Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR)

Abstract

Objective To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.Design Randomised controlled trial. Setting Five university hospital maternity units in France.Participants Women aged 18 or more with a singleton fetus at 35 or more weeks' gestation and planned vaginal delivery.Interventions Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth.Main outcome measure Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag. ResultsThe incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm. ConclusionsIn a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking.Trial registration ClinicalTrials.gov NCT01044082. IntroductionPostpartum haemorrhage remains a major complication of childbirth worldwide.1 Population based studies in high resource countries report a prevalence of severe postpartum haemorrhage of 0.5% to 1% of deliveries, 2-5 making it the main component of severe maternal morbidity. Uterine atony is the leading cause of postpartum haemorrhage, accounting for 60-80% of cases. 6Prevention of atonic postpartum haemorrhage is thus crucial, Active management of the third stage of labour has been proposed for the prevention of postpartum haemorrhage. 7 The standard definition for active management combines three procedures: an oxytocic drug administered immediately after birth, early cord clamping and cutting, and controlled cord traction. Several trials [8][9][10][11] in a meta-analysis 12 showed that active management of the third stage of labour is associated with a 60% reduction in the incidence of postpartum haemorrhage compared with expectant management. Given its efficacy, active management of the t...

Postpartum Hemorrhage; a Major Killer of Woman: Review of Current Scenario

“…(table 1) Furthermore the most recent Cochrane review of active versus expectant management of third stage of labor including seven studies, indicate a significant reduction in risk of PPH with AMTSL [54]. Though controlled cord traction was an initial component of AMTSL, but, three RCTs assessing AMTSL with and without cord traction found no significant difference in the risk of PPH [55][56][57]. Similarly regarding cord clamping, it was initially thought that early cord clamping was better, but latest studies indicate that the timing is not important [49].…”

Protocol for improving nursing performance towards placental examination at labor units

“…The cord is twisted spirally so as to safeguard the vessels and it's about 40 cm to 50 cm in length. [4] Primary placental abnormalities can effect on each fetal and maternal health. Thus, examination of the placenta could yield information on the impact of maternal disorders on the fetus or the reason behind preterm delivery, neurodevelopmental impairment, or fetal growth restriction.…”

“…Benefits of placental examination include clarification of the reason behind several adverse gestation outcomes, ascertainment of newborn risk factors for long-term neurodevelopmental sequelae, and improvement in the risk assessment for future pregnancies. [4] The placental examination is an essential component of the autopsy in cases of fetal or neonatal death. This examination additionally aids in adjudicating a number of difficult situations, such as legal issues regarding the presence of acute versus chronic perinatal stresses and insults, and the timing of these insults.…”

Manual Rotation to Decrease Operative Delivery in Posterior or Transverse Positions

“…19 The TRACOR trial was a multicenter randomized controlled trial with two parallel groups and took place in five French university hospitals between January 1, 2010, and January 31, 2011. The trial was approved by the Paris Ile de France III Committee for the Protection of research Subjects (ethics committee) in September 2009.…”

“…The objective of our study was to compare mode of delivery of women with fetuses in posterior position at full dilatation in two level III university hospitals, one with a policy favoring modifications of maternal position and the other with a policy favoring manual rotation using data from the TRACOR (TRAction of the CORd) prospective multicenter randomized trial. 19 …”