Active versus expectant management for women in the third stage of labour

  • Comment
  • Review
  • Intervention




Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries.


To compare the effectiveness of active versus expectant management of the third stage of labour.

Search strategy

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (May 2010).

Selection criteria

Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour.

Data collection and analysis

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

Main results

We included five studies (6486 women), all undertaken in hospitals in high-income countries. Four compared active versus expectant management, and one compared active versus a mixture of managements. Analysis used random-effects because of clinical heterogeneity. Active management reduced the average risk of maternal primary haemorrhage (more than 1000 ml) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women) and of maternal haemoglobin less than 9 g/dl following birth (RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women) for women irrespective of their risk of bleeding. We identified no difference in Apgar scores less than seven at five minutes. Active management showed significant increases in maternal diastolic blood pressure, after-pains, use of analgesia and more women returning to hospital with bleeding. There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. There were similar findings for women at low risk of bleeding except there was no significant difference identified for severe haemorrhage. Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here.

Authors' conclusions

Active management of third stage reduced the risk of haemorrhage greater than 1000 ml in an unselected population, but adverse effects are identified. Women should be given information on the benefits and harms to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third stage management. Data are also required from low-income countries. 

Plain language summary

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

Once a baby is born, the womb (uterus) continues to contract to push the placenta spontaneously off the uterine wall. The mother then delivers the placenta, or 'after-birth'. This is termed expectant management of the third stage of labour. Active management involves giving a drug (uterotonic) to contract the uterus, clamping the cord early (usually prior to, alongside, or immediately after administration of the uterotonic, which is before cord pulsation ceases) and applying traction to the cord with counter-pressure on the uterus to deliver the placenta. 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 maternal mortality in low-income countries where women are more likely to be poorly nourished, anaemic and have infectious diseases and bleeding disorders. In high-income countries, bleeding occurs much less often yet active management has become standard practice in many. This review looked at the balance of benefits and harms for the different ways of managing the third stage of labour, for all women and specifically for women at low risk of bleeding. Five studies were identified (6486 women), all in hospitals in high-income countries. Four of the studies looked at active versus expectant management. For all women, irrespective of risk of bleeding, active management of third stage reduced severe bleeding and anaemia in mothers. It also reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased.  For women at low risk of bleeding, findings were similar though there was no difference in the risk of severe bleeding. Some of the adverse effects experienced by the mothers, such as high blood pressure, nausea, vomiting, after-pains and use of pain relief after birth, may be due to use of ergot compounds. Women should be given information antenatally to help them make informed choices. WHO now recommends active management with delayed cord clamping, to allow baby's blood that is in the placenta to return to the baby's circulation through the umbilical cord, to reduce the likelihood of anaemia. More research is needed to see if just giving a uterotonic might reduce severe bleeding without reducing the baby's blood volume. More research is also needed on third stage in low-income countries.