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Safe Management of Third Stage Labor:
A technical report based on review of the current literature


Phyllis Long





14 July 2000
Phyllis Long, CNM, MSN
747A Liverpool Circle
Manchester, NJ, 08759 Safe management of third stage labor



Executive Summary

Postpartum hemorrhage (PPH) is the most common cause of maternal mortality in the world, the majority of these deaths occurring in
the developing world. The diagnosis and treatment of PPH is not technically complex. Death results from excess blood loss when intervention
is not available or accessible. Women who suffer a PPH, and do not die, are at increased risk for severe and prolonged iron deficiency anemia.

All pregnant women are at risk for PPH. Although risk factors for PPH have been identified, two-thirds of PPH occur in women without risk
factors. There is evidence that the actions of caregivers during labor affect the incidence of PPH. Mismanagement of third stage increases the risk
of disordered uterine action. Active management of third stage decreases the incidence of PPH. Active management of third stage means using a
package of interventions practiced routinely. The interventions include administration of an uterotonic drug immediately before or at the time of birth,
early cord clamping and separation, and delivery of the placenta by controlled cord traction. Active management of third stage is associated with a
reduction in the incidence of PPH by 50-70%. Beneficial results apply to all women, including those considered to be at low risk for third stage
complications. Maternal and neonatal risks associated with active management of third stage are minimal.

The physiologic process of placental separation and expulsion, and control of bleeding is dependent on uterine contraction and retraction. Safe
management of third stage is based on support for the physiologic process. The components of active management enhance the physiologic process
by providing peak levels of oxytocics during third stage and assuring prompt emptying of the uterus so that it can retract fully.

The relative importance of individual components of active management has not been determined. Alternatives to and additional components have
been proposed, such as oral uterotonics, draining the placental blood, nipple stimulation, and upright maternal position. The role of these interventions
in reduction of PPH has not been identified.

Steps for a safe active management procedure, derived from the current literature, are presented. Potential problems associated with active management
are cord avulsion, retained placenta, undiagnosed twin, inversion of the uterus, and PPH. These problems also occur spontaneously and must be managed
by the care provider present at birth.

Programmatic issues of providing active management of third stage include consideration of the cost, availability, storage and potential misuse of
uterotonic drugs, the level of care provider who can safely perform active management, and requirements for training.

Risks of third stage

Maternal mortality and morbidity
Third stage of labor is complicated by hemorrhage in a significant percentage of labors. Postpartum hemorrhage (PPH) is the most common cause

of maternal mortality in the world, accounting for approximately one-half of the 500,000 deaths per year. The vast majority of these deaths occur in
the developing world. [1]

The cause of most PPH is uterine atony. Poor contraction and retraction of the placental site after expulsion of the placenta causes 76-81% of PPH.[2]
Atony also predisposes to retention of placental fragments and uterine inversion, additional causes of PPH. A smaller number of PPHs are caused by
trauma to the genital tract and failure of normal blood clotting mechanisms. By the end of pregnancy, 600ml. of blood per minute flows to the uterus. Any
cause of blood loss of this magnitude can quickly lead to death.

The diagnosis and treatment of PPH is not technically complex. Death results from excess blood loss when intervention is not available or accessible.
Prompt recognition of excess bleeding during third stage and prompt action can save mothers’ lives. Interventions include uterine massage, uterotonic
drugs, and compression of the uterus. These life saving emergency interventions can be initiated in the community and maintained during transport to
higher-level facilities, when required, for blood replacement or invasive interventions.

Geographic differences in mortality rates from PPH reflect reduced access to trained caregivers, transport, and emergency obstetric services. A
community-based study in Zimbabwe revealed that PPH is the leading cause of maternal death in rural (40 per 100,000) but not in urban women
(8 per 100,000). [3]

Women who suffer a PPH, and do not die, are at increased risk for severe and prolonged iron deficiency anemia. A woman who begins pregnancy with
adequate iron stores and is well nourished or receives supplemental iron and folate will produce a red blood cell mass adequate to compensate for
moderate blood loss with normal delivery. In the developing world where women are less likely to begin pregnancy with adequate iron stores, they are at
greater risk of death from blood loss and of developing iron deficiency anemia and associated morbidity.

