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

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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 review included eight randomized trials involving 8,892 women.1 Four studies compared active vs. expectant management, and four compared active vs. mixed management, including variations of timing of uterotonics, cord clamping, and controlled cord traction. The studies were all conducted in hospitals, seven in World Bank–defined higher-income countries, and one in a lower-income country.

Low-quality evidence suggests that, when compared with expectant management, active management of the third stage of labor reduces the incidence of severe postpartum hemorrhage, defined by the authors and the World Health Organization as estimated or measured blood loss of 1,000 mL or more (relative risk [RR] = 0.3; 95% CI, 0.1 to 0.9; three studies; n = 4,635; NNT = 66; 95% CI, 44 to 127). Active management may reduce maternal anemia after birth, defined as a maternal hemoglobin level of less than 9 g per dL (90 g per L) at 24 to 72 hours postpartum (RR = 0.5; 95% CI, 0.3 to 0.8; NNT = 28; 95% CI, 17 to 73); two studies; n = 1,572). Active management of the third stage makes no difference in the number of infants admitted to neonatal units, and very low-quality evidence demonstrates that active management does not reduce or increase the number of newborns with jaundice requiring treatment (RR = 1.0; 95% CI, 0.6 to 1.7; two studies; n = 3,142). There were no data on whether active management reduces very severe postpartum hemorrhage at the time of birth (more than 2,500 mL), decreases maternal mortality, or changes the rate of neonatal polycythemia requiring treatment.

Potential harms of active management of the third stage of labor include an increase in maternal diastolic blood pressure (RR = 7.0; 95% CI, 2.99 to 16.43; two studies; n = 2,941); increased use of analgesia (RR = 2.53; 95% CI, 1.34 to 4.78; one study; n = 1,429); an increase in reported pain (RR = 2.53; 95% CI, 1.34 to 4.78; one study; n = 1,429); and an increased number of women returning to the hospital as an inpatient or outpatient because of bleeding (RR = 2.21; 95% CI, 1.29 to 3.79; two studies; n = 2,941).

Current guidelines from the Royal College of Obstetricians and Gynaecologists, the World Health Organization, and the Society of Obstetricians and Gynaecologists of Canada all recommend active management of the third stage of labor with delayed cord clamping rather than early cord clamping.68 ACOG recommends the use of uterotonics after all births.9 Advanced Life Support in Obstetrics, administered by the American Academy of Family Physicians, also recommends active management.10 The benefits and harms of active management should be discussed with all patients before this plan is enacted.

The practice recommendations in this activity are available at

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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