Push, pull, squeeze, clamp: 100 years of changes in the management of the third stage of labour as described by Ten TeachersBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e8270 (Published 19 December 2012) Cite this as: BMJ 2012;345:e8270
- 1Sanyu Research Unit, Department of Women’s and Children’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool, L8 7SS, UK
- Correspondence to: N Aflaifel, Omer Al Mukhtar University, Department of Obstetrics and Gynaecology, El Byda, Libya
The third stage of labour (between the delivery of the baby and the placenta) is the most dangerous time of childbirth for the mother. Many of today’s obstetricians were taught that “active management” of this stage (oxytocics, early cord clamping, and controlled cord traction) was the only safe way to deliver the placenta. Recent studies have shown that although prophylactic oxytocics are beneficial, early cord clamping is of no benefit (and could be harmful) and controlled cord traction has little benefit.1 We sought to place these changes in context through a historical study of obstetric practice over the last century.
The undergraduate textbook Obstetrics by Ten Teachers has been a favourite with students for many generations. First published in 1917 as Midwifery by Ten Teachers,2 the book was renamed in 19663 and is now in its 19th edition. Each edition is written by 10 leading obstetricians from the British Isles with the authors chosen by the senior editor. With a complete absence of references in the text, the series provides an excellent example of “eminence based” medicine and gives an insight into changes in labour ward practice over the past century.
We reviewed the regimens for the third stage of labour between 1917 and 2011 as described in the successive editions of the books. Copies were obtained from the University of Liverpool’s Harold Cohen library and from interlibrary loans as necessary.
Routine third stage management
Routine third stage management focuses on reducing blood loss and achieving rapid and complete delivery of the placenta. Figure 1⇓ and appendix 1 show details of changes over the past century. Although uterotonic drugs (drugs that enhance the contraction of the uterine muscle) in various forms have been used ever since the first edition, the practices of early cord clamping and controlled cord traction were taught only after the “active management of the third stage of labour” package was popularised in the 1960s.
Successive authors seem to have had reservations about the practice of early cord clamping, however, and have described its use as “an option” with use of the active management package or if the baby requires resuscitation. Oddly, the first mention of its routine use appears in the 2011 edition, just as national and international evidence based guidelines were dropping it as part of their recommendations, demonstrating the well recognised disconnect between “evidence based” and “eminence based” medicine.
The treatment of atonic postpartum haemorrhage
Atonic postpartum haemorrhage is the most common cause of bleeding after childbirth and results from poor contraction of the uterine muscle. See appendix 1 for details of its management since 1917.
The Ten Teachers series has always taught that uterotonic drugs are the best initial treatment for atonic postpartum haemorrhage. The standard drug has been ergot, but other early options included transabdominal intramyometrial ergometrine (1961-72) and oxytocin (1948). From 1995 onwards the choice of uterotonic drugs increased to include intravenous syntometrine, oxytocin infusion, prostaglandin F2α (intramuscular or directly into the uterine muscle), and misoprostol.
Aside from drug treatment, uterine massage (sometimes in combination with squeezing the uterus through the abdominal wall) has always been taught as the first line non-drug intervention. Early alternatives include a 180°F intrauterine douche with Dettol (a liquid antiseptic and disinfectant containing chloroxylenol) in 1938-42, and external or intra-abdominal aortic compression. The importance of bimanual uterine compression has increased gradually, moving from third to first option over the editions. Throughout the century, the importance of its early use was emphasised in the event of severe bleeding.⇓
Hysterectomy is usually kept as last line treatment and was not even mentioned as an option until 1966. Several physical methods have been taught to try to avoid it. Early editions (1917-35) suggested packing the uterus. This technique returned in the 2000 edition along with balloon tamponade and arterial embolisation as alternatives to arterial ligation. In 2011 uterine compression sutures were also recommended as a further alternative to hysterectomy.
The avoidance and treatment of retained placenta, where the placenta remains undelivered for 30-60 minutes postpartum, is a key part of third stage management. See appendix 1 for details of changes over the past century. From 1917 to 1955, the teachers recommend massaging the uterus until it is firmly contracted and then squeezing it repeatedly over five minutes to expel the placenta. If this failed, the last resort was to manually remove the placenta under general anaesthesia, but the teachers warn of the high risk of complications, including death from sepsis. Between 1935 and 1942, the use of an injection of saline into the intraumbilical vein was also recommended before any attempt at manual removal of placenta. In the latest editions (2000-2006), little discussion has been devoted to this subject, except to say that manual removal of placenta is the treatment of choice.