Who is at risk?
All pregnant women are at risk for PPH. Although risk factors for PPH have been identified, (figure 1) two-thirds of PPH occur in women without

risk factors. [2] Assuring that women at known risk for PPH deliver in health facilities, where uterotonic drugs, blood transfusion and trained care
providers are available, would reduce the risk of death from hemorrhage. Women with a history of previous PPH or risk factors that are identified during
the current pregnancy or during labor are among those at risk who should be cared for where emergency services exist.

Figure 1
Risk factors associated with postpartum hemorrhage
Risk factors from health history:
Primiparity
Ethnicity: Asian, Hispanic
History of PPH in previous pregnancy


Risk factors in current pregnancy:
Over-distended uterus (multiple gestation, hydramnios)
Placenta previa
Placental abruption
Blood clotting disorder
Pre-eclampsia


Risk factors identified during labor:
Disordered uterine action (prolonged labor, arrest at any stage)
Prolonged third stage, >30 minutes
Operative delivery (vacuum, forceps, Cesarean)
Uterine manipulation (version, extraction)
Induction or augmentation of labor
Tocolytics, narcotics, anesthesia



Caregivers’ impact on risk of PPH
There is evidence that the actions of caregivers during labor affect the incidence of PPH. Mismanagement of third stage increases the risk of disordered

uterine action. Actions that support the normal progress of second and third stage labor can reduce the risk of atony and genital tract trauma. A package
of prophylactic interventions, called active management, decreases the incidence of PPH.


Strategies to reduce the risk of post partum hemorrhage

Active management
Active management of third stage is consistently associated with a reduction in the risk of PPH and maternal anemia. [1] Active management of third

stage means using a package of interventions practiced routinely. The interventions include administration of an uterotonic drug immediately before or at
the time of birth, early cord clamping and separation, and delivery of the placenta by controlled cord traction. Active management is differentiated from
methods of managing third stage described as expectant, conservative or physiologic. These terms imply that an uterotonic drug is not given prior to
completion of third stage, signs of separation and descent of the placenta are awaited then the placenta is allowed to deliver spontaneously or with the
aid of gravity and nipple stimulation.

Evidence for efficacy
Active management of third stage requires the provider to intervene in a normal physiologic process when there are no signs of pathology. The health care

community must be sure of the efficacy and safety of a prophylactic intervention, to avoid causing harm. Although prophylactic interventions
(immunizations, antenatal nutritional supplements) are generally accepted, there is currently a backlash against routine medical interventions during labor.

Controlled trials offer convincing evidence of the efficacy and safety of active management of third stage labor.[1,4,5,6] Older reports, [7] including
population-based studies, [8] describe similar significant reduction in the incidence of PPH after active management was instituted. Active management
of third stage is associated with a reduction in the incidence of PPH by 50-70%. [1,5,9]The incidence of severe PPH, need for postpartum blood transfusion
and postpartum anemia are also reduced by this intervention. [1]. These beneficial results applied to all women, including those considered to be at low
risk for third stage complications.

Evidence for safety
Risks associated with active management of third stage are related to the uterotonic drug used. Maternal nausea, vomiting and raised blood pressure

are reported when ergometrine is a component of the intervention. Increased incidence of need for manual removal of the placenta was reported in one
trial of active management [1], and may be associated with ergometrine use. A potential maternal risk is adverse cardiovascular response to bolus
intravenous administration of uterotonic drugs.

Controlled trials that assessed neonatal outcomes show no important differences between offspring in either group. The rate of breastfeeding at hospital
discharge and at six weeks postpartum was higher in the groups managed actively. Active management poses a potential risk for mother and fetus if a
second twin is undiagnosed.

Mothers’ responses to the management of third stage favor active management due to the shorter duration of third stage. [10] Greater frequency of
pain with active management, reported in one trial, may be related to the method of placental delivery or the use of ergometrine.

Controversy
Since the 1970s consumers and some providers in developed countries have criticized the medical community for obstetric procedures carried out as

“routine”. Critics argue that active management of third stage begins a cascade of interventions with unforeseen effects on mother and baby. The rate of
PPH seems to hold little importance for women at low risk of hemorrhage or in modern hospital environments. [9] Instead emphasis is placed on the
risks of hypertension and unknown long-term physical and psychological disadvantages for mother and baby. Physiologic management or watchful
non-interference in third stage is currently advocated by a significant number of providers in developed countries. [11] Workers in developing countries,
however, are aware of the death toll from PPH among women who deliver unattended and without access to health care interventions.

