Active Management of Third Stage Labor

Labor Stages:

  • Stage 1: Beginning of regular contractions to pushing
  • Stage 2: Pushing phase until delivery of baby
  • Stage 3: Delivery of baby to delivery of placenta

The Third Stage of Labor is the time after the baby is born until the placenta (afterbirth) delivers. This normally takes from 5-30 minutes: there is a gush of blood, a sense of pressure, and the mom delivers the placenta in a few painless pushes. The midwife often coaches this process and guides it with light traction on the cord to finish the job. Although the mom and family are normally thrilled and focused on the new baby in their arms at this time, third stage is a period of increased risk and potential danger to the mother. If the placenta separates incompletely from the wall of the uterus, or only if part of it comes out, heavy bleeding, cramping and even hemorrhage can occur. There is no question that a complicated third stage, heavy loss of blood, and especially, hemorrhage, can severely disrupt bonding, mom's comfort and health after the birth, and even breast-feeding.

Research over recent years shows that a simple practice can greatly reduce this danger, called Active Management of Third Stage ("AMTS). The part of this practice that is most evidence-supported and helpful appears to be one thing: an intra-muscular injection of 10 units of oxytocin, or, in non-medical terms a shot of Pitocin in the leg, given just after the birth of the baby. We Loudoun Community Midwives have used AMTS increasingly since 2009, and seen a large reduction in the amount of heavy postpartum and third-stage bleeding for the mothers we care for. We do not think most women need to labor with an IV, but we strongly recommend this one practice as a safeguard against heavy bleeding. According to the World Health Organization, AMT reduces the risk of hemorrhage by 8-fold. In our experience, it does not seem to impair delayed cord-clamping, bonding, or breastfeeding. Due to this evidence, LCM practices AMTS routinely for the safety of our patients.

The World Health Organization Bulletin states:
Postpartum hemorrhage is one of the leading causes of maternal death worldwide; it occurs in about 10.5% of births and accounts for over 130 000 maternal deaths annually. Active management of the third stage of labour is highly effective at preventing postpartum hemorrhage among facility-based deliveries. In a systematic review of randomized controlled trials, active management of the third stage of labour was more effective than physiological management in preventing blood loss, severe postpartum hemorrhage (> 500 ml) and prolonged third stage of labour. Routine use of active management of the third stage of labour for all vaginal singleton births in health facilities is recommended by the International Federation of Gynecologists and Obstetricians (FIGO) and the International Confederation of Midwives (ICM), as well as by WHO.
Bulletin of the World Health Organization