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Meta-Analysis
. 2019 Feb 13;2(2):CD007412.
doi: 10.1002/14651858.CD007412.pub5.

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

Cecily M Begley  1 , Gillian Ml Gyte, Declan Devane, William McGuire, Andrew Weeks, Linda M Biesty
Affiliations
Meta-Analysis

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

Cecily M Begley et al. Cochrane Database Syst Rev. .

Abstract

Background: Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. This is an update of a review last published in 2015.

Objectives: To compare the effects of active versus expectant management of the third stage of labour on severe primary postpartum haemorrhage (PPH) and other maternal and infant outcomes.To compare the effects of variations in the packages of active and expectant management of the third stage of labour on severe primary PPH and other maternal and infant outcomes.

Search methods: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World health Organization International Clinical Trials Registry Platform (ICTRP), on 22 January 2018, and reference lists of retrieved studies.

Selection criteria: Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. Cluster-randomised trials were eligible for inclusion, but none were identified.

Data collection and analysis: Two review authors independently assessed the studies for inclusion, assessed risk of bias, carried out data extraction and assessed the quality of the evidence using the GRADE approach.

Main results: We included eight studies, involving analysis of data from 8892 women. The studies were all undertaken in hospitals, seven in higher-income countries and one in a lower-income country. Four studies compared active versus expectant management, and four compared active versus a mixture of managements. We used a random-effects model in the analyses because of clinical heterogeneity. Of the eight studies included, we considered three studies as having low risk of bias in the main aspects of sequence generation, allocation concealment and completeness of data collection. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes, which is reflected in the cautious language below.The evidence suggested that, for women at mixed levels of risk of bleeding, it is uncertain whether active management reduces the average risk of maternal severe primary PPH (more than 1000 mL) at time of birth (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, 3 studies, 4636 women, I2 = 60%; GRADE: very low quality). For incidence of maternal haemoglobin (Hb) less than 9 g/dL following birth, active management of the third stage may reduce the number of women with anaemia after birth (average RR 0.50, 95% CI 0.30 to 0.83, 2 studies, 1572 women; GRADE: low quality). We also found that active management of the third stage may make little or no difference to the number of babies admitted to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, 2 studies, 3207 infants; GRADE: low quality). It is uncertain whether active management of the third stage reduces the number of babies with jaundice requiring treatment (RR 0.96, 95% CI 0.55 to 1.68, 2 studies, 3142 infants, I2 = 66%; GRADE: very low quality). There were no data on our other primary outcomes of very severe PPH at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management reduces mean maternal blood loss at birth and probably reduces the rate of primary blood loss greater than 500 mL, and the use of therapeutic uterotonics. Active management also probably reduces the mean birthweight of the baby, reflecting the lower blood volume from interference with placental transfusion. In addition, it may reduce the need for maternal blood transfusion. However, active management may increase maternal diastolic blood pressure, vomiting after birth, afterpains, use of analgesia from birth up to discharge from the labour ward, and more women returning to hospital with bleeding (outcome not pre-specified).In the comparison of women at low risk of excessive bleeding, there were similar findings, except it was uncertain whether there was a difference identified between groups for severe primary PPH (average RR 0.31, 95% CI 0.05 to 2.17; 2 studies, 2941 women, I2 = 71%), maternal Hb less than 9 g/dL at 24 to 72 hours (average RR 0.17, 95% CI 0.02 to 1.47; 1 study, 193 women) or the need for neonatal admission (average RR 1.02, 95% CI 0.55 to 1.88; 1 study, 1512 women). In this group, active management may make little difference to the rate of neonatal jaundice requiring phototherapy (average RR 1.31, 95% CI 0.78 to 2.18; 1 study, 1447 women).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, for example, omitting ergot and deferring cord clamping, but we have no direct evidence of this here.

Authors' conclusions: Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours). Women could be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.It must be emphasised that this review includes only a small number of studies with relatively small numbers of participants, and the quality of evidence for primary outcomes is low or very low.

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Conflict of interest statement

Cecily Begley: was the lead researcher on the 'Dublin trial' (Begley 1990). Gill Gyte, Declan Devane, and a member of the Cochrane Pregnancy and Childbirth Group's staff independently reviewed Begley's paper and agreed inclusion in the review. GG and DD extracted data.

