Active Management of the Third Stage of Labour (AMTSL)

Definition of the Third Stage

Why Active Management?

• Decreases the duration of the third stage
• Reduces maternal blood loss
• Reduces the incidence of PPH
• Reduces the need for blood transfusion
• Reduces the need for additional uterotonic medication
• Swanson's Family Medicine Review, p. 516; Pfenninger & Fowler's Procedures for Primary Care, p. 1222

The Three Core Components of AMTSL

1. Uterotonic Administration

Important: Oxytocin should NOT be given as a rapid IV bolus (risk of cardiovascular collapse). It should also not be given before placental delivery if an undetected twin is possible, as it could trap placental fragments.

• Roberts & Hedges' Clinical Procedures in Emergency Medicine, p. 3781; Miller's Anesthesia 10e

2. Controlled Cord Traction (CCT) - Brandt-Andrews Maneuver

• Uterus becomes firmer and rises in the abdomen
• Umbilical cord lengthens by 5-10 cm
• Sudden gush of blood per vaginum

1. One hand placed suprapubically (over the lower uterine segment) to provide counter-traction - pushing the uterus cephalad and posteriorly to prevent uterine inversion
2. The other hand applies firm but gentle traction on the clamped cord
3. Ask the mother to bear down to assist with expulsion
4. As the placenta reaches the introitus, lift it upward and out; use gentle twisting traction to assist membrane delivery
5. Remove any retained membranes with ring forceps

Never apply forceful traction before placental separation - this risks cord avulsion or uterine inversion, a potentially catastrophic complication.

Controlled cord traction: one hand applies gentle cord traction while the other provides suprapubic counter-pressure, lifting the fundus upward to prevent inversion. - Roberts & Hedges' Clinical Procedures

Expression of placenta: the abdominal hand elevates the fundus upward and posteriorly (arrow) while the cord is held in position. The mother bears down to assist delivery. - Pfenninger & Fowler's Procedures for Primary Care

3. Uterine Massage

• After delivery of the placenta, the uterus is massaged transabdominally to promote and maintain contraction
• Continuous palpation to monitor for uterine atony
• Massage is repeated any time signs of uterine relaxation appear
• Rosen's Emergency Medicine, p. 3412; Swanson's Family Medicine Review, p. 516

Cord Management

• Early cord clamping is part of AMTSL; however, delayed cord clamping (30-60 seconds or more) is recommended by many guidelines (especially for preterm neonates) to allow placento-fetal transfusion
• Before cutting, allow 7-10 mL of cord blood to drain from the placental side - this shortens the third stage
• Check the cord for 3 vessels (2 arteries + 1 vein); a 2-vessel cord occurs in 1:500 deliveries and is associated with fetal anomalies

Management if Placenta Does Not Deliver Within 30 Minutes

1. The cervical os may have contracted around the placenta (trapped placenta) - try the Brandt maneuver: firm suprapubic pressure plus firm cord traction
2. Intra-umbilical vein injection of oxytocin (20 IU in 20 mL normal saline) may stimulate uterine contraction and facilitate delivery
3. If these fail → manual removal of the placenta under analgesia/anaesthesia (indicated in ~3% of vaginal deliveries)

Examination After Delivery

• Placenta: check for completeness - missing cotyledons suggest retained placental fragments
• Cord: count vessels; look for velamentous insertion or accessory lobes
• Perineum, vagina, and cervix: inspect for lacerations at 3 and 9 o'clock positions (cervical), ischial spine level (vaginal), and perineum

Fourth Stage Monitoring

• Frequent fundal height and tone checks
• Transabdominal massage if any uterine relaxation
• Continue oxytocin infusion to sustain uterine contraction

Summary Table