Retrospective Cohort Study Comparing Current Third Stage Management to Expedient Squatting Third Stage Management

Background: Active management of the delivery of the placenta results in 5% postpartum hemorrhage, 1% blood transfusions and an average blood loss of 500 cc. Shorter third stages are associated with decreased hemorrhage rates. The third stage can be shortened by instructing the birthing woman to squat and push out the placenta at 3 minutes postpartum. The objective of this study was to compare blood loss and PPH rates using Judy's 3,4,5 minute third stage expedient squatting protocol to variations of active and expectant third stage management among similar populations.Methodology: A retrospective cohort study was carried out comparing 1,098 planned homebirths attended in Israel, in which Judy’s 3,4,5 expedient squatting third stage technique was practiced, to 2,899 planned homebirths attended by midwives in British Columbia, Canada, where currently accepted third stage management was used. The inclusion criteria for both groups were: Singleton fetus in cephalic presentation; gestational age 37+0 to 41+6 weeks; spontaneous onset of labor; history of up to one previous cesarean; absence of significant pre-existing disease and absence of significant disease arising during pregnancy. The main outcomes were postpartum hemorrhage and manual removal of the placenta. Results: Using identical inclusion criteria and similar management, variations of active and expectant management resulted in 4% PPH over 1000 cc and 1.0% manual removal. Expedient squatting resulted in 2/1098 cases of PPH>500 cc, zero cases of PPH over 1000 cc and 0.7% manual removal. Conclusion: Judy’s 3,4,5 minute third stage management minimizes postpartum bleeding compared to other third stage protocols, reproducing postpartum hemorrhage rates indigenous to primates.