Fundal pressure versus controlled cord traction as part of the active management of the third stage of labour

Abstract

Background

There are two basic interventions to help to deliver the placenta as part of the active management of the third stage of labour: (1) fundal pressure, and (2) controlled traction on the umbilical cord. Both of these methods may, in addition, have adverse outcomes. Fundal pressure may interrupt the process of placental detachment and cause pain, haemorrhage or uterine inversion, and controlled cord traction, if undertaken before placental separation or without prior administration of a uterotonic drug, may have similar adverse effects. The obstetric clinical practice on this issue is not standardised.

Objectives

To determine the efficacy of fundal pressure versus controlled cord traction as part of the active management of the third stage of labour.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2010).

Selection criteria

We searched for published and unpublished randomised and quasi‐randomised controlled trials.

Data collection and analysis

Two review authors independently identified potential studies from the literature search and assessed them for methodological quality and appropriateness of inclusion.

Main results

The search strategies yielded five studies for consideration of inclusion. However, none of these studies fulfilled the requirements for inclusion in this review.

Authors' conclusions

We identified no randomised controlled trials comparing the efficacy of fundal pressure versus controlled cord traction as part of the active management of the third stage of labour. Hence controlled cord traction, after awaiting signs of placental separation, should remain the third component of the active management of third stage of labour, and follow the routine administration of a uterotonic drug and cord clamping.

Plain language summary

Fundal pressure versus controlled cord traction as part of the active management of the third stage of labour

Controlled cord traction to deliver the placenta should remain as part of the active management of third stage of labour.

The third stage of labour is the period from the birth of the baby until delivery of the placenta. There are two basic interventions to help to deliver the placenta as part of the active management of the third stage of labour: fundal pressure or controlled cord traction. Fundal pressure (Crede manoeuvre) involves placing one hand on the top of the uterus (uterine fundus) and squeezing it between the thumb and other fingers to help placental separation and delivery. Controlled cord traction involves traction on the umbilical cord while maintaining counter‐pressure upwards by placing a hand on the lower abdomen. Also, controlled cord traction should only follow signs of placental separation. Both these interventions, if not performed correctly, may have adverse outcomes including pain, haemorrhage and inversion of the uterus. Two other methods of placenta delivery are not advised because they may be dangerous: these are uterine manipulation and cord traction. The review found no randomised controlled trials to assess the use of fundal pressure as part of the active management of the third stage of labour. Therefore, controlled cord traction should continue as the method of placental delivery in the active management of third stage of labour.

Background

The third stage of labour is the period from the birth of the baby until delivery of the placenta. After the birth of the baby and the cessation of umbilical cord pulsation, the placenta separates from the uterine wall through the sponge lining of the decidua spongiosa and is delivered through the birth canal (Burnett 2001; Inch 1985). Separation of the placenta usually begins after the birth of the baby, as a result of uterine retraction or with the first contractions of the empty uterus. The classical signs of placental separation are: alteration of the form and size of the uterus, blood loss, descent and lengthening of the umbilical cord and the elevation of the uterine fundus (McDonald 2003). All signs are not always as apparent as this. The only definite sign of separation is when the placenta is expelled through the birth canal. There are a number of techniques to deliver the placenta once it has separated. According to popular opinion, two are not advised because they may be dangerous: (1) uterine manipulation, and (2) traction of the umbilical cord. Uterine manipulation may interrupt the process of placental detachment, and can cause pain, haemorrhage and uterine inversion. Traction of the umbilical cord, if undertaken before placental separation and without counter pressure, or without prior administration of a uterotonic drug, may also cause pain, haemorrhage or uterine inversion (Käser 1972; Lipitz 1988). 
 
 The estimated number of maternal deaths in 2000 for the world was 529,000 (WHO 2004). Many of these deaths resulted from complications of the third stage of labour. The pregnancy‐related (direct) maternal mortality rate in the United States is approximately seven to 10 women per 100,000 live births. National statistics suggest that approximately 8% of these deaths are caused by postpartum haemorrhage (PPH) (Berg 1996). In the developing world, maternal deaths due to PPH range from 5.9% to 48.5% (Khan 2006). The death of these mothers has serious implications for the newborn and any other surviving children.

