Just Say “No” to Active Management of Third-Stage Labor

by | Feb 13, 2024 | Labor and Birth Care

Technology does not enhance a natural process that is working. It can only mar or destroy it.
— David Stewart The Five Standards for Safe Childbearing

If you are pregnant or work with pregnant women and birthing people, you are likely aware of some of the controversies between the medical and physiologic approach that swirl around labor and birth care—induction, epidurals, home birth, and VBAC come to mind. This blog post will home in on one that isn’t so well known but nonetheless affects the health and wellbeing of mothers and babies and, as I will contend in this blog post, where medical management isn’t supported by the evidence when viewed with a critical eye.

So, what are we talking about here? Third stage is the time from the birth of the baby to the birth of the placenta. “Active management of third-stage labor” (AMTSL) is a package of routine medical-management interventions intended to “reduce bleeding and the risk of severe haemorrhage after the birth [blood loss of 1,000 mL, i.e., 2 pints, or more],” postpartum hemorrhage being a major cause of maternal death (Begley 2019). The package consists of:

  • Administering medication that causes uterine contraction (oxytocin or sometimes ergometrine or a mixture of both)
  • Immediate cord clamping
  • Controlled pulling on the umbilical cord to extract the placenta

This blog post will answer the questions:

  • What’s wrong with the theory behind AMTSL
  • What’s wrong with the practice of AMTSL
  • What’s wrong with the medical approach to third stage
  • What’s right about the physiologic approach to third stage

Along the way, I’ll point out flaws in the thinking behind the medical approach to third-stage management, which is that the physiologic process is prone to failure and that precautionary intervention is the solution to that problem.

After that, as usual, I’ll wrap up with “Your Takeaway,” which will discuss what you can do with what you’ve learned.

What’s Wrong with the Theory behind AMTSL?

As we saw above, the intent of AMTSL is to reduce bleeding and life-threatening hemorrhage, but there are problems with those goals. Let’s see what they are.

Does routine application of AMTSL significantly reduce the incidence of life-threatening postpartum blood loss?

Around the world, postpartum hemorrhage is a major cause of maternal death, but not in high-resource countries. In the U.S., the maternal mortality rate in 2018 attributable to postpartum hemorrhage was 2 per million births (Joseph 2021). Furthermore, that statistic doesn’t tell us whether those deaths were caused by uterine atony—the failure of the uterus to clamp down after the birth of the placenta—this being the only complication causing postpartum hemorrhage that active management can theoretically prevent.

What about severe morbidity?

A systematic review (a study of studies on a particular topic) of randomized controlled trials (participants are assigned by chance to one form of treatment or the other or to no treatment) of active versus “expectant” management, i.e., refraining from active management, reported that 14 fewer participants per 1,000 assigned to active management experienced blood loss of 1,000 mL or more compared with expectant management (Begley 2019). That’s a very small decrease, and while blood loss in the 1,000 mL range is serious, it isn’t life-threatening. One of the trials (1,429 participants) included in the review reported on very severe hemorrhage (blood loss of 2,500 mL or more), which does get into the territory of life-threatening, and found no instances in either group.

Is minimizing third-stage blood loss beneficial?

Active management’s other purpose is to reduce blood loss. But while too much is bad, it doesn’t follow that “as little as possible” is good. The systematic review provides evidence of this: as we saw in the previous paragraph, active management reduced the incidence of blood loss of 1,000 mL by 14 per thousand, but it also increased the incidence of returning to the hospital as an out- or in-patient because of abnormal bleeding by 15 per 1,000 (Begley 2019). In other words, for every study participant spared a hemorrhage of 1,000 mL or more by active management, another participant suffered bleeding complications after hospital discharge severe enough that they needed to return to the hospital for treatment because of it. As the systematic review puts it, there would be one more severe hemorrhage for every 66 women and birthing people who didn’t have active management but also one more return to the hospital for treatment of abnormal bleeding for every 65 who did (Begley 2019).

Conclusion:

In countries where there is adequate access to medical care, AMTSL can have no effect on maternal mortality and minimal, if any, effect on reducing life-threatening postpartum hemorrhage.

As for minimizing blood loss, thinking that if too much is bad, as little as possible must be good is an example of the flawed thinking of the medical approach. During pregnancy, blood volume expands and red blood cells increase to meet the needs of the growing baby. That excess needs to be shed, and, as the review’s data shows, routinely interfering with a process that is proceeding normally causes as many serious problems as it prevents.