Gill Gyte: I have written extensively on third‐stage management and was a co‐applicant on a five year study of care at preterm birth which included a pilot randomised controlled trial of delayed cord clamping with immediate neonatal care with cord intact versus early cord clamping (funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme [RPPG‐0609‐10107]). I am currently a Public and Patient Involvement representative on the Trial Management Group on a Health Technology Assessment funded clinical trial of carboprost versus oxytocin as first line treatment of primary postpartum haemorrhage, led by Professor Andrew Weeks based at University of Liverpool, UK. I also received royalties from John Wiley & Sons in respect of ‘A Cochrane Pocketbook – Pregnancy and Childbirth’ Hofmeyr GJ et al. 2008.

Declan Devane: was a member of the Data Monitoring Board for the Cord pilot trial ‐ immediate versus deferred cord clamping for very preterm birth (before 32 weeks' gestation). (The study is not included in this review.)

William McGuire: none known

Andrew Weeks: has been on a programme grant related to the timing of cord clamping, as well as investigating the use of misoprostol for postpartum haemorrhage prophylaxis in rural Uganda (Weeks AD, Ditai J, Ononge S, Faragher B, Frye LJ, Durocher J, Mirembe FM, Byamugisha J, Winikoff B, Alfirevic Z. The MamaMiso study of self‐administered misoprostol to prevent bleeding after childbirth in rural Uganda: a community‐based, placebo‐controlled randomised trial. BMC Pregnancy Childbirth. 2015 Sep 14;15:219). He is also one of nine designers of a small resuscitation trolley (the BASICS trolley; Weeks AD, Watt P, Yoxall CW, Gallagher A, Burleigh A, Bewley S, Heuchan AM, Duley L. Innovation in immediate neonatal care: development of the Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support (BASICS) trolley. BMJ Innov. 2015 Apr;1(2):53‐58) that allows neonatal resuscitation with an intact cord and the inventor of the PPH Butterfly, a device to allow minimally invasive uterine compression to treat postpartum haemorrhage (Cunningham C, Watt P, Aflaifel N, Collins S, Lambert D, Porter J, Lavender T, Fisher T, Weeks A. PPH Butterfly: a novel device to treat postpartum haemorrhage through uterine compression. BMJ Innov. 2017 Feb;3(1):45‐54.).

Linda M Biesty: none known.

