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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).

Catherine Deneux-Tharaux, senior researcher, Loic Sentilhes, professor of obstetrics and gynaecology, Françoise Maillard, medical statistician, Emmanuel Closset, hospital practitioner in obstetrics and gynaecology, Delphine Vardon

BMJ, Volume 28, Issue 346, Mar 2013
 

Editor’s comment: Prof. Jim Thornton: Controlled cord traction does not reduce post-partum haemorrhage
Controlled cord traction (CCT) is a time honoured component of the active management of the third stage of labour. But this large trial from France shows that, although the placenta gets delivered more quickly, CCT does not reduce blood loss or the rate of post-partum haemorrhage (the primary trial outcome). No uterine inversions occurred in either arm. The authors conclude that although CCT is safe, there is no evidence to recommend it in high resource settings.

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.

Results The 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.

Conclusions In 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.

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Commentaries by Editor Prof. Jim Thornton