Is it possible to gather unbiased data?
Critics point out sources of bias in trial data, such as providers that are only proficient in one method of conducting third stage, or the effect of narcotics

and maternal position on third stage progress. Sufficient evidence demonstrates that the advantages of active management outweigh any disadvantages. In
trials comparing active and expectant management, 1 in 5 women assigned to expectant management need an uterotonic drug for treatment of excess bleeding,
instead of prophylaxis. [9] These women cannot be allowed to remain without treatment to achieve “unbiased” data collection.

Physiology of third stage
To be safe, management of the third stage of labor must be based on and support the physiology of placental separation and descent. Reports from

ultrasound imaging of normal and complicated third stage add to our understanding of this physiology. [12] After delivery of the baby the placenta-free
uterine wall gradually thickens from less than 1 cm. to greater than 2 cm., followed by thickening of the placental site. Thickening of the uterine wall is the
result of contraction and retraction. The placenta does not separate until the uterine wall under the placental site attains full thickness. Gentle cord traction
before thickening of the uterine wall did not effect separation. The time required for separation of the placenta ranged from 2 – 18 minutes, with an average
of 5.5 minutes. No hematoma was observed between the placenta and uterus. After the placenta leaves the placental site, a small amount of blood collects.
Bleeding is thus a consequence, not a cause, of separation.

Following separation, the placenta and membranes descend from the placental site and are expelled from the uterus by contraction and retraction of the
myometrium. The recognized clinical signs of placental separation are more accurately signs that result from descent of the placenta.[13]
Clinical signs of placental separation and descent:
The uterus becomes globular.
The uterus becomes firmer.
The uterus rises in the abdomen.
The uterus becomes mobile.
The umbilical cord protrudes farther out of the vagina.


Blood escaping from the vagina is not a reliable sign of placental separation and descent because bleeding may occur with complete or partial separation or
trauma to the birth canal. Bleeding that results from separation is frequently retained inside the membranes and not visible before expulsion of the placenta
and membranes.

Efficient and coordinated uterine activity completes third stage and controls bleeding from the placental site. Endogenous oxytocin probably regulates
uterine activity. The circulating level of endogenous oxytocin is seen to peak at the time of birth and gradually decline during third and fourth stage. [14]
The mechanism by which factors such as drugs, infection, stress, rapid emptying of the uterus affect uterine activity has not been explained, but may be
mediated by inhibiting the release of maternal and/or fetal endogenous oxytocin.

Supporting the physiologic uterine activity before third stage
Understanding the physiology of third stage encourages providers to choose actions, before third stage, that support efficient and coordinated uterine

activity. It is well know that drugs such as tocolytics, narcotics, and some anesthetics inhibit uterine activity. Drug use can be minimized in labor.
High circulating levels of stress-related maternal catecholamines weaken uterine activity. Providers should provide reassurance, education, a comfortable
environment and emotional support for women in labor to minimize the stress response. Adequate hydration, nutrition and rest are not known to benefit
uterine activity but contribute to well being and may reduce stress.

Actions during second stage labor that may contribute to optimal uterine activity include assuring that the bladder is empty. Mechanical interference with
contraction is a known risk for atony. Slow delivery of the baby, over a period of 3 minutes, is important to ensure efficient uterine action. [7] The baby
should be pushed out by the uterus, not pulled out. PPH is associated with operative delivery but not precipitous delivery, in which the uterus is providing
the delivery force.


Active management of third stage

Components of active management and alternatives
Active management of third stage reduces the incidence of PPH. The individual component of active management that is most important for this reduction

is unknown. The importance of using all the components together is also unknown. Published information about the components is summarized here.

Uterotonic drugs
Oxytocin and ergometrine are the drugs used for active management in reported trials. Oxytocin 10u given intramuscularly (IM) or intravenously (IV) is

reported to be the best choice for achieving the goals of active management safely. Side effects are minimal. Syntometrine, a combination of 0.5mg
ergometrine maleate and 5u oxytocin, is given IM or IV. Syntometrine used routinely results in a slightly lower PPH rate than oxytocin alone. Side effects
of nausea and vomiting are common with Syntometrine and vasoconstriction, secondary to the ergot derivative, may potentially produce hypertension.
Oxytocin is less likely to be associated with retained placenta than ergot alkaloids.

