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Meta-Analysis
. 2015 Jan 29;1(1):CD008020.
doi: 10.1002/14651858.CD008020.pub2.

Controlled cord traction for the third stage of labour

G Justus Hofmeyr  1 , Nolundi T Mshweshwe, A Metin Gülmezoglu
Affiliations
Meta-Analysis

Controlled cord traction for the third stage of labour

G Justus Hofmeyr et al. Cochrane Database Syst Rev. .

Abstract

Background: 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.

Objectives: To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management.

Search methods: 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.

Selection criteria: Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally.

Data collection and analysis: Two authors assessed trial quality and extracted data using a standard data extraction form.

Main results: 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 (MD) -10.85 mL, 95% CI -16.73 to -4.98), and duration of the third stage of labour (two trials, 27,360 women; standardised MD -0.57, -0.59 to -0.54). There were no clear differences in use of additional uterotonics (three trials, 27,829 women; average RR 0.95, 95% CI 0.88 to 1.02), blood transfusion, maternal death/severe morbidity, operative procedures nor maternal satisfaction. Maternal pain (non-prespecified) was reduced in one trial (3760 women; RR 0.78, 95% CI 0.61 to 0.99).The following secondary outcomes were not reported upon in any of the trials: retained placenta for more than 60 minutes or as defined by trial author; maternal haemoglobin less than 9 g/dL at 24 to 48 hours post-delivery or blood transfusion; organ failure; intensive care unit admission; caregiver satisfaction; cost-effectiveness; evacuation of retained products; or infection.

Authors' conclusions: CCT has the advantage of reducing the risk of manual removal of the placenta in some circumstances, and evidence suggests that CCT can be routinely offered during the third stage of labour, provided the birth attendant has the necessary skills. CCT should remain a core competence of skilled birth attendants. However, the limited benefits of CCT in terms of severe PPH would not justify the major investment which would be needed to provide training in CCT skills for birth attendants who do not have formal training. Women who prefer a less interventional approach to management of the third stage of labour can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without increased risk of severe PPH, but that the risk of manual removal of the placenta may be increased.Research gaps include the use of CCT in the absence of a uterotonic, and the place of uterine massage in the management of the third stage of labour.

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Conflict of interest statement

GJH, AMG and NM participated in a multicentre clinical trial of controlled cord traction (Gülmezoglu 2012). Decisions regarding the inclusion and interpretation of this trial were checked independently by a Research Associate working for the Cochrane Pregnancy and Childbirth Group.

GJH receives royalties from UpToDate for chapters related to breech pregnancy, delivery of a baby in breech presentation and external cephalic version. UpToDate is an electronic publication by Wolters Kluwer to disseminate evidence‐based medicine (such as Cochrane reviews).

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 1 Blood loss ≥ 1000 mL.
1.2
1.2. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 2 Manual removal of the placenta.
1.3
1.3. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 3 Blood loss ≥ 500 mL.
1.4
1.4. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 4 Blood loss.
1.5
1.5. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 5 Duration of 3rd stage of labour (minutes).
1.6
1.6. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 6 Blood transfusion.
1.7
1.7. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 7 Additional uterotonics used.
1.8
1.8. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 8 Maternal death or severe morbidity.
1.9
1.9. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 9 Operative procedures.
1.10
1.10. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 10 Maternal death.
1.11
1.11. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 11 Maternal satisfaction.
1.12
1.12. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 12 Pain (not prespecified).
1.13
1.13. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 13 Cord rupture (not prespecified).
1.14
1.14. Analysis
Comparison 1 Controlled cord traction versus no controlled cord traction, Outcome 14 Uterine inversion (not prespecified).
2.1
2.1. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 1 Blood loss ≥ 1000 mL.
2.2
2.2. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 2 Manual removal of the placenta.
2.3
2.3. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 3 Blood loss ≥ 500 mL.
2.4
2.4. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 4 Blood loss.
2.5
2.5. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 5 Duration of 3rd stage of labour (minutes).
2.6
2.6. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 6 Blood transfusion.
2.7
2.7. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 7 Additional uterotonics used.
2.8
2.8. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 8 Maternal death or severe morbidity.
2.9
2.9. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 9 Operative procedures.
2.10
2.10. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 10 Maternal death.
2.11
2.11. Analysis
Comparison 2 Controlled cord traction versus no controlled cord traction (excluding sites using ergometrine ‐ not prespecified), Outcome 11 Uterine inversion (not prespecified).
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Update of

References

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