What’s Wrong with the Practice of AMTSL?

In this next section we’ll look at the evidence for the benefits, or more accurately, the lack of benefits of the individual components in the package.

  1. Administering medication that causes uterine contraction:

As I wrote above, routine administration of medication to contract the uterus slightly reduces the incidence of blood loss of 1,000 mL or more (1.0% vs. 2.4%) (Begley 2019). It also slightly reduces transfusions (1.0% vs. 2.9%) and somewhat reduces anemia (3.6% vs. 7.1%). None of these pose any long-term harm, though, and these benefits come at the cost of large numbers of women and birthing people having treatment they don’t need. In the expectant management group 21 percent were given medication to contract the uterus to control excessive bleeding, which means 79 percent of the routine treatment group could have avoided exposure to the drug and its potential harms, in particular, the need to return to the hospital for treatment of abnormal bleeding. In effect, then, what the systematic review tells us is that treating with a drug to contract the uterus when excessive bleeding occurs is as effective as the drug’s routine administration at preventing life-threatening hemorrhage and avoids incurring the risks of routine treatment.

But there’s still more.

The authors of the review point out a couple of factors that would tilt the review’s results in favor of AMTSL (Begley 2019). For one thing, because AMTSL was the norm at the hospitals participating in the trials, the midwives (midwives are the usual birth attendants in most countries) were unfamiliar with and (citing surveys in support of this) lacked confidence in their ability to carry out expectant management. For another, they would have been taught that AMTSL prevented life-threatening hemorrhage, a dreaded event on any labor ward, and they would therefore have been more anxious about expectant management. The reviewers offer evidence of the effect of both of these biases. Speaking to confidence, in one of the included trials, the incidence of diagnoses of severe hemorrhage fell from 21 percent in the preliminary pilot study to 7 percent in the last 6 months of the trial as the midwives gained skill and experience with expectant management. As for anxiety, the reviewers point out that blood loss estimates are subjective. Of necessity, birth attendants would know to which group trial participants belonged, and anxiety could affect judgment. This could lead both to overestimation of blood loss and could influence decisions made in the face of excessive bleeding in the expectant management group. In evidence of the latter, they note that more participants in the expectant management group had transfusions than had blood loss of 1,000 mL or more, which suggests that their care providers were, indeed, unduly anxious.

  1. Immediate cord clamping:

Immediate cord clamping is a spectacularly bad idea because it deprives babies of a considerable percentage of their blood supply by trapping it in the placenta. The systematic review reports an average decrease in birthweight of 77 g in the AMTSL group and cites a study of immediate cord clamping that found it reduced blood volume in full-term babies by about 20 percent (Begley 2019). I won’t go into details of the adverse consequences here because they’re in my blog post “Just Say ‘No’ to Immediate Umbilical Cord Clamping.”

In another example of the medical approach’s flawed thinking, the review notes that the reason for immediate clamping is to deliver the placenta quickly after administration of the contraction medication to prevent the placenta from being caught in the uterus (Begley 2019). The clamp provides a handle with which to draw it out. In other words, in the interest of furthering the use of one intervention of dubious value—the routine administration of medication to contract the uterus—the medical approach imposes another that significantly harms healthy, full-term babies and can prove lethal when they are preterm.

  1. Controlled pulling on the umbilical cord to extract the placenta:

A systematic review of trials of controlled pulling on the umbilical cord to extract the placenta versus expectant management explains that the rationale for it is: “to hasten the process of separation and delivery of the placenta, thus reducing blood loss and the incidence of retained placenta” (Hofmeyr 2015). The review continues with why retained placenta may be an issue: “It is thought that administration of a [drug that causes contraction] may cause . . . retention of the placenta if not combined with controlled cord traction,” a concern that, as I noted above, motivated immediate cord clamping so as to have a handle on the umbilical cord to use when extracting it. In other words, the theory behind extracting the placenta is to prevent a complication doctors themselves might potentially cause.

Leaving aside the problem with that reasoning, does it work?

