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No difference in PP hemorrhage with or without cord traction in 3rd stage of labor

Clinical Question:
Is management of the third stage of labor with controlled cord traction more beneficial than watchful waiting?

Bottom Line:
There is no difference in the risk of postpartum hemorrhage between controlled cord traction during the third stage of labor and watchful waiting for up to 30 minutes. The third stage of labor is shortened by approximately 3 minutes with controlled cord traction, and women are less likely to report pain. (LOE = 1b)

Reference:
Deneux-Tharaux C, Sentilhes L, Maillard F, et al. Effect of routine cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomized controlled trial (TRACOR). BMJ 2013;346:f1541-51.  [PMID:23538918]

Study Design:
Randomized controlled trial (nonblinded)

Funding:
Government

Allocation:
Concealed

Setting:
Inpatient (ward only)

Synopsis:
Many studies show a reduction of postpartum hemorrhage with active management of the third stage of labor. This involves oxytocin administration, early cord clamping and cutting, and controlled cord traction. However, controlled cord traction alone has not been adequately evaluated. Controlled cord traction has been studied in low-resource settings and found to be unnecessary. This multicenter randomized controlled trial (N = 4058), with a primary purpose of assessing whether cord traction reduces blood loss or postpartum hemorrhage, was conducted in France at 5 university hospitals. Women were eligible for inclusion if they had a vaginal delivery of a singleton fetus with a gestational age of at least 35 weeks. Women were excluded for severe hemostasis disease, placenta previa, in utero fetal death, multiple gestation, and if they did not understand French. In both arms of the study 5 IU oxytocin was administrated intravenously and the cord was clamped within 2 minutes of birth. The intervention of controlled cord traction was performed with uterine contractions and after thorough training of the clinicians involved. Standard practice (control intervention) was to wait for signs of spontaneous placental separation and descent into the lower uterine segment and facilitation of expulsion with maternal effort and/or soft tension on the cord if needed. Blood loss was measured with a collector bag which was left in place for at least 15 minutes or until the attending clinician judged that bleeding had stopped. Masking of women and clinicians was not feasible.There were no differences in incidence of postpartum hemorrhage (blood loss of at least 500 mL), severe hemorrhage (blood loss at least 1000 mL), blood loss at 15 minutes, or drop in maternal hemoglobin at day 2 postpartum. There were no uterine inversions. The mean duration of the third stage of labor was shorter in the controlled traction arm (5.5 minutes vs 8.7 minutes; 95% CI, -3.6 to -2.9) and fewer manual removals were performed (odds ratio [OR] = 0.69; 0.53-0.90). Women in the controlled traction arm less frequently reported pain during the third stage of labor (5.8% vs 7.4%; OR = 0.78; 0.61-0.99).

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