PPH is defined as an estimated maternal blood loss of 500 ml or more within 24 hours of delivery. Most healthy women can tolerate 500 to 1000 ml blood loss without serious morbidity (Bais 2004). The degree of blood loss associated with placental separation and delivery depends on how effectively the uterine muscles contract around the placental bed during and after separation, and whether there is any interference such as pulling on the cord prior to placental separation. The degree of blood loss will also be associated with the woman's blood clotting profile. The absolute timing for delivery of the placenta, without evidence of significant bleeding, remains unclear, but a period of about 10 minutes has been identified with active management of third stage (Gülmezoglu 2004; Prendiville 2000). The most important aim of the management of the third stage of labour is to avoid large amounts of blood loss (Käser 1972; Prendiville 2000).

Evidence shows that management of the third stage can directly influence important maternal outcomes such as blood loss, and the need for manual removal of the placenta (Brucker 2001). The third stage of labour can be managed actively or expectantly. For the mother, the third stage of labour is potentially the most hazardous part of childbirth, mainly because of the risk of PPH. As a measure to prevent PPH, active management has been widely adopted. Active management generally involves all three of the following interventions: routine prophylactic administration of a uterotonic agent, early cord clamping and controlled cord traction (Prendiville 1989; Prendiville 2000; Rogers 1998). Controlled cord traction involves traction on the cord while maintaining counter‐pressure upwards on the lower segment of the uterus, using a hand placed on the lower abdomen. The Crede manoeuvre for fundal pressure is a method to separate the placenta after delivery. One hand is placed on the uterine fundus and the uterus squeezed between the thumb and other fingers to facilitate placental separation and expel the placenta through the birth canal (Brandt 1933). However, this manoeuvre may produce great pain, so some do not recommend it (Beisher 2000). The length of third stage using this method is usually between five and 15 minutes (Beisher 2000).

An alternative to active management of the third stage of labour is expectant management (sometimes called conservative or physiological management). In expectant management, uterotonic drugs are not given prophylactically, the cord is neither clamped nor cut early, nor is controlled cord traction performed and the placenta is expelled by maternal effort in its own time. The length of expectant management is about 15 to 30 minutes (Usandizaga 1997).

Faulty management of the third stage of labour may increase the risk of inversion of the uterus (Miras 2002). Whether cord traction is free of danger, as has been claimed in recent years, remains unclear (Meinert 1984). However, the cord traction method in the third stage of labour could be dangerous in spite of other advantages (Sterigev 1979), whereas controlled cord traction is the standard third component of the active management of third stage (Prendiville 2000). Whether fundal pressure might be a more effective third component of the active management of third stage of labour merits investigation.

Objectives

To determine the efficacy of fundal pressure versus controlled cord traction as part of the active management of the third stage of labour.

Methods

Criteria for considering studies for this review

Types of studies

Randomised and quasi‐randomised controlled trials.

Types of participants

Women after vaginal birth where active management of the third stage is to be used (with other components of active management of the third stage being noted).

Types of interventions

Following routine administration of a uterotonic drug and early cord clamping:

1. Fundal pressure (Crede manoeuvre): a method to separate the placenta after delivery, by placing the hand on the uterine fundus in order to squeeze between the fingers the fundus to make the placenta separate and expel the placenta through the birth canal.

2. Controlled cord traction: involves traction on the cord while maintaining counter‐pressure upwards on the lower segment of the uterus, using a hand placed on the lower abdomen.

