WHO recommendations on cord management and uterine massage for the prevention of postpartum haemorrhage

WHO recommendations on cord management and uterine massage for the prevention of postpartum haemorrhage


  • In settings where skilled birth attendants are available, controlled cord traction (CCT) is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important. (Weak recommendation- High quality evidence)
  • In settings where skilled birth attendants are unavailable, CCT is not recommended- Strong recommendation, moderate-quality evidence
  • Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care- (Strong recommendation, moderate quality evidence)
  • Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation-(Strong recommendation, moderate-quality evidence)
  • Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin (Weak recommendation, low-quality evidence)
  • Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women (Strong recommendation, very-low-quality evidence)


Publication date: September 2012



These recommendations are based on a large RCT in which oxytocin 10 IU was used for the prevention of PPH in all participants. Based on this evidence, CCT was regarded as safe when applied by skilled birth attendants as it provides small beneficial effects on blood loss (average reduction of 11 ml on blood loss) and on the duration of the third stage of labour (average reduction of 6 minutes). The decision to implement CCT in the context of a prophylactic uterotonic drug should be discussed by the care provider and the woman herself.

If ergot alkaloids are used for the prevention of PPH, then CCT to minimize placenta retention is regarded as essential.

There is insufficient evidence to determine the benefit or risk of CCT when used in conjunction with misoprostol.

CCT is the first intervention to treat retained placenta, therefore the teaching of CCT in medical and midwifery curricula is essential.

The evidence base for recommendations for the timing of cord clamping includes both vaginal and caesarean births. The GDG considers this recommendation to be equally important for caesarean sections.

Delayed clamping should be performed during the provision of essential newborn care. For essential newborn care and resuscitation, please refer to the WHO guidelines on neonatal resuscitation.

The recommendations for the timing of cord clamping apply equally to preterm and term births. The GDG considers the benefits of delayed clamping for preterm infants to be particularly important.

Some health professionals working in areas of high HIV prevalence have expressed concern regarding delayed cord clamping as part of management of the third stage of labour. These professionals are concerned that during placental separation, a partially detached placenta could be exposed to maternal blood and this could lead to a micro-transfusion of maternal blood to the baby. It has been demonstrated that the potential for maternal-to-child transmission of HIV can take place at three different points in time: micro-transfusions of maternal blood to the fetus during pregnancy (intra-uterine HIV transmission), exposure to maternal blood and vaginal secretions when the fetus passes through the birth canal in vaginal deliveries (intra-partum transmission), and during breastfeeding (postnatal infection). For this reason, the main intervention to reduce the maternal-to-child transmission is the reduction of maternal viral load through the use of antiretroviral drugs during pregnancy, childbirth and postnatal period. There is no evidence that delaying the cord clamping increases the possibility of HIV transmission from the mother to the newborn. Maternal blood percolates through the placental intervillous space throughout pregnancy with a relatively low risk of maternal fetal transmission before delivery. It is highly unlikely that separation of the placenta increases exposure to maternal blood, and is highly unlikely that it disrupts the fetal placental circulation (i.e. it is unlikely that during placenta separation the newborn circulation is exposed to maternal blood). Thus, the proven benefits of a 1 – 3 minute delay at least in clamping the cord outweigh the theoretical, and unproven, harms. Late cord clamping is recommended even among women living with HIV or women with unknown HIV status.

There is a lack of evidence regarding the role of uterine massage for PPH prevention when no uterotonic drugs are used, or if a uterotonic drug other than oxytocin is used.

Although the GDG acknowledged that one small study reported that sustained uterine massage and clot expulsion were associated with a reduction in the use of additional uterotonics, there is lack of robust evidence supporting other benefits. However, the GDG considered that routine and frequent uterine tone assessment remains a crucial part of immediate postpartum care, particularly for the optimization of early PPH diagnosis.

Based on the most recent evidence, understanding of the contribution of each component of the active management of the third stage of labour package has evolved. The GDG considered that this package has a primary intervention: the use of an uterotonic. In the context of oxytocin use, CCT may add a small benefit, while uterine massage may add no benefit for the prevention of PPH. Early cord clamping is generally contraindicated.


WHO recommendations for the prevention and treatment of postpartum haemorrhage

Evidence Base and GRADE tables for this recommendation


Supporting systematic reviews

Mshweshwe NT, Hofmeyr GJ, Gülmezoglu AM. Controlled cord traction for the third stage of labour. Cochrane Database of Systematic Reviews. 2012(Issue 3.1.

Art. No.: CD008020).

McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. 2012;

Rabe H, Reynolds GJ, Diaz-Rosello JL, McDonald SJ, Middleton P. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews. 2012;Issue 31

Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews. 2012



VIDEO: Active management of third stage of labour


Other WHO content related to these recommendations

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice


Education material for teachers of midwifery. Managing postpartum haemorrhage


These recommendations should be cited as: WHO Reproductive Health Library. WHO recommendation on cord management and uterine massage for the prevention of postpartum haemorrhage (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.