see ****
The objective of this retrospective cohort study was to compare the
efficacy of Judy’s 3,4,5 minute third stage algorithm to variations of
active and expectant third stage management among similar homebirth
populations during the same time period.
• Methods
Two populations with identical participant selection criteria, similar
labor management, and different third stage management were compared.
Both groups consist of women planning attended homebirths in countries
with free, socialized medicine, with midwives who are similarly
trained to limit medical interventions in labor. PPH was defined as
blood loss over 1000 cc in the first 2 hours after birth in both groups.
In the study group, estimated blood loss was documented to the nearest 5
cc for all births.
The study group was all births attended from Jan. 1, 2000- Dec. 31, 2020
by the All The Way Home Birth Service serving the Jewish population in
Israel, a population of approximately 5 million. All midwives working
for All The Way Home Birth Service are formally trained and licensed.
All The Way Home birth practice provides free homebirth to any qualified
woman who cannot afford the generally affordable fee. Each birth
outcome was recorded in a patient record and an Excel spreadsheet
immediately following the birth. The criteria for inclusion as a patient
in both homebirth practices were: Singleton fetus; cephalic
presentation; gestational age greater than 36 and less than 41 completed
weeks of pregnancy; spontaneous onset of labor; history of up to one
previous cesarean; absence of significant pre-existing disease including
heart disease, hypertensive chronic renal disease or type 1 diabetes;
absence of significant disease arising during pregnancy
including hypertension disorders during pregnancy with proteinuria
(> 0.3 g/L by urine dipstick), antepartum hemorrhage after
20 weeks’ gestation, gestational diabetes requiring insulin, active
genital herpes, placenta previa or placental abruption. All
participants gave written informed consent to deliver the placenta using
Judy’s 3,4,5 minute algorithm and to have their outcomes anonymously
published. The study group’s third stage was managed by cutting the
cord exactly 3 minutes after the birth if the woman consents to it,
pushing out the placenta in squatting at 3 minutes; getting into bed by
4 minutes and checking the abdomen to make sure the uterus is contracted
at 5 minutes and to massage it to contract if it is not. A prophylactic
0.125 mg pill of Methergine was given orally at 10 minutes postpartum to
women who had lost 250 cc by 10 minutes postpartum.
The first 500 births were delivered on plastic sheets without absorbent
pads, measuring blood loss with a measuring cup. Clots of blood were
collected, formed into a ball and blood loss calculated according to the
diameter of the ball: 3 cm diameter round clot = 15 cc blood loss, 4 cm
= 33 cc; 5 cm = 65 cc blood loss; 6 cm = 113 cc, 7 cm = 180cc; 8 cm
diameter ball = 270 cc blood loss; 9 cm= 380 cc; 10 cm = 523 cc; 12 cm
= 900 cc blood loss. Both PPH over 500 cc and over 1000cc were
documented.
Janssen et. al. 2009 was selected as the control group because it
reports the lowest PPH rate among the high-quality homebirth studies.
[17,18] Janssen et.al. 2009 most closely matches the study group in
time-period, Jan. 1, 2000, to Dec. 31, 2004, population, and birth
management and most importantly, had identical inclusion criteria to the
study group. British Columbia, a province of Canada, had a population
of 4.4 million at the time of the study. Like Israel, midwifery care is
accessible to all women in the province who meet the standards for low
obstetric risk. The midwives in British Columbia use variations and
combinations of active and expectant management. [19] Their database
defines PPH as ≥1000 mL blood loss. [20]
The primary outcome measure was the rate of postpartum hemorrhage over
1000 cc. Secondary outcome measure was manual removal of
placenta. Formal ethical approval of this research was received from
the Hadassah Medical Organization Helsinki Committee Institutional
Review Board on April 14, 2014.
• Results
During the study period, 2,899 women attended by a registered midwife
began labour with the intention of giving birth at home in British
Columbia and 2,691 did so, using currently accepted third stage
management; 1,098 women attended by a registered midwife began labor
with the intention of giving birth at home in Israel of which 1,093
births did so using the 3,4,5 third stage protocol. Patient
demographics- see Table 1.
