Active management of third stage of labour with special reference to misoprostol

Mariyam S. Ahmed, Anand N. Bhalerao


Active management of third stage of labour is an effective method of preventing postpartum hemorrhage. It includes administration of uterotonic immediately after delivery of the baby, delaying cord clamping for at least 1-3 minutes to reduce rates of infant anaemia, performing controlled cord traction for removing the placenta and postpartum vigilance, ie, assess the uterine tone to ensure a contracted uterus; and continue to check every 15 minutes for 2 hours. If there is uterine atony, fundal massage should be performed and patient should be monitored more frequently. Though oxytocin is the best drug for routine prophylaxis, misoprostol is a relatively newer drug which is now included in the various guidelines for prevention and treatment of postpartum hemorrhage. It can be used as an effective and safe drug in areas with poor access to skilled healthcare providers and facilities.


Active management, Misoprostol, Maternal deaths, Postpartum hemorrhage, Third stage

Full Text:



AbouZahr C. Global burden of maternal death and disability. In: Rodeck C, ed. Reducing maternal death and disability in pregnancy. Oxford: Oxford University Press; 2003:1-11.

Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2014;(2):CD003249.

Knight M, Tuffnell D, Kenyon S,Shakespeare J, Gray R, Kurinczuk JJ, editors, on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. Oxford: National Perinatal Epidemiology Unit, University of Oxford;2015.

Alexander J, Thomas PW, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev. 2002;(1):CD002867.

Prendiville WJP, Elbourne D, McDonald SJ. Active versus expectant management in the third stage of labour [Cochrane review]. Chichester: The Cochrane Library;2000.

Managing complications of pregnancy and childbirth: a guide for midwives and doctors. Geneva: World Health Organization, United Nations Population Fund, United Nations Children’s Fund and The World Bank; 2003 (WHO/RHR/00.7).

NICE. Intrapartum care. CG190. 2014. Available at

Ladhani N, Lalonde AB. Management of the third stage of labour to prevent postpartum hemorrhage. J Obstet Gynaecol Canada. 2004 Mar 1;26(3):203-4.

van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ: Br Med J. 2006 Nov 4;333(7575):954.

McDonald SJ, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. Cochrane Database Syst Rev. 2004:CD000201.

Oladapo OT, Fawole B, Blum J,Abalos E. Advance misoprostol distribution for preventing and treating postpartum haemorrhage. Cochrane Database Syst Rev. 2012;(2):CD009336.

Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012;(8):CD000494.

Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012;(4):CD005457.

Novikova N, Hofmeyr GJ, Cluver C. Tranexamic acid for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2015;(6):CD007872.

Blanchard K, Clark S, Winikoff B, Gaines G, Kabani G, Shannon C. Misoprostol for women’s health: a review. Obstet Gynecol. 2002;99(2):316-332.

Hofmeyr GJ, Walraven G, Gulmezoglu AM, Maholwana B, Alfirevic Z, Villar J. Misoprostol to treat postpartum haemorrhage: a systematic review. Br J Obstet Gynaecol. 2005;112(5):547-553.

Gerstenfeld TS, Wing DA. Rectal misoprostol versus intravenous oxytocin for the prevention of postpartum hemorrhage after vaginal delivery. Am J Obstet Gynecol. 2001;185(4):878-882.

Davies NM, Longstreth J, Jamali F. Misoprostol therapeutics revisited. Pharmacotherapy. 2001;21:60-73.

Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB et al. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomized controlled trial. Lancet. 2006;368:1248-53.

Gülmezoglu AM, Villar J, Ngoc NT, Piaggio G, Carroli G, Adetoro L et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet. 2001;358(9283):68995.

Chong YS, Chua S, Arulkumaran S. Severe hyperthermia following oral misoprostol in the immediate postpartum period. Obstet Gynecol. 1997;90:703-4.

Bon GR, Van Zee A.Overdose of misoprostol in pregnancy. Am J Obstet Gynecol. 1994;171:561-2.

Joy SD, Sanchez-Ramos L, Kaunitz AM. Misoprostol use during the third stage of labor. Int J Gynecol Obstet. 2003 Aug;82(2):143-52.