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Uterotonic
Signs of placental
separation
Delivery of the
placenta
Uterine massage
Advantages
Disadvantages
Table 6. Comparison of Physiologic and Active Management
of the Third Stage of Labor (AMTSL)4
Physiologic (expectant)
management
Uterotonic is not given before
the placenta is delivered.
Wait for signs of separation:
• gush of blood
• lengthening of cord
• uterus becomes rounder and
smaller as the placenta
descends
Placenta delivered by gravity
assisted by maternal effort.
Massage the uterus before the
placenta is delivered.
• Does not interfere with normal
labor process.
• Does not require special
drugs/supplies.
• May be appropriate when
immediate care is needed for
the baby (such as
resuscitation) and no trained
assistant is available.
• May not require a birth
attendant with injection skills.
• The length of the third stage is
longer compared to AMTSL.
o Blood loss is greater
compared to AMTSL.
o Increased risk of PPH.
Active management
Uterotonic is given within one
minute of the baby’s birth (after
ruling out the presence of a
second baby).
Do not wait for signs of
placental separation. Instead:
• Palpate the uterus for a
contraction.
• Wait for the uterus to contract.
• Apply CCT with
countertraction.
Placenta delivered by controlled
cord traction (CCT) while
supporting and stabilizing the
uterus by applying countertraction.
Massage the uterus after the
placenta is delivered.
• Decreases the length of the
third stage.
• Decreases the likelihood of
prolonged third stage.
• Decreases average blood loss.
• Decreases the number of PPH
cases.
• Decreases the need for blood
transfusion.
• Requires uterotonic drugs and
items needed for
injection/injection safety.
• Requires a birth attendant with
experience and skills giving
injections and using CCT.
(The definition of active management as described in this table differs from the original research protocol
in the Bristol and Hinchingbrooke trials because the original protocols included immediate cord clamping
and did not include massage of the uterus. In the Hinchingbrooke trial, midwives used either CCT or
maternal effort to deliver the placenta.)
4 Rogers J, et al. 1998. Active versus expectant management of the third stage of labour: the
Hinchingbrooke randomized controlled trial. Lancet 351:693–699.
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