Active management of the third stage of labor

Active management of the third stage of labor (AMTSL) is an evidence-based, low-cost intervention used to prevent postpartum hemorrhage.

The current components of AMTSL include:

Administration of a uterotonic agent (oxytocin is the drug of choice) within one minute after birth of the baby and after ruling out the presence of another baby
Controlled cord traction with counter-traction to support the uterus
Uterine massage after delivery of the placenta
Scientific evidence supporting AMTSL

Giving a uterotonic drug to prevent PPH promotes strong uterine contractions and leads to faster retraction and placental separation and delivery. Several large, randomized controlled trials have investigated whether physiologic management or active management is more effective in preventing PPH. These trials have consistently shown that active management provides several benefits for the mother compared to physiologic management. Table 1 provides detailed results from two important studies, the Bristol (Prendiville et al, 1988) and Hinchingbrooke (Rogers et al, 1998) studies, comparing active and physiologic management of the third stage of labor.

These results show that only 12 women need to receive AMTSL to prevent one case of PPH. This means that AMTSL is a very effective and cost-efficient public health intervention. These studies also confirm that AMTSL decreases:

Incidence of PPH
Length of third stage of labor
Percentage of third stages of labor lasting longer than 30 minutes
Need for blood transfusion
Need for uterotonic drugs to manage PPH
Table 1. Bristol and Hinchingbrooke study results comparing active and physiologic management of the third stage of labor

Factors Study



PPH Bristol


Hinchingbrooke 6.8%

Average length of the third stage of labor Bristol
5 minutes

15 minutes

Hinchingbrooke 8 minutes
15 minutes

Third stage of labor longer than 30 minutes Bristol


Hinchingbrooke 3.3%

Blood transfusion needed Bristol


Hinchingbrooke 0.5%

Additional uterotonic drugs needed to manage PPH Bristol


Hinchingbrooke 3.2%

Steps for AMTSL

There are three main components or steps of AMTSL-administering a uterotonic drug, CCT, and massaging the uterus-which should be implemented along with the provision of immediate newborn care.

Text Box: 1. Thoroughly dry the baby, assess the baby’s breathing and perform resuscitation if needed, and place the baby in skin-to-skin contact with the mother
After delivery, immediately dry the infant and assess the baby’s breathing. Then place the reactive infant, prone, on the mother’s abdomen.* Remove the cloth used to dry the baby and keep the infant covered with a dry cloth or towel to prevent heat loss.

Figure 1. Put the baby on the mother’s abdomen

*If the infant is pale, limp, or not breathing, it is best to keep the infant at the level of the perineum to allow optimal blood flow and oxygenation while resuscitative measures are performed. Early cord clamping may be necessary if immediate attention cannot be provided without clamping and cutting the cord.

Text Box: 2. Administer a uterotonic drug within one minute of the baby’s birth

Administering a uterotonic drug within one minute of the baby’s birth stimulates uterine contractions that will facilitate separation of the placenta from the uterine wall. Before giving the uterotonic drug it is important to rule out the presence of another baby. If the uterotonic drug is administered when there is a second baby, there is a small risk that the second baby could be trapped in the uterus.

The steps for administering a uterotonic drug include:

Before performing AMTSL, gently palpate the woman’s abdomen to rule out the presence of another baby. At this point, do not massage the uterus.

If there is not another baby, begin the procedure by giving the woman 10 IU of oxytocin IM in the upper thigh. This should be done within one minute of childbirth. If available, a qualified assistant should give the injection.
Note: Oxytocin is the uterotonic drug of choice. If oxytocin is not available, give ergometrine 0.2 mg intramuscularly, Syntometrine 1 mL intramuscularly, or misoprostol 400-600 mcg orally.

Figure 2. Give a uterotonic drug

Text Box: 3. Cut the umbilical cord

Clamp and cut the cord following strict hygienic techniques after cord pulsations have ceased or approximately 2-3 minutes after birth of the baby, whichever comes first.

Figure 3. Pulsating and nonpulsating umbilical cord

Text Box: 4. Keep the baby warm
Place the infant directly on the mother’s chest, prone, with the newborn’s skin touching the mother’s skin. While the mother’s skin will help regulate the infant’s temperature, cover both the mother and infant with a dry, warm cloth or towel to prevent heat loss. Cover the baby’s head with a cap or cloth.

