Controlled cord traction for the third stage of labour

• Published in: Cochrane database of systematic reviews 2015-01, Vol.1 (1), p.CD008020-CD008020
• Main Authors: Hofmeyr, G Justus, Mshweshwe, Nolundi T, Gülmezoglu, A Metin
• Format: Article
• Language: English
• Subjects: Care during childbirth; Constriction; Ergonovine - administration & dosage; Extraction, Obstetrical - methods; Female; Humans; Labor Stage, Third; Oxytocics - administration & dosage; Placenta; Postpartum Hemorrhage - prevention & control; Pregnancy; Pregnancy & childbirth; Randomized Controlled Trials as Topic; Umbilical Cord
• ISSN: 1469-493X
• DOI: 10.1002/14651858.CD008020.pub2

Active management of the third stage of labour (AMTSL) consists of a group of interventions, including administration of a prophylactic uterotonic (at at or after delivery of the baby), baby, cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage. Recent recommendations are to delay cord clamping until the caregiver is ready to initiate CCT. The package of AMTSL reduces the risk of postpartum haemorrhage, (PPH), as does one component, routine use of uterotonics. The contribution, if any, of CCT needs to be quantified, as it is uncomfortable, and women may prefer a 'hands-off' approach. In addition its implementation has resource implications in terms of training of healthcare providers. To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 January 2014), PubMed (1966 to 29 January 2014), and reference lists of retrieved studies. Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally. Two authors assessed trial quality and extracted data using a standard data extraction form. We included three methodologically sound trials with data on 199, 4058 and 23,616 women respectively. Blinding was not possible, but bias could be limited by the fact that blood loss was measured objectively.There was no difference in the risk of blood loss ≥ 1000 mL (three trials, 27,454 women; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.77 to 1.08). Manual removal of the placenta was reduced with CCT (two trials, 27,665 women; RR 0.69, 95% CI 0.57 to 0.83). In the World Health Organization (WHO) trial the reduction in manual removal occurred mainly in sites where ergometrine was used routinely in the third stage of labour. The non-prespecified analysis excluding sites routinely using ergometrine for management of the third stage of labour found no difference in the risk of manual removal of the placenta in the WHO trial (one trial, 23,010 women; RR 1.03, 95% CI 0.73 to 1.46). The policy of restricting the third stage of labour to 30 minutes (4057 women; RR 0.69, 95% CI 0.53 to 0.90) may have had an effect in the French study.Among the secondary outcomes, there were reductions in blood loss ≥ 500 mL (three trials, 27,454 women; RR 0.93, 95% CI 0.88 to 0.99), mean blood loss (two trials, 27,255 women; mean difference (