Controlled Cord Traction for Postpartum Hemorrhage
Objective. To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.
Design. Randomised controlled trial.
Setting. Five university hospital maternity units in France.
Participants. Women aged 18 or more with a singleton fetus at 35 or more weeks’ gestation and planned vaginal delivery.
Interventions. Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth.
Main Outcome Measure. Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag.
Results. The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm.
Conclusions. In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking.
Postpartum haemorrhage remains a major complication of childbirth worldwide. Population based studies in high resource countries report a prevalence of severe postpartum haemorrhage of 0.5% to 1% of deliveries, making it the main component of severe maternal morbidity. Uterine atony is the leading cause of postpartum haemorrhage, accounting for 60-80% of cases. Prevention of atonic postpartum haemorrhage is thus crucial, and preventive measures are recommended for all women giving birth, given that individual risk factors are poor predictors.
Active management of the third stage of labour has been proposed for the prevention of postpartum haemorrhage. The standard definition for active management combines three procedures: an oxytocic drug administered immediately after birth, early cord clamping and cutting, and controlled cord traction. Several trials in a meta-analysis showed that active management of the third stage of labour is associated with a 60% reduction in the incidence of postpartum haemorrhage compared with expectant management. Given its efficacy, active management of the third stage of labour has been included in international and national guidelines for the prevention of postpartum haemorrhage. An adequate evaluation of the specific efficacy of each of its components, however, has not been done. The independent efficacy of using a preventive oxytocic has been shown with a good level of evidence and is therefore often considered the essential component of active management of the third stage of labour. This is not the case for controlled cord traction. Although most guidelines for the prevention of postpartum haemorrhage include controlled cord traction, actual implementation is highly variable; in Europe ranging from 12% in Hungary to 95% in Ireland. In countries such as France, where controlled cord traction is not recommended, pulling the cord in the absence of any sign of placenta separation is considered poor practice because of the potential risk of uterine inversion.
The variation in use of controlled cord traction may be explained by the paucity of available evidence for assessing the efficacy of controlled cord traction for the prevention of postpartum haemorrhage or its potential risks. Until recently only two trials conducted in the 1960s and with important limitations had assessed the specific effect of controlled cord traction and they had conflicting results. Recently, a large randomised controlled trial conducted in eight low and middle income countries reported that the risk of severe postpartum haemorrhage was not increased by the omission of controlled cord traction as part of the active management of the third stage of labour. The authors concluded that controlled cord traction could be omitted in non-hospital settings. However, the results of this trial may be relevant for low and middle income countries and not applicable to other countries. We therefore assessed the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.
Abstract and Introduction
Abstract
Objective. To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.
Design. Randomised controlled trial.
Setting. Five university hospital maternity units in France.
Participants. Women aged 18 or more with a singleton fetus at 35 or more weeks’ gestation and planned vaginal delivery.
Interventions. Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth.
Main Outcome Measure. Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag.
Results. The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm.
Conclusions. In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking.
Introduction
Postpartum haemorrhage remains a major complication of childbirth worldwide. Population based studies in high resource countries report a prevalence of severe postpartum haemorrhage of 0.5% to 1% of deliveries, making it the main component of severe maternal morbidity. Uterine atony is the leading cause of postpartum haemorrhage, accounting for 60-80% of cases. Prevention of atonic postpartum haemorrhage is thus crucial, and preventive measures are recommended for all women giving birth, given that individual risk factors are poor predictors.
Active management of the third stage of labour has been proposed for the prevention of postpartum haemorrhage. The standard definition for active management combines three procedures: an oxytocic drug administered immediately after birth, early cord clamping and cutting, and controlled cord traction. Several trials in a meta-analysis showed that active management of the third stage of labour is associated with a 60% reduction in the incidence of postpartum haemorrhage compared with expectant management. Given its efficacy, active management of the third stage of labour has been included in international and national guidelines for the prevention of postpartum haemorrhage. An adequate evaluation of the specific efficacy of each of its components, however, has not been done. The independent efficacy of using a preventive oxytocic has been shown with a good level of evidence and is therefore often considered the essential component of active management of the third stage of labour. This is not the case for controlled cord traction. Although most guidelines for the prevention of postpartum haemorrhage include controlled cord traction, actual implementation is highly variable; in Europe ranging from 12% in Hungary to 95% in Ireland. In countries such as France, where controlled cord traction is not recommended, pulling the cord in the absence of any sign of placenta separation is considered poor practice because of the potential risk of uterine inversion.
The variation in use of controlled cord traction may be explained by the paucity of available evidence for assessing the efficacy of controlled cord traction for the prevention of postpartum haemorrhage or its potential risks. Until recently only two trials conducted in the 1960s and with important limitations had assessed the specific effect of controlled cord traction and they had conflicting results. Recently, a large randomised controlled trial conducted in eight low and middle income countries reported that the risk of severe postpartum haemorrhage was not increased by the omission of controlled cord traction as part of the active management of the third stage of labour. The authors concluded that controlled cord traction could be omitted in non-hospital settings. However, the results of this trial may be relevant for low and middle income countries and not applicable to other countries. We therefore assessed the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.
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