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Amtsl

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AMTSL active management third stage labour components guidelines 2024

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"active management" "third stage of labour" postpartum hemorrhage prevention

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https://iris.who.int/bitstreams/c71a1c3a-5df3-43f3-8993-b530…

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WHO 2025 AMTSL updated guidelines oxytocin delayed cord clamping controlled cord traction

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Here is a complete overview of AMTSL (Active Management of the Third Stage of Labour):

AMTSL - Active Management of the Third Stage of Labour

What is AMTSL?

AMTSL is a package of evidence-based interventions applied immediately after delivery of the baby to reduce blood loss during the third stage of labour (delivery of the placenta). Its primary goal is to prevent postpartum haemorrhage (PPH), the leading cause of maternal death worldwide.

Components of AMTSL

AMTSL comprises three core steps, performed in sequence:

1. Administration of a Uterotonic Drug

  • Given within 1 minute after birth of the baby (after ruling out a second baby)
  • First choice: Oxytocin 10 IU IM or IV slow push
  • Mechanism: stimulates myometrial contraction, compresses uterine blood vessels, and reduces blood loss
  • Alternatives when oxytocin is unavailable:
    • Ergometrine / methylergonovine (avoid in hypertension)
    • Misoprostol 600 mcg oral/sublingual (for low-resource settings)
    • Carbetocin (long-acting oxytocin analogue)

2. Delayed Cord Clamping (DCC)

  • Cord clamped 1-3 minutes after birth (or after pulsations cease, whichever comes first)
  • Allows placental transfusion to the newborn - reduces neonatal anaemia and improves iron stores
  • CCT (controlled cord traction) is then initiated once ready

3. Controlled Cord Traction (CCT)

  • After signs of placental separation (see below), apply gentle downward traction on the cord while the other hand provides suprapubic counter-pressure (Brandt-Andrews manoeuvre)
  • Counter-pressure prevents uterine inversion
  • Never apply forceful traction before separation - risk of cord avulsion or uterine inversion
Signs of placental separation:
  1. Uterus becomes globular and firm
  2. Sudden gush of blood
  3. Cord lengthens/protrudes further from vagina
Note: Routine uterine massage after delivery of the placenta is not recommended as a routine step in WHO's updated guidelines - it is reserved for when the uterus feels soft (atonic).

Why AMTSL Matters

  • Reduces PPH incidence by up to 60-70% compared to expectant (physiological) management
  • Reduces the need for additional uterotonic agents and blood transfusion
  • Shortens the duration of the third stage of labour

WHO 2025 Updated AMTSL Summary

StepAction
1Oxytocin 10 IU IM/IV within 1 min of birth
2Delayed cord clamping (1-3 min)
3Controlled cord traction with counter-pressure
4Uterine massage only if uterus is atonic (not routine)

Important Cautions

  • Without uterotonics: CCT is NOT recommended - risk of cord rupture, partial placental separation, haemorrhage, and uterine inversion
  • Uterine inversion is a catastrophic complication of improper technique
  • Always examine the placenta for completeness after delivery - retained fragments cause secondary PPH
  • Inspect vulva, vagina, and cervix for lacerations after every delivery
Sources: Roberts & Hedges' Clinical Procedures in Emergency Medicine (p. 3775); WHO AMTSL Guidelines; GLOWM AMTSL Wall Chart
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