Timings : Mon to Sat pm

Dr.Niraj Mahajan
Dr.Niraj Mahajan
Dr.Niraj Mahajan


AMTSL - Active management of third stage of labor

By AdminPosted On 05-Oct-2016


Postpartum haemorrhage is leading causes of maternal death worldwide (10% of births). AMTSL is highly effective at preventing postpartum haemorrhage. As a part of AMTSL which of the following drug/s should be administered?a) Inj. Oxytocin 10U I/Mb) Inj. Oxytocin 10U I/Vc) Inj. Methyl ergometrin 0.2mg along with Inj. Oxytocin 10U I/Md) Inj. Syntometrin I/Me) Tab. Misoprost 600 mg orallyCorrect Answer: a) Inj. Oxytocin 10U I/M (Ref: WHO 2012)1) A uterotonic, preferably oxytocin, 10 IU IM immediately after all births, including cesarean sections2) Delayed (1–3 minutes after birth) cord clamping3) Controlled cord traction for delivery of the placenta4) Fundal massage5) Regular and frequent assessment of uterine tone by palpation of the uterine fundus after delivery of the placenta

2. Early Vs Delayed Cord Clamping

After the childbirth (either Normal Delivery or Cesarean Section) of full term fetus in a low-risk woman (means without any high-risk) umbilical cord should be clampeda) Immediately after the deliveryb) Within 1-3 minutes of deliveryc) Within 3-5 minutes of deliveryd) Within 10 minutes of deliveryCorrect Answer: b) Within 1-3 minutes of delivery. Because of the benefits to the baby, the cord should not be clamped earlier than necessary for applying cord traction in AMTSL. For the sake of clarity, it is estimated that this will normally take around three minutes. Newborn anemia has been reported as an important outcome of early cord clamping. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.Milking the cord four times from the placental end toward the infant has been shown to benefit preterm infants when compared to either clamping the umbilical cord immediately or waiting delaying the clamping of the cord. Delaying cord clamping for 30-120 seconds has been shown to improve heart and lung function, reduces the need for blood transfusion, better circulatory stability, less intraventricular haemorrhage (all grades) and lower risk for necrotising enterocolitis. Umbilical cord milking stabilized cerebral oxygenation and perfusion in VLBW infants by improving LV diastolic function by increasing LV preload.Delaying the clamping of the umbilical cord, however in extremely premature infants is not considered safe, since it also delays the resuscitation that these infants need immediately after birth. Milking the umbilical cord is believed have similar benefits. Early clamping may be required if the newborn is asphyxiated and immediate resuscitation is necessary.Ref: WHO 2012; FIGO 2012

3. Oxytocin : Before or After Placenta Expulsion

Should oxytocin be administered before or after placental expulsion? To prevent retention of placenta and also with reference to delayed cord clamping.Answer: Administration of oxytocin before or after placental expulsion does not significantly influence the major clinical outcomes such as the incidence of PPH or duration of the third stage of labour. This is an important finding because a previous systematic reviews had found a trend towards an increased rate of placental retention following active management of the third stage of labour in which uterotonic drugs had been administered prior to or at the beginning of the third stage of labour in women at low risk of haemorrhage. The administration of oxytocin after expulsion of the placenta has the advantage of reducing the risk of over-infusion of placental blood to the baby. There is already evidence to show the beneficial effects of delaying cord clamping and of cord drainage. Ref: WHO 2011; FIGO 2012

4. Misoprostol for AMTSL

WHO has recommended Tab. Misoprostol, orally used alone (i.e. without other components of the AMTSL) by auxiliary nurse midwives at home or in village subcentres. How much is the recommended oral dose by WHO?

a) 200 µg
b) 400 µg
c) 600 µg
d) 800 µg
e) 1000 µg

Correct Answer: c) 600 µg. WHO(2011) and FIGO (2012) recommends, in the absence of personnel to offer AMTSL (where it is not possible to use oxytocin or another injectable uterotonic such as ergometrine or an oxytocin), it is recommended that the trained health worker should offer misoprostol 600 micrograms orally immediately after the birth of the baby. In such cases no active intervention to deliver the placenta should be carried out.

5. Prophylaxis of PPH during cesarean section in a low risk woman

a) 20 u Oxytocin @ fast
b) 20 u Oxytocin @ 60 drops/ min
c) 20 u Oxytocin @ 30 drops/ min
d) 10 u Oxytocin @ 60 drops/ min
e) 10 u Oxytocin @ 30 drops/ min
f) Inj. Prostodin (PGF2 alpha) 125 mcg i/m
g) Tab. Misoprost (PGE1) 400 mcg sublingual

Correct Answer: e) 10 u Oxytocin @ 30 drops/ min. WHO recommends 10U of Oxytocin for prevention of PPH. 10U:500ml = 20000mIU/1000ml = 20mIU/ml. If we start at 30 drops /min, 40mIU/min will be infusion rate. Oxytocin has amino-acid homology similar to arginine vasopressin. Thus not surprisingly, it has similar antidiuretic action, and when infused at dosages of 20mIU/min or more, renal free water clearance decreases markedly. If aqueous fluid are infused in appropriate amounts along with oxytocin, water intoxication can lead to convulsions, coma, and even death. So the drop rate for 10U oxytocin drip should not be more than 30drops/ min.

Prev Next

"Authored By Dr.Niraj Mahajan"

Enquire Now

Location Map

Our Doctor


Dr. Niraj Mahajan

MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.

Read more [+]

Call Us