What is the Third Stage of Labour?
Labour has four stages. The first is cervix dilation from 0 to 10 cm. The second is pushing and delivery of the baby. The third stage — delivery of the placenta — typically lasts 5 to 30 minutes. The fourth stage is the immediate postpartum recovery period in the first 1–2 hours.
The third stage carries the highest risk of haemorrhage. Without active management, uterine atony — failure of the uterus to contract — is the most common cause of postpartum haemorrhage (PPH).
What Does AMTSL Stand For?
AMTSL stands for Active Management of the Third Stage of Labour. It is a set of three evidence-based clinical steps performed immediately after the baby is born that together reduce the risk of PPH by up to 60% compared to expectant (passive) management.
The Three Steps of AMTSL
- Step 1 — Uterotonic administration: Give oxytocin 10 IU intramuscularly within ONE minute of the baby's birth. Oxytocin causes sustained uterine contraction and is the first-line recommendation by WHO and the Government of India. Where oxytocin is unavailable, misoprostol 600 mcg oral is the recommended alternative.
- Step 2 — Controlled cord traction (CCT): Apply gentle, steady traction on the umbilical cord while applying counter-pressure (guard) on the suprapubic area to stabilise the uterus. This is also called the Brandt-Andrews technique. Do not apply cord traction before the uterus contracts — wait for the uterotonic to take effect.
- Step 3 — Uterine massage: After the placenta is delivered, massage the uterine fundus to maintain tone and prevent atony. Check regularly over the next 15–30 minutes.
Why Is AMTSL Important in India?
Postpartum haemorrhage — defined as blood loss of 500 ml or more within 24 hours of delivery — accounts for approximately 25–30% of all maternal deaths in India. Most are preventable with timely and correct application of AMTSL.
AMTSL is recommended by the World Health Organization (WHO), the Government of India Ministry of Health and Family Welfare, the Indian Nursing Council (INC), and the International Confederation of Midwives (ICM). Every nurse, ANM, GNM, and midwife conducting deliveries must be competent in AMTSL.
Key Points to Remember
- Give oxytocin within 1 minute of birth — timing is critical
- Apply counter-pressure before cord traction — never pull the cord without uterine support
- After placenta delivery, check it for completeness — retained fragments cause haemorrhage
- Document blood loss accurately at every delivery
- If PPH occurs despite AMTSL, escalate immediately and follow your facility's obstetric emergency protocol
Common Mistakes to Avoid
- Delaying oxytocin administration beyond 1 minute after birth
- Applying aggressive cord traction before the uterotonic takes effect
- Skipping uterine massage after placenta delivery
- Failing to check the placenta for completeness
- Under-estimating blood loss by visual assessment alone
Learn AMTSL Online — Free, INC Certified
The Normal Labour and Birth and AMTSL course on Aastrika Sphere covers all four stages of labour, normal vaginal delivery, and the full AMTSL protocol. It includes animated clinical films, video lectures, practical procedure guides, and case-based assessments. The course was developed by the Indian Nursing Council in collaboration with the Safe Delivery App curriculum.
Duration: approximately 12 hours of self-paced learning. INC awards a certificate and 7.5 CNE credit hours on completion. The course is rated 4.74 out of 5 by over 54,000 learners and is free to enroll with no deadline.