Active Management of Third Stage

(Managed Third Stage)

As the baby is born (or sometimes after just the first shoulder is born) a drug is given which makes the uterus contract. These drugs are called uterotonics, and the one you are given will depend on the country you live in and on any local guidelines.

[More information on drugs and doses]

The cord is then clamped, either immediately after the birth of the baby or, in some European countries, this is delayed until after the cord has stopped pulsating.

In some countries, the cord is gently pulled during a contraction of the uterus, usually while applying counter-pressure to the uterus with the other hand, by placing a hand just above the woman's pubic bone. This is to help the placenta descend and is called ‘controlled cord traction’.

The placenta is usually delivered within a few minutes.

There are some variations in way third stage can be actively managed:

Variations in the drug used.

Time of administering the drug - the drugs can be given any time after the baby's head has crowned up until the placenta has been delivered. In the UK most maternity units routinely give the drug after the appearance of the baby's first shoulder rather than waiting for the baby to be born. However it should be possible to negotiate a delay before being given the uterotonic drug if you would prefer to, especially if you would like to delay cord clamping (see below).

Time of clamping the cord - this can be done immediately after the birth of the baby or later, which allows the baby's blood in the cord and placenta to return to the baby. Studies show that delaying cord clamping for just a few minutes improves outcomes for baby, improving the amount of iron in their blood, reducing the likelihood of anaemia and helping them adjust to their surroundings better. One American study concluded "it is likely that delayed clamping is compatible with active management of the third stage of labor. Uterotonic agents administered following birth and prior to cord clamping have been shown to increase the rate of placental transfusion and are thus likely to enhance the effect of delayed clamping. Although this approach has not been studied, a joint statement from the International Federation of Gynaecology and Obstetrics and the International Confederation of Midwives on active management of the third stage of labor already recommends that delayed clamping be incorporated as part of the active management approach to placental delivery." (For other links about delayed cord clamping, see our Links page). It is not known if this conclusion varies with the use of different drugs (eg oxytocin vs oxytocin plus ergometrine).

If blood loss is not controlled after this package of care, or the placenta does not come away within a specified time period (between about 5-30 minutes), the healthcare professionals can intervene to help.

See more about the third stage of labour: