Active Management of the Third Stage

Active management is the default third-stage approach recommended by WHO, ACOG, and FIGO to reduce postpartum hemorrhage. Modern practice usually keeps the uterotonic and uterine assessment, while cord traction is optional (WHO says it's a minor add-on if a skilled attendant is present).

Each link opens the full review on the publisher's site in a new tab.

• WHO recommendations on prevention and treatment of postpartum haemorrhage↗WHO
• Cochrane: Active versus expectant management for women in the third stage of labour↗Cochrane

• ·Reduces average blood loss and rate of PPH >500 mL and >1000 mLReview sources ↓
• ·Especially beneficial with hemorrhage risk factors (long labor, induction, twins, prior PPH)Review sources ↓

• ·More nausea, headache, and afterpainsReview sources ↓
• ·Cord traction if done inappropriately can cause uterine inversion or cord avulsion (rare)Review sources ↓

• ·Modified active management (uterotonic only, no traction)Review sources ↓
• ·Physiologic management by informed choice in low-risk birthsReview sources ↓
• ·Delayed cord clamping FIRST, then uterotonicReview sources ↓

Cochrane 2019 (active vs. expectant management) and WHO PPH guidance support routine uterotonic at birth; delayed cord clamping is compatible with active management.

For most topics, guidelines from ACOG, WHO, and other major bodies broadly agree on the core safety points (when to act in an emergency, informed-consent standards, monitoring baselines). Where reasonable people — and even guidelines — differ tends to be around thresholds (when to start or stop something), preferences (comfort, environment, support), and values (how you weigh small risks against benefits). Use the questions below to explore those pieces with your care team.

Educational only. Your care team can help you weigh what applies to your specific situation.

• Pitocin After Birth (Third Stage of Labor)A dose of synthetic oxytocin often offered after baby is born to help the uterus contract as the placenta is delivered.
• Physiologic (Expectant) Third StageLetting the placenta deliver on its own without routine uterotonics or cord traction, with careful observation.
• Delayed / Optimal Cord ClampingWaiting at least 30–60 seconds (often longer) after birth before clamping and cutting the umbilical cord.
• Postpartum Hemorrhage (PPH)Bleeding of ≥ 500 mL after vaginal birth or ≥ 1000 mL after cesarean — or any bleeding making you unstable. Most PPH is treatable when caught fast. Every U.S. birthing unit now runs a standardized 'hemorrhage bundle' with clear escalation steps.
• Controlled Cord TractionGentle downward pressure on the cord to help deliver the placenta once it has separated — no longer routine in low-risk births.

A short BRAIN-style set you can bring to any conversation about interventions, monitoring, or care decisions.

• ?Why are you recommending this now — is it urgent, routine, or optional?
• ?What happens if we wait an hour (or longer) before deciding?
• ?What signs would tell us this is working — or that we need to change course?
• ?What are the alternatives, including doing nothing?
• ?What would you recommend if this were your family?
• ?What would change your recommendation?

Tap a source to open the original guideline or review in a new tab.

• ·WHO recommendations on prevention and treatment of postpartum haemorrhage↗ — WHO
• ·Cochrane: Active versus expectant management for women in the third stage of labour↗ — Cochrane

Plain-language paraphrase. Re-verify before publish.

Last reviewed: 2026-07-03

• v1.0.0 · 2026-07-03 · LlaMamma editors

  Initial active management topic.

New guidance from ACOG, WHO, Evidence Based Birth, or other listed sources is recorded here and can be updated remotely without a new app release.