Figure 4. Keep the baby in skin-to-skin contact

Text Box: 5. Perform controlled cord traction

CCT helps the placenta descend into the vagina after it has separated from the uterine wall and facilitates its delivery. It is important that the placenta be removed quickly once it has separated from the uterine wall because the uterus cannot contract efficiently if the placenta is still inside. CCT includes supporting the uterus by applying pressure on the lower segment of the uterus in an upward direction towards the woman’s head, while at the same time pulling with a firm, steady tension on the cord in a downward direction during contractions. Supporting or guarding the uterus (sometimes called “counter-pressure” or “counter-traction”) helps prevent uterine inversion during CCT. CCT should only be done during a contraction.

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Note: CCT is not designed to separate the placenta from the uterine wall but to facilitate its expulsion only. If the birth attendant keeps pulling on an unseparated placenta, inversion of the uterus may occur.
The steps for CCT include:

Wait for cord pulsations to cease or approximately 2-3 minutes after birth of the baby, whichever comes first, and then place one clamp 4 cm from the baby’s abdomen.
Note: Delaying cord clamping allows for transfer of red blood cells from the placenta to the baby that can decrease the incidence of anemia during infancy.
Gently milk the cord towards the woman’s perineum and place a second clamp on the cord approximately 2 cm from the first clamp.
Cut the cord using sterile scissors under cover of a gauze swab to prevent blood spatter. After mother and baby are safely cared for, tie the cord.
Place the clamp near the woman’s perineum to make CCT easier (Figure 5).
Hold the cord close to the perineum using a clamp (Figure 5).

Figure 5. Clamping the umbilical cord near the perineum

Place the palm of the other hand on the lower abdomen just above the woman’s pubic bone to assess for uterine contractions (Figure 6). If a clamp is not available, controlled cord traction can be applied by encircling the cord around the hand.

Figure 6. Holding the cord close to the perineum with the clamp or hand, maintain hand on uterine fundus to palpate the next contraction.

Wait for a uterine contraction. Only do CCT when there is a contraction.
With the hand just above the pubic bone, apply external pressure on the uterus in an upward direction (toward the woman’s head) (Figure 7).
At the same time with your other hand, pull with firm, steady tension on the cord in a downward direction (follow the direction of the birth canal). Avoid jerky or forceful pulling.

Figure 7. Applying CCT with countertraction to support the uterus

If the placenta does not descend during 30–40 seconds of controlled cord traction (i.e. there are no signs of placental separation), do not continue to pull on the cord:

Gently hold the cord and wait until the uterus is well contracted again. If necessary, use a sponge forceps to clamp the cord closer to the perineum as it lengthens;
With the next contraction, repeat controlled cord traction with counter traction.

Do not release support on the uterus until the placenta is visible at the vulva. Deliver the placenta slowly and support it with both hands (Figure 8).
Figure 8. Supporting the placenta with both hands

As the placenta is delivered, hold and gently turn it with both hands until the membranes are twisted (Figure 9).
Slowly pull to complete the delivery. Gently move membranes up and down until delivered (Figure 10).

Figure 9. Delivering the placenta with a turning and up-and-down motion Figure 10. Slowly pull to complete delivery of the placenta.

If the membranes tear, gently examine the upper vagina and cervix wearing high-level disinfected or sterile gloves and use a sponge forceps to remove any pieces of remaining membrane.

Text Box: 6. Massage the uterus

Massage the uterus immediately after delivery of the placenta and membranes until it is firm (Figure 11). Massaging the uterus stimulates uterine contractions and helps to prevent PPH. Sometimes blood and clots will be expelled during this process. After stopping massage, it is important that the uterus does not relax again. Instruct the woman how to massage her own uterus, and ask her to call if her uterus becomes soft.

Figure 11. Massaging the uterus immediately after the placenta delivers

Text Box: 7. Examine the placenta

Examine the fetal and maternal sides of the placenta and membranes to ensure they are complete. A small amount of placental tissue or membranes remaining in the woman can prevent uterine contractions and cause PPH.