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 1 Severe primary postpartum haemorrhage (PPH) at time of birth (clinically estimated or measured blood loss ≥ 1000 mL).
1.4
1.4. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 4 Maternal Hb < 9 g/dL 24‐72 hours postpartum.
1.5
1.5. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 5 Admission to neonatal special/intensive care.
1.6
1.6. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 6 Neonatal jaundice requiring phototherapy or exchange transfusion.
1.10
1.10. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 10 Primary blood loss ≥ 500 mL at time of birth (clinically estimated or measured).
1.13
1.13. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 13 Mean maternal blood loss (mL) at time of birth (clinically estimated or measured).
1.16
1.16. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 16 Maternal blood transfusion.
1.18
1.18. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 18 Therapeutic uterotonics during third stage and/or within 24 hours.
1.19
1.19. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 19 Mean length of third stage.
1.20
1.20. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 20 Manual removal of placenta as defined by study authors.
1.21
1.21. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 21 Postnatal diastolic blood pressure > 90 mmHg between birth of baby and discharge from the labour ward.
1.22
1.22. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 22 Postnatal vomiting between birth of baby and discharge from the labour ward.
1.23
1.23. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 23 Any analgesia between birth of the baby and discharge from labour ward.
1.25
1.25. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 25 Secondary blood loss/any vaginal bleeding needing treatment (after 24 hours and up to 6 weeks).
1.27
1.27. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 27 Surgical evacuation of retained products of conception.
1.28
1.28. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 28 Afterpains ‐ abdominal pain associated with the contracting uterus in the postpartum period.
1.29
1.29. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 29 Apgar score < 7 at 5 minutes.
1.30
1.30. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 30 Birthweight.
1.38
1.38. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 38 Exclusive breastfeeding at discharge from hospital.
1.40
1.40. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 40 Return to hospital as in‐ or outpatient because of bleeding (not pre‐specified).
1.41
1.41. Analysis
Comparison 1 Active versus expectant management of 3rd stage of labour (all women), Outcome 41 Postnatal maternal mean Hb (outcome not pre‐specified).
2.1
2.1. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 1 Severe primary PPH at time of birth (clinically estimated or measured blood loss ≥ 1000 mL).
2.4
2.4. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 4 Maternal Hb < 9 g/dL at 24‐72 hr.
2.5
2.5. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 5 Admission to neonatal special/intensive care.
2.6
2.6. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 6 Neonatal jaundice requiring phototherapy or exchange transfusion.
2.10
2.10. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 10 Primary blood loss ≥ 500 mL at time of birth (clinically estimated or measured).
2.13
2.13. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 13 Mean maternal blood loss (mL at the time of birth, clinically estimated or measured.
2.16
2.16. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 16 Maternal blood transfusion.
2.18
2.18. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 18 Therapeutic uterotonics during third stage and/or within 24 hours.
2.19
2.19. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 19 Mean length of third stage.
2.20
2.20. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 20 Manual removal of placenta as defined by study authors.
2.21
2.21. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 21 Postnatal diastolic blood pressure > 90 mmHg between birth of baby and discharge from the labour ward.
2.22
2.22. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 22 Postnatal vomiting between birth of baby and discharge from the labour ward..
2.23
2.23. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 23 Any analgesia between birth of the baby and up to discharge from labour ward.
2.25
2.25. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 25 Secondary blood loss/any vaginal bleeding needing treatment (after 24 hours and up to 6 weeks).
2.27
2.27. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 27 Surgical evacuation of retained products of conception.
2.28
2.28. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 28 Afterpains ‐ abdominal pain associated with the contracting uterus in the postpartum period.
2.30
2.30. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 30 Birthweight.
2.40
2.40. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 40 Return to hospital as in‐ or outpatient because of bleeding (not pre‐specified).
2.41
2.41. Analysis
Comparison 2 Active versus expectant management of 3rd stage of labour (women at low risk), Outcome 41 Postnatal maternal mean Hb (outcome not pre‐specified).
5.8
5.8. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 8 Maternal blood transfusion.
5.9
5.9. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 9 Therapeutic uterotonics during third stage and/or within 24 hours.
5.10
5.10. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 10 Mean length of third stage.
5.11
5.11. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 11 Manual removal of placenta as defined by study authors.
5.12
5.12. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 12 Surgical evacuation of retained products of conception.
5.13
5.13. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 13 Birthweight.
5.14
5.14. Analysis
Comparison 5 Active versus mixed management of 3rd stage (delayed uterotonic, delayed cord clamping, no controlled cord traction), Outcome 14 Postnatal maternal mean Hb.
9.1
9.1. Analysis
Comparison 9 Active versus mixed management (uterotonic after placental delivery, immediate cord clamping and no controlled cord traction)  , Outcome 1 Severe primary PPH at time of birth (clinically estimated or measured blood loss ≥ 1000 mL).
9.10
9.10. Analysis
Comparison 9 Active versus mixed management (uterotonic after placental delivery, immediate cord clamping and no controlled cord traction)  , Outcome 10 Primary blood loss ≥ 500 mL at time of birth (clinically estimated or measured).
9.16
9.16. Analysis
Comparison 9 Active versus mixed management (uterotonic after placental delivery, immediate cord clamping and no controlled cord traction)  , Outcome 16 Maternal blood transfusion.
9.17
9.17. Analysis
Comparison 9 Active versus mixed management (uterotonic after placental delivery, immediate cord clamping and no controlled cord traction)  , Outcome 17 Clinical signs of severe blood loss.
9.18
9.18. Analysis
Comparison 9 Active versus mixed management (uterotonic after placental delivery, immediate cord clamping and no controlled cord traction)  , Outcome 18 Therapeutic uterotonics during third stage and/or within 24 hours.
9.19
9.19. Analysis
Comparison 9 Active versus mixed management (uterotonic after placental delivery, immediate cord clamping and no controlled cord traction)  , Outcome 19 Mean length of third stage.
10.1
10.1. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 1 Severe primary PPH at time of birth (clinically estimated or measured blood loss ≥ 1000 mL).
10.4
10.4. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 4 Maternal Hb < 9 g/dL at 24‐72 hr.
10.10
10.10. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 10 Primary blood loss ≥ 500 mL at time of birth (clinically estimated or measured).
10.13
10.13. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 13 Mean maternal blood loss (mL) at time of birth (clinically estimated or measured).
10.16
10.16. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 16 Maternal blood transfusion.
10.18
10.18. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 18 Therapeutic uterotonics during third stage and/or within 24 hours.
10.19
10.19. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 19 Mean length of third stage.
10.20
10.20. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 20 Manual removal of placenta as defined by study authors.
10.28
10.28. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 28 Not prespecified: afterpains at 2 hours after birth (id 20458).
10.29
10.29. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 29 Not pre‐specified: afterpains the day after birth (id 20458).
10.31
10.31. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 31 Birthweight.
10.42
10.42. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 42 Postnatal maternal mean Hb (outcome not pre‐specified).
10.43
10.43. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 43 Severe primary PPH after placental delivery and up to 2 hours (clinically estimated or measured blood loss ≥ 1000 mL) ‐ not pre‐specified.
10.44
10.44. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 44 Severe primary PPH at time of birth and up to 2 hours (clinically estimated or measured blood loss ≥1000 mL) ‐ not pre‐specified.
10.45
10.45. Analysis
Comparison 10 Active versus mixed management (no routine uterotonic, early cord clamping, no controlled cord traction), Outcome 45 Mean blood loss (mL) (clinically estimated or measured at birth and up to 2 hours (not pre‐specified).
11.4
11.4. Analysis
Comparison 11 Active versus mixed management (no routine uterotonic, early cord clamping, controlled cord traction), Outcome 4 Maternal Hb < 9 g/dL at 24‐72 hr.
11.19
11.19. Analysis
Comparison 11 Active versus mixed management (no routine uterotonic, early cord clamping, controlled cord traction), Outcome 19 Mean length of third stage.
11.20
11.20. Analysis
Comparison 11 Active versus mixed management (no routine uterotonic, early cord clamping, controlled cord traction), Outcome 20 Manual removal of placenta as defined by study authors.
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Update of