Route of administration
Oxytocin and Syntometrine can be given IM or IV. Both oxytocin and ergometrine are associated with adverse cardiovascular side effects when given by

IV bolus.[13, 15] The use of these drugs for prophylaxis should be limited to administration intramuscularly or in dilution in IV infusion. Oxytocin, given
IM, acts within 2-3 minutes, egometrine within 6-7 minutes. [16]

Timing of drug administration
Timing of drug administration for active management varies among clinical trials and clinical protocols. The time period is short and includes from

administration “with crowning” to “immediately after the birth of the baby”. The most frequent instructions for timing are “with, or as soon as possible
after, birth of the anterior shoulder”

Alternatives for stimulating uterine activity
Oral ergometrine 0.4 mg. has been compared with placebo and oxytocin IM, all given immediately after birth. [17] Oral ergometrine produced too little

effect on blood loss to be a reliable alternative to parenteral administration for active management of third stage. Misoprostol, an oral prostaglandin tablet,
is currently under investigation as an acceptable alternative to injection of oxytocics for active management. [3] Injectable prostaglandins are strong
uterotonics used widely to treat PPH.

Suckling and manual nipple stimulation are known to increase uterine activity and have been investigated as methods to decrease the rate of PPH. Suckling,
initiated three minutes after birth, produced no difference in rate of PPH compared with traditional management by trained traditional birth attendants
(TBA) in Malawi. [18] Bilateral manual nipple stimulation started immediately after delivery and continuing for 15 minutes, produced lab evidence of
increased intrauterine pressure. Levels of intrauterine pressure achieved with Syntometrine injection were higher than with nipple stimulation. [19] The
role of nipple stimulation and suckling in prevention of acute third stage hemorrhage has not been established.

Early cord clamping and cutting
Early clamping of the umbilical cord implies clamping before beginning controlled cord traction (CCT) and before the cord stops pulsating. Early cord

clamping shortens the duration of third stage but significant effect on the rate of PPH is undocumented.[20] It has been suggested that early clamping of
the cord produces adverse effects in the neonate by reducing the volume of placental blood transfused. Lower hemoglobin levels are reported in infants
after early cord clamping. [21] The long-term effects, in terms of stored iron and infant health have not been clarified. Delayed cord clamping may expose
the baby to greater risk of blood borne infection. [5]

Drainage of placental blood from the cord after clamping and cutting has been observed to reduce blood loss and decrease the duration of third stage in
women who had received prophylactic uterotonics. [18] Similar benefits from cord drainage were demonstrated in low risk women who did not receive
prophylactic oxytocics. [22]

Controlled cord traction
Controlled cord traction is thought to be associated with decreased loss of blood and shorter third stage when compared with less active approaches

for expulsion of the placenta. [20] A recent trial that allowed CCT or maternal effort for completion of third stage did not report observations on the
different methods. [5]

Clinical trials of active management report variations in timing of initiation of CCT with no change in beneficial results. CCT is initiated immediately
after birth, [23] as soon after birth as the operator recognizes uterine contraction, [6] and after signs of separation and descent are noted. [5]

Posture for third stage
Upright maternal posture should theoretically encourage spontaneous expulsion of the placenta with the aid of gravity. While previous reports linked

maternal upright posture with increased risk of PPH, a recent study showed that upright posture did not adversely affect the rate of PPH. [5] Active
management decreased PPH rates regardless of the woman’s posture.

Guidelines for active management of third stage

Action Rationale and notes
1 Empty bladder during second stage Avoid mechanical interference of full bladder
2 Give IM uterotonic drug with or as soon

as possible after birth of the anterior shoulder a. The physiologic endogenous peak of oxytocin seems to be at time
of birth. Time drug administration to simulate physiologic timing.
b. Once the anterior shoulder is seen the risk of shoulder dystocia

obstructing the progress of birth has passed.
3 Control delivery so it occurs over 2-3 minutes.