Note: Follow infection prevention guidelines when handling contaminated equipment, supplies, and sharps.
To examine the placenta for completeness:

1. Hold the placenta in the palms of the hands with the maternal side facing upward and make sure that all lobules are present and fit together (Figure 12).

Figure 12. Examining the maternal side

2. Hold the cord with one hand, allowing the placenta and membranes to hang down. Place the other hand inside the membranes, spreading your fingers to ensure that membranes are complete (Figure 13).

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3. Dispose of the placenta as appropriate.

Figure 13. Checking the membranes

Text Box: 8. Examine the lower vagina and perineum
Gently separate the labia and inspect the lower vagina and perineum for lacerations that may need to be repaired to prevent further blood loss (Figure 14).
Repair lacerations or episiotomy.
Gently cleanse the vulva, perineum, buttocks, and back with warm water and a clean compress.
Apply a clean pad or cloth to the vulva.
Evaluate blood loss.
Explain all examination findings to the woman and, if she desires, her family.

Figure 14. Gently inspect the lower vagina and perineum for lacerations

Text Box: 9. Provide immediate care

After examining the placenta and external genitals, continue caring for the mother and newborn.

If the woman has chosen to breastfeed, the mother and baby may need assistance to breastfeed within the first hour after the birth and before transferring them out of the delivery room (Figure 23). Assess readiness of the woman and newborn to breastfeed before initiating breastfeeding; do not force the mother and baby to breastfeed if they are not ready.

Figure 15. Encourage breastfeeding within the first hour after birth.

Also ensure that:

The baby is kept warm.
The mother and baby are kept together.
The mother and baby are not left alone.
The woman and baby stay in the delivery room for at least one hour after delivery of the placenta.
PMTCT interventions are provided per national guidelines.
AMTSL practices are recorded as required by local protocols (on the partograph, woman’s chart, or delivery log).
The woman receives information about how she will be cared for during the next few hours.
Text Box: 10. Monitor the woman and newborn immediately after delivery of the placenta

Perform a comprehensive examination of the woman and newborn one and six hours after childbirth. Continue with routine care for the woman and newborn, provide interventions to prevent / reduce the risk of MTCT of HIV according to national guidelines, and follow applicable requirements for recording information about the birth, monitoring of the woman and newborn, and any care provided.

Monitor and care for the woman

During the first two hours after the delivery of the placenta, monitor the woman at least every 15 minutes (more often if needed) to:
Palpate the uterus to check for firmness.
Massage the uterus until firm. (Ask the woman to call for help if bleeding increases or her uterus gets soft.)
Check for excessive vaginal bleeding.
Take action to evaluate and treat PPH immediately if excessive bleeding is detected.
Ensure the uterus does not become soft after massage is stopped.
Instruct the woman how the uterus should feel and how she can massage it herself.
Encourage the woman to eat and drink.
Ask the companion to stay with the woman.
Encourage the woman to pass urine.
Inform the woman about danger signs and when she should call for help.
Monitor and care for the newborn

Check the baby at the same time you check the mother every 15 minutes during the first two hours after childbirth:

Check the baby’s breathing.
Check the baby’s color.
Check warmth by feeling the baby’s feet.
Check the cord for bleeding.
Take immediate action if a problem is detected.


Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of the third stage of labour. British Medical Journal. 1988;297: 1295–1300.

Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of the third stage of labour: the Hinchingbrooke randomized controlled trial. Lancet. 1998;351:693–699.

Sources for illustrations:

Gomez P, Kinzie B, Metcalfe G. Active Management of the Third Stage of Labor: A Demonstration [CD-ROM]. Baltimore, MD: JHPIEGO; 2005. (Figures 2, 5, 6, 7, 8, 12, 13, and 14)

Marshall M, Buffington ST, Beck D, Clark A. Life-Saving Skills Manual for Midwives. Unpublished 4th edition. Washington, DC: American College of Nurse-Midwives; 2007. (Figures 9, 10, and 11)

Chaparro, C. Essential delivery care practices for maternal and newborn health and nutrition. Unit on Child and Adolescent Health / Pan American Health Organization: Washington, DC, 2007. (Figures 1, 3, 4, and 15)

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