Controlled Cord Traction Research Articles

Management of the third stage of labour in women at low risk of postpartum haemorrhage

Objective: To compare active management with physiological management of the third stage of labour in women at low risk of postpartum haemorrhage. Design: Randomised allocation of women in labour at low risk of postpartum haemorrhage to either physiological or active management of the third stage. Setting: Labour ward in a district general hospital. Patients: 193 Women with spontaneous vaginal delivery at term completed the study. Exclusion criteria were induction or augmentation of labour, antepartum or previous postpartum haemorrhage, premature rupture of membranes, previous caesarean section, raised blood pressure, cervical lacerations and third degree tears. Interventions: Active management with syntometrine and controlled cord traction; or physiological management, where the cord was not clamped and the placenta was delivered by maternal effort. Measurements: Blood loss was measured subjectively at delivery and estimated objectively by comparing the haemoglobin in labour with that on the third postpartum day. The duration of the third stage was also measured as was the incidence of retained placenta and blood transfusion. Results: There was no significant difference in the estimated blood loss or haemoglobin drop between the two groups ( P > 0.5). In addition the duration of the third stage was significantly longer in the physiological group ( P < 0.001). Out of 90 women having physiological management, 7 received oxytocics for presumed postpartum haemorrhage. Only one case in the active group required further oxytocics and one other case in this group required a manual removal of placenta. Conclusions: This preliminary study confirms that active management results in a reduction in the length of the third stage of labour. However, it suggests that active management does not reduce blood loss when compared to physiological management in the woman at low risk of postpartum haemorrhage.

Does Cord Drainage of Placental Blood Facilitate Delivery of the Placenta?

A series of 1,908 women delivering vaginally, and actively managed in stage 3 of labour, were randomly assigned to 2 groups to study if cord drainage of placental blood facilitated delivery of the placenta. Prophylactic oxytocics were given with the birth of the anterior shoulder. In both groups, early cord clamping was practised, timing being at the midwives' discretion. In the control group the cord remained clamped; in the drainage group the cord was unclamped and the volume of placental blood measured. Controlled cord traction completed active management at evidence of separation/descent of the placenta. Rates for retained placenta, postpartum haemorrhage and transfusion were similar. It was concluded that when the third stage of labour is actively managed, placental drainage of cord blood confers no extra benefits. Pre- and post-delivery Kleihauer tests were performed on blood from 20 women in each group. All tests were negative. Contrary to previous work, this does not suggest that cord drainage reduces the fetomaternal transfusion rate. The well known association of prolonged duration of stage 3 of labour and the risk of haemorrhage was strongly confirmed.

Plasma oxytocin during third stage of labour: comparison of natural and active management.

The incidences of postpartum haemorrhage and retained placenta have decreased with the use of synthetic oxytocin and controlled cord traction. Whether such treatment is valuable is open to question because of the lack of clinical and physiological studies. The physiological effects of synthetic oxytocin on plasma concentrations of oxytocin and events during delivery were assessed. Plasma oxytocin concentration was determined in serial samples during the late second stage and throughout the third stage of labour in 25 women. Ten women received combined ergotamine and synthetic oxytocin intramuscularly and 15 were not treated. The geometric mean plasma oxytocin concentration significantly increased in the women given oxytocin when measured before and after delivery of the fetal anterior shoulder (3.1 (SD 2.0) pmol/l before and 15.9 (2.7) pmol/l after). Six of the women who did not receive treatment showed a significant increase in geometric mean plasma oxytocin concentration before and after delivery of the fetal shoulder (3.2 (2.0) pmol/l before and 6.4 (2.0) pmol/l after) and nine did not show an increase (geometric mean 2.4 (3.1) pmol/l before and 2.2 (2.2) pmol/l after). Of these nine women, two had an abnormal third stage of delivery; one woman had a postpartum haemorrhage and one required manual removal of the placenta. As it is impossible to predict which women will show a rise in the plasma concentration of endogenous oxytocin, intramuscular oxytocin should be given routinely.

Third Stage Management

The normal physiology of the third stage of labour and the effect of oxytocics at the end of the second stage have been discussed. An assessment of the results of different policies of third stage management has been made, including a comparison of the advantages and disadvantages of the traditional method versus the use of controlled cord traction. It is recommended that ergometrine (0.25 mg) be administered intravenously after delivery of the baby, and the exclusion of a second twin. Once the uterus has contracted the placenta should then be delivered by the technique of controlled cord traction.

