The third stage: delivering the placenta
Active management is standard. The evidence is more uncertain than that implies.
After the baby is born, active management means three things: an injection of a drug to contract the uterus, early cord clamping, and pulling gently on the cord to deliver the placenta. Expectant management means waiting for the placenta to come away on its own.
Across 8 trials and 8,892 women, active management reduced severe bleeding over 1,000 mL (relative risk 0.34), but the reviewers rated this very low certainty and stated explicitly that they are uncertain of the finding. Active management may reduce anemia. It is also associated with harms: raised blood pressure afterward, pain, and returning to hospital with bleeding. In low-risk women specifically, it was uncertain whether there is any difference at all.
The reviewers recommended that women be given balanced information on both benefits and harms to support an informed choice, and flagged concerns about the early cord clamping component in particular.