What is active management of the third stage of labor?

Active Management of the Third Stage of Labor

Active management of the third stage of labor (AMTSL) is a package of interventions designed to prevent postpartum hemorrhage, consisting primarily of prophylactic uterotonic administration (oxytocin 5-10 IU IV/IM) immediately after delivery of the baby, with optional controlled cord traction to deliver the placenta. 1

Core Components

The essential elements of active management have evolved based on evidence:

• Administer oxytocin 5-10 IU via slow IV infusion (over 1-2 minutes) or 10 IU intramuscularly at the time of anterior shoulder delivery or immediately after complete infant delivery, before placental expulsion. 1
• Controlled cord traction may be applied to facilitate placental delivery once signs of separation appear. 2, 3
• Delayed cord clamping for 1-3 minutes after birth is now recommended as part of third-stage care, as it benefits neonatal hematological outcomes without increasing maternal blood loss when combined with immediate oxytocin administration. 1

Why Active Management Works

The primary mechanism preventing postpartum hemorrhage is sustained myometrial contraction that mechanically compresses and occludes uterine blood vessels at the placental implantation site—not the hemostatic system itself. 4 Oxytocin enhances uterine contractility and promotes placental separation, reducing bleeding risk. 1, 4

Evidence for Effectiveness

Active management reduces severe maternal outcomes compared to expectant management:

• Severe primary PPH (>1000 mL) may be reduced, though the evidence quality is very low. 5
• Maternal anemia (Hb <9 g/dL) after birth is likely reduced (RR 0.50,95% CI 0.30-0.83). 5
• Mean maternal blood loss is reduced by approximately 79 mL, and PPH >500 mL is substantially reduced (RR 0.38,95% CI 0.32-0.46). 6
• Duration of third stage is shortened by approximately 10 minutes. 6

Route of Oxytocin Administration

The route matters when oxytocin is used alone:

• When oxytocin is the only intervention, intravenous administration reduces hemorrhage risk by 76% compared to intramuscular administration. 2
• When combined with controlled cord traction, route of administration has no effect on hemorrhage risk. 2
• Never administer oxytocin as a rapid IV bolus (must be given over at least 1-2 minutes) to avoid hypotension and tachycardia. 1

Controlled Cord Traction

The value of controlled cord traction depends on whether oxytocin is used:

• Among women receiving no oxytocin prophylaxis, controlled cord traction reduces hemorrhage risk by nearly 50%. 2
• Among women receiving intramuscular oxytocin, controlled cord traction reduces hemorrhage risk by 66%. 2
• When oxytocin is given intravenously, controlled cord traction confers no additional benefit. 2

Interventions No Longer Recommended

• Routine sustained uterine massage is not recommended as a universal component of AMTSL, as evidence does not support its requirement. 1
• In fact, uterine massage has been associated with increased hemorrhage risk in some studies. 2
• Early cord clamping (before 1 minute) is no longer recommended; delayed clamping for 1-3 minutes is now standard. 1, 3
• Manual removal of the placenta should not be performed routinely to reduce PPH risk outside specialized structures, except in cases of severe and uncontrollable hemorrhage. 1

Special Population Considerations

For women with respiratory diseases (asthma, COPD, cystic fibrosis):

• Oxytocin is the uterotonic of choice. 1
• Ergometrine is absolutely contraindicated due to risk of bronchospasm. 1
• Prostaglandin F2α must be avoided as it can cause bronchoconstriction. 1

For women with hypertension or cardiovascular disease:

• Use a single intramuscular dose of oxytocin for active management. 1
• Ergometrine is contraindicated. 1

For 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. 1

For women with BMI ≥30:

• All should receive active management due to increased PPH risk. 1
• Establish early venous access during labor for women with BMI >40. 1

Management of Postpartum Hemorrhage When It Occurs

If bleeding develops despite prophylaxis:

• Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset (efficacy decreases 10% for every 15 minutes of delay). 1, 3
• Consider additional uterotonic agents per institutional protocol. 7

Common Pitfalls to Avoid

• Do not delay oxytocin administration until after placental delivery—it must be given immediately after infant delivery. 1
• Do not give oxytocin as a rapid IV bolus faster than 1-2 minutes. 1
• Do not use ergometrine in patients with hypertension or respiratory disease. 1
• Do not perform routine manual placental removal to prevent PPH. 1

Terminology Update

The term "active management of the third stage of labor" as a combined intervention bundle is being phased out in favor of "third-stage care," which promotes implementation of evidence-based interventions that are safe and beneficial for both mother and neonate. 3 This reflects the evolution away from a rigid bundle toward individualized, evidence-based component interventions.