<div></div><div>Background</div><div>A protocol for preventing postpartum hemorrhage of 500 cc or more at
vaginal birth appeared in 2010. The logic behind the protocol is to get
the placenta delivered expediently because if the placenta is delivered
by 5 minutes, the uterus contracts and closes off the blood vessels
preventing uterine atony. Delivering the placenta in squatting uses
gravity and correct physiology to enable the placenta to come out whole,
avoiding the problem of retained placenta.</div><div>Methodology</div><div>The study group were all the births from Jan. 1, 2000- March 18, 2020
(n=1,024) by the ALL THE WAY HOME birth practice in Israel. All the
midwives who work for ALL THE WAY HOME birth service are licensed. Each
birth outcome was recorded in a patient record and copied onto a google
spreadsheet immediately after each birth.&nbsp; The practice includes low
risk women who fulfill the following criteria: Singleton fetus; cephalic
presentation or breech presentation determined after the onset of labor;
gestational age greater than 35+5 and less than 42 completed weeks of
pregnancy; spontaneous onset of labor; absence of significant
pre-existing disease including heart disease, hypertensive chronic renal
disease or type 1 diabetes; absence of significant disease arising
during pregnancy, including pregnancy-induced hypertension with
proteinuria (&gt; 0.3 g/L by urine dipstick), antepartum
hemorrhage after 20 weeks’ gestation, gestational diabetes requiring
insulin, active genital herpes, placenta previa or placental abruption.
&nbsp; All women consented to delivering the placenta using Judy’s 3,4,5
minute protocol previously described(1-3). All women in Israel have
access to ALL THE WAY HOME birth practice. The practice provides free
homebirth to any woman who cannot afford to pay the inexpensive fee.</div><div>The comparison group were all planned home births attended by registered
midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia,
Canada (<i>n</i> = 2889) (4) Midwifery care is funded by the provincial
Ministry of Health and is accessible to all women in the province who
meet the standards for low obstetric risk&nbsp; The criteria for inclusion in
British Columbia were identical to the study group with 4 additional
exclusionary rules: Gestational age greater than 36 and less than 41
completed weeks of pregnancy; Mother has had no more than 1 previous
cesarean section; Labor might be induced on an outpatient basis using
prostaglandin or amniotomy; and Mother has not been transferred to the
delivery hospital from a referring hospital.</div><div>Results</div><div>Study group: Nulliparous=&nbsp; 266 (26%)</div><div>Comparison group: Nulliparous= 1215/2889 (42%)</div><div>Study: Gave birth vaginally: 100%</div><div>Comparison: gave birth vaginally 2691/2889 (93%)</div><div>Study: Amniotomy 51 (5%), Pitocin augmentation 0 (0%)</div><div>Comparison: Amniotomy 560 (19%), Pitocin augmentation 172/2889 (6%)</div><div>Study: 1 (out of 1,024) case of postpartum hemorrhage over 500 cc. (0%)
Typically, about 20 cc of coagulated blood appears attached to the
placenta and about 80 cc on the diaper pad when the woman gets up to
urinate and changes her pad at two hours postpartum. Five women lost 450
cc. One exceptional case in which the woman wanted to die at birth and
kept screaming “I want to die” lost exactly 800 cc, on a plastic
sheet, collected and measured in a jar. The blood was mixed with
amniotic fluid, so may have been less than 800 cc.</div><div>Comparison: 110 (4.1%) out of 2,691 vaginal births, over 500 cc.</div><div>Study: Manual removal&nbsp;3 (0%)</div><div>Comparison group: Manual removal 560 (19%)</div><div>Conclusions</div><div>Judy’s 3,4,5 prevents postpartum hemorrhage using the simple tool of
expedient squatting between 3 and 4 minutes after birth.&nbsp; A direct
relationship between the occurrence of postpartum hemorrhage (PPH) and
the length of the third stage was established by the elegant 2005 Magann
et al study. IV Pitocin was used immediately after the delivery of the
newborn in every birth. Despite the routine use of prophylactic Pitocin
immediately after delivery of the newborn, PPH was a common result,
however only where the third stage was longer than 3 minutes. Timing of
the delivery of the placenta was the factor associated with PPH, not the
use of Pitocin. “For third stages of labor more than 10 minutes
compared with third stages less than 10 minutes there was twice the risk
of postpartum hemorrhage. For a third stage of labor more than 20
minutes compared with less than 20 minutes there was four times the risk
of postpartum hemorrhage,&nbsp;and for third stages over 30 minutes compared
to those less than 30 minutes there was 6 times the risk of PPH.” (5)
This study underlines the fact that it is expedience rather than IV
Pitocin that prevents PPH. The most common definition for PPH, loss of
over 1000 cc in the first hour, is experienced by about 5% of vaginal
births, even using active management. (6) This bleeding is due to
uterine atony, which means inadequate contraction of the uterus. At
about 95% of vaginal births, the uterus contracts enough after the
birth of the baby to close off the arteries that once supplied the
placenta, regardless of when the placenta delivers.&nbsp; However, 5% of the
time, the uterus does not contract enough after the birth of the fetus
to close off the arteries previously supplying the placenta. The 5% of
cases that suffer PPH are cases where it takes the placenta longer than
3 minutes after the birth of the baby, to deliver. In order to allow the