The systematic review found no evidence that using the umbilical cord to extract the placenta reduced blood loss of 1,000 mL or more or the need for transfusion (Hofmeyr 2015). It reported a small reduction (1.4% vs. 2%) in the need to manually remove a retained placenta, a procedure in which a doctor puts a hand inside the uterus and scoops out the placenta; however, they offer an explanation for this. Participants in both arms of the trials were given a drug to contract the uterus. By far the largest trial included in the review (23,681 participants) found that when they eliminated participants who were given ergometrine (as opposed to oxytocin), the difference in rates of manual removal of a retained placenta disappeared (Gulmezoglu 2012). Ergometrine, the trial’s investigators wrote, is associated with increased probability of retained placenta, which means participants assigned to expectant management who received ergometrine would be at greater risk of retained placenta because they wouldn’t have had the extraction procedure to prevent it.

In addition, the practice has harms. The review reported one case of uterine inversion—pulling the uterus inside out—among the participants in the routine placental extraction group (1 per 10,000) and notes that controlled extraction is a skill that requires training to be managed safely (Hofmeyr 2015). It also reports an incidence of the umbilical cord snapping of 44 per 1,000 in the routine extraction group versus 1 per 1,000 in the expectant management group. In Birthing Your Placenta, the authors discuss risks of pulling on the cord (Edwards 2018). They mention the possibility of uterine inversion and continue with the potential of causing excessive bleeding and the need for manual removal, a procedure not without risks, should the birth attendant try to pull out a placenta that hasn’t completely separated or is abnormally adherent to the uterus. They note too that the cord may snap at the point where it connects to the placenta, which may also lead to needing manual removal. They add that the probability of incurring these complications increases if the placenta has an extra lobe or the umbilical cord is attached at the placenta’s edge. As midwife Amy Romano and I write in our book Optimal Care in Childbirth, “Even with proper technique, is it really a good idea to pull on the umbilical cord when it is impossible to know how well the other end is attached?”

Before we leave this section, I want to consider how long to wait before calling it a retained placenta and removing it manually. As we saw in this section’s first paragraph, the medical approach has it that third-stage duration correlates with hemorrhage, but this isn’t the case. Hemorrhage incidence will spike at whatever duration practitioners tolerate before resorting to manual removal. The spike may be for a number of reasons (Bais 2004; Combs 1991; Dombrowski 1995). It may be because the reason for prolonged third-stage was an abnormally adherent placenta, or it may be because an overtired uterus desensitized to oxytocin failed to contract to deliver the placenta and then failed to clamp down on maternal blood vessels once the placenta was out. It may also be a consequence of the procedure itself. The problem with believing “the shorter the better” when it comes to third-stage duration is that the anxiety it generates leads to unnecessary manual removals. Midwife Rachel Reed writes: “Once you have . . . given an oxytocic drug you need to finish the job and get the placenta out. If you have not, and there is no bleeding or concerns about the woman, then… how long is a piece of string?” That being said, you can’t wait indefinitely, so what’s a reasonable time limit? U.K. national guidelines for care in labor define prolonged third stage, aka retained placenta, as 60 minutes after the baby’s birth with physiologic care (NICE 2023). In yet another example of flawed medical-approach thinking, the cutoff is 30 minutes with AMTSL, although logically, if there’s no problem, there’s no problem. The type of management shouldn’t make a difference to acceptable third-stage duration.

Conclusion:

One by one, the elements of the AMTSL package fall away when subjected to closer scrutiny.

Routine administration of medication to contract the uterus has no meaningful benefits over treating excessive bleeding when it occurs, and it causes problems of its own. Furthermore, clinician anxiety and lack of confidence with expectant management may lead to overestimation of blood loss and the need for transfusion, which means differences in outcomes between routine use of AMTSL and expectant management may be smaller than appear.

Immediate cord clamping has no benefits and introduces serious harms, including life-threatening harm to preterm infants. Despite research going back decades establishing this fact, thanks to the ingrained beliefs of the medical approach, leaving the umbilical cord alone until it’s done its job of returning the blood in the placenta to the baby’s circulation has yet to become standard practice.

Controlled pulling on the umbilical cord to extract the placenta also has no benefits and if done without skill and care, has the potential to be disastrous—not to mention that the reason for doing it is to prevent harm (retained placenta) caused by administering a drug to contract the uterus, which we have seen is unnecessary at most births.

What’s Wrong with the Medical Approach to Third Stage?

