Once a baby is born, the womb (uterus) continues to contract to push the placenta spontaneously off the uterine wall. The mother then
delivers the placenta, or 'after-birth'. This is termed expectant
management of the third stage of labour. Active management involves
giving a drug (uterotonic) to contract the uterus, clamping the cord
early (usually prior to, alongside, or immediately after administration
of the uterotonic, which is before cord pulsation ceases) and applying
traction to the cord with counter-pressure on the uterus to deliver the
placenta. Specific ways the three components are applied often vary.
Mixed management uses some, but not all, of the three components. Active management was introduced to try to reduce haemorrhage, which is a
major cause of maternal mortality in low-income countries where women
are more likely to be poorly nourished, anaemic and have infectious
diseases and bleeding disorders. In high-income countries, bleeding
occurs much less often yet active management has become standard
practice in many. This review looked at the balance of benefits and
harms for the different ways of managing the third stage of labour, for
all women and specifically for women at low risk of bleeding. Five
studies were identified (6486 women), all in hospitals in high-income
countries. Four of the studies looked at active versus expectant
management. For all women, irrespective of risk of bleeding, active
management of third stage reduced severe bleeding and anaemia in
It also reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs
for pain relief. The number of women returning to hospital with bleeding
For women at low risk of bleeding, findings were similar though there was no difference in the risk of severe bleeding.
Some of the adverse effects experienced by the mothers, such as high
blood pressure, nausea, vomiting, after-pains and use of pain relief
after birth, may be due to use of ergot compounds.
Women should be given information antenatally to help them make informed choices. WHO now
recommends active management with delayed cord clamping, to allow baby's
blood that is in the placenta to return to the baby's circulation
through the umbilical cord, to reduce the likelihood of anaemia.
More research is needed to see if just giving a uterotonic might reduce
severe bleeding without reducing the baby's blood volume. More research
is also needed on third stage in low-income countries.