Technical Series 1: Active management of the third stage of labor


AMTSL is an intervention to facilitate the delivery of placenta by enhancing uterine
contraction and retraction.
Active management of the third stage should be practiced on all women in labour, since
it reduces the incidence of PPH due to uterine atony.
Components of Active Management of the Third Stage of Labour (AMTSL)
1. Immediate administration of uterotonic drug
2. Controlled cord traction
3. Uterine massage
1. Uterotonics:


Injection Oxytocin - administer 10 units IM immediately after the delivery of the
baby.
Oral Misoprostol 600 mcg is the preferred alternative to Oxytocin particularly for
home deliveries.
Uterotonic
Route
agent
Dosage
Onset of
action
Duration
of action
Contraindication
Storage (0 C)
Oxytocin
IM
10 units
2-4 mins
20 mins
Never give IV bolus
15 – 30 0 C
Misoprostol
Oral
600 µg
12 – 15
mins
20 – 40
mins
Nil
Room Temp.
2. Controlled cord traction (CCT):
Ensure that the placenta is delivered completely with all the membranes. Retained
placental fragments or pieces of membrane will cause PPH. Do NOT exert excessive traction
on the cord while performing CCT. Never squeeze or push the uterus to deliver the
placenta.
 Clamp the umbilical cord once the cord pulsations stop (except - Pre maturity, Rhiso immunization, HIV, Foetal distress).
 Keep one hand on hardened uterus; apply counter traction just above the symphysis
pubis.
 Apply gentle traction on the cord.
 Ensure completeness of placenta upon its delivery.
 If the placenta does not descend within 30-40 seconds of CCT, i.e. there are no signs
of placental separation, do NOT continue to pull on the cord.
 The signs of placental separation are:
- The uterus becomes hard and globular (uterine contraction).
- The extra-vulval portion of the cord lengthens.
- There is a sudden gush of blood when the placenta separates.
- If the fundus of the uterus is gently pushed up towards the umbilicus, the
cord will not recede into the vagina.
Fig: Controlled cord traction

Examination of the placenta, membranes and the umbilical cord
- Maternal surface of the placenta: Look for the following:
 All the lobules must be present.
 The lobules should fit together.
 There should be no irregularities in the margins.
- Foetal surface: Look for free-ending vessels, holes and for the insertion of the
cord.
- Membranes: The chorion, amnion and umbilical cord should be inspected
3. Uterine massage:
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
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Massage the uterus till uterus is contracted and feels hard.
Palpate the uterus every 15 minutes and repeat massage as needed during the first
2 hours.
Monitor that uterus does not relax after the massage is stopped.
Further Reading:
1. Trainees’ Handbook for Training of Medical Officers in Pregnancy Care and
Management of Common Obstetric Complications ( download link:
http://www.gujhealth.gov.in/Portal/Tender/2/8_TraineesHandbookforTrainingofMOs
inpregcare.pdf )
2. Basic Emergency Obstetric Care – A Reference Manual
3. Comprehensive Emergency Obstetric Care - A Reference Manual for
Specialist/Surgeons
4. Guidelines For Ante-Natal Care And Skilled Attendance At Birth By ANMs And LHVs
(download link:
http://www.gujhealth.gov.in/images/SIHFW_Training_Modules/Maternal_Health_Trai
ning_Modules.zip )
5. Skilled Birth Attendance-A Handbook for ANMs LHVs and Staff Nurses (download link:
http://www.gujhealth.gov.in/Portal/Tender/2/2_SBAHandbookforANMLHVandSN.pdf)
Flow chart for AMTSL:
Confirm the absence of additional baby by per abdominal examination
Immediately after delivery of baby, administer inj. Oxytocin 10U IM.
Clamp the umbilical cord close to perineum and hold with one hand.
Place the other hand just above the pubic symphysis & apply counter traction
upwards.
Maintain slight tension on the cord & gently pull downwards when the uterus
contracts (as evidenced by uterus becoming hard & globular).
As the placenta delivers hold it with both hands & gently turn the placenta so
that the membranes are twisted.
Massage the uterine fundus until the uterus is well contracted.
Examine the maternal & foetal surfaces of the placenta for completeness of
cotyledons & membranes.
Make sure that the uterus is firmly contracted, monitor vaginal bleeding &
measure vital signs for 2 hours after delivery.