­­­­­­­­­­Retrospective cohort study comparing current third stage management to expedient squatting third stage management
Authors:  Judy Slome Cohain, CNM
Address:  judyslome@hotmail.com
Affiliation: Private Practice- corresponding author
Snail mail: Alon Shvut 37, Israel 90433     Telephone 972545493109
Second author: Rina E. Buxbaum, MD   rina1511@gmail.com
Affiliation: Hadassah Ein Kerem Medical Center
A shortened running title : Preventing PPH using expedient squatting
Abstract
Objective:  To compare current the third stage management to expedient squatting at 3 minutes postpartum.
Design, Setting, Sample and Methods: A retrospective cohort study of 1,098 planned, attended low risk vaginal births in Israel using Judy’s 3,4,5 minute third stage protocol compared to 2,691 attended low risk vaginal births in British Columbia using various forms of active or expectant management of the third stage of labor.
Main Outcome measures:  PPH>1000, PPH>500 and manual removal of placenta
Results: Among similar groups of low risk births, active management, or expectant management resulted in 4.1% PPH over 1000 cc, whereas Judy’s 3,4,5 minute protocol resulted in 0% PPH over 500 cc.
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.
•       Introduction
Cochrane reviews found no evidence that active management reduces the risk of primary postpartum hemorrhage (PPH) over 1000 cc and found active management increases afterbirth pains, increases the need for postpartum analgesia, increases the incidence of postpartum diastolic blood pressure greater than 90 mmHg, and results in increased rehospitalizations due to bleeding. [1]  The PPH rate at vaginal birth was 5% both before and after the adoption of Active Management. [2-4]   Active Management appears to have superior outcomes only when compared to the 13% PPH rates associated with Expectant Management. [1] The failure of Active Management to prevent PPH is not surprising since it is based on the presumption that women evolved to require external administration of synthetic Oxytocin to avoid hemorrhage.   Humans share the same placental physiology as apes and chimpanzees who never hemorrhage unless the birth is interfered with by humans. [5,6] It follows that if humans deliver the placenta the way apes and chimps do, they also would not hemorrhage. A demonstration of this appears on YouTube: https://www.youtube.com/watch?v=AAJPW4p6rzU