Delivery of a placenta that is already separated but retained within the lower segment of vagina has been discussed throughout the editions (except 2011). Until 1980, the recommended treatment was to push down on the fundus of the uterus so that the uterus acted as a piston against the placenta and expelled it. The editions from 1961 to 1995 also described cord traction as an option to deliver the separated placenta (replaced by the Brandt-Andrews method from 1972).
A common problem is a contraction ring of the cervix or lower uterus that obstructs the clinician who is attempting manual removal. In the early editions (1917-31) this was treated by dilating the ring with steady pressure with the finger tips. In 1935, however, the concept of uterine relaxation with amyl nitrite was introduced. Two 5 minim (an old fashioned measure of liquid equivalent to about 60 µL) capsules were broken under the anaesthetic mask to relax the ring and allow spontaneous expulsion of the placenta. This recommendation persisted until 1990, although in the latter years volatile liquid anaesthetic agents were given as an alternative.
The Ten Teachers collection provides an intriguing insight into the history of medical care in pregnancy throughout the past 100 years. Although only a snapshot of the teaching from a single textbook, it has provided us with the opinions of some of the most respected obstetricians of their day. It is therefore likely to be representative of medical student teaching generally at that time, especially in the first half of the century when Ten Teachers was one of few textbooks available.
An examination of a century of practice provides us with three lessons. Firstly, with scientific evidence absent for much of the century, the management practices have tended to ebb and flow according to the experts’ opinion and cultural acceptability. This is most clearly seen with the use of controlled cord traction for routine delivery of the placenta and umbilical vein injection for retained placenta. The recommendations regarding the timing of cord clamping, however, are also of interest. Throughout the century, right up until the latest edition (2011), teachers have taught that the cord should usually be clamped only after the baby stops crying and the cord stops pulsating (although the option of early cord clamping was introduced in the 1960s as part of the active management). This teaching persisted up to the most recent edition, when the teaching changed and students were taught to clamp the cord early. This is ironic given that it comes just at a time when there is a widespread change back to delayed cord clamping, led by guidelines from World Health Organization, the International Federation of Gynecology and Obstetrics (FIGO), and the Royal College of Obstetricians and Gynaecologists. Thus, although the chapters pay lip service to evidence based medicine from the 1980s (by providing a list for further reading), the textbook’s recommendations are not always in line with the latest evidence. This could reflect the age of the “eminent teachers” as well as the opinion that undergraduate teaching should reflect expert’s practice rather than the regularly changing latest evidence.
Secondly, the change in teaching clearly shows a lowering of the threshold for invasive treatments. As safer anaesthetics and antibiotics became available, so invasive treatments could be introduced at a much earlier stage. For example, with a retained placenta, students were initially taught to try to avoid the manual removal of the placenta at all costs because of the danger of perforation and death from sepsis. With antibiotics reduced and surgical morbidity, however, there was a lowering of the threshold for intervention such that manual removal went from being a fourth line treatment in the 1930s to first line from the 1960s onwards. This coincided with the dramatic reduction in maternal deaths in the United Kingdom in the 1940s and shows the greater confidence of obstetricians in their ability to prevent surgical complications. The same is true of hysterectomy for severe haemorrhage. This was not mentioned in the first half of the century, presumably because mortality from the surgery was so high that it was not worth attempting in a woman who was already severely shocked from haemorrhage. In the 1966 edition, however, it was introduced as a possible lifesaving operation. This was made possible only with the introduction of blood transfusions, a technique that allowed women to be resuscitated before this high risk surgery.
Finally, several recent “innovations” are found to simply be rediscoveries of old technologies that have been used successfully in the past but went out of fashion. This is seen with the use of amyl nitrate for retained placenta, which was recommended until 1990 but discarded thereafter. It is only in recent years that the technique (with intravenous or sublingual glyceryl trinitrate) has been the subject of high quality randomised trials that have shown that it might be both safe and effective after all.4 It is soon to be further investigated in a large randomised trial in the UK. The same is true for “delayed” cord clamping as outlined above and uterine packing (although the tamponade is usually done now with an intrauterine balloon). This phenomenon is not uncommon elsewhere in maternity care, with progesterone (to prevent preterm labour) and the transcervical Foley catheter (for the induction of labour) being other recent examples where “outdated” interventions have been rediscovered. As medical researchers, we could do a lot worse than to explore historical texts to see what techniques and treatments have been discarded a little too hastily. Does anyone fancy working with us on a randomised trial of the intrauterine Dettol douche?
Cite this as: BMJ 2012;345:e8270
Contributors: NA researched the previous editions, wrote the first draft of the manuscript, and constructed the figures. AW had the idea for the article, revised the article, and is the guarantor. Both authors approved the final version.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.