Comment in

References

References to studies included in this review

Begley 1990 {published and unpublished data}
    1. Begley CM. Comparative Studies in the Third Stage of Labour [thesis]. Dublin: Trinity College, University of Dublin, Ireland, 1989.
    1. Begley CM. A comparison of 'active' and 'physiological' management of the third stage of labour. Midwifery 1990;6:3‐17. - PubMed
    1. Begley CM. A comparison of physiological and pharmacological methods of managing the third stage of labour. Personal communication 1987.
    1. Begley CM. The effect of ergometrine on breast feeding. Midwifery 1990;6:60‐72. - PubMed
Jangsten 2011 {published and unpublished data}
    1. Jangsten E, Bergh I, Mattsson LA, Hellstrom AL, Berg M. Afterpains: a comparison between active and expectant management of the third stage of labor. Birth 2011;38(4):294‐301. - PubMed
    1. Jangsten E, Mattsson LA, Lyckestam I, Hellstrom AL, Berg M. A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial. BJOG 2011;118(3):362‐9. - PubMed
    1. NCT01221051. A comparison of active and expectant management of the third stage of labor. clinicaltrials.gov/ct2/show/NCT01221051 (first received 14 October 2010).
Jerbi 2007 {published data only}
    1. Jerbi M, Hidar S, Elmoueddeb S, Chaieb A, Khairi H. Oxytocin in the third stage of labor. International Journal of Gynecology & Obstetrics 2007;96(3):198‐9. - PubMed
Khan 1997 {published data only}
    1. Khan GQ, John IS, Wani S, Doherty T, Sibai BM. Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomised controlled trial. American Journal of Obstetrics and Gynecology 1997;177(4):770‐4. - PubMed
Prendiville 1988 {published data only}
    1. Elbourne DR, Harding J. The Bristol third stage trial. Proceedings of Research and the Midwives Conference; 1989; Manchester, UK. 1989:19‐31.
    1. Harding JE, Elbourne DR, Prendiville WJ. Views of mothers and midwives participating in the Bristol randomized, controlled trial of active management of the third stage of labor. Birth 1989;16:1‐6. - PubMed
    1. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ 1988;297:1295‐300. - PMC - PubMed
Rogers 1998 {published data only}
    1. ISRCTN63422923. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. isrctn.com/ISRCTN63422923 (first received 23 January 2014).
    1. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial [see comments]. Lancet 1998;351(9104):693‐9. - PubMed
    1. Wood J, Rogers J, Elbourne D, McCandlish R, Truesdale A. The Hinchingbrooke third stage trial. International Confederation of Midwives 24th Triennial Congress; 1996 May 26‐31; Oslo, Norway. 1996:140.
Thilaganathan 1993 {published data only}
    1. Thilaganathan B, Cutner A, Latimer J, Beard R. Management of the third stage of labour in women at low risk of postpartum haemorrhage. European Journal of Obstetrics & Gynecology and Reproductive Biology 1993;48:19‐22. - PubMed
Yildirim 2016 {published data only}
    1. Yildirim D, Ozyurek SE, Ekiz A, Eren EC, Hendem DU, Bafali O, et al. Comparison of active vs. expectant management of the third stage of labor in women with low risk of postpartum hemorrhage: a randomized controlled trial. Ginekologia Polska 2016;87(5):399‐404. - PubMed

