International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Patel M et al. Int J Reprod Contracept Obstet Gynecol. 2016 Jan;5(1):80-83

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20151605
Research Article

A study on active management of third stage of labour as per WHO

guidelines: efficacy and complications
Manthan M. Patel*, Mahima Jain

Department of Obstetrics and Gynaecology, PDU medical college, Rajkot, Gujarat 360001, India

Received: 23 October 2015

Accepted: 10 December 2015

*Correspondence:
Dr. Manthan M Patel,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: the objective of the study was to evaluate efficacy and complications of AMTSL as per WHO
guidelines.
Methods: A total of 100 low risk patients assigned randomly at obstetrics department, P.D.U. medical college,
Rajkot. Hundred women received i.m. oxytocin 10 IU at the delivery of anterior shoulder of the baby, received uterine
massage and delivery of placenta by controlled cord traction and blood loss is measured.
Results: Mean blood loss is 119 ml. One case had blood loss >500 ml. Mean duration of third stage of labour is 5.16
minutes. Mean time taken by uterus to contract was 3.8 minutes.
Conclusions: AMTSL must be employed for prevention of postpartum haemorrhage (PPH) as advised by W.H.O.
AMTSL as a routine protocol significantly brings down incidence of PPH.

Keywords: Oxytocin, Active management of third stage of labour (AMTSL), Postpartum haemorrhage PPH, Blood
loss

INTRODUCTION Eclampsia, Unsafe abortion, and Obstructed labor. PPH is

the leading single direct cause of maternal mortality,
Maternal mortality accounting for a quarter of all maternal deaths worldwide
and causing approximately 140,000 deaths annually.3,4
Taj mahal - One of the Seven Wonders of the World. One
of the greatest monuments, dedicated to the memory of Khan et al, using various datasets, estimated that
―Queen Mumtaz ―who died after her last childbirth of hemorrhage is the main cause of maternal mortality in
postpartum haemorrhage in 1630 –is a testimony to grim Asia and Africa – accounting for 30% or more of all
reminder of the tragedy of maternal mortality that can maternal deaths. ―If mother receives postpartum care as
befall any woman in childbirth.1 The World Health assiduously as they receive prenatal care, maternal
Organization states that every minute, at least one woman mortality would decrease.‖-Li et al in 1996.5 Atonic PPH
dies from complication related to pregnancy or childbirth is the most common cause of PPH and the leading cause
that means 529000 women a year.2 Developing countries of maternal death. To prevent atonic PPH, interventions
account for 99% (286 000) of the global maternal deaths should therefore be targeted at all women during
with sub- Saharan Africa region alone accounting for childbirth. To reduce blood loss after delivery, the WHO
62% (179 000) followed by Southern Asia (69 000). recommends the Active Management of the Third Stage
(Trends in maternal mortality: 1990-2013 by W.H.O, of Labor (AMTSL) be offered to all women delivering
UNICEF) The main direct causes of maternal death with skilled attendants (WHO 2007).6,7
include Postpartum-hemorrhage (PPH), Sepsis,

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Prevention of PPH8,9  Cardiac disease

 Multiple pregnancy
Reaffirming and Refining Best Practice for PPH  Induced delivery
Prevention. (WHO 2012 Recommendations) Active  Primie gravidae
management of the third stage of labour (AMTSL) is still  Operative delivery
a best practice, with the use of uterotonics now the most  Ante-partum haemorrhage
critical element. Oxytocin remains the uterotonic of  Delivery with episiotomy
choice for AMTSL. Oxytocin (10 IU, IM or IV) is the
 If BT/CT is abnormal
preferred uterotonic based on studies on the safety and
 Pregnancy with previous c- section
effectiveness of uterotonics. Other elements of
AMTSL—controlled cord traction and immediate fundal
Each patient had received i.m. oxytocin at the delivery of
massage—are optional for PPH prevention. Delayed cord
anterior shoulder of the baby, uterine massage for 4
clamping (performed after 1 to 3 minutes after birth) is
minutes and placental delivery is done by controlled cord
still recommended for all births to reduce infant
traction as prescribed by WHO. No other oxytocic has
anaemia—while beginning essential newborn care at the
been administered except inj. Oxytocin 10IU i.m. unless
same time. Postpartum abdominal uterine tonus
assessment for early identification of uterine atony is patient develops PPH.
recommended for all women. Compared with physiologic
management, active management of the third stage of After delivery of baby all fluids/liquor/blood is
labor reduced the risk of PPH, the need for blood immediately removed from the delivery table and a fresh
transfusion, the incidence of prolonged third stage (longer specially prepared plastic sheet (brasss-V type) with
than 30 min), and the need for additional therapeutic funnel attached to its lower part replaced by the doctor.
uterotonic drugs in all three trials.10,11,12 He has also collected the specially prepared 10 x 10 cms
delivery pads soiled for visual assessment of blood loss.
The total blood is collected in calibrated vessel after the
Assessments of blood loss13-17
delivery of the baby, delivery of placenta and through the
4th stage of labour (1hour).
The BRASSS-V drape was developed by the NICHD-
funded Global Network UMKC/ JNMC/UIC
The frequency of observation of blood loss is grouped in
collaborative team to specifically estimate postpartum
blood loss. (The name ‗BRASSS-V‘ was coined by following categories.
adding the first letter of the names of the seven
collaborators who developed the drape.) The drape has a 0-50ml, 51-100ml, 101-150ml, 151-200ml, 201-250ml,
calibrated and funnelled collecting pouch, incorporated 251-300ml, 301-350ml, 351-400ml, 401-450ml, 451-
within a plastic sheet that is placed under the buttocks of 500ml, 501-550ml, 551-600ml. etc.
the patient immediately after the delivery of the baby.
Use of the drape diagnosed postpartum haemorrhage four The total amount of blood loss is calculated as follows:
times as often as the visual estimate.
Blood collected in calibrated vessel plus soiled pads.
METHODS
Soiled pads-quarter of pad soiled = 5ml, half of pad
The study was conducted at Department of Obstetrics soiled = 10ml, ¾ of pad soiled = 20ml, fully soiled pad =
&Gynaecology, P D U Medical College, Rajkot, from 5th 30ml).
Jan 2014 to 4th Jan2015. Ethical committee approval was
taken. Low risk women were included in the study. The doctor has also observed the time lag between
administration of the drug and contraction & retraction of
Inclusion criteria uterus and duration of the third stage of labour (after
delivery of baby to complete delivery of placenta).
Normal /low risk patients assigned randomly in age group
of 19-35 years. The observations for duration of third stage of labour are
noted in minutes using stop clock. The doctor has also
 Second, third , fourth gravidae meticulously observed the side effects of the drugs
 Vertex presentation mentioned in literature as well as other untoward effects
 Delivery without episiotomy and note temperature, pulse, BP, Respiration in case
records. (Data sheet proforma attached for observations).
 BT/CT is normal
 Spontaneous delivery
Notes on safety & risk reduction
Exclusion criteria
Inj. Oxytocin 10 IU is found to be safe if given i.m. as
 Traumatic PPH shown by review of literature. If any patient develops
haemorrhage in excess of 500 ml or develops any
 PIH

