Editor:As a little girl, I remember my traveling salesman father literally carrying his heavy suitcase.  Then someone patented the idea to put wheels under suitcases. This amazing idea was immediately adapted and in time, improved upon with better designs. No randomized trials were needed to test whether wheels attached to the bottom of suitcases were useful.  The same will hopefully be true of expedient delivery of the placenta in squatting. Expedient delivery of the placenta in squatting prevents all postpartum hemorrhage and results in very little postpartum bleeding.Human postpartum hemorrhage was eliminated by natural selection millions of years ago. Since it is a deadly trait at the time of birth, it cannot be passed on. Great apes and chimpanzees have the same placenta as humans and lose a spoon full of blood at birth except in the rare occurrence that the chimp or ape birth is interfered with by people.  I was motivated to prevent postpartum hemorrhage to optimize birth outcomes. I found that if the woman delivers the placenta like a chimpanzee, she never hemorrhages.  One minute after the birth, the woman gets into squatting and pushes the placenta out in squatting without waiting for a contraction.https://youtu.be/AAJPW4p6rzU  I have delivered 1,120 consecutive births in which this was done and not a single woman lost 1000 cc or more and only one (suicidal) woman lost more than 500 cc.  The protocol appeared in the literature in 2010. (1) It has not caught on like attaching wheels under suitcases.  For the past 100 years, throughout the high income world, 1 in 20 women has a postpartum hemorrhage,  losing at least one liter of her approximately 3 liter blood volume at birth.   Some of them need a blood transfusion which involves the risks of transfusions such as bloodborne diseases and transfusion reactions.  Women after hemorrhaging who do not get blood transfusions are more prone to infections.Attempts to publish this data retrospectively has been rejected because it is not a randomized controlled trial (RCT). This censorship of a logical, life saving protocol is dubious at best since a RCT could never be blinded.  The same doctor or midwife who assists the woman to deliver the placenta in squatting would also be measuring blood loss, making the study no more objective than a retrospective cohort study.  In addition, a RCT is only needed if there is risk of untoward effects from an intervention such as from a drug, vaginal checks or breaking the sac.  Here nothing is done to the woman.  The woman getting into a squat a minute or two after the birth and pushing out the placenta has no side effects other than limiting blood loss. Like suitcase wheels, there is no scientific justification for RCT testing for expedient squatting delivery of the placenta.To date, a reasonable explanation for not publishing this retrospective cohort study does not appear to exist.  Could it be the desire to maintain the status quo is due to the profitability of hemorrhage in all birth settings?  What I do know is, like wheels on suitcases, all you have to do is try it once to see how well it works.Judy Slome Cohain, CNMAlon Shvut, Israel 904331.Cohain JS. A Proposed Protocol for Third Stage Management-Judy’s 3,4,5,10 minute method. Birth 2010; 37(1)84-5.

Abstract Objective: To compare current the third stage management to expedient squatting at 3 minutes postpartum. Design, Setting, Sample and Methods: A retrospective cohort study of 1,098 planned, attended low risk vaginal births in Israel using Judy’s 3,4,5 minute third stage protocol compared to 2,691 attended low risk vaginal births in British Columbia using various forms of active or expectant management of the third stage of labor. Main Outcome measures: PPH>1000, PPH>500 and manual removal of placenta Results: Among similar groups of low risk births, active management, or expectant management resulted in 4.1% PPH over 1000 cc, whereas Judy’s 3,4,5 minute protocol resulted in 0% PPH over 500 cc. Conclusion: Evidence supports less postpartum bleeding and postpartum hemorrhage when women deliver the placenta in squatting 3 minutes after birth. The risks are minimal and the data suggests the likelihood of a very positive outcome, making it recommended for practitioners in all settings to try it.

­Letter to the Editor, BJOG Exchange

Background: Postpartum hemorrhage (PPH) was deadly prior to blood transfusions, and therefore either never existed or was eliminated by evolution millions of years ago. No animals hemorrhage. Human PPH appears to be a relatively recent occurrence, perhaps coinciding with the decrease in the use of squatting. The first documented case of human postpartum hemorrhage appears around 1400 AD. Regardless of which third stage protocol is used, 95% of low risk women do not hemorrhage, but about 5% do. A protocol called Judy’s 3,4,5 calls for squatting out the placenta between 3 and 5 minutes postpartum in order to lower the 5% PPH rate to the same rate as experienced by other mammals, i.e. zero. Methodology: A retrospective cohort study of 1,027 planned, attended low risk vaginal births in Israel using Judy’s 3,4,5 minute third stage protocol compared to 2,691 attended low risk vaginal births in British Columbia using various forms of active or expectant management of the third stage of labor. Results: Among similar groups of low risk births, active management, or expectant management resulted in 4% PPH over 1000 cc, whereas Judy’s 3,4,5 minute protocol resulted in 0% PPH over 500 cc. Conclusion: Judy’s 3,4,5 minute protocol is logical, using gravity to deliver the placenta expediently. It results in 0% postpartum hemorrhage over 500 cc and an average blood loss of 100 cc in the first hour after the birth of the newborn, which compares favorably to any other third stage protocol.

Background: Postpartum hemorrhage was a deadly characteristic eliminated by evolution. No animals hemorrhage. The first case of documented human postpartum hemorrhage appears in the literature around 1400 AD. Human PPH appears to be a relatively recent occurrence, perhaps coinciding with the decrease in the use of squatting. A protocol called Judy’s 3,4,5 calls for squatting delivery of the placenta between 3 and 5 minutes postpartum. Methodology: A retrospective cohort study of 1,024 planned, attended homebirths in Israel using Judy’s 3,4,5 minute third stage protocol compared to 2,691 planned homebirths resulting in vaginal births in British Columbia using active management or expectant management of the third stage of labor. Results: Among similar groups of low risk births, active management, or expectant management resulted in 4.1% PPH over 500 cc, whereas Judy’s 3,4,5 minute protocol resulted in 0% PPH over 500 cc. Conclusion: Judy’s 3,4,5 minute protocol continues to result in less blood loss than any other third stage protocol at vaginal birth. The average blood loss is 100 cc for the first two hours after the birth of the newborn.