Active management of the third stage of labour is the administration of uterotonic agents (preferentially oxytocin) followed by controlled cord traction and uterine massage (after the delivery of the fetus). Applying active management of the third stage of labour (AMTSL) is the key to reducing the risk of complications listed below.The term "active management" indicates that you are not waiting for the physiology of placental separation. So, every woman who comes to delivery to the health facility/ community will get AMTSL, and it is a standard management of the third stage of labour. The main benefits of AMTSL are the following:

  • Duration of the third stage of labour will be short.
  • Less maternal blood loss.
  • Less need for oxytocin in post partum.
  • Less anaemia in the post-partum.

Drugs used for AMTS

The uterotonic agents are drugs which are acting on uterine muscle to prevent postpartum haemorrhage and its complications. The most common uterotonic drugs used for active management of the third stage of labour are the following.

  • Oxytocin is the preferred drug for AMTSL and 1st line drug for PPH caused by uterine atony.
  • Ergometrine for non-hypertensive mothers.
  • Misoprostol has the advantage that it is cheap and stable at room temperature. It can be distributed through community-based distribution systems.
  • Uterotonics require proper storage.
  • Misoprostol: room temperature, in a closed container.
  • Oxytocin: 15-30°C, protect from freezing.

Complications Occurring During the Third Stage of Labour

Women who give birth attended by an unskilled healthcare provider (like you) are more likely to experience complications at all stages of labour, including the third stage. These complications are listed below.

The normal and spontaneous delivery of the placenta during the third stage might be expected; complications can still arise unpredictably so you should always be prepared for the emergency.

Common Complications of Third Stage of Labour

These complications are more likely to occur if the third stage is not properly managed, using the AMTSL approach:

i) Retained placenta:

The placenta remains inside the uterus for longer than 30 minutes after delivery of the baby, usually due to:

  • Inadequate uterine contractions to expel the placenta.
  • The cervix might have retracted too fast and partially closed, trapping the placenta in the uterus.
  • The full bladder is maybe obstructing placental delivery.

ii) Excessive bleeding (PPH):

The loss of more than 500 ml of blood following delivery of the baby. Most bleeding comes from where the placenta was attached to the uterus and is bright or dark blood and usually thick. PPH occurs when the uterus fails to contract well, usually due to:

  • Atonic (relaxed) uterus; the muscular wall of the uterus could not contract powerfully enough to arrest the natural bleeding which occurs when the placenta separates.
  • Traumatic PPH -this occurs due to the laceration of the vagina, cervix and the uterus.

iii) Uterine inversion:

The uterus is pulled "inside out" as the baby, or the placenta is delivered, usually due to:

  • Poor management of AMTSL
  • Applying mixed method (Fundal pressure and cord traction).

(N.B . You must never apply the combined method because of the risk of inversion of the uterus)

The General Management of Third Stage Complications Is:

  • Shout for help.
  • Put the mother in shock position. I.e, Elevate the bed from the bottom to increase blood flow to the brain.
  • Try to remove placenta if it is detached and trapped in the cervix.
  • Massage the uterus continually till she arrives at a higher health facility.
  • If the bladder is full help the mother to urinate.
  • Refer urgently to the higher health facility.

Components of Active Management of the Third Stage of Labour (AMTSL)

i) Use of uterotonic agents

Steps for application:

  • Palpate the abdomen to rule out the presence of an additional fetus(s).
  • Give oxytocin 10international units IM or misoprostol 400-600 mcg orally, ergometrine 0.25mg for non-hypertensive mothers check their blood pressure.
  • Put your one hand on the abdomen and wait for the contraction caused by oxytocin.
  • If the uterus is well contracted, support the uterus up by your second round just above the woman's pubic bone and apply control cord traction with counter pressure.

ii) Apply controlled cord traction with counter pressure

Steps for application:

  • Clamp the cord, close to the perineum and hold it with one hand.
  • Place the other hand just above the woman's pubic bone and stabilise the uterus by applying counter-pressure during controlled cord traction.
  • Keep slight tension on the cord and wait for a strong uterine contraction (2-3 minutes).
  • With the strong uterine contraction, encourage the mother to push and very gently pull downward on the cord to deliver the placenta. Continue to apply counter-pressure to the uterus.
  • If the placenta does not descend during 30-40 seconds of controlled cord traction, do not continue to pull on the cord.
  • Gently hold the cord and wait until the uterus is well contracted again.
  • With the next contraction, repeat the controlled cord traction with a counter-pressure.
  • As the placenta delivers, hold the placenta in two hands and gently turn it until
    • the membranes are twisted. Slowly pull to complete the delivery.
  • If the membranes tear, gently examine the upper vagina and cervix wearing sterile/disinfected gloves and use a sponge forceps to remove any pieces of membranes that are present.
  • Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placenta fragments and took appropriate action. I.e., your action here is an immediate referral to the higher health institution after securing an IV line.

Controlled cord traction. The right hand is pulling the clamped umbilical cord (making traction) while the left hand is exerting counter-pressure on the lower abdomen, just above the pubic bone.

Figure 5.2. a) Controlled cord traction with counter-pressure; b) As the placenta delivers, hold the placenta in two hands and gently turn it until the membranes are twisted.

iii) Uterine massage

After the placenta is delivered; massage the uterus until it is well contracted. Palpate for a contracted uterus every 15 minutes and repeat uterine massage as needed during the first 2 hours of the postpartum period then every 30 minutes. Show the woman how to rub her own uterus. Ensure that the uterus does not become relaxed (soft) after you stop uterine massage (Figure 5.3).

Figure 5.3. The health worker shows how the mother massages her womb.


Table 5.1. A summary of AMTSL.

iv) Examine the placenta for completeness

Evaluating placental completeness is critical and importance in the delivery room. Retained placental tissue is associated with postpartum haemorrhage and infection. The maternal surface of the placenta should be inspected to become sure that all cotyledons (segments of the placenta) are present. Then the fetal membranes should be inspected for the edges of the placenta. Large vessels beyond these edges indicate the possibility that an entire placental lobe (e.g., succenturiate or accessory lobe) may have been retained. You also examine the presence of the two arteries and one vein on the fetal part of the umbilical cord. The figure below shows you how you examine the placenta and identify the missing cotyledons.

Figure 5.4. a) Examine the maternal surface of the placenta to see if it is intact or not; b) Hold the membranes open like this to check they are complete.


The above figure shows you the remaining lobes or cotyledons on the maternal surface of the placenta, and she is at risk to develop postpartum haemorrhage. So you should recognise these issues and refer the woman to a higher health institution for intervention.

v) Checking tears on the vaginal and perineal area
After managing delivery, you should check tear using torch light and gauze. If there is tearing, you should refer the mother to the higher health institution. (N.B: Do not to attempt to suture it!.)

Last modified: Friday, 12 May 2017, 11:38 AM