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 Patel M et al. Int J Reprod Contracept Obstet Gynecol. 2016 Jan;5(1):80-83

hemodynamic deterioration, patient shall be managed as blood loss. Armbruster and Fullerton showed that cord
per routine therapeutic method immediately using other drainage could reduce the length of the third stage.
oxytocic (inj. methyl ergometrine, inj. Carboprost Soltani et al. also believe there is a small reduction in the
250mcg tab. Misoprostol 600mcg) surgical methods and length of the third stage of labor when cord drainage is
intravenous fluids if required to ensure safety of the applied. The association between duration of third stage
patient. of labour and blood loss is considered to be extremely
statistically significant.
RESULTS
Table 3: Blood loss observed during study.
Table 1: Demographic profile.
Blood loss (In ML) Frequency (n=100)
Factors N=100 <50 21
Age (years) 51-100 39
24-29 51 101-150 14
30-35 19 151-200 07
Area 201-250 14
Urban 58 251-300 01
Rural 42 301-350 01
Religion 351-400 02
Hindu 91 401-450 00
Muslim 09 451-500 00
Parity >500 01
Para 2 53 Mean blood loss in present study group was 119.4 ml.
Para3 31
Para4 16 Table 4: Side effects of inj. oxytocin in present study.

In present study, Out of total 100 cases 51 patients (51%) Side effects No. of Patients (n=100)
belonged to 24-29 years group and 30%belonged to 18- Shivering 03
23yrs of group, and 19% belonged to >30 years of age Nausea 02
group. Mean age was 25.9 years. Majority 58% of Vomiting 01
participants belong to urban area, 42% belong to rural Fever 00
area. Since the medical college located in city, majority Hypertension 00
of patients are from city area. In present study, 53patients Hypersensitivity 00
(53%) belonged to parity 2, 31% belongs to parity 3 and
16%were of parity 4. Median parity was 2.
Shivering and nausea were most common side effects of
inj. Oxytocin observed during present study.
Table 2: Association of duration of 3rd stage of labour
(in minutes) and blood loss.
Table 5: Association of baby weight with mean blood
loss.
Duration of third stage of
Blood loss (M.L.)
labour (minutes)
Baby weight (in K.G.) Mean blood loss (in ML)
<5 90
1.5-2.0 55
6-10 123
2.1-2.5 79
>10 335
2.6-3.0 94
Duration of 3rd
Blood loss Blood loss 3.1-3.5 175
stage of Labour Total
<200 ml >200 ml 3.6-4.0 186
(minutes)
>4.1 330
≤4 50 00 50
≥5 31 19 50
The association between Baby weight and blood loss is
statistically considered as extremely significant. As the
Mean duration of third stage of labour was
baby weight increases, the blood loss will also increase.
5.16minutes.With AMTSL duration of third stage of
labour shortened out. 98% of the participants had
DISCUSSION
duration of third stage of labour <10 minutes. This proves
the efficacy of AMTSL. In an investigation by Magann et
The purpose of the study is to evaluate the efficacy of
al. the median length of the third stage of labor was 7
AMTSL in active management of third stage of labour
minutes. Jerbi et al. recommended the use of oxytocin in
for prevention of post-partum haemorrhage [by
order to shorten the third stage and prevent PPH and
measuring blood loss], duration of 3rd stage of labour and

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 Patel M et al. Int J Reprod Contracept Obstet Gynecol. 2016 Jan;5(1):80-83

side effects of oxytocin. The Chi square test was used for 5. Li XF. The postpartum period: the key to maternal
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significant. Longer the duration of third stage, more will The Inclusion Of Misoprostol In The Who Model
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