Do not pull the baby out. Stimulate infant respiration. Slow delivery promotes effective uterine action.
4 Palpate the mother’s abdomen briefly and gently to

rule out a second baby in the uterus. Undiagnosed twin with shared circulation may be placed at risk if cord is
drained.
5 Clamp the cord in 2 places, then cut the cord between

the clamps. If no clamps are available, tie the cord,
close to the baby, cut the cord. Avoid splash or spray of blood from cord.

6 Remove clamp from placental end of cord (if clamped)

and drain blood into a non-porous container. There is evidence that draining the placental blood shortens third stage.
7 Assess for signs of placental separation and descent.
a. See if the cord has lengthened at the vulva
b. Look at or feel the position of the uterus in

relation to the abdomen, to detect if the uterus has
risen closer to the umbilicus.
c. Feel the shape of the uterus to see if it is globular,

or ball shaped.
d. Gently grasp the fundus and see if the uterus

moves freely from side to side.
e. Notice if there is any bleeding from the vagina. Remember that bleeding is not a sure sign of separation and descent.

U/S studies show that the placenta will not separate from the uterus
with cord traction, and that cord traction before separation carries a risk
of uterine inversion. Trials of active management in which CCT was
initiated only after signs of separation and descent occurred achieved
equivalent beneficial results as those in which CCT occurred immediately
and independently of signs of separation and descent.
8 If signs of separation and descent are not evident or

only partially present, and the uterus is well contracted,
place your hands to do CCT (see step 9) and watch
for cord movement Signs may be missed because in most labors the placenta will separate and
start to descend while the provider is caring for the baby. A firmly
contracted uterus is a prerequisite for any manipulation to prevent uterine
inversion. This maneuver to verify separation and descent is the same as
that to initiate CCT.
9 Prepare for controlled cord traction as follows.

First make sure, again, that the uterus is firmly contracted.
a. Place the palm of the left hand, on the lower abdominal

wall against the anterior surface of the uterus.
b. Gently lift any slack cord out of the vagina. Grasp

the umbilical cord, close to the vulva, in the right hand.
c. Lift the uterus toward the mother’s chest.
d. Watch and feel for movement of the cord toward

the vagina.If the cord does not move into the vaginal and
you do not feel a pull against the hand holding the uterus,
separation of the placenta is confirmed. Continue with
step 10.
e. If you feel or see the cord pull toward the vagina, the

placenta has probably not separated or descended. If there
is no heavy bleeding, stop. Wait 5 minutes and repeat
these steps. Adapted from several authors. [23], [6] The firmly contracted uterus prevents inversion. This step
confirms that the placenta has separated and descended and is ready for
expulsion by CCT or suggests that this has not happened. If there
is no hemorrhage, the safe course of action is to stop and wait.
10 When separation and descent of the placenta have

been confirmed, begin CCT as follows.
a. Lift the uterus toward the chest and maintain

this lifting pressure.
b. Apply continuous gentle cord traction, pulling

the cord downward, toward the rectum.
c. If you can feel the placenta moving downward

by the lengthening of the cord, continue this action slowly.
d. If you do not feel any movement of the placenta

or cord lengthening, stop. If the mother complains of pain,
stop. Do not push on the fundus or ask the mother to push
while traction is made. Follow step 9.e. The purpose of the CCT maneuvers is to straighten out the birth canal
and facilitate downward movement of the placenta. Lifting the uterus off of
the placenta is a safer image for providers to visualize than pulling the
placenta out of the uterus. The uterus is always in the palm of the
abdominal hand and cannot be inverted while this position is maintained.
Pain may indicate that the placenta is not separated and may be a sign
inversion will occur.

11 When the placenta appears at the vulva change
the position of the hand holding the cord. Lift the placenta
out of the vagina by pulling the cord upward, toward
the ceiling. With the abdominal hand massage the fundus. The birth canal curve describes a 90-degree angle. Once the placenta is at
the vulva, uterine guarding is no longer required to prevent inversion.

12 Receive the placenta in 2 hands, close to the vulva. Avoid breaking trailing membranes.

13 If the membranes do not slip out of the vagina
with the placenta, twist or rotate the whole placenta
several times to make a thicker rope of the membranes.
Gently move the rope of membranes up and down until it
comes out of the vagina. Avoid tearing the membranes and leaving them in the cervix

14 Massage the uterus until it is very firm. Repeat this
action frequently if the uterus is not firm. Teach the mother
to self-massage the uterus. Encourage breastfeeding. Maintain strong uterine contraction during the immediate postpartum
period to prevent excess bleeding.