Variations of active and expectant third stage protocols resulted in 4%
(110/2899) PPH over 1000 cc in the first two hours. The 345 protocol
resulted in zero PPH > 1000 cc in the first two hours, i.e.
active/expectant involves a 20 times higher risk of PPH compared to
expedient squatting.
The 3,4,5 minute third stage protocol resulted in blood losses of an
average of 100 cc in the first hour; one PPH = 800 cc in the first hour
of a grandmultiparous woman with no anemia or history of hemorrhages,
but whose birth followed shortly after the violent murder of her
brother. After the birth of the placenta, she screamed uncontrollably
and continuously for 20 minutes that she wished she was dead. This made
it appear that PPH was psychological in origin. The other PPH was 500
cc, a late PPH starting 5 hours after birth in a 26 year old, P3, 41+1,
after a 16 hour labor, 3600 gm baby, with hemoglobin level of 8.0 g/L at
the start of labor. She received one unit of blood. No negative side
effects of third stage squatting protocol were observed among 1,093
vaginal births.
Discussion
Main findings:
In the study population, Judy’s 3,4,5 third stage protocol decreased
average postpartum bleeding in the first hour from 500 cc to 100 cc;
decreased PPH over 1000 cc from 4% to 0%; and did so without negative
side effects or financial expense. The 345 is logical, has been
tried on a large sample, and has been proven to reduce PPH as well as
average blood loss. The habit of laying supine to deliver the placenta
results in at least 4% PPH of over a liter of blood. No mother objected
to not holding her baby for the one minute that it takes to deliver the
placenta in squatting. Several fathers were raving after the birth
about how special it was for them to hold a baby so soon after birth. As
practitioners garnered more experience with expedient squatting, less
oral methergine was administered.
No other protocol has reported an average blood loss of less than 500
cc in the first hour and 0% postpartum hemorrhage over 1000 cc.
[21] Without exception, all other low risk populations report
higher PPH rates: 4.4% PPH over 1000 cc. [19] 4.6% PPH over 1000
cc. [22] 9.3% over 500 cc. [23] and 11.7% PPH over 500 cc.
[24] The two largest high quality homebirth studies: Birthplace
and DeJonge et.al. did not document PPH rates at all.
[25,26] Large hospital studies looking at multiple sites and
reporting on tens of thousands of vaginal births, continue to report 5%
PPH at vaginal birth. [4]
Strengths and limitations:
In the study group, 20% of labors were augmented with bilateral
nipple massage which results in oxytocin receptor stimulation, the goal
of IV Pitocin. The lack of use of IV Pitocin in the study group to
augment labor is unlikely to explain a 0% PPH because prior to
the synthesis and use of Pitocin starting in 1953, the PPH rate was also
5% [2] and PPH rates in the absence of Pitocin augmentation in
hospital are currently 4%. [4] Theories extrapolated from in vitro
studies suggest that Pitocin augmentation in labor causes PPH because it
attenuates oxytocin-induced contractility of human myometrium.
[27-29] A theory for how Pitocin continuously augments uterine
contractions in labor, yet immediately after birth the receptors that
were sensitive to Pitocin become insensitive to Pitocin, is lacking. The
association of Pitocin augmentation with PPH might be due to an
increased delay in delivery of the placenta at births augmented with
Pitocin, perhaps due to a feeling that the freely flowing IV Pitocin
will protect the woman from PPH.
The published association between longer duration of the second stage as
causing increased PPH also lacks a logical theory because indeed, during
long second stages, the uterus continues effectively contracting until
the fetus emerges and no reason has been provided for why it should not
contract afterwards. [30] Long second stages are usually a result
of a large fetus or an anesthetized or unmotivated woman. Where women
push for 15, 17 and even 22 hours, no increase in PPH was observed as
long as the placenta is delivered within 5 minutes of the birth.
