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Feature Christmas 2012: Evolution of Practice

Push, pull, squeeze, clamp: 100 years of changes in the management of the third stage of labour as described by Ten Teachers

BMJ 2012; 345 doi: (Published 19 December 2012) Cite this as: BMJ 2012;345:e8270
  1. Nasreen Aflaifel, research fellow1,
  2. Andrew Weeks, professor of international maternal health 1
  1. 1Sanyu Research Unit, Department of Women’s and Children’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool, L8 7SS, UK
  1. Correspondence to: N Aflaifel, Omer Al Mukhtar University, Department of Obstetrics and Gynaecology, El Byda, Libya aflaifel{at}

Should we look back at historical methods to see if we are missing a trick? Aflaifel and Weeks trace the history of managing the third stage of labour

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 …

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