The goal of AMTSL is to prevent major maternal morbidity and mortality consequent to postpartum hemorrhage, but the medical approach to third stage begs the question of the degree to which medical management of labor increases the probability of excessive bleeding after the birth. An ounce of prevention is worth a pound of cure. If you truly want to right-size postpartum blood loss, you start by minimizing the use of interventions known to increase it. These include (Begley 2019; Erickson 2019; Fahy 2010):

  • Cesarean delivery
  • Labor induction
  • Labor augmentation
  • Epidurals
  • Instrumental vaginal delivery (vacuum extraction or forceps)
  • Episiotomy

As I wrote above, though, what drives the medical approach is the belief that the physiologic process is prone to failure, and the clinician’s role is to proactively intervene to prevent those failures. That belief acts as blinders, rendering those who hold it unable to see the harms of routinely intervening or that, absent a reason to intervene, that supporting and facilitating the physiologic process would achieve optimal outcomes without introducing harms.

This brings us to the physiologic approach, which does exactly that.

What’s Right about the Physiologic Approach to Third Stage?

The physiologic approach starts from the premise that pregnancy and childbirth are healthy, normal experiences for most women, birthing people, and babies. It follows, then, that the best outcomes will be obtained by promoting and facilitating the unfolding of the physiologic process and reserving medical intervention for times when these measures prove inadequate.

Proponents of the physiologic approach point out that the physiologic approach to third stage isn’t merely “expectant management,” i.e., doing nothing, but is itself a set of practices designed to work with the physiologic process to foster normal blood loss, an uncomplicated birth of the placenta, and optimal mental and physical health in mother and baby (Davis 2012; Fahy 2010). Physiologic care includes:

  • No routine administration of medication to contract the uterus.
  • Delaying clamping of the umbilical cord for several minutes or until after delivery of the placenta. Delaying cord clamping has a potential advantage for mothers as well as babies. Draining the spongy, engorged placenta might allow uterine contractions to peel it away and expel it more easily. A systematic review pooling data from trials of placental drainage found that this was, in fact, the case. Allowing the placental blood to drain out through the umbilical cord shortened the average length of time to placental delivery by a couple of minutes (Wu 2017). Bizarrely, in these trials placental drainage was accomplished by immediately clamping and cutting the cord and then opening the clamp on the placenta’s side,* it never occurring to the researchers that the blood in the placenta was supposed to go somewhere and that “somewhere” was into the baby.
    *Umbilical cord clamping is done in two places, and the cut is made between them.
  • No pulling on the umbilical cord to extract the placenta.
  • Skin-to-skin contact between mother and baby and encouragement to put the baby to breast if the mother is planning on breastfeeding. The rationale is that skin-to-skin contact and breast stimulation trigger oxytocin secretion, and research backs that it does, in fact, reduce the probability of excessive postpartum bleeding (Saxton 2015).
  • Keeping mother and baby warm. Warmth and a peaceful, calm environment foster the natural flow of hormones—including oxytocin—that promote bonding between mom and baby and successful breastfeeding.
  • When signs of placental separation are evident, birthing the placenta by maternal effort and using upright positioning (squatting) to increase the effect of gravity. It may also involve using gentle pulling on the cord to guide the placenta out.

Let’s see how well that approach works out.

An Australian study compared postpartum hemorrhage rates with planned physiologic third-stage care versus planned AMTSL at births at low risk for excessive postpartum bleeding (Fahy 2010). Blood loss of 1,000 mL or more was more common (3% vs. 1%) at births where AMTSL was planned than when physiologic care was planned.

New Zealand investigators used a national database to analyze data from women and birthing people at low-risk for complications (Davis 2012). They found that while the absolute difference between groups was small, compared with physiologic care, AMTSL doubled the probability of blood loss of 1,000 mL or more.

A U.S. study of vaginal births in a hospital midwifery service evaluated the relationship between risk factors for postpartum hemorrhage and the effectiveness of AMTSL (Erickson 2019). In labors with more physiologic elements (fewer inductions, low use of IVs, eating and drinking as desired, early breastfeeding), fewer cases of progress delay, and less genital suturing, AMTSL nearly tripled the probability of blood loss of 1,000 mL or more, although, as with the New Zealand study, the absolute difference was small.

Conclusion:

Routine use of AMTSL is not only unnecessary but detrimental at births with more physiologic elements and fewer factors that increase bleeding.

Your Takeaway

So, how can you minimize your chances of excessive postpartum bleeding?

