[Active management of the third stage of labour (AMTSL) - the end of a 50 years-dogma?]

Abstract

Post-partum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Since more than 50 years AMTSL has been proposed for the prevention of PPH and is still recommended in current guidelines. The 3 key components of AMTSL are the prophylactic administration of oxytocin, clamping and cutting of the umbilical cord immediately after delivery of the baby and controlled cord traction. AMTSL has proven to reduce the rate of severe PPH by 70%. Despite of the long tradition of AMTSL it is still unclear, which of the 3 components significantly contributes to the reduction in PPH. Cochrane analyses and a recent metaanalysis gave strong evidence, that prophylactic oxytocin administration reduces the risk of PPH significantly, however, the optimal dose and mode of application is still a matter of debate.Until a little while ago no randomized controlled studies exist regarding the significance of controlled cord traction and the time of cord clamping in AMTSL. A randomized WHO trial 2012 and the 2013 published TRACOR (Traction of the CORd)-trial from France could clearly demonstrate that controlled cord traction is not associated with a significant reduction in postpartum blood loss and in the risk of severe PPH. A Cochrane analysis 2008 and a recent randomized trial from Sweden came to the conclusion, that there are no significant -differences between early (< 15 s) and delayed (> 1-3 min) cord clamping in the reduction of PPH and severe PPH. Uterine massage after delivery of the placenta, placental cord drainage and umbilical vein injection of uterotonics after delivery of the baby as part of AMTSL are not evidence-based methods. It has taken 50 years since AMTSL was first described for it to become clear that prophylactic oxytocin is the most important and the only evidence-based component of AMTSL. Future guidelines and textbooks should consider these new -findings.