Mod Midwives: Postpartum Hemorrhage and Active Management of the Third Stage of Labor

In this week’s podcast, Nedra and Gina talk about postpartum hemorrhage (PPH) and an option that is available to you: Active Management of the Third Stage of Labor. In this episode we cover some background information about postpartum hemorrhage: the definition of PPH, how often it occurs, and causes, risk factors, prevention, and treatment.

Postpartum hemorrhage will occur in 3-5% of all births. It is blood loss in excess of 500 milliliters, or about 2 cups. While most cases are unpredictable, there are a number of risk factors that increase your chances of bleeding excessively. 

Risk Factors that Increase Your Chance of a Hemorrhage

  • Previous postpartum hemorrhage
  • Anemia
  • Polyhydramnios (excessive amniotic fluid)
  • Macrosomia (big baby)
  • Long labor, especially in the second stage
  • Very fast labor
  • Grand multiparity (having baby 5 or more)
  • Nulliparity (having your first baby)
  • Uterine fibroids
  • Assisted reproductive techniques

(Nyflot, 2017 and Alsammani, 2019)

Treatment of Postpartum Hemorrhage

Generally, we practice what’s called “Expectant Management of the Third Stage,” which is simply watchful waiting after the birth. If a bleed begins, we would treat it. We treat PPH with three medications: Pitocin (synthetic oxytocin), Cytotec (misoprostol), or Methergine. While some people may wish to use herbal remedies for bleeding, the time to action for herbs is too long to treat an active bleed. If you have one or more risk factors for PPH, or even if you don’t, you may want to consider active/mixed management of the third stage of labor (AMTSL), which has been shown to significantly decrease the risk of postpartum hemorrhage (Evensen, 2017). 

Active/Mixed Management of the Third Stage 

Active management is the standard of care in most medical practices and includes an injection, immediate cord clamping, and controlled cord traction. In our practice active management is really more of a mixed management. What we would do is a prophylactic injection of 10 international units of Pitocin followed by gentle cord traction after we see signs of placental separation. Because active management is so effective at reducing the risk of of PPH, and because most hemorrhages are unexpected, you may certainly request this approach regardless of other risk factors.

Risks of Active Management

Some people are concerned that synthetic oxytocin could interfere with endogenous oxytocin levels and lead to postpartum mood disorders. However, the evidence is weak and inconclusive (Taylor et al, 2020). Since excess blood loss is almost certainly associated with postpartum mood disorders (Sentilhes, 2011), you certainly have to weigh your pros and cons carefully. 


Alsammani, M. A., Jafer, A. M., Khieri, S. A., Ali, A. O., & Shaaeldin, M. A. (2019). Effect of Grand Multiparity on Pregnancy Outcomes in Women Under 35 Years of Age: a Comparative Study. Medical archives (Sarajevo, Bosnia and Herzegovina), 73(2), 92–96.

Begley, C. M., Gyte, G. M., Devane, D., McGuire, W., & Weeks, A. (2011). Active versus expectant management for women in the third stage of labour. The Cochrane database of systematic reviews, (11), CD007412.

Bell, A. F., Erickson, E. N., & Carter, C. S. (2014). Beyond labor: the role of natural and synthetic oxytocin in the transition to motherhood. Journal of midwifery & women’s health, 59(1), 35–108.

Evensen, A., Anderson, J. M., & Fontaine, P. (2017). Postpartum Hemorrhage: Prevention and Treatment. American family physician, 95(7), 442–449.

Güngördük, K., Olgaç, Y., Gülseren, V., & Kocaer, M. (2018). Active management of the third stage of labor: A brief overview of key issues. Turkish journal of obstetrics and gynecology, 15(3), 188–192.

Nyfløt, L. T., Sandven, I., Stray-Pedersen, B., Pettersen, S., Al-Zirqi, I., Rosenberg, M., Jacobsen, A. F., & Vangen, S. (2017). Risk factors for severe postpartum hemorrhage: a case-control study. BMC pregnancy and childbirth, 17(1), 17.

Sentilhes, L., Gromez, A., Clavier, E., Resch, B., Descamps, P., & Marpeau, L. (2011). Long-term psychological impact of severe postpartum hemorrhage. Acta obstetricia et gynecologica Scandinavica, 90(6), 615–620.

Taylor A. Thul, Elizabeth J. Corwin, Nicole S. Carlson, Patricia A. Brennan, Larry J. Young, (2020) Oxytocin and postpartum depression: A systematic review,

Psychoneuroendocrinology, 120, 104793,