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Original articles

Impact of controlled cord traction in the management of the third stage of labor on postpartum hemorrhage

a randomized controlled trial

Hanafi, Sherif; El-Shehawy, Hazem; Meshmesh, Khairy

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Evidence Based Women's Health Journal: May 2014 - Volume 4 - Issue 2 - p 78-81
doi: 10.1097/01.EBX.0000435383.13740.e8
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Abstract

Introduction

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in developing countries 1. The risk for PPH increases significantly if the third stage of labor is prolonged for more than 30 min 2. Active management of the third stage of labor has been proposed and recommended by the WHO in 2007, as a shorter third stage of labor is associated with a reduced risk for PPH. Active management of the third stage of labor consists of administration of an intramuscular or intravenous uterotonic agent (oxytocin 10 mg), cord clamping no more than 3 min after delivery of the baby, and controlled cord traction (CCT) 3. CCT was introduced by Brandt and Andrew 4 in 1933 and further modified by Spencer in 1962 5 as a suprapubic elevation of the uterine fundus with a steady gentle controlled traction of the umbilical cord 6. A few trials have been published comparing the effect of CCT with or without administration of oxytocic agents following placental delivery, which revealed no significant impact on reducing the risk for PPH 7. The aim of the current study was to evaluate the effect of CCT on the duration of the third stage of labor and on the risk of PPH during the third and fourth stages of labor.

Patients and methods

The current randomized controlled trial was conducted in Ain Shams University Maternity Hospital between March 2010 and December 2010. All included women were parous and pregnant with a singleton term low-risk pregnancy. Women with high-risk pregnancies (e.g. those with severe pre-eclampsia/eclampsia or diabetes mellitus), bleeding diathesis, antepartum hemorrhage or intrauterine fetal demise were not recruited. Eligible women were randomized into two groups. Women allocated to group I (CCT group) received an intramuscular injection of 10 U of oxytocin immediately after delivery of the baby, followed by cord clamping once pulsations ceased (or 3 min after delivery of the fetus) and CCT using the modified Brandt–Andrew maneuver (suprapubic elevation of the uterine fundus along with maintained gentle controlled traction of the umbilical cord). Women allocated to group II (the hands-off group) received an intramuscular injection of 10 U of oxytocin immediately after delivery of the fetus, followed by cord clamping once pulsations ceased (or 3 min after delivery of the fetus), and spontaneous placental delivery was awaited without uterine massage or traction of the umbilical cord. Spontaneous delivery of the placenta in the latter group was facilitated only by maternal expulsive efforts. Eligible women were recruited, randomized, and allocated to their group during the first stage of labor. Women who underwent an emergency cesarean section, who had an episiotomy performed, or who developed birth tract injuries during labor were excluded from the trial. Randomization was performed by an independent statistician using a computer-generated randomization system. The primary outcome was the incidence of PPH. PPH was defined as postpartum blood loss greater than 500 ml or if there was a hemodynamic impact on the delivering woman. Secondary outcomes included the duration of the third stage of labor, need for manual removal of the placenta, and a need for blood transfusion and uterine inversion. Duration of the third stage was calculated using a stop-watch started once the fetus was delivered. Blood lost after delivery of the fetus was collected in a clean metal bowl draining the end of a plastic sheath set beneath the parturient woman. All used packs and gauzes were weighed before and after delivery. The weight difference (in grams) was multiplied by 1.06 (which is the density of blood) to estimate the blood loss in millilitres. The total postpartum blood loss was calculated by adding this estimated blood loss from the used gauzes and packs to the blood collected in the metal bowl.

Sample size calculation

Sample size was calculated using EpiInfo, version 6.0 (USD, Inc., Stone Mountain, Georgia, USA), setting the type-1 error (α) at 0.05 and the power (1−β) at 0.8. Data from a previous study 8 showed that the incidence of PPH was 5.8% in women who underwent CCT and 11% in women who did not [odds ratio 0.5, 95% confidence interval (CI) 0.34–0.63]. Calculation according to these values produced a minimal sample size of 209 women in each group. Assuming an exclusion rate of 10%, the minimal sample size would be 229 in each group. Therefore, a total of 460 women should be recruited into the current trial.

Statistical analysis

Statistical analysis was performed using statistical package for social sciences (SPSS Inc.) for Windows, version 15.0 (MedCalc Software, Mariakerke, Belgium). Difference between two independent groups was estimated using independent Student’s t-test in addition to the mean difference and its 95% CI (for numeric variables) or the χ2-test (for categorical variables). Yates’s continuity correction was applied to the χ2-test when one or more of the expected values were less than 5. Significance level was set at 0.05.

