5/9/05njm

**Q. Does the active management of the third stage of labor really
work?**

A. Yes, active management of the third stage of labor decreases blood
loss. See details

Active management of the third stage of labor will decrease postpartum
hemorrhage and shorten the third stage of labor.

**Background**

The best approach to management of the third stage of labor is
controversial. The two approaches are:

  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Expectant management --- Expectant or
physiologic management consists of delivery of the placenta without the
use of uterotonic agents, cord clamping, or cord traction.\
\
  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Active management --- Active management
generally consists of early cord clamping, controlled cord traction, and
administration of an uterotonic agent. This strategy will decrease
postpartum haemorrhage and shorten third stage.

A classic study randomly assigned 1795 women to expectant or active
third stage labor management. Actively managed patients received 5 IU of
[oxytocin]{.underline} and 0.5 mg of ergometrine upon delivery of the
fetal anterior shoulder followed by controlled cord traction. Almost all
women allocated to active management actually received it, while just
under one-half of those allocated to physiological management received
no intervention. The active management group had a significantly lower
incidence of postpartum hemorrhage (6 versus 18 percent) and a shorter
median duration of the third stage (5 versus 15 minutes).

A Cochrane review of five studies comparing active versus expectant
management of the third stage of labor found that active management was
associated with reduced risks of: maternal blood loss (weighted mean
difference -79.33 mL, 95 percent CI -94.29 to -64.37); postpartum
hemorrhage of more than 500 mL (relative risk 0.38, 95 percent CI 0.32
to 0.46); and prolonged third stage of labor (weighted mean difference
-9.77 minutes, 95 percent CI -10.00 to -9.53). Active management was
defined as administration of a prophylactic oxytocic before delivery of
the placenta; typically with early cord clamping and cutting and
controlled traction of the umbilical cord. The authors concluded that
\"active management should be the routine management of choice for women
expecting to deliver a baby by vaginal delivery in a maternity hospital.

**Definitions**

**Postpartum hemorrhage (PPH)** is an obstetrical emergency that can
follow vaginal or cesarean delivery. It is a major cause of maternal
morbidity and mortality, with sequelae such as shock, renal failure,
acute respiratory distress syndrome, coagulopathy, and Sheehan\'s
syndrome. The incidence is approximately 3 percent of births.

**Retained placenta** --- Retained placenta is variously defined as a
placenta that has not been expelled by 30 to 60 minutes after delivery
of the baby.\* It occurs in 1:100 to 1:200 deliveries and is an
important cause of postpartum hemorrhage. A retained placenta is usually
removed manually, under anesthesia or with conscious sedation, to
prevent bleeding and infection.

\*World Health Organization. Maternal and Child Health and Family
Planning. The prevention and management of postpartum haemorrhage.
Report of a technical working group. WHO / MCH 1990; 90.7:3.

**Online Resources**

**Indian Health MCH Frequently Asked Question**

**Q.** **Should Active Management of the Third Stage of Labor Be
Routine?**

**A.** American Family Physician presents a review of the Cochrane
Library

[http://www.aafp.org/afp/20030515/cochrane.html](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.aafp.org/afp/20030515/cochrane.html)

**UpToDate: Management of the third stage of labor**

<http://www.uptodateonline.com/application/topic.asp?file=labordel/10159&type=A&selectedTitle=1~3>

**UpToDate: Treatment of postpartum hemorrhage**

<http://www.uptodateonline.com/application/topic.asp?file=postpart/4483>

**Evidence Based References**

Giacalone PL et al A randomised evaluation of two techniques of
management of the third stage of labour in women at low risk of
postpartum haemorrhage. BJOG. 2000 Mar;107(3):396-400.

[CONCLUSION:]{.underline} Cord drainage decreases the duration of the
third stage of labour and reduces blood loss but not the incidence of
manual removal of the placenta.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10740337>

Thilaganathan B et al Management of the third stage of labour in women
at low risk of postpartum

haemorrhage. Eur J Obstet Gynecol Reprod Biol. 1993 Jan;48(1):19-22.

[CONCLUSIONS:]{.underline} This preliminary study confirms that active
management results in a reduction in

the length of the third stage of labour. However, it suggests that
active management does not reduce blood loss when compared to
physiological management in the woman at low risk of postpartum
haemorrhage.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8449257>

Prendiville WJ et al The Bristol third stage trial: active versus
physiological management of third

stage of labour. BMJ. 1988 Nov 19;297(6659):1295-300.

[CONCLUSIONS]{.underline}\--Policy of active management practised in
this trial reduces incidence of postpartum haemorrhage, shortens third
stage, and results in reduced neonatal packed cell

volume.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3144366>

Prendiville WJ, Elbourne D, McDonald S. Active versus expectant
management in the third stage of labour. Cochrane Database Syst Rev.
2000;(3):CD000007.\
[REVIEWER\'S CONCLUSIONS]{.underline}: Routine \'active management\' is
superior to

\'expectant management\' in terms of blood loss, post partum haemorrhage
and other

serious complications of the third stage of labour. Active management
is,

however, associated with an increased risk of unpleasant side effects
(eg nausea

and vomiting), and hypertension, where ergometrine is used. Active
management

should be the routine management of choice for women expecting to
deliver a baby

by vaginal delivery in a maternity hospital. The implications are less
clear for

other settings including domiciliary practice (in developing and
industrialised

countries).

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10908457>

or

<http://www.update-software.com/cochrane/abstract.htm>

Rogers J, et al Active versus expectant management of third stage of
labour: the Hinchingbrooke

randomised controlled trial. Lancet. 1998 Mar 7;351(9104):693-9.

[INTERPRETATION:]{.underline} Active management of the third stage
reduces the risk of PPH, whatever the woman\'s posture, even when
midwives are familiar with both approaches. We recommend that

clinical guidelines in hospital settings advocate active management
(with oxytocin alone). However, decisions about individual care should
take into account the weights placed by pregnant women and their
caregivers on blood loss compared with an intervention-free third stage.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9504513>

Mitchell GG, Elbourne DR. The Salford Third Stage Trial. Oxytocin plus
ergometrine versus oxytocin alone in the active management of the third
stage of labor. Online J Curr Clin Trials. 1993 Aug 13;Doc No 83

[CONCLUSIONS:]{.underline} Judged on the basis of this trial alone,
oxytocin plus ergometrine is more effective than oxytocin alone in the
prevention of postpartum hemorrhage. However, evidence from other trials
shows that the ergometrine component not uncommonly has side effects of
nausea, vomiting, and raised blood pressure. The implications for
practice therefore depend on the relative weights placed on these
competing risks by women and clinicians. Further research is needed to
quantify these along with research into possible differential effects on
longer-term outcomes and into the implications of a higher dose of
oxytocin.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8306013>

Gulmezoglu AM, et al WHO multicentre randomised trial of misoprostol in
the management of the third stage of labour. Lancet. 2001 Sep
1;358(9283):689-95.

[INTERPRETATION:]{.underline} 10 IU oxytocin (intravenous or
intramuscular) is preferable to 600 microg oral misoprostol in the
active management of the third stage of labour in hospital settings
where active management is the norm.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11551574>