Journal of Midwifery & Women’s Health
org
Commentary
Management Terminology During the Third Stage
of Labor
Mavis N. Schorn1 , CNM, PhD
INTRODUCTION
A variety of terms are used to describe types of care pro-
vided during the third stage of labor such as physiologic
management, expectant management, and active manage-
ment. However, the definitions of these terms are not clear
or consistent in the literature or in practice. For example,
although the terms physiologic management and expectant
management are often used interchangeably, they do not
always have the same meaning. In some cases, these terms
could be synonymous, but in others, they are distinctive. The
use of the term active management of the third stage of
labor (AMTSL) may mean administration of a uterotonic
only or it could mean partial or full application of the AMTSL
bundle. The purpose of this commentary is to recommend
clarity when these terms are used to describe third stage
management and to discuss the implications when the terms
are used incorrectly or interchangeably in research, practice,
and education. This commentary is not for the purpose of
recommending one method over another.
PHYSIOLOGIC MANAGEMENT
Three major US midwifery organizations collaborated to de-
scribe physiologic care as supporting normal intrapartum
physiologic processes for the purpose of enhancing optimal
outcomes for women and newborns.1 Although there is lim-
ited scientific evidence as to what constitutes physiologic
management of the third stage of labor, this consensus state-
ment suggested that physiologic management of the third
stage of labor may be characterized by providing care that
promotes spontaneous expulsion of the placenta, in its en-
tirety, resulting in uterine involution and a normal amount of
blood loss while also optimizing the mother-newborn dyad
without disruption or intervention.
Baker defined a physiologic approach to care as not
administering a prophylactic uterotonic, conducting cord
traction, or clamping the umbilical cord while it is still
pulsing.2 In an attempt to explain what it is, rather than
what it is not, Baker further described physiologic care
as “enhancing the woman’s normal physiologic process by
providing a birthing environment that aids her body’s release
1
School of Nursing, Vanderbilt University, Nashville,
Tennessee
Correspondence
Mavis N. Schorn
Email: Mavis.schorn@vanderbilt.edu
ORCID
Mavis N. Schorn https://orcid.org/0000-0002-6797-2272
1526-9523/09/$36.00 doi:10.1111/jmwh.13098
www.jmwh.
CEU
of oxytocin”2(p36) and provided theoretical suggestions as to
how this type of environment may be achieved. Maintaining
skin-to-skin contact between the woman and her newborn
in an environment that creates a perception of safety, such
as maintaining privacy, comfortable temperature, and soft
lighting, is thought to optimize physiologic completion of the
third stage of labor but is rarely controlled for or reported
in third stage of labor research.2-6 In addition to avoidance
of prophylactic uterotonics and cord traction, management
practices used during the third stage and referred to as
supporting physiologic care are listed in Table 1.
A consensus statement, collaboratively written by the
American College of Nurse-Midwives (ACNM), Midwives
Alliance of North America (MANA), and the National As-
sociation of Certified Professional Midwives (NACPM), also
included additional factors that promote physiologic comple-
tion of the third stage of labor, such as spontaneous onset
and progression of labor and birth and a resulting physiologic
amount of blood loss.1 Thus, effects of interventions during
the first and second stage of labor on optimal third stage of la-
bor outcomes are being investigated. For example, Erickson et
al found that women who received oxytocin for induction or
augmentation benefited most from AMTSL, whereas women
who did not receive oxytocin during the first or second stage
of labor did not receive the same benefit.7
EXPECTANT MANAGEMENT
In contrast to physiologic management, expectant man-
agement is characterized as waiting hopefully for a desired
outcome without intervention or treatment.8 Another way
to define expectant management is waiting and watching.
Expectant management may support, or be a component of,
physiologic management, but the term used alone does not
necessarily include steps considered important to physiologic
completion of the third stage of labor.2-6
For example, waiting and watching for a woman to spon-
taneously expel her placenta in a semirecumbent position
may result in excessive blood accumulation behind the pla-
centa before the third stage is eventually completed, possibly
resulting in excessive blood loss or a postpartum hemorrhage.