[31]
A critique of squatting protocol, by practitioners who have never tried
the 345, is that the study group midwives are underreporting excess
postpartum bleeding and PPH. Underreporting of PPH is suspected even in
the highest quality studies. [1] The best definition of PPH is a
larger than 20 g/L drop in Hgb level compared to the level before the
birth but this requires documentation of routine and reliable blood
testing before and after the birth. Erickson et.al. rightfully suggests
the term PPH applies to both PPH over 500 cc and those over 1000 cc
because it is challenging or impossible to distinguish between them
[page 610] since both 600 cc and 1050 cc of blood cover an entire
60X90 pad. However, a 100 cc blood loss does not cover any entire pad.
It is therefore impossible to confuse 100 cc blood loss with blood loss
of 500 cc at birth. Blood loss of 100 cc in the first hour typically
means one tablespoon attached to the placenta, another 35 cc on the
60x90 pad she gives birth on, and 4 tablespoons or 50 cc seen one hour
after birth on the pad used starting from 5 minutes after birth when she
got into bed. The knee jerk excuse to discard an overlooked protocol
cannot be applied to this protocol.
The study group had fewer nulliparas: 26% vs. 44%. Nulliparity is
associated with higher rates of PPH. [4] The difference
in nulliparity rates could account for a slightly lower PPH rate in the
study group but not the dramatic reduction found. On the other hand,
although the control group did not report grandmultiparity, it is likely
the study group had a higher rate of grandmultiparity, as the fertility
rate in Israel is higher than in British Columbia. Grandmultiparity is
associated with higher rates of PPH. [4] No increase in PPH was
found among grandmultiparas when Judy’s 3,4,5 was used. The findings
suggest the associations with PPH pinned
on nulliparity or grandmultiparity are due to other qualities of
nulliparous and grandmultiparous births since they disappear when the
placenta is delivered at 3 minutes.
Interpretation
Except for exceptional cases, women appear not to experience
PPH>500 cc where the placenta is delivered in squatting
expediently.
Conclusion:
Evidence supports less postpartum bleeding and postpartum hemorrhage
when women deliver the placenta in squatting 3 minutes after birth. The
risks are minimal and the data suggests the likelihood of a very
positive outcome, making it recommended for practitioners in all
settings to try it.
Acknowledgements:
Ethics approval and consent to participate- Formal ethical approval of
this research was received from the Hadassah Medical Organization
Helsinki Committee Institutional Review Board on April 14, 2014. All
methods were performed in accordance with guidelines and regulations
provided in the ethics approval. All participants gave written consent
to participate and have their outcomes published anonymously. Consent
for publication- all participants gave written consent for their
outcomes to be published anonymously.
Availability of data and materials- The datasets used and analyzed
during the current study available from the corresponding author on
reasonable request. Competing interests- all authors declare no
competing interests.
Funding- all expenses out of pocket, No funding was provided by anyone
else.
Authors’ contributions- JSC wrote most of the paper. REB did analysis
and proofing the paper.
Acknowledgments- thanks to all participants, authors, peer reviewers and
editor.
References
1. Begley CM, Gyte GML, Devane D et.al. Active versus expectant
management for women in the third stage of labour. Cochrane Database of
Systematic Reviews 2019,Issue 2. Art. No.: CD007412
2. Melody GF. Primary postpartum hemorrhage. Calif Med.
1951;75(6):425-429.
3. Magann EF, Evans S,Chauhan SP et.al.The length of the third stage of
labor and the risk of postpartum hemorrhage.Obstet Gynecol.
2005;105(2):290-3.
4. Erickson EN, Lee CS, Carlson NS. Predicting Postpartum
Hemorrhage After Vaginal Birth by Labor Phenotype. J
Midwifery Womens Health. 2020;65(5):609-620.
5. Carter AM, Pijnenborg R. Evolution of invasive placentation with
special reference to non-human primates.
Best Pract Res Clin Obstet Gynaecol. 2011;25(3):249-57.
6. Abrams ET, Rutherford JN. Framing postpartum hemorrhage as a
consequence of human placental biology: an evolutionary and comparative
perspective. Am Anthropol. 2011. 113, 3, 417-30.
7. Chamberlain G. British maternal mortality in the 19th and early 20th
centuries. J R Soc Med. 2006;99(11):559-563.
8. Abrams ET, Rutherford JN. Framing postpartum hemorrhage as a
consequence of human placental biology: an evolutionary and comparative
perspective. Am Anthropol. 2011. 113, 3, 417-30.
