“Every minute around the world 380 women become pregnant,

190 women face unplanned or unwanted pregnancies,

110 women experience pregnancy related complications,

40 women have unsafe abortions,

1 woman dies.”

The World Health Organization states that every minute, at least one woman dies from complications related to pregnancy or childbirth – that means 529 000 women a year. Unavailable, inaccessible, unaffordable, or poor quality care is fundamentally responsible.

The main causes for the occurrence of postpartum hemorrhage are: Uterine atony (80%), retained placenta, trauma to genital tract, coagulation disorders and uterine inversion.

Previous controlled trials support the administration of oxytocin to reduce the risk of postpartum hemorrhage after vaginal delivery, especially when compared with either placebo or no active intervention. A meta-analysis, available through the Cochrane database and WHO’s Reproductive Health Library, confirmed that active management was associated with reduced maternal blood loss (including PPH and severe PPH), reduced postpartum anemia, and decreased need for blood transfusion.

More information on evidence about active management of the third stage of labor can be found in the research section of this theme button as well as in section B from the toolkit also available through this theme button.

Women who survive postpartum hemorrhage are likely to suffer from anemia and other complications. These women often must receive blood transfusions and are susceptible to the associated risks of transfusion reactions or infection with HIV or hepatitis.

Bleeding that cannot be controlled using drugs often requires surgery, including hysterectomy. Such procedures are costly and painful, and the resulting loss of fertility may be emotionally devastating. In addition, they carry the risk of infection, reaction to anesthesia and other complications.

There are several uterotonic agents (that can make the uterus contract) available; examples are oxytocin, syntometrine, ergometrine, methylergometrine and misoprostol. There is much research going on to provide evidence to which drug is the best to use.

To date the drug of choice is oxytocin as is stated in the ICM-FIGO joint statement.

Postpartum hemorrhage (PPH) is defined as the loss of 500ml or more of blood from the genital tract after delivery of the baby that usually occurs in the first 2 to 4 hours after delivery but can occur later. McCormick et al. states that, "A more accurate definition of postpartum hemorrhage is any blood loss that causes a physiological change (e.g., low blood pressure) that threatens the woman’s life."

Unfortunately, waiting until there is a physical change would mean death for most women in developing-country settings, as immediate back-up or emergency obstetric care is not always available.

The World Health Organization states 529 000 women die from complications related to pregnancy and childbirth a year. Postpartum hemorrhage accounts for of 34% and 31% of women dying from complications related to pregnancy or childbirth in Africa and Asia, respectively.

There are two methods for managing the third stage of labor. One of these is the physiologic ("expectant") management in which oxytocin are not used; placenta is delivered by gravity and maternal effort. The other one is the active management in which an uterotonic agent is administered, after the cord is clamped, the placenta is delivered by controlled cord traction (CCT) with counter-traction on the fundus (upper part of the womb), uterine massage takes place after delivery of the placenta as appropriate.

Active management of the third stage of labor (AMTSL) is an evidence-based, low-cost intervention used to prevent postpartum hemorrhage. The Bristol23 and Hinchingbrooke12 randomized control trials provided conclusive evidence that active management of the third stage of labor (AMTSL) significantly reduces postpartum hemorrhage, decreases blood loss and decreases the need for blood transfusions.

In response to the growing evidence supporting the use of active management of the third stage of labor (AMTSL) for the prevention of PPH, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) issued a joint statement. The November 2003 joint statement  promotes AMTSL to save mother’s lives. ICM and FIGO further state:                    

"Every attendant at birth needs to have the knowledge, skills and critical judgment needed to carry out active management of the third stage of labour and access to needed supplies and equipment."  

 In 2006, a second ICM/ FIGO joint statement was issued. The first ICM/ FIGO joint statement had caused many discussions amongst midwives in the world. The different opinions of midwives in different part of the world, made it clear that midwifery skills don't need to be performed in the same (standardized) way. The emphasis of ICM and FIGO was still on promoting evidence-based interventions to prevent PPH but nuances were made by saying that the interventions should be used properly and after informed consent. This gave space to the different settings (low and high resources) and thus the need for standardized interventions in which midwives do their work and even important, it gave room to women's voices towards their care during childbirth. Both ICM and FIGO endorse international recommendations that emphasize the provision of skilled birth attendants and improved obstetric services as central to efforts to reduce maternal and neonatal mortality.

Three steps of AMTSL

Active management of the third stage of labor consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony.  The three components of AMTSL are:

1. Administration of a uterotonic agents;
2. Controlled cord traction;
3. Uterine massage after delivery of placenta, as appropriate.

The third component – uterine massage - was not present in the Hinchingbrooke randomized controlled trial (1998, see also “Recent evidence on AMTSL”) but it was the ICM that took the initiative to add the uterine massage so that the skilled birth attendants would stay alert on the late PPH.

Oxytocin is the uterotonic drug of choice. But in the second ICM/ FIGO Joint Statement, the two key partners call upon national regulatory agencies and policy makers to approve misoprostol for PPH prevention and treatment. 

In a study conducted by the WHO `Stability of Injectable Oxytocics in Tropical Climates` there was, on average, no loss of potency of oxytocine after twelve months refrigerated storage, and about 14% loss after one year at 30°C in the dark (range 9-19%), No destabilizing effect of light was found.
  

