Methods	RCT with randomisation of individual women in balanced blocks, with allocation to 1 of 2 delivery postures within each arm
Participants	UK hospital setting. High-income country. Inclusion criteria: 1512 women at low risk of PPH giving birth at study hospital (including water births). Exclusion criteria: placenta praevia, previous PPH, APH after 20 weeks’ gestation, Hb <10 g/dL or MCV < 75 fL, non-cephalic presentation, multiple pregnancy, intrauterine death, epidural anaesthesia, parity > 5, uterine fibroid, oxytocin augmentation infusion, anticoagulation therapy, intended instrumental or OVB, duration of gestation < 32 weeks, (plus any other contraindication, in clinician’s view)
Interventions	Intervention: active management of 3rd stage (N = 748). Two arms: active management - upright position (N = 374); Active management - supine position (N = 374): prophylactic oxytocin (19.5%) or ‘oxytocin + ergometrine’ (75%) as soon as possible after birth of anterior shoulder (within 2 minutes of birth). Number of units/ mL not given, nor reason for the difference; immediate cord clamping and cutting; delivery of the placenta by CCT or maternal effort. Control: expectant management of 3rd stage (N = 764). Two arms: expectant management - upright position (N = 381); expectant management - supine position (N = 383): no prophylactic administration of uterotonic drug; no cord clamping until after pulsation ceased; delivery of placenta within 1 hour by maternal effort. Data included in Comparisons 1 & 2.
Outcomes	Pre-specified outcomes: PPH (> 500 mL) as assessed/estimated by the attending MW (used for power calculation); severe PPH 1000 mL), blood transfusion, iron tablets post-natally, Hb at 24-48 hours P/N, self-completed questionnaire on maternal fatigue and depression at 6 weeks P/N, nausea, vomiting, headache, hypertension, manual removal of placenta, ERPC, neonatal outcomes, views of mothers and staff
Notes	High-income setting Actual management used in the active arm: 699 (93.4%) had full active management; 95% given prophylactic uterotonic before delivery of placenta; 93% cord clamped before pulsation ceased; 46% CCT; 44% upright Actual management used in the expectant arm: 488 (63.9%) had full expectant management; 21% received oxytocic for treatment, and 2.5% prophylactically; cord left un-clamped till pulsation ceased 70%; placenta delivered by CCT 12%; 43% upright The setting is described as one where the midwives were “similarly confident” in active and expectant management. However, the questionnaire administered to 92 of the 153 midwives prior to the trial commencement showed that, whereas 84% felt “very confident” of active management, only 41% were “very confident” of expectant management Maternal mean Hb levels were reported with SEs and so SDs were calculated
Risk of bias
Bias	Authors’ judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Variable sized balanced blocks “…randomisation envelopes were prepared in advance.." in an external academic unit -National Perinatal Epidemiology Unit, Oxford
Allocation concealment (selection bias)	Low risk	Sequentially numbered, opaque, sealed envelopes stored on the ward. Entry to the trial occurred when an envelope was opened
Incomplete outcome data (attrition bias) All outcomes	Low risk	Data available on 1507 out of 1512 at discharge (less than 0.5% attrition, approximately equal losses in both groups) At 6 weeks follow-up less than 5% attrition.
Selective reporting (reporting bias)	Unclear risk	Both significant and non-significant results presented but we have not been able to check the trial protocol. Most as above reported plus others. Only a few neonatal outcomes reported
Other bias	Low risk	Initial power calculation suggested a sample size of 2000. Interim analysis showed a higher PPH rate than expected, so sample size was revised to 1500 and the trial stopped earlier than expected once the recalculated sample size was reached - no suggestion of bias