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BMJ 2012; 344 doi: (Published 14 March 2012) Cite this as: BMJ 2012;344:e1800

Women can deliver safely without controlled traction on the cord

Controlled traction on the umbilical cord helps deliver the placenta, but it has little impact on a woman’s risk of postpartum haemorrhage, say researchers. Cord traction can be omitted safely in women who deliver without the help of properly trained birth attendants.

Their large trial compared active management of the third stage of labour with and without cord traction in more than 24 000 women having a single vaginal delivery. Roughly 2% of women in both groups lost a litre or more of blood (239/11 621 v 219/11 621; risk ratio 1.09, 95% CI 0.91 to 1.31).

Management without cord traction wasn’t conclusively “non inferior” (primary results just missed a prespecified threshold), but women managed this way lost just 10 mL more blood than controls (3.9 to 16.4). Cord traction shortened the third stage by an average of 6.5 minutes (6.2 to 6.8). The practice seemed safe in this trial but may not be so safe in poorly trained hands, says an editorial (doi:10.1016/S0140-6736(12)60354-7). Uterine inversion is rare but can be life threatening.

A uterotonic such as oxytocin, not controlled traction on the cord, is the most important component of a managed third stage, says the editorial. Women in this trial had 10 IU of oxytocin immediately after delivery of the baby, and overall rates of bleeding were low.

Administration of a uterotonic is relatively easy with disposable syringes prefilled with oxytocin and easier still with tablets of misoprostol. International agencies trying to reduce maternal mortality now have a better idea where to direct scarce resources.

Caffeine gives small boost to popular analgesics


Many popular analgesics are combined with caffeine, an additive that boosts effectiveness by around 10%, according to a meta-analysis. All 19 trials in the analysis compared a single dose of …

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