References to studies excluded from this review

Abdel‐Aleem 2010 {published data only}
    1. Abdel‐Aleem H, Singata M, Abdel‐Aleem M, Mshweshwe N, Williams X, Hofmeyr GJ. Uterine massage to reduce postpartum hemorrhage after vaginal delivery. International Journal of Gynecology & Obstetrics 2010;111(1):32‐6. - PubMed
Deneux‐Tharaux 2013 {published data only}
    1. Deneux‐Tharaux C, Sentilhes L, Maillard F, Closset E, Vardon D, Lepercq J, et al. Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR). BMJ (Clinical Research Ed.) 2013;346:f1541. - PMC - PubMed
Gulmezoglu 2012 {published data only}
    1. Gulmezoglu AM, Lumbiganon P, Landoulsi S, Widmer M, Abdel‐Aleem H, Festin M, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non‐inferiority trial. [Erratum appears in Lancet. 2012 May 5;379(9827):1704]. Lancet 2012;379(9827):1721‐7. - PubMed
    1. Gulmezoglu AM, Widmer M, Merialdi M, Qureshi Z, Piaggio G, Elbourne D, et al. Active management of the third stage of labour without controlled cord traction: a randomized non‐inferiority controlled trial. Reproductive Health 2009;6:2. - PMC - PubMed
Hoffman 2006 {published data only}
    1. Hoffman M, Castagnola D, Naqvi F. A randomized trial of active versus expectant management of the third stage of labor [abstract]. American Journal of Obstetrics and Gynecology 2006;195(6 Suppl 1):S107.
    1. Hoffman M, Naqvi F, Sciscione A. A randomized trial of active versus expectant management of the third stage of labor [abstract]. American Journal of Obstetrics and Gynecology 2004;191(6 Suppl 1):S82.
    1. NCT00473707. A randomized trial of active versus expectant management of the third stage of labor. clinicaltrials.gov/show/NCT00473707 (first received 15 May 2007).
Kashanian 2010 {published data only}
    1. Kashanian M, Fekrat M, Masoomi Z, Ansari NS. Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stage of labour: a randomised controlled trial. Midwifery 2010;26(2):241‐5. - PubMed
Magann 2006 {published data only}
    1. Magann EF, Doherty DA, Briery CM, Niederhauser A, Chauhan SP, Morrison JC. Obstetric characteristics for a prolonged third stage of labor and risk for postpartum hemorrhage. Gynecologic and Obstetric Investigation 2008;65(3):201‐5. - PubMed
    1. Magann EF, Doherty DA, Briery CM, Niederhauser A, Morrison JC. Timing of placental delivery to prevent post‐partum haemorrhage: lessons learned from an abandoned randomised clinical trial. Australian and New Zealand Journal of Obstetrics and Gynaecology 2006;46(6):549‐51. - PubMed
Muller 1996 {published data only}
    1. Muller R, Beck G. Active management of the third stage of labour. 19th Swiss Congress of the Swiss Society of Gynecology and Obstetrics; 1996 June; Interlaken, Switzerland. 1996.
Neri‐Mejia 2016 {published data only}
    1. Neri‐Mejia M, Pedraza‐Aviles AG. Active management of the third stage of labor: three schemes of oxytocin: randomised clinical trial. Ginecologia y Obstetricia De Mexico 2016;84(5):306‐13. - PubMed
Ramirez 2001 {published data only}
    1. Ramirez O, Benito V, Jimenez R, Valido C, Hernandez C, Garcia JA. Third stage of labour: active or expectant management? preliminary results [abstract]. Journal of Perinatal Medicine 2001;Suppl 1(Pt 2):364.
Vasegh 2005 {published data only}
    1. Vasegh FR, Bahiraie A, Mahmoudi M, Salehi L. Comparison of active and physiologic management of third stage of labor. HAYAT: The Journal of Tehran Faculty of Nursing & Midwifery 2005;10(23):102.

References to studies awaiting assessment

Rosario 1973 {published data only}
    1. Rosario YP Do, Jain CK. Active management of third stage of labour. Journal of Obstetrics and Gynaecology of India 1973;23(1):66‐9.

Additional references

Abouzaher 1998
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