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Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR)

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1541 (Published 28 March 2013) Cite this as: BMJ 2013;346:f1541
  1. Catherine Deneux-Tharaux, senior researcher1,
  2. Loic Sentilhes, professor of obstetrics and gynaecology2,
  3. Françoise Maillard, medical statistician1,
  4. Emmanuel Closset, hospital practitioner in obstetrics and gynaecology3,
  5. Delphine Vardon, hospital practitioner in obstetrics and gynaecology4,
  6. Jacques Lepercq, professor of obstetrics and gynaecology5,
  7. François Goffinet, professor of obstetrics and gynaecology and senior researcher16
  1. 1INSERM U953, Epidemiologic Research in Perinatal, Women’s, and Children’s Health, Pierre et Marie Curie University, Paris, France
  2. 2Department of Obstetrics and Gynaecology, University Hospital, Angers, France
  3. 3Department of Obstetrics and Gynaecology, Jeanne de Flandre University Hospital, Lille, France
  4. 4Department of Obstetrics and Gynaecology, University Hospital, Caen, France
  5. 5Department of Obstetrics and Gynaecology, St Vincent de Paul-Cochin University Hospital, Assistance Publique Hôpitaux de Paris, Paris
  6. 6Port-Royal Maternity Unit, Department of Obstetrics and Gynaecology, Cochin University Hospital, Assistance Publique Hôpitaux de Paris, Paris
  1. Correspondence to: C Deneux-Tharaux INSERM U953, Maternité Port-Royal, 75014 Paris, France catherine.deneux-tharaux{at}inserm.fr
  • Accepted 19 February 2013

Abstract

Objective To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.

Design Randomised controlled trial.

Setting Five university hospital maternity units in France.

Participants Women aged 18 or more with a singleton fetus at 35 or more weeks’ gestation and planned vaginal delivery.

Interventions Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth.

Main outcome measure Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag.

Results The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm.

Conclusions In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking.

Trial registration ClinicalTrials.gov NCT01044082.

Footnotes

  • The full trial protocol can be accessed at www.u953.idf.inserm.fr/page.asp?page=5211. We thank the independent data monitoring committee chaired by JM Treluyer from the Unité de Recherche Clinique Paris Centre; the women who participated in the trial; the staff from the participating maternity units for including women, and the members of the TRACOR Study Group (see supplementary file). Inserm Unit 953 has received a grant from the Bettencourt Foundation (Coups d’élan pour la Recherche française) in support of its research activities.

  • Contributors: CD-T participated in the design of the study, obtained funding, participated in the central monitoring of data collection, supervised the cleaning, analysis, and interpretation of the data and the drafting and revision of the paper, and has seen and approved the final version. She had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. LS participated in the design of the study, supervised the inclusion of women and the running of the trial in his hospital, participated in the revision of the paper, and has seen and approved the final version. FM participated in the central monitoring of data collection, supervised the cleaning of the data, conducted the analysis, participated in the drafting and the revision of the paper, and has seen and approved the final version. EC participated in the design of the study, supervised the inclusion of women and the running of the trial in his hospital, participated in the revision of the paper, and has seen and approved the final version. DV participated in the design of the study, supervised the inclusion of women and the running of the trial in her hospital, participated in the revision of the paper, and has seen and approved the final version. JL participated in the design of the study, supervised the inclusion of women and the running of the trial in his hospital, participated in the revision of the paper, and has seen and approved the final version. FG is the principal investigator of the trial; he participated in the design of the study, obtained funding, participated in the central monitoring of data collection, supervised the cleaning, analysis, and interpretation of the data and the drafting and revision of the paper, and has seen and approved the final version. He had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. CD-T and FG are guarantors for the paper.

  • Funding: The TRACOR trial was funded by the French Ministry of Health under its clinical research hospital programme (contract No P081206). The Ministry of Health had no role in the design and conduct of the study, the collection, management, analysis, or interpretation of the data, and the preparation, review, and approval of the manuscript or in the decision to submit for publication.

  • 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: support from the French Ministry of Health for the submitted work; LS was a board member and carried out consultancy work and lecturer for Ferring; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the Paris-Ile de France III Committee for the Protection of Research Subjects (Ethics Committee) in September 2009.

  • Data sharing: No additional data available.

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