There are two approaches to the third stage of labour (the birth of the placenta): the physiological (natural) approach which is basically watchful waiting, and the placenta makes its way out in its own time; the other approach is "active management" where the mother is injected with an oxytocic (medication to cause the uterus to contract) immediately after the birth, the cord is clamped and cut, and the obstetrician or midwife pulls on the cord to deliver the placenta (controlled cord traction). Past research has shunned any "mixing" of these two approaches, suggesting it's all-or-nothing: either do all components of physiological management (no clamping or cutting of the cord, no injection and no pulling the placenta out, baby skin-to-skin with Mum, preferably breastfeeding, and Mum in an upright position); or do all components of active management. Any mixing (eg giving syntocinon but not clamping and cutting the cord) was to be avoided as it would only increase the chance of excessive bleeding.
Now, a very exciting study has demonstrated that controlled cord traction can be omitted from the management of the third stage of labor without a significant increase in the risk of bleeding.
"We draw two inferences from these results: first, controlled cord traction is safe and its use can be continued in settings in which it is routinely practised; and second, the main component of active management is the uterotonic and in settings in which the full package cannot be used safely, focus should be on the uterotonic component,"
(Uterotonic means a medication that is given to make the uterus contract)
Almost a third of pregnancy-related deaths in Africa and Asia are a result of postpartum hemorrhage. The contribution of controlled cord traction on decreasing blood loss has been largely unknown, however, and often requires the presence of trained birth attendants.
Many women would be accepting of an injection to minimise bleeding, but object to having their baby's cord clamped and cut, and their placenta pulled out. This study demonstrates a manner in which the third stage can be assisted to minimise bleeding, while also being acceptable to women. In my practice, most women choose a physiological third stage, without the injection, and most achieve this. On occasion, it's necessary to administer Syntocinon to make the uterus contract and stem the flow of blood, and I have found that this can be done without cutting the cord. If the woman is upright, especially if she sitting on a toilet, the placenta generally comes out very easily and so it is not necessary to use cord traction.
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