Types of outcome measures

• Postpartum haemorrhage

• Severe postpartum haemorrhage (clinically estimated blood loss of at least 1000 ml)

• Length (or duration) of the third stage of labour

• Number of units of packed red cell transfused

• Number of participants transfused

• Number of doses of uterotonic agents

• Maternal pain during the third stage of labour

• Length of stay in hospital

• Retained placenta

• Manual removal of placenta

• Uterine inversion

• Use of analgesics

Search methods for identification of studies

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register by contacting the Trials Search Co‐ordinator (August 2010).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co‐ordinator and contains trials identified from: 

1. quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);

2. weekly searches of MEDLINE;

3. handsearches of 30 journals and the proceedings of major conferences;

4. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group. 

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co‐ordinator searches the register for each review using the topic list rather than keywords.  

For details of the additional searches carried out in the previous version of this review, please seeAppendix 1.

We did not apply any language restrictions.

Data collection and analysis

Study selection

We screened the results of the search strategy for potentially relevant trials and independently assessed them for inclusion using a predesigned eligibility form based on the inclusion criteria. We resolved disagreements through discussion until a consensus was reached. We were unable to identify any randomised controlled trials eligible for inclusion in this Cochrane review. Therefore, we could not perform the data analyses that we had planned. If trials are identified and included in the review in future, we will adhere to the protocol as described below and, where necessary, request any additional information from the main study authors.

Assessment of methodological quality of included studies

We will assess the validity of each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005).

(1) Selection bias (randomisation and allocation concealment)

We will assign a quality score for each trial, using the following criteria: 
 (A) adequate concealment of allocation, such as telephone randomisation, consecutively‐numbered, sealed opaque envelopes; 
 (B) unclear whether adequate concealment of allocation; 
 (C) inadequate concealment of allocation, such as open list of random‐number tables, sealed envelopes.

(2) Performance bias (blinding of participants, researchers and outcome assessment)

We will assess blinding using the following criteria: 
 (A) blinding of participants (yes/no/unclear); 
 (B) blinding of caregiver (yes/no/unclear); 
 (C) blinding of outcome assessment (yes/no/unclear).

However, it will not be possible to blind participants and caregivers when using these interventions.

(3) Attrition bias (loss to follow up)

We will assess completeness to follow up using the following criteria: 
 (A) less than 5% of participants excluded; 
 (B) 5% to 10% of participants excluded; 
 (C) more than 10% and less than 20% of participants excluded; 
 (D) more than 20% of participants excluded.

Data extraction and management

Guiomar Peña‐Martí (GP) will design a form to extract data and Gabriella Comunián‐Carrasco (GC) will validate it. GP and GC will extract the data independently using the agreed form. We will resolve discrepancies through discussion. We will use the Review Manager software (RevMan 2003) to double enter the data.

When information regarding any of the above is unclear, we will attempt to contact authors of the original reports to provide further details.

Measures of treatment effect

We will carry out statistical analysis using the Review Manager software (RevMan 2003). We will use fixed‐effect meta‐analysis for combining data if trials are sufficiently similar.

For dichotomous data, we will present results as summary relative risks with 95% confidence intervals.

For continuous data, we will use the weighted mean difference if outcomes are measured in the same way between trials. We will use the standardised mean difference to combine trials that measure the same outcome, but use different methods. If there is evidence of skewness we will report this.

We will analyse data on an intention‐to‐treat basis. Therefore, all participants with available data will be included in the analysis in the group to which they are allocated, regardless of whether or not they received the allocated intervention. If in the original reports participants are not analysed in the group to which they were randomised, and there is sufficient information in the trial report, we will attempt to restore them to the correct group.

Assessment of heterogeneity

We will apply tests of heterogeneity between trials if appropriate using the I² statistic. If we identify high levels of heterogeneity among the trials (exceeding 50%), we will explore it by performing sensitivity analysis. A random‐effects meta‐analysis will be used as an overall summary if this is considered appropriate.

Sensitivity analyses

We will carry out sensitivity analysis to explore the effect of trial quality. This will involve analysis based on an A, B, C or D rating of selection bias, performance bias and attrition bias, as well as including and excluding quasi‐randomised trials. The results of high‐quality studies will be compared with those of poorer quality studies, where studies rated A for all quality criteria will be compared with those rated B, C or D.

