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Delivering the placenta with active, expectant or mixed management in the third stage of labour

Begley CM, Gyte GML, Devane D, McGuire W, Weeks A
Published Online: 
9 November 2011

Once a baby is born, the womb (uterus) continues to contract, causing the placenta to separate from the uterine wall. The mother then delivers the placenta, or 'after-birth'. This is called expectant management of the third stage of labour. Active management of the third stage involves giving a drug (uterotonic) to contract the uterus and clamping the cord early (usually prior to, alongside, or immediately after giving the uterotonic, before cord pulsation ceases). In addition, traction is applied to the cord with counter-pressure on the uterus to deliver the placenta (controlled cord traction). Specific ways the three components are applied often vary. Mixed management uses some, but not all, of the three components. Active management was introduced to try to reduce haemorrhage, which is a major cause of women dying in low-income countries where women are more likely to be poorly nourished, anaemic and have infectious diseases. In high-income countries, bleeding occurs much less often, yet active management has become standard practice in many countries.

This review looked at different ways of managing the third stage of labour, for all women and specifically for women at low risk of bleeding. Seven studies were identified (8247 women), all in hospitals, six in high-income countries and one in a low-income country. Four studies compared active with expectant management and three compared active with mixed management.

Overall more data are needed to be confident in the findings. However, for all women, irrespective of their risk of bleeding, active management reduced severe bleeding and anaemia. However, it also reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, vomiting and the number of women returning to hospital with bleeding.  

For women at low risk of bleeding, findings were similar though there was no difference in risk of severe bleeding.

Women should be given information antenatally to help them make informed choices. Some of the adverse effects experienced by mothers may possibly be avoided by using specific uterotonic drugs. Delaying cord clamping may benefit the baby by preventing the reduction in blood volume from early cord clamping, but more research is needed to be sure. Also it may be that just giving a uterotonic might reduce severe bleeding without reducing the baby's blood volume. More research is also needed on the third stage in low-income countries. 

This record should be cited as: 
Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD007412. DOI: 10.1002/14651858.CD007412.pub3
Assessed as up to date: 
27 September 2011