What exactly is active management of third stage of labor?

Abstract

I have followed research developments in the area of prevention and treatment of postpartum hemorrhage in the last decade with interest. The fact that contractions of the uterus are necessary to prevent bleeding after placental separation has been known for centuries, so attempts to devise interventions to facilitate this process were a logical quest. These interventions, now referred to as active management of third stage of labor (AMTSL), initially involved the pharmacological stimulation of uterine muscle fibers with oxytocics and later included measures aimed at facilitating rapid placental separation and delivery. AMTSL has been demonstrated in randomized controlled trials to reduce the incidence of postpartum hemorrhage (>500 ml) compared to an expectant or ‘hands-off’ approach. Thus, AMTSL is being promoted globally by international health partners as the major effort to reduce the incidence of maternal mortality secondary to atonic postpartum bleeding. While there is general agreement on the beneficial effects of AMTSL, there appears to be no consensus on its exact components and their individual definition. This is reflected in the disparities in internationally recommended guidelines on AMTSL over the last few years and the gross variations in the adoption and practice of active management and its components throughout the world (1,2). A Cochrane review described it as a set of interlocking interventions comprised of administration of a prophylactic uterotonic with or after delivery of the baby, early umbilical cord clamping and cutting, and placental delivery by controlled cord traction (3). A joint recommendation issued by the International Confederation of Midwives and International Federation of Gynecology and Obstetrics (ICM/FIGO) in 2003 (4) included the following components: administration of uterotonic agent within one minute following delivery of the baby, controlled cord traction and uterine massage after placental delivery without any reference to the timing of cord clamping, while in the WHO Recommendations for the Prevention of Postpartum Haemorrhage (5), delayed cord clamping was added to the components recommended by ICM/FIGO, to accommodate recent evidence suggesting beneficial effects of delayed cord clamping to the baby. These recommendations differ in the timing and clarity of their description/definition of some of the components as well as the various components constituting AMTSL (Table I). There is no specific time recommended by the Cochrane review for administration of prophylactic uterotonic, while the recommended time limits of ‘within one minute’ by ICM/FIGO and WHO were not supported by any scientific evidence. Similarly, the Cochrane review on active vs. passive management does not refer to the use of uterine massage as part of AMTSL whereas the ICM/ FIGO statement on AMTSL does include uterine massage. It is interesting to note that uterine massage was included in the ICM/FIGO recommendation, even though the only pilot trial on the subject that was published three years after the statement was issued showed no significant difference in the incidence of postpartum hemorrhage (>500 ml) between women who had massage and those who did not (6). Available evidence from randomized trials evaluating relative effectiveness of alternative definitions of each component of AMTSL has so far questioned the need for strict adherence to existing guidelines regarding individual components of AMTSL. For instance, a double-blinded randomized controlled trial of 1,486 women receiving AMTSL to isolate the effect of timing of uterotonic agent demonstrated that administration of uterotonic agent before and after delivery of the placenta has equal effectiveness in the prevention of postpartum hemorrhage (7). In practical terms, it is reasonable to suppose that administration of uterotonics after placental delivery is outside the recommended time limits of ICM/FIGO and WHO. The physiological relation between the recommended steps of AMTSL which primarily guided