Results

Description of studies

The search strategies yielded five studies for consideration of inclusion. However, none of these studies met the basic inclusion criteria of comparing controlled cord traction versus fundal pressure. For more information, see the table 'Characteristics of excluded studies'.

Risk of bias in included studies

We did not identify any studies that were eligible for inclusion in this Cochrane review.

Effects of interventions

The searches did not identify any randomised controlled trials eligible for inclusion in this Cochrane review.

Discussion

There are currently no randomised, or quasi‐randomised, controlled trials comparing fundal pressure with controlled cord traction as part of the active management of the third stage of labour. One trial, which probably came closest to the research question, assessed (following intramuscular oxytocic administration) the use of controlled cord traction compared with maternal effort and fundal pressure only if maternal effort was unsuccessful (Bonham 1963). This trial showed controlled cord traction associated with less blood loss.

In order to consider the benefits and risks of fundal pressure compared with controlled cord traction as part of the active management of third stage, a randomised controlled trial comparing both interventions would need to be conducted. However, it may not be a research priority given the suggested disadvantages of Crede fundal pressure (Lipitz 1988; Miras 2002).

Authors' conclusions

Implications for practice.

The evidence shows there are no randomised controlled trials to support the use of fundal pressure rather than controlled cord traction as part of the active management of the third stage of labour. Therefore, controlled cord traction should continue as the method of placental delivery in the active management of third stage of labour.

Implications for research.

A randomised controlled trial to compare fundal pressure with controlled cord traction as part of the active management of third stage of labour is probably not a research priority.

What's new

Date	Event	Description
6 August 2010	New search has been performed	Search updated. No new trials identified.

History

Protocol first published: Issue 3, 2005
 Review first published: Issue 4, 2007

Date	Event	Description
3 September 2008	Amended	Converted to new review format.

Appendices

Appendix 1. Search strategy

(CENTRAL) (The Cochrane Library 2006, Issue 2); MEDLINE (1966 to April 2006); EMBASE (1988 to April 2006) and LILACS (1982 to April 2006)

(third stage OR 3rd stage OR cord traction OR fund* pressure OR uterine inversion) AND (postpartum haemorrhage OR post partum haemorrhage OR post‐partum haemorrhage OR postpartum hemorrhage OR post partum hemorrhage OR post‐partum hemorrhage OR pph OR blood loss OR blood‐loss OR blood loss).

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

Study	Reason for exclusion
Bonham 1963	Quasi RCT compared 'cord traction' with 'maternal effort and then fundal pressure if maternal effort was unsuccessful'.
Giacalone 2000	RCT compared 'placental cord drainage plus cord traction' with 'expectant delivery'. It is unclear how many women required fundal presssure.
Kemp 1971	Quasi RCT compared 'cord traction as part of the active management of third stage' with 'syntometrine plus abdominal manipulation'. Throughout the paper, the term 'abdominal manipulation' was used, except in the printed instructions for staff where it was called 'gentle fundal pressure'. This study was excluded because it was about 'cord traction' rather than 'controlled cord traction' and the control group also included 'early dividing of the umbilical cord'.
Khan 1997	RCT compared 'controlled cord traction' with 'a minimal intervention group where the placenta was delivered by maternal effort'.
Sharma 2005	RCT compared 'placental cord drainage' with 'controlled cord traction'.
Thomas 1990	RCT compared 'placental cord drainage plus controlled cord traction' with 'controlled cord traction'.

RCT: Randomised controlled trial

Contributions of authors

Dr Peña developed and wrote the protocol and the first draft of the review. Dr Comunián provided general advice on the protocol and the review.

Sources of support

Internal sources

• Universidad de Carabobo, Venezuela.

External sources

• Iberoamerican Cochrane Centre, Spain.

Declarations of interest

None known.

New search for studies and content updated (no change to conclusions)