A woman may also spontaneously expel her placenta safely,
completely, and with a physiologic amount of blood loss,
with expectant management. However, midwifery care also
includes attention to the woman’s behavior and to signs of
placental separation, placental expulsion, and blood loss
while attending to a private and safe birthing environment.
Begley et al define expectant management of the third stage
of labor as primarily being a hands-off approach in which
the birth attendant waits for signs of placental separation and

c 2020 by the American College of Nurse-Midwives 301
 Table 1. Physiologic Management Practices for the Third Stage
of Labor
Continuously and unobtrusively observe the woman and her
newborn for normal physiology to occur
Assess the woman’s adaptation (signs of too much blood loss,
discomfort)
Maintain warmth of both the woman and newborn
Maintain privacy for the newborn
Encourage and assist the woman into an upright position
Encourage the woman to focus on her newborn
Other family or friends present should stay focused on the
woman and newborn
Encourage the woman to empty her bladder
Maintain skin-to-skin contact between the woman and
newborn
Following signs of placental separation, encourage the woman
to bear down to expel the placenta
Clamp and cut the cord after placental pulsation ceases or
placenta expulsion
Assist the woman into a comfortable position after expulsion
Sources: Baker,2 Fry,3 Hastie and Fahy,4 Schorn and King,5 National Collaborating
Centre for Women’s and Children’s Health.6
the placenta is expelled spontaneously, sometimes with the
aid of gravity, maternal pushing, or nipple stimulation.9 This
expanded definition, beyond mere waiting and watching, is
more consistent with the term physiologic management,
rather than expectant management.
ACTIVE MANAGEMENT
AMTSL includes a bundle of interventions that has changed
over time. The most current bundle is still described in a
variety of ways, including (1) administration of a prophy-
lactic uterotonic, early cord clamping, and controlled cord
traction9 ; (2) administration of a prophylactic uterotonic, de-
layed cord clamping, and controlled cord traction6,10,11 ; or (3)
solely the use of a prophylactic uterotonic.12-18 The ACNM
Position Statement defined AMTSL as administration of a
uterotonic, delayed cord clamping, and controlled cord trac-
tion and recommended it as the standard of care in low-
resource settings.10 Sometimes AMTSL is used to describe
midwifery practice without any description.19
Table 2 lists recommendations of national and interna-
tional organizations and expert consensus opinions regarding
practices during the third stage of labor. The list included is
not exhaustive of all organizations or practices, but it is notable
that all but one recommended the use of prophylactic utero-
tonics, with oxytocin being the preferred drug. A US multidis-
ciplinary consensus statement stated that that women who do
not have postpartum hemorrhage risk factors, who are having
a physiologic birth (defined as spontaneous labor onset, with-
out regional anesthesia or other medications), and who make
an informed choice to decline prophylactic oxytocin can be
supported in this decision.16 This consensus statement did not
302
recommend any other components of AMTSL with or with-
out the administration of a uterotonic.16
The consensus statement written by ACNM, MANA, and
NACPM in 2012 was for the purpose of describing physiologic
birth and was not focused only on the third stage of labor.1
However, management practices were included specific to the
third stage of labor, and the use of uterotonics, cord traction,
and uterine massage were not included.1 There were recom-
mendations for delayed cord clamping, early breastfeeding,
and maternal-newborn skin-to-skin contact.1
MIXED USE OF TERMS
The terms expectant management and physiologic manage-
ment are used primarily to describe care during the third
stage that does not include prophylactic uterotonic adminis-
tration. Two sentinel randomized controlled trials published
in 1988 and 1998 compared active management with phys-
iologic management.22,23 The trials used different terms for
the comparison groups: active versus physiologic manage-
ment of the third stage of labor 22 and active versus expec-
tant management of the third stage of labor.23 However,
