WHO recommendation on controlled cord traction after vaginal birth for the prevention of postpartum haemorrhage in settings where skilled birth attendants are available

WHO recommendation on controlled cord traction after vaginal birth for the prevention of postpartum haemorrhage in settings where skilled birth attendants are available

 

Recommendation

In settings where skilled birth attendants are available, controlled cord traction is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important.

 (Weak recommendation, high-quality evidence)

 

Publication history

First published: September 2012

Updated: no update planned 

Assessed as up-to-date:  September 2012

 

Remarks

  • This recommendation is based on a large RCT in which oxytocin 10 IU was used for the prevention of postpartum haemorrhage (PPH) in all participants. Based on this evidence, controlled cord traction (CCT) was regarded as safe when applied by skilled birth attendants as it provides small beneficial effects on blood loss (average reduction of 11 ml on blood loss) and on the duration of the third stage of labour (average reduction of 6 minutes).
  • The decision to implement CCT in the context of a prophylactic uterotonic drug should be discussed by the care provider and the woman herself.
  • If ergot alkaloids are used for the prevention of PPH, then CCT to minimize placenta retention is regarded as essential.
  • There is insufficient evidence to determine the benefit or risk of CCT when used in conjunction with misoprostol.
  • Based on the most recent evidence, understanding of the contribution of each component of the active management of the third stage of labour package has evolved. The GDG considered that this package has a primary intervention: the use of an uterotonic. In the context of oxytocin use, CCT may add a small benefit, while uterine massage may add no benefit for the prevention of PPH. Early cord clamping is generally contraindicated.

 

Background

Postpartum haemorrhage is defined as blood loss of 500ml or more within 24 hours after birth. PPH is the primary cause of nearly one-fifth of all maternal deaths globally. Most of these deaths occur during the first 24 hours after birth. The majority could be prevented through the use of prophylactic uterotonics during the third stage of labour, and by timely and appropriate management.

Cord traction may hasten the process of separation and delivery of the placenta, thus reducing blood loss and the incidence of retained placenta. It is thought that administration of a uterotonic drug may cause uterine contraction and retention of the placenta if not combined with controlled cord traction. Controlled cord traction is one of the components of active management of the third stage of labour that requires training in manual skill for it to be performed appropriately. (1)

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, based on the GRADE approach. (2,3) Outcomes used for this recommendation were the prioritized outcomes from the WHO recommendations on prevention and treatment of postpartum haemorrhage (2012).(4)

One systematic review provided evidence for this recommendation. (1) Data on relevant outcomes and comparisons were extracted.

WHO convened a Guideline Development Group (GDG) meeting in March 2012. This group of independent experts used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences, magnitude of effect, balance of benefits versus disadvantages, resource usage, and feasibility, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For all women giving birth (P), does controlled cord traction during the third stage of labour (I) compared to standard care (C) improve outcomes (O)?

 

Evidence Summary

Evidence supporting this recommendation was extracted from two randomized trials (>24 000 women). The trials compared CCT in the third stage of labour with a ‘hands-off’ (i.e. no CCT) approach to the third stage of labour. (1)

No difference was observed between the groups in terms of severe PPH. No differences were reported for other critical outcomes. CCT was associated with a reduced risk of mild PPH, the overall amount of blood loss, and the duration of the third stage of labour. (High-quality evidence)

The trial interventions (the active management of the third stage of labour with and without cord traction) were delivered by skilled birth attendants. The quality rating of the evidence was therefore downgraded for indirectness when applied to births not assisted by skilled attendants. (Moderate-quality evidence).

There is some uncertainty regarding how frequently retained placenta occurs. It is hypothesized that there is an increased risk of retained placenta when CCT is omitted in association with the use of prophylactic ergometrine. As the trials primarily used oxytocin as the prophylactic uterotonic, the quality rating of the evidence was downgraded for indirectness when applied in the context of ergometrine. In the WHO trial, hospitals in Philippines were found to commonly use ergometrine in addition to oxytocin and, in these settings, an increased risk of retained placenta was observed. (Moderate-quality evidence)

Further information on evidence supporting this recommendation are available here.

 

 

Implementation considerations

 

  • The successful introduction of evidence-based policies related to the prevention and management of PPH into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

 

Research implications

The GDG did not identify any research priorities related to this recommendation.

Related Links

WHO recommendations on prevention and treatment of postpartum haemorrhage (2012) - full documentand evidence tables

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2nd ed)

VIDEO: Active management of third stage of labour

Education material for teachers of midwifery. Managing postpartum haemorrhage.

 

Links to supporting evidence:

 

Mshweshwe NT, Hofmeyr GJ, Gülmezoglu AM. Controlled cord traction for the third stage of labour. Cochrane Database of Systematic Reviews. 2012(Issue 3.1. Art. No.: CD008020).

 

References

  1. Mshweshwe NT, Hofmeyr GJ, Gülmezoglu AM. Controlled cord traction for the third stage of labour. Cochrane Database of Systematic Reviews. 2012(Issue 3.1. Art. No.: CD008020).
  2. WHO. WHO Handbook for Guideline Development (second edition). Geneva: World Health Organization; 2014.
  3. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-6. Epub 2011/01/05. doi: 10.1016/j.jclinepi.2010.07.015. PubMed PMID: 21208779.
  4.  WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization, 2012.

 

Citation: WHO Reproductive Health Library. WHO recommendation on the use of controlled cord traction after vaginal birth for the prevention of postpartum haemorrhage (September 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.