Post-partum haemorrhage (PPH; excessive bleeding) immediately after giving birth is a major killer of women in developing countries, responsible for a third of maternal deaths in Africa and Asia. Results of an international trial published Online First in The Lancet are the first to show that omitting controlled cord traction has little effect on the risk of severe bleeding, indicating that effective prevention of PPH could be accomplished with just a uterotonic agent (e.g. oxytocin).
"Our findings have important implications for expanding access to effective care and could have a substantial impact on maternal survival in places where skilled medical staff are in short supply and physical barriers to access remain. Health workers with less training than skilled birth attendants (but with sufficient skills to administer an oxytocin injection) are far more numerous and will be able to deliver this life-saving treatment to more women", explains Metin Gϋlmezoglu from WHO, Geneva, Switzerland, lead author of the study.
Until now, WHO has recommended active management of the third stage of labourgiving women oxytocin immediately after delivery of the baby, controlled cord traction, and delayed clamping and cutting of the cord. The WHO Recommendations for Prevention and Management of Postpartum Haemorrhage guidelines are due to be revised next week in light of these findings.
In this study, women about to give birth vaginally in hospitals and health-care centres from eight countries were randomly assigned to placental delivery with the aid of gravity and mother pushing (simplified package) or controlled cord traction immediately after uetrine contraction and cord clamping (full package). In both groups oxytocin was given immediately after birth.
Findings showed that 239 (2.1%) of 11621 women in the simplified group had blood loss of 1000 ml or more compared with 219 (1.9%) of 11621 women in the full package group. As such, for every 581 women managed with the simplified approach, only one additional woman would experience severe blood loss (≥ 1000 ml). The average blood loss was about 11 ml greater and third-stage labour about 7 min longer with the simplified package.
The authors say: "Controlled cord traction adds only marginally to the beneficial effect of the full package. Because the main component of the management package is oxytocin, in settings in which no skilled birth attendants are present to give the full package, efforts should focus on the uterotonic (primarily oxytocin) to reduce PPH."
They conclude: "Our findings strengthen the need to focus on strategies to scale up the use of oxytocin in peripheral health-care settings as the primary component of active management of the third stage of labour."
In an accompanying Comment, Yap-Seng Chong from Yong Loo Lin School of Medicine, National University of Singapore and Sabaratnam Arulkumaran from St George's Medical School, London, UK, say: "If Millennium Development Goal 5 is to be achieved eventually, care of women in pregnancy and childbirth must be borne partly by community midlevel providers because of the chronic shortage of qualified medical staff in rural areas. The findings of this study can be applied across most settings by equipping community birth attendants with a prophylactic uterotonic agent given at delivery
The administration of these agents should not need a high level of training or manual dexterity, but will have a profound impact on maternal survival."