15 Examine the birth canal for lacerations, by separating

the labia and looking closely at the tissues, and at the
amount of bleeding. Avoid missing lacerations, or heavy bleeding after placenta.

16 Examine the placenta and membranes for completeness. Although it is difficult to accurately assess for missing cotyledons, an effort
should be made to assess completeness and note any incomplete placental
tissue or membranes.

17 Dispose of placenta, membranes and any collected
blood in a way that prevents human contact. Prevent infection by using recommended disposal methods.

18 Clean the mother’s vulva, legs and help her put on
clean clothes. Give her something to drink. Assess her
general condition. Help her to empty the bladder. Make sure the woman is in satisfactory condition, and ready to begin the
recovery period with rest, hydration. Diuresis begins immediately after
delivery and a full bladder interferes with uterine contraction.

Potential problems of active management of third stage
Providers who manage third stage using active management protocols need to be able to manage the potential problems of third stage. These problems

may be associated with the interventions or they may occur spontaneously. The provider who is present at the time of delivery will be responsible for
management of problems. Management protocols for these third stage problems are outside the scope of this paper.

Partial separation of the placenta and hemorrhage
It is commonly understood that handling the uterus may cause disordered uterine action leading to partial separation and hemorrhage. [24] Gentle

guarding or feeling the uterus, with the hand remaining still on the fundus is the recommended procedure. Rough manipulation to assess for signs of
separation is avoided. Hemorrhage with the placental undelivered requires manual removal.

Cord avulsion
A small percentage of cords will separate from the placenta, in spite of correct performance of CCT and gentle traction. Preterm delivery and

velamentous cord insertion increase the risk of cord avulsion. Unless there is a hemorrhage, there is no need for manual removal to extract the placenta.
Appropriate management is as follows:
Re-assess for signs of placental separation and descent
If placenta is not separated, and there is no hemorrhage, wait.
If (or when) the placenta is separated, use maternal effort or fundal pressure to expel the placenta.


Inversion of the uterus
Uterine inversion can be a spontaneous complication of third stage and is associated with life-threatening hemorrhage and exposure of the uterus to

infection. The conditions that predispose to uterine inversion are: uterine atony, an open cervix and pushing or pulling pressure on the uterus. Misuse
of CCT can potentially cause uterine inversion. Following the recommended steps and cautions for management of third stage should prevent operator
caused uterine inversion.

Retained placenta
Retained placenta may be caused by tonic contraction of the uterus associated with ergometrine administration, although the reported occurrence is

small. The amount of bleeding dictates the management of this problem. Hemorrhage makes manual extraction of the placenta imperative.

Hemorrhage after delivery of the placenta
All postpartum hemorrhages cannot be prevented. Prompt recognition and treatment of hemorrhage is imperative to save the life of the mother. Uterotonic

drugs, compression of the uterus by the internal or external approach and referral are critical elements of PPH management.

Program issues related to provision of active management of third stage

Uterotonic drugs
The cost and availability of drugs and syringes are deterrents to implementation of the standard active management package in developing countries.

Active management requires administration of the drug at the time of delivery. In settings where the client’s family is sent to purchase drugs this
process would have to be negotiated before the birth. Storage of the drugs by providers or families requires review. Both ergometrine and oxytocin
are unstable when not stored under refrigeration. Ergometrine loses potency when exposed to light. When refrigerated storage is not possible, the
effective life of these drugs at room temperature is 3 months. [1]

Uterotonic drugs have been misused in misguided and dangerous attempts to start or augment labor or cause abortion. Possible misuse of uterotonic
drugs at all level of the health care system suggests that methods to safeguard the public are needed if these drugs are made accessible for use in active
management of third stage.

Who should be trained to provide active management?
Active management of third stage, provided by doctors and midwives in health care facilities, is reported to decrease the incidence of PPH. It is unknown

if the same results would be achieved in different birth settings by a different level provider. Administration of drugs and obstetric procedures for active
management may be subject of health care regulations.

Intervention in an otherwise normal physiologic process should only be considered if the intervention can be performed safely, assuring that the benefit
outweighs the risk. The major clinical skills required for different components of active management and are presented below.

