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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. Furthermore, a breach in trial protocol in one of the countries where they used Syntometrine rather than oxytocin for prophylaxis found that the use it Syntometrine without CCT lead to a large increase in retained placenta rates. This association was not seen in sites using oxytocin alone. This adds to earlier suspicions that the use of ergometrine for prophylaxis is not only a cause of significant side-effects to the woman such as high blood pressure and vomiting, but also increases the rate of retained placenta.



Carbetocin, a rather expensive synthetic long-acting version of oxytocin, had been hoped to provide the extended action of ergometrine without the side effects thus making it the ideal oxytocin for prophylaxis. To the disappointment of many however, the recent CHAMPION study has shown that there is absolutely no difference in efficacy between carbetocin and oxytocin (Widmer 2018).

The one potential benefit is that this new version is heat-stable, although it still needs to be given intramuscularly. Thus, there may be a few places where it is possible to give injections but where there is an unstable cold chain - and in these areas it might be cost-effective to use intramuscular carbetocin rather than oxytocin. This will depend however on the manufacturers who are still finalising their price of carbetocin for low resource settings. 

Attention has now turned to the ideal way to administer oxytocin. With concerns about the use of ergometrine, and the finding that misoprostol was not as effective as oxytocin, the standard advice had been to use oxytocin 10 international units intramuscularly as first-line prophylaxis. This seemed to be a solution that was both effective and relatively free from side-effects, a factor that is critical when giving prophylaxis to healthy, normal women (the majority of whom will not develop postpartum haemorrhage).

It has always been thought that it