Third Stage Management: How Important is it?

The normal physiology of the third stage of labour and the effect of oxytocics at the end of the second stage have been discussed. An assessment of the results of different policies of third stage management has been made, including a comparison of the advantages and disadvantages of the traditional method versus the use of controlled cord traction. It is recommended that ergometrine (0.25 mg) be administered intravenously after delivery of the baby, and the exclusion of a second twin. Once the uterus has contracted the placenta should then be delivered by the technique of controlled cord traction.

Tensile strength of the umbilical cord

The tensile strength of the umbilical cord has been measured, and an attempt was made to relate this to placental or fetal factors. Two hundred cords were examined from term spontaneous vertex deliveries. The average load required to rupture the cords was 12.9 pounds (5.88 Kg.) with a variability between 4 (1.81 Kg.) and 24 pounds (10.89 Kg.). The majority of cords ruptured at their placental insertion. No useful relationship was found between the cord strength and the weight of its placenta or infant, and there was no relationship between the cord length and its tensile strength. If the tension on the cord does not exceed 7 pounds (3.18 Kg.) during controlled cord traction, then the cord will rupture in only 2 per cent of cases.

An inverted uterine fundus carrying placenta: How does this happen or why is it mistaken?

A second gravida with normal antenatal period delivered a baby within an hour of admission and also expelled placenta which appeared at vagina. This placenta was adhererent to the fundus of uterus which was inverted but was persistently pulled out as uterine inversion was unrecognized. This case report will be of help to many of us who may mistake such condition. A habit to palpate the fundus of uterus and make sure it is contracted before controlled cord traction will help making the diagnosis in time. Keywords. Controlled cord traction, fundal attachment of placenta, uterine inversion doi:10.3126/njog.v2i2.1459 N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 69 - 71

Active management of third stage of labor

Objective: Overall objective of the study was to see effects of active management of third stage of labour (AMSTL) with oxytocin. Specific objective of the study was to look for incidence of Post-Partum Haemorrhage (PPH), length of 3rd stage, incidence of retained placenta and average blood loss. Methodology: A hospital based prospective, descriptive, observational study was carried out from 1st July 2005 to 30th June 2006 at department of Obstetrics and Gynaecology, Kathmandu Medical College Teaching Hospital (KMCTH). All patients undergoing vaginal delivery excluding twins, polyhydraminios and instrumental deliveries were included in the study. The active management of 3rd stage included administration of 10 units IU of oxytocin, early cord clamping, controlled cord traction and uterine massage. Blood loss was estimated by visual inspection and measured by jar pressed against perineum. Result: Total number of deliveries during the study period was 530. There were 13 cases of PPH. Incidence of PPH was 2.4%. There were six cases each of uterine atony and genital tract trauma. One case was of retained placenta requiring Manual Removal (MRP). Average third stage duration was less than 5 minutes. Average blood loss was 90 ml. In 2 cases the third stage lasted more than 30 mins. Conclusion: Active management of 3rd stage of labour reduces the incidence of PPH from uterine atony, reduces the duration as well as average blood loss during third stage.condition. Key words: Labor analgesia; epidural, combined spinal epidural; complications, dural puncture, postdural puncture headache (PDPH); prevention. doi:10.3126/njog.v1i2.1490 N. J. Obstet. Gynaecol Vol. 1, No. 2, p. 25 - 27 Nov-Dec 2006

Active management of third stage of labor: Assessment of standard of care in one of the training institute

