Chulalongkorn Medical Journal


Objective : To compare simplified active management of the third stage oflabor (AMTSL) package with the full AMTSL package in the activemanagement of the third stage of labor with respect to the amountof bleeding.Design : Randomized controlled trial.Setting : Nongkai Hospital.Materials and Methods : Two hundred women with imminent vaginal delivery wererandomized into two groups, namely: the study and controlgroups in the study group, simplified package of the third-stagelabormanagement [oxytocin injection, cord clamping, uterinemessage, without controlled cord traction (CCT)] were performed.In the control group, full package of the third-stage-management(oxytocin injection, cord clamping, controlled cord traction anduterine message) were performed. The primary outcome measurewas blood loss during the third stage of labor. The duration ofthe third stage of labor, blood transfusion, the use of additionaloxytocin to treat PPH, blood loss of 500 ml or more, incidenceof retained placenta, manual removal of the placenta, additionalsurgical procedures (e.g. hysterectomy, ligation of blood vessels),incidence of uterine inversion were compared.Results : In 200 cases with vaginal delivery, 100 cases were assigned tothe study group, and the rest 100 cases were assigned tothe control group. The mean blood loss in the study group [withoutcontrolled cord traction (CCT)] and the control group (full AMTSLpackage) were 354.12 ml and 335.25 ml, respectively. The meanblood loss was 18.87 ml lower in the control group (full AMTSLpackage) than in the study group (without CCT): however, thisdifference was not statistically significant (P = 0.12). The durationof the third stage of labor in the control group (full AMTSLpackage) was statistically significantly less than the study group(without CCT) (6.85 ± 5.91 vs. 9.21 ± 3.64: P = 0.001). Theincidence of postpartum hemorrhage, blood transfusion, the useof additional oxytocin to treat postpartum hemorrhage (PPH),retained placenta, manual removal of the placenta were lower inthe control group (full AMTSL package) but there was notstatistical difference. There was no additional surgical procedures(e.g. hysterectomy, ligation of vessels), incidence of uterineinversion in both groups.Conclusions : Blood loss in third stage of labor in the simplified AMTSL packagewas higher than in the full AMTSL package, but without statisticallysignificance. The present findings support a larger clinical trialto determine whether the simplified AMTSL package may notincrease the risk of PPH and it may, therefore, be recommendedfor the peripheral levels of the health care system.


Faculty of Medicine, Chulalongkorn University

First Page


Last Page