Figure 2: Skills required to perform active management of third stage
Component of Active management Clinical skill requirement
1 Administer IM uterotonic drug IM drug administration
Infection prevention techniques
Ability to time the injection appropriately
Ability to diagnose twin pregnancy
2 Drain the cord Unclamp the placental end of the cord to allow blood to drain out
Infection prevention techniques when handling blood
3 Assess for and recognize signs of

placental separation and descent Identification of cord lengthening
Palpation of uterine changes
Avoid manipulation of uterus
Interpret the meaning of observed sign(s)
Assess separation and descent of placenta based on signs (are there enough signs to indicate

separation?)
4 Assess for uterine contraction Palpation of uterus to judge firmness of contraction
Decision making to wait for contraction if the uterus is not firmly contracted
5 Perform CCT Proper hand placement
Coordination to push uterus upward and maintain downward traction on cord at the same time
Ability to identify that the placenta is not separated when uterus is felt to be pulled down by

cord traction
Ability to judge amount of traction
Detect if the placenta is advancing
Decision making based on progress, judgment of when to stop
6 Deliver the placenta Identify time to stop traction downward and lift placenta from vagina
Ability to change hand placement and use both hands to catch placenta


The manual skills required to perform active management are not complicated but require adherence to safety guidelines; not proceeding if the uterus
is poorly contracted, waiting for signs of separation, keeping the uterus elevated and in contact with the palm. Clinical judgments involve timing of drug
administration and continual assessment of progress, maternal pain, uterine consistency, and amount of bleeding. Problem solving skills required include
making decisions based on the assessments; should the procedure be initiated, continued, stopped? Incorrect performance of CCT can increase the risk
of hemorrhage, retained placenta, inverted uterus and avulsed cord. In summary a moderate level of clinical knowledge, judgment and skill is required to
safely provide the components of active management of third stage as described in standard packages.

Alternative methods to prevent PPH may be worth consideration where providers do not have the requisite skills for safe use of the standard package.
These components include:
Slow delivery of the baby
Early nipple stimulation and/or suckling
Draining blood from the placental end of the cord
Facilitating expulsion of the placenta by maternal effort


Training providers in active management of third stage
The clinical skills in figure #2 suggest steps or components for a training plan. Development of the clinical judgments required could start with case

studies and role-playing with the use of models. Repeated clinical experiences with actual deliveries is required to learn the amount of traction that is
safe, the direction of uterine displacement, the coordinated elevation of the uterus and traction on the cord and the technique for twisting the placenta to
rope the membranes. Training and monitoring in the safe performance of active management requires the supervisor to be able to observe and coach the
learner through a number of actual deliveries.

Infection prevention
Infection prevention is a major concern for providers caring for women in second and third stage of labor. Active management increases the potential

exposure of participants to blood. Draining of the cord, cord traction, giving IM injections, handling the placenta are all potential sources of exposure.
Procedures for preventing infection transmission, developed specifically for third stage management, will increase the safety of providers and families.


Unanswered questions about management of third stage

Uterine massage
Is there evidence that self-massage of the uterus is effective to maintain a firmly contracted uterus? Does teaching self-massage of the uterus decrease

the frequency of provider assessment of the postpartum uterus?

Nipple stimulation
Nipple stimulation increases intrauterine pressure and stimulates uterine contractions. Would nipple stimulation, initiated earlier than in reported trials

[19], provide a satisfactory alternative to uterotonic drugs?

Uterotonic drug without CCT
The Hinchingbrooke trials included maternal effort as well as CCT for expulsion of the placenta. A difference in efficacy and safety of methods of

placental delivery was not reported[5]. Would benefits of active management be achieved with administration of an uterotonic followed by expulsion
of the placenta by maternal effort in a squatting position?

Maternal position
Traditionally women have been turned to the dorsal position for management of third stage for ease in observing the blood loss form the vagina and

ease in palpation of the uterus. [24] The left lateral position during labor has been associated with increased intensity of uterine contractions. Would
a left lateral maternal position for third stage decrease the duration of third stage and PPH rates?




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an overview of the evidence from controlled trials. British Journal of Obstetrics and Gynaecology, 1988. 95: p. 3-16.
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