ACTIVE MANAGEMENT OF 3RD STAGE OF LABOR

COMPONENTS OF ACTIVE MANAGEMENT OF THIRD STAGE

OF LABOR
1. Use of oxytocic after the birth of baby
2. Delayed cord clamping (≥1-3 minutes)
3. Delivery of placenta by controlled cord traction
4. Intermittent uterine tone assessment ( note: uterine massage is no
longer a part of AMTSL as per the latest guidelines of WHO)
DETAILS OF EACH COMPONENT OF AMTSL
Step 1: Use of Oxytocics
OXYTOCIN: it is the preferred drug and the drug recommended by
WHO for preventing PPH
Dose=10 units IM or IV infusion
Route Onset of action Duration of action
IM bolus Within 3 mins 3 hours
IV infusion immediate 1 hour

Note: Oxytocin should not be given as IV bolus due to risk of marked

transient fall in BP , abrupt increase in cardiac output, myocardial
ischemia and chest pain.
-oxytocin is synthesized in the paraventucular nucleus of hypothalamus
-it is nonapeptide
-synthetic oxytocin is octapeptide
-half life= 3-4 minutes
-oxytocin loses its effectiveness unless it is stored at 2*-8*C
-at room temperature its shelf life is 3 months
-it is the hormone responsible for milk ejection
-it increases uterine contraction physiologically and law of polarity is
maintained hence it is used for inducing labor and augmenting labor also

If Oxytocin is not available then WHO recommends use of oxytocics

like:
1. Ergometrine (0.25 mg) or Methylergometrine (0.2 mg): They bring
about titanic contraction, hence should not be used for inducing or
augumenting labor. It should not be used during pregnancy.
Side Effect: Transient increase in BP
Contraindication: Conditions in which
ergomatrine/methylergometrine is absolutely contraindicated
(however,active management with oxytocin can be done in all
cases)
TOPER
T: Twin pregnancy
O: Organic heart disease
P: Preeclampsia
E: Eclampsia
R: Rh negative female
2. Inj PGF-2a (Carboprost):Dose 250 mcg IM. It is contraindicated in
bronchial asthma patients. It acts mainly on myometrium of uterus
hence used in AMTSL and in PPH but not in inducing labor.
3. PGE1- misoprostol: available as tablet. WHO recommends use of
600 mcg orally for preventing PPH, i.e, during active management
 of third stage of labor. PGE1 can act on both cervix and uterus and
hence is used for:
a) Ripening of cervix (25-50 mcg every 3-6 hours orally or
vaginally)
b) Inducing labor
c) AMTSL
d) For treating PPH
Side effects: Nausea, vomiting , abdominal pain , shivering or
hyperpyrexia , hypotension. It is contraindicated in previous
cesarean patients.
4. Syntometrine: it is 5 units of oxytocin and 0.5 mg methergine. It is
expensive.
5. Carbetocin: dose 100mcg IV over 1 minute for AMTSL, i.e, for
preventing PPH. It is and analogue of oxytocin and has action
similar to oxytocin. Its advantage is, it has longer half life=85-100
minutes.
6. Tranexamic acid: it is an antifibrinolytic drug which has been
approved by WHO for treating and preventing PPH.

STEP 2: Delayed cord clamping

-delayed cord clamping means clamping the cord between 1-3
minutes of birth
-early cord clamping means clamping the cord before 1 minute
Advantage of delayed cord clamping
80ml of blood (i.e, 50 mg of elemental iron) present in the cord goes
to the newborn and helps in preventing neonatal anemia.
 Thus in all cases except the ones listed below- delayed cord clamping
is advised.
Conditions in which early cord clamping is done:
-baby is hypoxic and needs resuscitation or mother is
hemodynamically unstable.
-known heart disease in baby.
-if cord is avulsed or IUDR with abnormal cord Doppler evaluation
Note: earlier in preterm babies, HIV-positive mothers, and Rh
negative females early cord clamping is done in them also.

STEP 3: Delivery of placenta by controlled cord traction (Modified

Brandt-Andrews Technique)
Here with one hand uterus is pushed upwards and backwards and with
other hand traction is given to cord in downward and forward direction
in a steady and slow manner, until complete expulsion of the placenta
occurs.
Note:
-if the placenta is undelivered after 30 minutes, it is called ‘Retained
Placenta’.
-controlled cord traction is only recommended by WHO if skilled birth
attendant is available, otherwise not.
STEP 4: Intermittent uterine tone assessment
-after delivery for early identification of uterine atony, tone assessment
is recommended for all births (uterine massage is now not a component
of AMTSL)
REMEMBER: most important component of AMTSL is the use of
oxytocic.
WHO Recommendations for Active Management of the Third Stage
of Labour (AMTSL), 2012
The use of uterotonics for the prevention of postpartum haemorrhage
(PPH) during the third stage of labour is recommended for all births.
Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the
prevention of PPH.
In settings where skilled birth attendants are available, controlled cord
traction (CCT) is recommended for vaginal births if the care provider
and the parturient woman regard a small reduction in blood loss and a
small reduction in the duration of the third stage of labour as important.
In settings where skilled birth attendants are unavailable, CCT is not
recommended.
Sustained uterine massage is not recommended as an intervention to
prevent PPH in women who have received prophylactic oxytocin.
Postpartum abdominal uterine tonus assessment for early identification
of uterine atony is recommended for all women.
CCT is the recommended method for removal of the placenta in
caesarean section.
Improvement in the active management of the third stage of
labor for the prevention of postpartum hemorrhage in
Tanzania: a cross-sectional study.
PLACE: Tanzania
AUTHOR: Dunstan R. Bishanga, John Charles, Gaudiosa Tibaijuka,
Rita Mutayoba, Mary Drake, Young-Mi Kim, Marya Plotkin, Neema
Rusibamayila & Barbara Rawlins
YEAR: 2018
PUBLICATION: BMC Pregnancy and Childbirth volume 18, Article
number: 223 (2018)

Conclusion
The quality of PPH prevention increased substantially in
facilities that implemented competency-based training and
quality improvement interventions, with the most dramatic
improvement seen at lower-level facilities. As Tanzania
continues with efforts to increase facility births, it is imperative
that the quality of care also be improved by promoting use of
up-to-date guidelines and ensuring regular training and
mentoring for health care providers so that they adhere to the
guidelines for care of women during labor. These measures can
reduce maternal and newborn mortality.