the 2 studies used exactly the same description of the control
group: (1) try not to give an oxytocic; (2) try to leave the cord
intact until the placenta is expelled; (3) try not to use cord trac-
tion or other uterine interference; (4) encourage the woman
to focus on feeling contractions or the urge to push; (5) once
the woman feels the urge to push or signs of placental separa-
tion are noted, encourage her into an upright position to allow
gravity to assist in placental expulsion; and (6) if there is delay
in expulsion, encourage breastfeeding.22,23
In contemporary literature, the terms expectant man-
agement and physiologic management, or in some cases
physiological management, have continued to be used in-
terchangeably. The authors in a midwifery textbook used in
most US midwifery education programs described expectant
and physiologic as the same type of management.5 A system-
atic review of physiologic management of the third stage of
labor following a physiologic labor and birth used both terms,
expectant management and physiologic management, as
search terms.24 The authors outlined components of expec-
tant management for studies included in the review and use
the terms physiologic and expectant interchangeably.24 The
most recent Cochrane systematic review comparing active
versus expectant management for the third stage of labor
stated that expectant management is also known as physi-
ologic management.9 This review also stated that the term
AMTSL was applied if all 3 components were used (pro-
phylactic uterotonic, controlled cord traction, and early cord
clamping), and expectant management was applied if none
of the 3 components of AMTSL were used. Studies that used
only portions of AMTSL or expectant management were con-
sidered mixed management. Either of these examples may in-
clude other practices listed in Table 1 that support physiologic
completion of the third stage, confounding the description of
care even further.
IMPLICATIONS
The wide variation of practices midwives and physicians pro-
vide during the normal third stage of labor creates significant
Volume 65, No. 3, May/June 2020
 Table 2. Organization and Expert Consensus Recommendations for Vaginal Birth and Normal Third Stage of Labor Managementa
Management Components

Continuous Maternal-
Uterine Massage Newborn
Prophylactic Cord After Placenta Early Cord Early Breast- Maternal Skin-to-Skin
Organizations Uterotonic Traction Expulsion Clamping feeding Positioning Contact
12 b
ACOG 2017 Yes No No No No – –
ACNM10 2017 Yesb Yes, as No No – – –
required
ACNM, MANA, No – – No Yes – Yes
1
NACPM 2012
AWHONN13 Yesb,c – – – – – –
2015
CNGOF, SFAR14 Yesb No No No No No
2016
ICM, FIGO15 Yesb Yes Yes – – – –
2003
CMQCC, Yesb,c – – – – – –
ACOG, SOAP,
AABB,
AAFP16 2015
NATA, FIGO, Yesb No No No No No –
EBCOG,
ESA17 2019
NICE6 2014 Yesb,c Yes – No – – –
18 b
RCOG 2016 Yes – No No – – –
SOGC20 2018 Yesb – Yes No – – –
11,21 b d
WHO 2012, Yes Yes No No – – –
2018

Abbreviations: AABB, American Association of Blood Banks; AAFP, American Academy of Family Physicians; ACNM, American College of Nurse-Midwives; ACOG,
American College of Obstetricians and Gynecologists; AWHONN, Association of Women’s Health, Obstetric and Neonatal Nurses; CMQCC, California Maternal Quality
Care Collaborative; CNGOF, French College of Gynaecologists and Obstetricians; EBCOG, European Board and College of Obstetrics and Gynaecology; ESA, European
Society of Anaesthesiology; FIGO, International Federation of Gynaecologists and Obstetricians; ICM, International Confederation of Midwives; MANA, Midwives Alliance
of North America; NACPM, National Association of Certified Professional Midwives; NATA, Network for the Advancement of Patient Blood Management, Haemostasis and
Thrombosis; NICE, National Institute for Health and Care Excellence; SFAR, French Society of Anesthesiology and Intensive Care; SOAP, Society for Obstetric Anesthesia
and Perinatology; SOGC, Society of Obstetricians and Gynaecologists of Canada.
a
Yes, specifically recommended; No, specifically stated not to include; -, no recommendation provided.
b
Oxytocin is identified as the preferred uterotonic.
c
Women without risk factors and having a physiologic birth who decline administration of prophylactic uterotonic may be supported in their decision.
d
Cord traction should be offered only if by a skilled birth attendant.

