

Second-Line Options

• Carbetocin is highly effective after both vaginal and cesarean delivery 7

• Oxytocin plus ergometrine combination is effective but increases side effects (nausea, vomiting, hypertension) 7, 3

• Oxytocin plus misoprostol is effective for PPH prevention 7

• Misoprostol alone (when oxytocin unavailable) is less effective than oxytocin but better than placebo 3

Ergometrine Contraindications

• Never use ergometrine in women with: hypertension, preeclampsia, respiratory disease (asthma, COPD), or cardiovascular disease 1, 8

• Ergometrine causes vasoconstriction and bronchospasm 8

Evidence Quality and Rationale

The recommendation for active management is based on high-quality evidence from multiple Cochrane reviews demonstrating that prophylactic oxytocin reduces severe PPH (>1000 mL) by 66% (RR 0.34) and maternal hemoglobin <9 g/dL by 50% (RR 0.50) 9. The most recent comprehensive review (2024) confirms these benefits and recommends abandoning the term "active management of the third stage" as a bundled intervention, instead advocating for "third stage care" with evidence-based individual components 7.

The critical intervention is oxytocin administration—this single component drives the reduction in postpartum hemorrhage, while other historical components of "active management" (early cord clamping, routine cord traction) provide minimal benefit or may cause harm. 7, 3