The third stage of labor begins immediately after the baby is born and ends with the complete delivery of the placenta and fetal membranes. This phase carries a high risk for the mother because the raw placental site inside the uterus bleeds freely. Normally, uterine muscle fibers contract tightly to clamp down on the open blood vessels, a natural process known as myometrial retraction. Without this effective contraction, excessive bleeding can quickly lead to postpartum hemorrhage, which remains a leading cause of maternal mortality in Nigeria. Midwives must remain vigilant during this short window, as complications can develop with little warning.
Active Management of the Third Stage of Labor, commonly called AMTSL, is a bundle of lifesaving interventions designed to prevent postpartum hemorrhage. Instead of waiting for the placenta to deliver spontaneously, the midwife actively assists the process to reduce blood loss.
Giving a uterotonic drug is the single most important component of AMTSL. This medication must be given within one minute of the baby's birth after you have checked to make sure there is no second baby hiding in the uterus.
Once the uterotonic has taken effect and the uterus feels hard, the midwife performs controlled cord traction (CCT) paired with suprapubic counter-pressure.
To do this safely, hold the clamped umbilical cord close to the perineum. With your other hand placed flat on the mother's lower abdomen above the pubic bone, push the uterus gently upward and away from the pelvis while pulling the cord downward only during a contraction. Never pull on the cord without pushing the uterus upward, as this can cause the terrifying complication of uterine inversion, where the uterus turns inside out.
After the placenta and membranes are safely delivered, the third core component of AMTSL begins. The midwife must massage the uterine fundus through the mother's abdominal wall until the uterus remains firm on its own.
Feel for the fundus and rotate your hand in a circular motion. This tactile stimulation encourages the muscle fibers to stay tightly contracted, which compresses the open blood vessels. Palpate the uterus every fifteen minutes during the first two hours after birth to ensure it does not relax, a condition known as uterine atony.
Even with perfect AMTSL, complications can still arise. A retained placenta occurs when the tissue fails to deliver within thirty minutes of birth. If the placenta does not separate, manual removal under regional or general anesthesia may be necessary. Another emergency is a postpartum hemorrhage caused by uterine atony, which requires rapid intervention with bimanual compression, additional uterotonics, and IV fluids. Midwives must always inspect the delivered placenta carefully to make sure no small cotyledon or membrane pieces were left behind inside the uterine cavity.