challenges for researchers and clinicians. A national survey
of nurse-midwives, certified professional midwives, family
practice physicians, and obstetricians found that routine
care during the third stage of labor included more than 100
identified practices.25,26 These practice differences spanned
environmental, maternal, medical or pharmacologic, and
other components of care. In addition, it is unclear what
effect lighting, noise (including phone or pagers), number
of people present, or other birthing environmental variables
have on physiologic completion of the third stage of labor.27
Research
For purposes of research, findings would be more meaning-
ful and applicable if terms were clearly defined and used in
a consistent manner. The bundling of physiologic practices
presents challenges for researchers. For example, bundling
practices into one term such as physiologic makes it difficult
to determine which individual practice actually contributes
to physiologic completion of the third stage or whether the
practice is only effective because it is bundled, or clustered,
with other practices. Over time, the changing practice bun-
dles included in AMTSL have resulted in confusion as to
what is actually included in AMTSL. As the evidence for in-
dividual practices in AMTSL, such as timing of umbilical
cord clamping, has advanced, the outcomes of early stud-
ies must be re-evaluated. In reality, midwives and physicians
in the United States most often use a combination of active
and physiologic management and rarely use only expectant
management.25 Researchers should be consistent in the use

Journal of Midwifery & Women’s Health r www.jmwh.org 303

of terms to allow for specific comparisons or application of
outcomes.
Practice
Describing care provided during the third stage of labor in
which no uterotonic is administered as physiologic manage-
ment or expectant management is not sufficient. For exam-
ple, does the phrase, “following expectant management for 30
minutes, a manual removal was conducted, and the placenta
was removed and intact” mean the woman was assisted into
an upright position and encouraged to focus on contractions
or an urge to push while she is holding her newborn skin to
skin with the umbilical cord still intact? Or does it mean that
the woman was in a semirecumbent position, talking on the
phone, with the newborn being assessed at a warmer with the
cord already cut? In most cases, when midwives write that ex-
pectant management was used during the third stage of labor
in the health record, they actually mean that physiologic or
mixed management was used. Because of the confusion over
terms, documenting the specific components of care provided
during the third stage of labor would allow for continuous
quality improvement assessments as well as improved clarity
if there were complications attributed to care during the third
stage of labor.
Education
The 2017 International Confederation of Midwives’ (ICM)
position statement on the role of the midwife during the third
stage of labor stated that midwifery curricula and continuing
midwifery education should include physiologic management
along with AMTSL.19 In the 2018 update to the essential
competencies for midwifery practice according to ICM, “ev-
idence about third stage management” (without more detail)
was included as an essential competency.28 The ACNM Core
Competencies for Midwifery Practice includes application
of knowledge, skills, and abilities to third stage management
techniques as a competency.29 These third-stage manage-
ment competencies should include knowledge, theory, and
philosophy for physiologic management and AMTSL. If
the terms physiologic management, expectant manage-
ment, and AMTSL are confusing for experienced midwives,
educating new midwives on these terms is even more
challenging.
CONCLUSION
Midwives should consider consistently using the term physi-
ologic management rather than expectant management be-
cause based on practice patterns, physiologic or mixed man-
agement is actually what is commonly used. When oxytocin
is administered prophylactically during the third stage of la-
bor but other components of AMTSL are not used, midwives
should not record that they used AMTSL. Midwives should
have an awareness of risk factors for hemorrhage, be knowl-
edgeable regarding various options for care, have the skills
necessary to assess women during the third stage of labor,
and excel in clear use of terminology to promote joint deci-
sion making with women and their families to promote safety
304
while also supporting the principles of autonomy and joint
decision-making.
CONFLICT OF INTEREST
The author has no conflicts of interest to disclose.
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