  • Eat a healthy diet rich in iron. Anemia predisposes to excessive bleeding.
  • Choose care providers who practice the physiologic approach. Physiologic care in labor reduces the odds of excessive postpartum bleeding. It also reduces the use of medical interventions that increase bleeding, including cesarean surgery, induction, instrumental delivery, and episiotomy.
  • Choose care providers who reserve inducing labor for medical indications. Lengthy exposures to high doses of oxytocin fatigue the uterine muscle cells, potentially leaving them unable to clamp down after the delivery of the placenta (Buckley 2023).
  • Consider making an epidural your “Plan Bstrategy for coping with labor pain. It probably isn’t epidurals per se that increase the odds of excessive bleeding but their indirect effect. Epidurals interfere with mobility, which helps with labor progress. Long labors can tire out the uterus, predisposing to excessive bleeding after the birth. Also, contractions often need bolstering with IV oxytocin with an epidural in place, and as I wrote in the previous bullet, overexposure to oxytocin contributes to uterine muscle fatigue.

What about optimal third-stage management?

  • Decline AMTSL.
  • Provided there are no factors that put you at risk for excessive bleeding after the birth, decline routine administration of a drug to contract the uterus.
  • If a precautionary dose of medication to contract the uterus is indicated in your case, decline immediate cord clamping and umbilical cord traction to extract the placenta. Omitting them increases neither bleeding nor placental retention (Begley 2019).
  • If time is passing and the placenta isn’t coming, try strategies to facilitate birthing it. Putting the baby to breast or even the baby just nuzzling the breast releases oxytocin, which will also stimulate uterine contraction. Kneeling upright or squatting puts gravity in your favor. (Gravity-positive positioning is usually possible even with an epidural with assistance and spotters.) If you’re feeling anxious about experiencing more contractions, remind yourself that birthing the soft, spongy placenta doesn’t hurt.
  • Provided there is no concern about bleeding or other concern about your condition, decline manual placental removal before 1 hour. As I noted above, the U.K. national guidelines for care in labor define prolonged third stage, aka retained placenta, as 60 minutes after the baby’s birth with physiologic care (NICE 2023).
  • If planning birth at home or at a freestanding birth center, find out if the midwives have oxytocin (Pitocin; Syntocinon) available to treat excessive postpartum bleeding. Having physiologic care reduces the odds of excessive postpartum bleeding, but it does still happen.

References

Bais JM, Eskes M, Pel M, et al. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2004;115(2):166-72.

Begley CM, Gyte GM, Devane D, et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2019;2(2):CD007412.

Buckley S, Uvnas-Moberg K, Pajalic Z, et al. Maternal and newborn plasma oxytocin levels in response to maternal synthetic oxytocin administration during labour, birth and postpartum – a systematic review with implications for the function of the oxytocinergic system. BMC Pregnancy Childbirth 2023;23(1):137.

Combs CA, Murphy EL, Laros RK, Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77(1):69-76.

Davis D, Baddock S, Pairman S, et al. Risk of severe postpartum hemorrhage in low-risk childbearing women in New Zealand: exploring the effect of place of birth and comparing third stage management of labor. Birth 2012;39(2):98-105.

Dombrowski MP, Bottoms SF, Saleh AA, et al. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995;172(4 Pt 1):1279-84.

Edwards N, Wickhham S. Birthing Your Placenta. Birthmoon Creations; 2018.

Erickson EN, Lee CS, Grose E, et al. Physiologic childbirth and active management of the third stage of labor: A latent class model of risk for postpartum hemorrhage. Birth 2019;46(1):69-79.

Fahy K, Hastie C, Bisits A, et al. Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study. Women Birth 2010;23(4):146-52.

Goer H, Romano A. Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing; 2012.

Gulmezoglu AM, Lumbiganon P, Landoulsi S, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet 2012;379(9827):1721-7.

Hofmeyr GJ, Mshweshwe NT, Gulmezoglu AM. Controlled cord traction for the third stage of labour. Cochrane Database Syst Rev 2015;1(1):CD008020.

Joseph KS, Boutin A, Lisonkova S, et al. Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations. Obstet Gynecol 2021;137(5):763-71.

National Institute for Health & Care Excellence (NICE). Intrapartum care; 2023.

Saxton A, Fahy K, Rolfe M, et al. Does skin-to-skin contact and breast feeding at birth affect the rate of primary postpartum haemorrhage: Results of a cohort study. Midwifery 2015;31(11):1110-7.

Wu HL, Chen XW, Wang P, et al. Effects of placental cord drainage in the third stage of labour: A meta-analysis. Sci Rep 2017;7(1):7067.

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