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

Evidence Summaries

Level of Evidence = C
Active management of the third stage of labour may reduce the mother´s risk of haemorrhage greater than 1000 ml compared to expectant management.

Comment: The quality of evidence is downgraded by indirectness (differences between the interventions of interest and those studied) by study limitations (possible selective outcome reporting bias).

A Cochrane review 1 included 8 studies with a total of 8 892 subjects. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 ml) (RR 0.34, 95% CI 0.14 to 0.87; 3 trials, n=4636) and of maternal haemoglobin (Hb) less than 9 g/dl following birth (RR 0.50, 95% CI 0.30 to 0.83; 2 trials, n=1572). No difference in the incidence in admission of infants to neonatal units was found (average RR 0.81, 95% CI 0.60 to 1.11; 2 trials, n=3207) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68; 2 trials, n=3142). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 ml), maternal mortality, or neonatal polycythaemia needing treatment. Active management showed a significant decrease in primary blood loss greater than 500 ml, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified).


1. Begley CM, Gyte GM, Devane D et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2019;(2):CD007412.  [PMID:30754073]

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