Active Management of the Third Stage of Labor (AMTSL) decreases the chance and intensity of postpartum hemorrhage (PPH). Postpartum hemorrhage is the loss of more than half a liter of blood during delivery, and it occurs in about 1 in 10 births accounting for about 100,000 maternal deaths per year. The third stage of labor is the time after the birth of the baby through the delivery of the placenta.
Mechanism of Action
Active management of the third stage of labor is composed of three steps: the administration of oxytocin or other uterotonics, cord traction to ease placental delivery, and uterine massage. The uterotonic helps the uterus contract which has the dual benefits of helping to deliver the placenta and slow the loss of blood. Similarly, cord traction in coordination with the natural contractions encourages a clean delivery of the placenta. Finally, the uterine massage both encourages clean delivery of the placenta while also helping to ensure against avulsion and uterine inversion.
Current Use in High-Resource Settings
Active management of the third stage of labor is included in the standard of care in high-resource settings. Hospital based deliveries will commonly use IV Oxytocin and often fluids as well to help manage the risk of hemorrhage. Furthermore, these facilities have the ability to use more invasive techniques such as balloon tamponade, various types of surgery and uterine artery embolization to control hemorrhage if AMSTL fails.
Current use in low-Resource Settings
Correct use of AMTSL has been observed in about 1 in ten cases in public hospitals in Nicaragua and about 60% of cases in Benin as well as a variety of rates in between in a study of seven low income countries. AMTSL is also uncommon among home birth attendants, though the practices are encouraged by the WHO. However, this practice requires training for the proper use of uterotonics, cord traction and massage.