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Here is a comprehensive overview of Active Management of the Third Stage of Labour (AMTSL):
Active Management of the Third Stage of Labour (AMTSL)
What Is the Third Stage of Labour?
The third stage of labour spans the delivery of the infant to the delivery of the placenta. Signs of placental separation include:
- The uterus becomes firmer and rises
- The umbilical cord lengthens 5–10 cm
- A sudden gush of blood
These signs normally occur within 5–10 minutes of birth but may take up to 30 minutes. Beyond 18 minutes, the risk of postpartum haemorrhage (PPH) increases significantly — up to six times more likely after 30 minutes.
AMTSL vs. Expectant Management
| Feature | Expectant (Physiological) | Active (AMTSL) |
|---|---|---|
| Oxytocin | Not given routinely | Given with/after anterior shoulder |
| Cord clamping | Awaited naturally | Early clamping & traction |
| Uterine massage | Not routine | After placental delivery |
| Duration of 3rd stage | Longer | Shorter |
| Blood loss | Higher | Reduced by ~2/3 |
| Need for transfusion | Higher | Lower |
AMTSL is the preferred approach because it decreases: duration of the third stage, maternal blood loss, need for blood transfusion, and need for additional uterotonic medication.
The Three Components of AMTSL
1. Uterotonic Administration
- Administer an oxytocic agent once the anterior shoulder is delivered
- Standard regimen: Oxytocin (Pitocin) 10–20 units IM or 20–40 units in 1 L IV fluid
- Oxytocin must not be given before placental delivery because it can trap placental fragments or mask an undetected twin
2. Controlled Cord Traction (CCT)
- Apply firm but gentle traction on the clamped umbilical cord
- Simultaneously apply counter-pressure above the symphysis pubis (Brandt-Andrews manoeuvre) to prevent uterine inversion
- Avoid overaggressive traction — can detach placenta from cord and cause haemorrhage
- Any attempt to deliver the placenta before separation is contraindicated
3. Uterine Massage (Fundal Massage)
- Performed after delivery of the placenta
- Monitor uterus for tone; massage transabdominally if any relaxation is detected
- Observe for at least 1 hour post-delivery (the "fourth stage")
Cord Clamping & Examination
- Plastic clamp placed ~3–4 cm from the umbilicus; Kocher clamp ~3–5 cm distally
- Cord is normally a 3-vessel structure (2 arteries + 1 vein)
- A 2-vessel cord (single umbilical artery) occurs in 1:500 deliveries and is associated with fetal anomalies
- Allowing cord blood to drain may shorten the third stage
If Placenta Does Not Deliver Within 30 Minutes
- Consider placenta trapped by a contracted cervical ring
- Apply the Brandt manoeuvre: firm suprapubic pressure to stabilize the uterus while delivering the placenta
- If retained, ring forceps can be used to carefully remove remaining membranes
PPH Management (If It Occurs)
If uterotonic and massage fail:
- First-line: Bimanual uterine compression + IV/IM oxytocin (10–30 units in 1 L IV)
- Second-line:
- Methylergonovine (ergometrine) 0.2 mg IM q2–4h — contraindicated in hypertension
- 15-methyl PGF₂α (Carboprost/Hemabate) 0.25 mg IM q15–90 min (max 8 doses)
- Supplemental oxygen, IV access, CBC, type & crossmatch, coagulation studies
Key Points
- AMTSL reduces PPH incidence by approximately two-thirds
- Uterine atony accounts for 75–90% of PPH cases
- Despite increased maternal nausea/vomiting with active management, AMTSL is highly encouraged
- The fourth stage (first hour post-delivery) is the highest-risk period for PPH — close monitoring is essential
Sources: Rosen's Emergency Medicine, 9e; Pfenninger & Fowler's Procedures for Primary Care, 3e; Textbook of Family Medicine, 9e; Swanson's Family Medicine Review
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