The original description of active management of the third stage of labour had three components—delivery of a prophylactic uterotonic drug, early cord clamping and cutting, and controlled cord traction.1 When randomised trials in the 1980s found that this package reduced the risk of severe postpartum haemorrhage by 70%,2 active management was adopted widely. It was thought to be especially important in low resource settings, where more than 20 000 deaths occur each year as a result of haemorrhage.3 In these settings, active management of the third stage has almost become a mantra for the safe motherhood movement.

But in the half century since active management was described, we have never known which component is the most important. Guidelines from around the world have varied widely in their selection of oxytocic agent, early cord clamping, cord traction, uterine massage, and cord drainage.4 Controlled cord traction became popular only when it was incorporated into the active management package in 1962, and, although there were no major randomised trials of cord traction, it was thought to decrease the incidence of postpartum haemorrhage and retained placenta.5

The required evidence on cord traction appeared in March this year.6 Gulmezoglu and colleagues from the World Health Organization’s maternal health research network conducted a large multicentre controlled trial to examine the effect of active management of the third stage of labour with and without …