Results

A total of 464 women were recruited; of them 230 were randomized to group I (the CCT group) and 234 were randomized to group II (the hands-off group). Sixty-one women were excluded from the trial. A total of 403 women (201 in group I and 202 in group II) were thus included in the final analysis. Figure 1 shows the allocation and course of the included and excluded women.

F1-4
Figure 1:
Allocation and course of included and excluded women.

The mean age of the included women was 28.27±4.92 years (range: 20–42). The median parity was 2 (range: 1–4). The mean gestational age at delivery was 39.56±1.15 weeks (range: 37–42). There were no significant differences between the women of the two groups with respect to age, parity, and gestational age at delivery. The mean birth weight was 3338±440.54 g (range: 2500–4250) and 3472±365.01 g (range: 2750–415) in groups I and II, respectively. The mean placental weight was 564.67±73.42 g (range: 420–710) and 578.67±60.83 g (range: 460–690) in both groups, respectively. These latter differences were not significant. There were no significant differences between women in the two groups with respect to initial (antepartum) vital signs. The mean duration of the third stage of labor was significantly lower among women in group I when compared with women in group II (mean difference 3.58 min, 95% CI 3.29–3.87, P<0.001) (Table 1). The mean postpartum blood loss in the third stage of labor and the mean total postpartum blood loss were significantly lower in group I (the CCT Group) compared with group II (the hands-off group). The latter two differences, although statistically significant, were clinically insignificant (Table 1). There were no significant differences between women in the two groups with respect to the incidence of PPH greater than 500 ml [2 (1.5%) vs. 3 (1.98%), respectively, P=0.573]. There were no cases of PPH greater than 1000 ml in either group (Table 2). There were no cases of acute uterine inversion, nor cases that needed blood transfusion in either group. Manual removal of a retained placenta was encountered in two (0.99%) cases in group I (the CCT group), in contrast to three (1.5%) cases in group II (the hands-off group); this difference was not significant (Table 2).

T1-4
Table 1:
Difference between the two groups with respect to the duration of the third stage of labor and postpartum blood loss
T2-4
Table 2:
Difference between the two groups with respect to postpartum complications

Discussion

The current trial showed that CCT, as a component of the active management of the third stage of labor, was associated with a significant reduction in the duration of the third stage of labor compared with that of the ‘hands-off’ technique. CCT implies initiating umbilical cord traction after administration of a oxytocic agent and once the uterus contracts without awaiting signs of placental separation 6, an approach that was associated with a statistically and clinically significant reduction in the duration of the third stage of labor. The impact of CCT on reducing the postpartum blood loss, although statistically significant, was clinically marginal. The mean differences in postpartum blood loss in the third stage of labor and total postpartum blood loss were 39 ml (95% CI 34.7–43.3) and 39.82 ml (95% CI 34.6–45.1), respectively. This was further confirmed by the insignificant difference between women in the two groups with respect to the incidence of PPH greater than 500 ml and the nullity of cases with PPH greater than 1000 ml in both groups. Similar findings were previously shown in a study conducted by Kashanian et al.9, who found a nonsignificant difference between women who underwent CCT and women who had spontaneous placental expulsion with respect to blood loss in the third stage of labor (mean difference 15.07 ml, 95% CI −33.12 to 54.88, P=0.723). Kashanian et al.9 also found a significantly shorter duration of the third stage of labor among women in the CCT group (4.69±5.51 vs. 6.34±5.03 min, P=0.028). In a systematic review of 204 parturient women randomized into two groups similar to those in the current trial, Althabe et al.10 showed that there were no significant differences between women in the two groups with respect to postpartum blood loss or the incidence of PPH (mean difference 28.2 ml, 95% CI −35.9 to 92.3, P=0.126). Several points of strength were present in the current trial. Eligible women were randomly allocated to one of the two groups in the first stage of labor. Women who had any source of blood loss other than placental site bleeding were excluded. Blood loss was measured in a standardized manner. Hemoglobin or hematocrit difference is one of the most important markers of peripartum blood loss. The postpartum hemoglobin and hematocrit should be checked 48 h postpartum, which was not feasible in women who delivered vaginally, as the standard practice of our institute is to discharge low-risk women 6 h postpartum.

Conclusion

CCT was associated with a significant reduction in the duration of the third stage of labor but with a marginal insignificant reduction in the postpartum blood loss and incidence of PPH in parous low-risk women.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

References

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Keywords:

active management of the third stage of labor; controlled cord traction; postpartum hemorrhage; third stage of labor

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