This document discusses the active management of the third stage of labor (AMTSL) to prevent postpartum hemorrhage (PPH). It defines the four stages of labor and focuses on the third stage. AMTSL includes administering a uterotonic after birth, controlled cord traction, and uterine massage. It compares the physiological and active approaches and outlines the steps of AMTSL, which reduces the risk of PPH by 60% compared to expectant management. These steps include administering oxytocin or misoprostol after birth, delayed cord clamping, controlled cord traction, and massaging the uterus until firm.

1. ACTIVE MANAGEMENT OF THIRD STAGE OF
LABOR
Azael Haward
azahwrd1@gmail.com
The University of Dodoma
Dodoma, Tanzania
March, 2019
Azael Haward MD 1

2. 1. Introduction of Labor
2. Approaches for management of labor
3. Steps of AMTSL
4. References
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3. Acronyms
AMTSL – Active management of third stage of labor
PPH – Post-partum hemorrhage
CCT – Controlled Cord Traction
PMCT- prevention of mother-to-child transmission care
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4. Stages of Labor
First stage - begins with the onset of
contractions and ends when the cervix
is fully dilated (10 cm).
Divided into two phases,
• latent phase
• active phase
Second stage (pushing stage)
full dilatation to delivery
Third stage -
birth to delivery of the placenta and
membranes
Fourth stage
delivery of the placenta and goes 1-6
hours, or until the uterus remains firm
on its own.
• helps uterus readjustment to the
nonpregnant state.
• prevent hemorrhage from uterine
atony and the cervical or vaginal
lacerations.
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5. Third stage of Labor
birth of the baby and the delivery of the placenta and membranes.
• Typically 10 to 30 minutes;
• if > 30 minutes, is considered to be prolonged.
• If lasts longer than 18 minutes, it a/w a significant risk of PPH;
• 6x risk of PPH when it lasts longer than 30 minutes.
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6. Approaches for managing the third stage of
labor
There are two main approaches for managing the third stage of labor:
the physiologic (or expectant) approach and the active approach.
Table 1 compares how the third stage is managed using each of these
approaches.
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7. Physiological vs AMTSL
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8. continued
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9. WHY AMTSL
• Studies have shown that AMTSL prevents up to 60% of PPH and
provides several benefits for the woman compared to expectant
management.
• Additionally AMTSL have shown to decrease,
i. Incidence of PPH
ii. Length of third stage of labor
iii. Percentage of third stage of labor lasting longer than 30 minutes
iv. Need for blood transfusion
v. Need for uterotonic drugs to manage PPH.
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10. Scientific evidence supporting use of AMTSL
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11. Steps in AMTSL
1. Uterotonic drug
2. Clamping and cutting the cord
3. CCT
4. Massaging the uterus
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12. Step 1 Uterotonics
• Administer a uterotonic within 1
minute after the baby’s birth and
after ruling out the presence of
another baby
The uterotonic of choice are
• oxytocin 10 IU IM
• Give 600 μg of misoprostol by
mouth
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13. Step 2 Cord cutting
• Clamp and cut the cord after
cord pulsations have ceased or
approximately2–3 minutes after
birth of the baby, whichever
comes first.
• Cover the cord with a piece of
gauze when cutting the cord to
avoid splashing blood.
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14. Step 3 CCT
1. Place the clamp near the
woman’s perineum to make
CCT easier.
2. Place the palm of the other
hand on the lower abdomen
just above the woman’s
pubic bone to assess for
uterine contractions.
• If a clamp is not available, CCT
can be applied by encircling
the cord around the hand.
1 2
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15. Delivery of the placenta
• As the placenta is delivered, hold
and gently turn it with both
hands until the membranes are
twisted.
• Slowly pull to complete the
delivery. Gently move
membranes up and down until
delivered.
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16. Step 4 Uterine massage
• Immediately after delivery of the
placenta and membranes until it is
firm.
• During recovery, assist the woman
to breastfeed, monitor the
newborn and woman closely,
• palpate the uterus every 15
minutes for 2 hours to make sure it
is firm and
• monitor the amount of vaginal
bleeding.
• Provide PMTC as needed
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17. Safe motherhood
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18. References
• Prevention of Postpartum Hemorrhage: Implementing Active
Management of the Third Stage of Labor (AMTSL) A Reference
Manual for Health Care Providers 2007
• The Safer Motherhood Knowledge Transfer Program
• Tanzania Standard Treatment and Guidelines 2017
• www.glowm.com
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