Cochrane for Clinicians

Putting Evidence into Practice

Active vs. Expectant Management in the Third Stage of Labor


Am Fam Physician. 2021 Apr 1;103(7):404.

Author disclosure: No relevant financial affiliations.

Clinical Question

Does active management of the third stage of labor reduce severe primary postpartum hemorrhage or improve other outcomes?

Evidence-Based Answer

Very low-quality evidence suggests that active management of the third stage of labor reduces the risk of severe primary postpartum hemorrhage greater than 1,000 mL (number needed to treat [NNT] = 66; 95% CI, 44 to 127). Low-quality evidence suggests that active management may reduce the incidence of maternal anemia (NNT = 28; 95% CI, 17 to 73). Potential harms of postnatal hypertension, pain, and readmission to the hospital because of bleeding have been identified.1 (Strength of Recommendation: B, Cochrane review without clear recommendation, based on low- to very low-quality evidence, with a small number of studies with relatively small numbers of participants.)

Practice Pointers

Postpartum hemorrhage, defined by the American College of Obstetricians and Gynecologists (ACOG) as “cumulative blood loss of ≥ 1,000 mL or blood loss accompanied by signs/symptoms of hypovolemia within 24 hours following the birth process,”2 is a common complication of pregnancy, affecting 3% to 5% of patients,3 and remains a leading cause of maternal death in the United States. From 2008 to 2017, hemorrhage caused 13.1% of pregnancy-related deaths.4 Developed as a strategy to prevent postpartum hemorrhage, active management of the third stage of labor includes the administration of a prophylactic uterotonic, early cord clamping, and cord traction with counterpressure on the uterus to deliver the placenta.5 In expectant management of the third stage of labor, the placenta is delivered spontaneously following the usual signs of placental separation. The authors of this Cochrane review compared the effects of active management vs. expectant management and the effects of mixed management (using one or two of the techniques above) vs. expectant management on postpartum hemorrhage and other maternal and neonatal outcomes.

This Cochrane

Author disclosure: No relevant financial affiliations.


show all references

1. Begley CM, Gyte GMI, Devane D, et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2019;(2):CD007412....

2. American College of Obstetricians and Gynecologists. reVITALize: obstetrics data definitions (version 1.0). Accessed November 17, 2019.

3. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55.

4. Davis NL, Smoots AN, Goodman DA. Pregnancy-related deaths: data from 14 U.S. Maternal Mortality Review Committees, 2008–2017. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2019.

5. Prendiville WJ, Elbourne DR. Care during the third stage of labour. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective Care in Pregnancy and Childbirth. Oxford University Press; 1989:1145–1169.

6. Leduc D, Senikas V, Lalonde AB. No. 235-Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can. 2018;40(12):e841–e855.

7. Prevention and management of postpartum haemorrhage: Green-top guideline no. 52. BJOG. 2017;124(5):e106–e149.

8. World Health Organization. Active management of the third stage of labour. Accessed February 6, 2020.

9. Shields LE, Goffman D, Caughey AB; Committee on Practice Bulletins–Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017;130(4):e168–e186.

10. Advanced Life Support in Obstetrics Provider Manual. 9th ed. American Academy of Family Physicians; 2020.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at



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