Objective To compare blood loss in women actively and expectantly managed in the third stage of labour. Design Randomised controlled trial (RCT).Setting Two delivery units at a Swedish university hospital.Population Healthy women with normal pregnancies, at gestational age 34-43 weeks, with singleton cephalic presentation and expected vaginal delivery.Methods The women were randomly allocated to either active (n = 903) or expectant (n = 899) management of the third stage of labour.Main outcome measures The primary outcome was blood loss > 1000 ml, and secondary outcomes were mean blood loss, duration of third stage, retained placenta, haemoglobin level and blood transfusion.Results Blood loss > 1000 ml occurred in 10% of the actively managed group and 16.8% of the expectantly managed group (P < 0.001). Mean blood loss was 535 ml in the actively managed group and 680 ml in the expectantly managed group (P < 0.001). A prolonged duration of the third stage was associated with increased blood loss. Increased placenta weight was associated with increased blood loss. The haemoglobin level was 118 g/dl in actively managed women and 115 g/dl in expectantly managed women (P < 0.001) the day after childbirth. The occurrence of retained placenta and the number of blood transfusions did not differ between the groups.Conclusions Active management of the third stage of labour was associated with less blood loss compared with expectant management. It is reasonable to advocate this regime, especially in primiparous women.Keywords Active management, active management of the third stage of labour, expectant management, oxytocin, postpartum haemorrhage, third stage of labour.

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