9. https://medicalxpress.com/news/2020-10-genetic-postpartum-hemorrhage.html Last
accessed Feb 4,2021.
10. Anderson JM, Etches D. Prevention and management of postpartum
hemorrhage. Am Fam Physician. 2007;75(6):875-82.
11. Neiman E, Austin E, Tan A et.al. Outcomes of Waterbirth in a US
Hospital-Based Midwifery Practice: A Retrospective Cohort Study of Water
Immersion During Labor and Birth. J Midwifery Womens Health.
2020;65(2):216-223.
12. Williams JW, Pritchard JA, MacDonald PC (1980). Williams Obstetrics.
16th ed. New York:Appleton-Century-Crofts.
13. Cohain JS. A Proposed Protocol for Third Stage Management-Judy’s
3,4,5,10 minute method. Birth 2010; 37(1)84-5.
14. Cohain JS. Back to Basics to Eliminate Postpartum Hemorrhage at
Vaginal Birth. Birth 2016; 43(1)93.
15. Cohain JS. Minimizing bleeding and tearing at vaginal births. Women
and Birth 2018;31(2):e144.
16. Cohain JS. Expedient squatting third-stage technique to prevent
excessive bleeding at birth. MIDIRS Midwifery Digest. 2020;30(4):495-6
17. Cohain JS. Instead of attacking homebirth, hospital practitioners
should be trying to understand why their outcomes compare unfavorably to
homebirth outcomes. BJOG. 2016;123(7):1231.
18. Janssen PA, Saxell L, Page LA et.al. Outcomes of planned home birth
with registered midwife versus planned hospital birth with midwife or
physician. CMAJ 2009;181(6-7):377–383.
19. Tan WM, Klein MC, Saxell L, Shirkoohy SE, Asrat G. How do physicians
and midwives manage the third stage of labor? Birth. 2008;35(3):220-9.
20. Janssen PA, Lee SK, Ryan EM et.al. Outcomes of planned home births
versus planned hospital births after regulation of midwifery in British
Columbia. CMAJ. 2002;166(3):315-323.
21. Fahy KM. Third stage of labour care for women at low risk of
postpartum haemorrhage. J Midwifery Womens Health 2009;54(5): 380–386.
22. Bolten N, de Jonge A, Zwagerman E et.al. Effect of planned place of
birth on obstetric interventions and maternal outcomes among low-risk
women: a cohort study in the Netherlands. BMC Pregnancy Childbirth.
2016;16(1):329.
23. Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned
home and planned hospital births in low-risk women attended by midwives
in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth.
2009;36(3):180-189.
24. Campiotti M, Campi R, Zanetti M et.al. Low-Risk Planned
Out-of-Hospital Births: Characteristics and Perinatal Outcomes in
Different Italian Birth Settings. Int J Environ Res Public Health.
2020;17(8):2718.
25. Birthplace in England Collaborative Group, Brocklehurst P, Hardy P
et.al. Perinatal and maternal outcomes by planned place of birth for
healthy women with low risk pregnancies: the Birthplace in England
national prospective cohort study. BMJ. 2011;343:d7400.
26. de Jonge A, Peters L, Geerts CC et.al. Mode of birth and medical
interventions among women at low risk of complications: A cross-national
comparison of birth settings in England and the Netherlands. PLoS One.
2017;12(7):e0180846.
27. Balki M, Ramachandran N, Lee S, Talati C. The recovery time
of myometrial responsiveness after oxytocin-induced desensitization in
human myometrium in vitro. Anesth Analg. 2016;122(5):1508–1515.
28. Balki M, Erik-Soussi M, Kingdom J, Carvalho J. Oxytocin pretreatment
attenuates oxytocin-induced contractions in human myometrium.
Anesthesiology. 2013;119(3):552–561.
29. Talati C, Carvalho JCA, Luca A, Balki M. The effect of intermittent
oxytocin pretreatment on oxytocin-induced contractility of human
myometrium in vitro. Anesth Analg. 2019;128(4):671–678.