Recent evidence on AMTSL

Effectiveness of AMTSL in reducing the incidence of postpartum hemorrhage (PPH) and the need for PPH treatment has been investigated by a number of large trials. The Hinchingbrooke12 randomized control trials provided evidence that AMTSL significantly reduces postpartum hemorrhage, decreases blood loss, and decreases the need for blood transfusions. Findings from a WHO multi-center study indicated that 10 IU oxytocin (intravenous or intramuscular) is preferable to 600 microgram of oral misoprostol http://www.pphprevention.org/files/PPHEnglish.pdf in the AMTSL in hospital settings where active management is the norm19. In the research section of the theme button PPH you can find an abstract of this article.

One recently published study in Vietnam found that AMTSL was associated with reduced risks for prolonged third stage beyond 30 minutes, supplemental oxytocin, and bimanual compression. When cases with first stage oxytocin augmentation were excluded, AMTSL was associated with a 34 percent reduction in PPH incidence5. Although a WHO multicenter trial concluded that, in hospital settings, oxytocin is preferable to misoprostol in AMTSL19, in home births without a skilled attendant, misoprostol may be the only technology available to control PPH. The safety and efficacy of misoprostol as an alternative to oxytocin is now well documented. A study in a university teaching hospital in England demonstrated that giving misoprostol to women immediately after childbirth resulted in significantly lower rates of PPH than when the third stage of labor was managed only through controlled cord traction and rubbing the uterus. Studies also found that 18 percent of women would experience PPH if the placenta were delivered on its own, 2.7 percent if oxytocin were used, and 3.6 percent if misoprostol were used20. A recent study from India provided evidence that oral misoprostol was associated with about 50 percent reduction (from 12.0 percent to 6.4 percent) in the rate of acute postpartum hemorrhage and mean blood loss. The WHO recommends that AMTSL should be practiced only by skilled providers due to the risk of inversion of uterus during controlled cord traction and that, in the absence of active management of the third stage of labour, a uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH.

More information on evidence about active management of the third stage of labor can be found in the research section (hyperlink to research part) of this theme button as well as in section B from the toolkit also available through this theme button.

A factsheet

A fact sheet is a collection of information about, in this case AMTSL. This fact sheet gives a short summary of the what why and when of AMTSL: AMTSL fact sheet for policy makers and program managers:

Ghana

(To be able to read these documents acrobat reader is needed. It’s easy to install and download is free at: http://www.adobe.com/products/acrobat/readstep2.html)

A survey was designed by the Global Network for Perinatal and Reproductive Health to advance understanding of current AMTSL practices in different countries.
Surveys have been conducted in Ethiopia, Tanzania, El Salvador, Honduras, Nicaragua, and Guatemala and Indonesia. These eight country surveys focus on policy, provider-related factors, and supplies and logistics. When viewed together, these components provide important insights on routine use of AMTSL. 

Survey reports of countries where AMTSL was implemented:
Ethiopia
Tanzania
El Salvador
Guatemala
Honduras
Nicaragua
Indonesia
Cirebon District in Indonesia

This AMTSL poster  offers a visual presentation of the three steps of AMTSL.

This animated demonstration is a useful tool to practice the steps of AMTSL.
AMTSL: a demonstration
Note: The online version can be easily viewed on most computer systems, but may take longer to load via slower/dial-up Internet connections. If necessary, you may be prompted to install a free Macromedia Flash™ Player plug-in on your computer. The installation process is easy and should take only a few moments to complete.

The toolkit “Preventing postpartum hemorrhage” is a useful document for midwives. It consists of different sections that can be consulted by clicking on the items below:
Introduction: ( shows the table of content of the toolkit and offers useful links and recourses for prevention of PPH.

Section B: Evidence Base for AMTSL: the new and updated toolkit ”Preventing postpartum hemorrhage” contains update evidence for AMTSL as a measure to prevent PPH.

Section C: Clinical care and treatment guidelines for prevention of PPH: this section contains the clinical care and treatment guidelines for prevention of PPH, based on the WHO manual Managing complication in pregnacy and Childbirth: a guide for midwives and doctors

Section D: Drugs for AMTSL: This section contains key reference articles on the research on drugs used for AMTSL.

Policy documents
The steps to implement AMTSL in national midwifery policy, have been done by different countries. Reports of how that process took place can be found under Implement AMTSL.  In this section, documents can be consulted and used to support member association who aim to implement AMTSL in their own community.

AMTSL survey tool: The aim of the AMTSL national survey study is to advance our understanding of current AMTSL practices, to provide ministries of health and their international partners with the descriptive information necessary to assess AMTSL practices and to identify major barriers to its use.

Study design description:  A description of the study, as well as a template of the document that most countries have used to request ethical approval for the study.

Sampling plan for AMTSL survey:  It provides guidelines on designing the sample and on drawing the actual sample of health facilities to be included in the study.

Identifying barriers for the implementation of AMTSL:  Set of qualitative tools to help programme planners to understand various barriers that can be faced by implementing AMTSL.

General Guidelines for Collection of Qualitative Research Data on Active Management of the Third Stage of Labor (AMTSL)