5.3 Controlled Cord Traction

Controlled cord traction involves traction on the cord, combined with counterpressure upwards on the uterine body by a hand placed immediately above the symphysis pubis. In two controlled trials this procedure has been compared with less active approaches, sometimes entailing fundal pressure (Bonham 1963, Kemp 1971). In the controlled traction groups a lower mean blood loss and shorter third stages were found, but the trials do not provide sufficient data to warrant definite conclusions about the occurrence of postpartum haemorrhage and manual removal of the placenta. In one trial patient discomfort was less if controlled traction was used. However, in 3% the cord was ruptured during controlled cord traction. A rare but serious complication associated with controlled cord traction is inversion of the uterus. Although the association might be with a wrong application of the method, the occurrence of inversion of the uterus still is a matter of concern. The above mentioned trials have apparently gathered data on women in a supine position. The impression of midwives attending deliveries with the woman in the upright position during the second and third stage is that the third stage is shorter and placental separation is easier, although the loss of blood is more than in the supine position. However, apart from blood loss, these aspects have not been investigated in randomized trials. Presumably controlled cord traction as described in the textbooks would be more difficult to perform in the upright position.