30. Dionne MD, Deneux-Tharaux C, Dupont C, Duration of expulsive efforts
and risk of postpartum hemorrhage in nulliparous women: a
population-based study. PLoS One. 2015;10(11):e0142171.
31. Cohain JS. Three cases of Prolonged Second Stage of Labor 14, 17 and
24 hours. Midwifery Today.
2017:122:18-20.
****Additionals to background:
The following further additional comments in background are only to
answer the inquiries of previous peer review:
The protocol to prevent all PPH over 1000 cc at vaginal birth has been
in the medical literature since 2010. The most common objection to the
theory that all PPH is preventable is the misconception that in previous
centuries women died at birth in droves from PPH, not infection. The
evidence shows that infection caused the deaths of 1.5% of mothers
1911-1935 in the United Kingdom (UK). Maternal death from PPH in the UK
in that period was the very rare result of malpractice such as a poorly
managed low lying placenta or trauma to the cervix or uterus at
delivery. [7] Only in the past few decades is postpartum hemorrhage
the reason for the majority of maternal deaths, with rates of PPH
increasing year by year in the past decade, mostly from the overuse of
cesarean surgery. There continues to be a desire to find a genetic basis
of PPH. [8,9] It would be more reasonable to assume that any genes
involved in primate PPH were eliminated by natural selection millions of
years ago since PPH is a deadly trait.
Birth is the only circumstance for which losing 500 cc of blood is
considered acceptable. The Cochrane review explains that the current
average blood loss of 500 cc at vaginal birth is acceptable since people
who donate blood also lose 500 cc without deleterious
effects. [1] This is a strange justification in light of the facts
that blood donation is not done to improve health but rather a
compromise of one person’s well-being to improve anothers; pregnant
women are ineligible to donate blood; postpartum blood loss is not an
exact amount like blood donation; and postpartum blood losses of 500 cc
in the first hour can be mistaken for actual blood loss of 1000 cc.
[1,4] It would be more logical to define and treat postpartum blood
loss the way all other types of bleeding: as deleterious and worthy of
preventing.
There is a direct relationship between PPH > 1000 cc and
the length of the third stage such that PPH increases linearly with the
passing of every second of third stage [3,10] Studies showing this
linear relationship failed to conclude that shortening the third stage
would prevent PPH. [3,11] Except in the rare case of
placenta accreta, the placenta detaches within a minute of the birth as
a result of the dramatic change in shape of the uterus as the baby
delivers. [12] In current practice, women lay supine in bed with
the heavy, flaccid, detached placenta lying on the posterior or dorsal
wall of the uterus below the level of the cervix while the wound where
the placenta was previously attached, is bleeding into the uterus and
the cervix is closing. When the woman is supine, the detached placenta
has an uphill ascent against the forces of gravity. Requiring the
placenta to ascend against gravity sometimes delays the delivery. Any
delay provides additional time for the wound to bleed as well as
additional time for the cervix to close. A closing cervix creates the
need to squeeze the placenta through a narrower passage, sometimes
leaving bits behind resulting in PPH due to retained placenta.
Delivering the placenta at 3 minutes after birth in squatting, uses
expedience, gravity, the downward force of the diaphragm and the
abdominal muscles to deliver the placenta completely and before uterine
atony or placental retention can cause excess bleeding.
[13-16] The woman gets into squatting at 3 minutes after the birth
and the practitioner reminds her to push out the placenta without
waiting for the sensation of a uterine contraction. There is no reason
not to cut the cord unless the newborn is not breathing and requires
resuscitation. By 1 minute after birth, the placenta has detached from
the uterus and newborn cord/placental circulation has been shunted to
the lungs. However, where there is objection to cutting the cord at 3
minutes, the woman can squat and deliver the placenta with the cord
attached to the newborn. Once the complete placenta is delivered, the
uterus contracts thereby closing off uterine blood vessels that
previously fed the placenta, preventing uterine atony, the cause of the
majority of PPH. The protocol can be carried out in any setting,
requiring no equipment other than a way to accurately time 3 minutes,
such as a digital watch. It is likely that less bleeding would occur if
the woman squatted BEFORE 3 minutes but in general, women appreciate
three minutes to recover from the birth of the baby.
1