Objective: To find out the quality of service (standard steps of the procedures) incorporated in the active management of the third stage of labor (AMTSL) in Maternity Hospital, Thapathali, Kathmandu, Nepal. Methods: Prospective (single blind) study, where the (uninformed) service providers had no knowledge that they were being assessed of their performances regarding the proper conduct of the AMTSL, in randomly selected 325 laboring women during all shifts of the day by 4 interns who carefully documented the findings in pre prepared standard 3 month duration reference during in the year 2061/2062 (2004/2005) in Maternity Hospital Thapathali, Kathmandu, Nepal. Results: (Pre) loading of oxytocin was correctly done immediately when the women were seen to bear down at second stage of labor. In 99.5% of cases (irrespective of duty shift). In 5.8 % of cases, the oxytocin doses were different from standard 10 units. The possibility of second twin was not ruled out in 81.9% before the administration of 10 units of IM oxytocin. Moreover, the study that controlled cord traction was revealed or showed applied in 50% of the cases without confirming uterine contraction while counter traction to the uterus was given in most of the cases (98.5%) along with effective examination of the placenta for its completeness in 98.2 % cases. Conclusion: This study shows that improvement in the standard AMTSL practices is still needed in the training providing institution, which demand ensuring the absence of twin tactfully before giving IM oxytocin within 2 minutes invariably after the delivery of the babies and also in giving slight traction on to the umbilical cord gently during uterine contraction along with counter traction to the uterus. Key words: Active management of third stage of labor AMTSL, oxytocin, uterine massage. doi:10.3126/njog.v1i2.2394 N. J. Obstet. Gynaecol Vol. 1, No. 2, p. 28-30 Nov-Dec 2006

Post partum haemorrhage: Prevalence, morbidity and management pattern in Dhulikhel Hospital

Post partum haemorrhage (PPH) is the leading cause of maternal death worldwide. PPH occurs in up to 18% of total births. Among different factors, PPH due to uterine atony is the primary and direct cause of maternal mortality comprising about 90%. The objective of the present study was to assess the prevalence, morbidity and management pattern of PPH in Dhulikhel Hospital. Hospital based retrospective study was carried out at Kathmandu University School of Medical Science, Dhulikhel Hospital from the period of January 2007 till October 2009. The study group included total of 60 patients. All women who had PPH both primary and secondary were studied. Information regarding total number of deliveries obtained from Obstetrics ward. The cases with PPH were identified and detail records were reviewed using standard format. The main outcome measures used for the analysis were amount of blood loss, cause of PPH and treatment methods. In Dhulikhel hospital, from January 2007 till October 2009 a total of 3805 deliveries took place. Out of which 60 women had PPH. The prevalence was 16/1000 deliveries. There are 41 (68.3%) cases of primary PPH and 19 (31.7%) cases of secondary PPH. PPH was found more in home deliveries, unbooked case and in multiparas. The mean blood loss was 1055 ml. As an aetiology, retained placenta and retained placental bits of tissue was found in 37(61.7%) cases, atonic uterus in 10 (16.7%) cases, genital tract trauma in 8(13.3%), sepsis of genital tract in 3(5%), case of ruptured uterus in one case and a case of angle bleeding from previous uterine scar following caesarean section. Among all 15 (25%) cases underwent manual removal of placenta, 5(8.3%) underwent controlled cord traction, 3 (5%) underwent manual removal of placenta followed by check curettage in cases of retained placenta, 16 (26.7%) cases were managed by check curettage for retained bits of placental tissue and membrane. Trauma in genital tract was managed by repair of trauma in 6 (10%) cases. Hysterectomy was required in 3 (5%) cases. Conservative management with uterotonics only required in 12 (20%) cases. Active management of third stage of labour can prevent PPH so delivery by skilled hand in hospital should be promoted. Secondary PPH besides primary can result in significant maternal morbidity. It also deserves similar attention.

Controlled cord traction in the management of the third stage of labour.

Acta Obstetricia et Gynecologica ScandinavicaVolume 46, Issue 3 p. 354-358 Controlled Cord Traction In The Management Of The Third Stage Of Labour Osmo Laitinen, Osmo Laitinen Institute of Midwifery, Helsinki, FinlandSearch for more papers by this authorAlarik Jahkola, Alarik Jahkola Institute of Midwifery, Helsinki, FinlandSearch for more papers by this author Osmo Laitinen, Osmo Laitinen Institute of Midwifery, Helsinki, FinlandSearch for more papers by this authorAlarik Jahkola, Alarik Jahkola Institute of Midwifery, Helsinki, FinlandSearch for more papers by this author First published: January 1967 https://doi.org/10.3109/00016346709158638Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume46, Issue3January 1967Pages 354-358 RelatedInformation

Controlled Cord Traction

Controlled Cord Traction

Controlled cord traction in management of the third stage of labour.

Controlled cord traction in management of the third stage of labour.