The evolving nature of active management of the third stage of labour (AMTSL).

Updated: Sep 25, 2018


Dr Andrew D Weeks


It used to be so simple. Every student knew that active management of the third stage consisted of an oxytocic, controlled cord traction, and early clamping of the umbilical cord. But the times they are a’changing.


Umbilical cord clamping


First it was the cord. We realised that the concerns about oxytocin transfer to the neonate were ill founded and that early cord clamping in fact leads to increased rates of anaemia and low iron stores in the neonate. Protocols started to change. The final nail in the coffin came earlier this year with the publication of two well conducted randomised trials showed that in premature infants early cord clamping increased all-cause mortality in the neonate by some 30% (Tarnow-Mordi 2017, Duley 2018).


This makes delaying cord clamping one of the most effective interventions anywhere in health care and those who persist in immediate clamping are at risk of complaints, litigation and censure. Let no-one say that they haven’t been warned!

Controlled cord traction


This aspect also came under scrutiny with a large WHO randomised trial (Gulmezoglu 2012). This found that the effect of controlled called traction (CCT) was minimal. It shortened the duration of the third stage but had no effect on rates of postpartum haemorrhage.


Interestingly though, around 6% of those in the CCT arm still required traction to deliver the placenta. Fur