cord to stop pulsing, the cord should not be cut before 2 minutes
postpartum. Third stage protocol has to take into consideration the need
for the newborn to be attached to the cord for the 1-2 minutes after
birth to provide the correct amount of blood and oxygen to the newborn.</div><div>The largest RCT,&nbsp;studying 849 women, used to justify active management
of the third stage, reported postpartum hemorrhage rates over 1000 cc of
5 to13 percent (6). The postpartum hemorrhage rate, defined as losing
over 500 to 1000 cc in low-risk women, was 4% among 862 home births
(7), and 4% among 2,899 planned home births (4). There is no published
protocol, other than Judy’s 3,4,5 that results in zero postpartum
hemorrhage whether defined as losing over 500 cc or 1000 cc. (8)&nbsp; &nbsp;
Blood loss is hard to measure. However, birth practitioners are familiar
with what 10 cm or full dilation means. A 10 cm diameter ball of blood
equals 524 cc blood loss. If the various clots and blood on the chux pad
add up to a 10 cc diameter ball then the birthing woman had a hemorrhage
over 500 cc. This is the average blood loss at vaginal birth today. &nbsp;
Half a liter or 500 cc is 15% of the woman’s blood volume and although
not life threatening,&nbsp;using expedient delivery of the placenta in
squatting, most of this blood loss can be prevented.</div><div>Except in the rare cases of placenta accreta, the placenta detaches
within a minute of the birth. (9) As the baby delivers, the uterus
changes shape such that the wall the placenta was previously attached
to, no longer exists as it was before.(9)&nbsp; Delivering the placenta by 5
minutes after birth, in squatting, uses gravity to help deliver the
placenta before uterine atony and placental retention occur. In contrast
to this, if the woman is laying down, the placenta detaches and follows
the pull of&nbsp;gravity downward, and ends up laying on the posterior side
of the uterus below the level of cervix. Simultaneously, the cervix
begins to close. When delivering the placenta with the woman laying
down, the placenta has to fight its way out against gravity and the
closing cervix. At births, using active management, where the placenta
is delivered with the woman laying down, 5% experience blood loss over
1000 cc and 1% experience the placenta getting stuck behind a closed
cervix and some women experience both.&nbsp; Manual removal is performed in
about 1% of hospital vaginal births.&nbsp;This can be improved upon by
having the woman squat. The question of what about women who cannot
squat is a valid one. The answer is: Women having babies are young.
Nearly all of them&nbsp;can still squat for a minute if they are motivated to
do so. &nbsp; They are motivated to do so because it prevents them from
having a hemorrhage.</div><div>It is logical for there to be a way to have hardly any blood loss
at birth.&nbsp; No animals other than humans lose more than a spoonful of
blood at birth. Humans have the same placental attachment as apes and
chimpanzees, yet, apes and chimpanzees (10) never hemorrhage except in
zoos where the birth is interfered with. Knowing this, it seems logical
where there is a desire to prevent postpartum hemorrhage, to have the
woman deliver the placenta by 5 minutes postpartum in squatting.</div><div>Disclosure of interests:&nbsp; No conflicts of interest on the part of the
author.</div><div>Contribution to authorship: JSC planned, carried out, analysed
and wrote the work.</div><div>Details of ethics approval: Impossible to get Review Board
(IRB) for homebirth study in Israel. The Review Board refused to
entertain anything outside the hospital setting. Patient consent
received from every participant.</div><div>Funding: All expenses out of pocket of the author.</div><div>References:</div><div>1.Cohain JS. A Proposed Protocol for Third Stage Management- Judy’s
3,4,5,10 minute method. Birth 2010; 37(1)84-5.</div><div>2. Cohain JS. Back to basics to eliminate postpartum hemorrhage at
vaginal birth.&nbsp; Birth 2016;43(1):93.</div><div>3. Cohain JS. Minimizing bleeding and tearing at vaginal births: one
practitioner’s experience. Women and Birth 2018;31(2):e144.</div><div>4. Janssen PA, Saxell L, Page LA, et al. Outcomes of planned home birth
with registered midwife versus planned hospital birth with midwife or
physician. CMAJ 2009;181(6-7):377–383.</div><div>5. Magann EF, Evans S, Chauhan SP, Lanneau G, Fisk AD, Morrison JC.The
length of the third stage of labor and the risk of postpartum
hemorrhage.Obstet Gynecol. 2005;105(2):290-3.</div><div>6. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant
management in the third stage of labour. Cochrane Database Systematic
Rev 2000;3:CD000007.</div><div>7.Janssen PA, Lee SK, Ryan EM, et al. Outcomes of planned home births
versus planned hospital births after regulation of midwifery in British
Columbia. CMAJ 2002;166(3):315–323.</div><div>8. Fahy KM. Third stage of labour care for women at low risk of
postpartum haemorrhage. J Midwifery Womens Health 2009;54(5): 380–386.</div><div>9. Williams JW, Pritchard JA, MacDonald PC (1980). Williams Obstetrics.
16th ed. New York: Appleton-Century-Crofts.</div><div>10.&nbsp;<i>Carter
AM</i>,<i>Pijnenborg
R</i>. Evolution of invasive placentation with special reference to
non-human
primates.<i>Best
Pract Res Clin Obstet Gynaecol.</i> 2011;25(3):249-57.</div><div>A YouTube of placental delivery&nbsp; called,”<i>Judy’s 3.4.5
minute protocol eliminates severe postpartum hemorrhage over 1000 cc</i>shows a woman delivering her placenta using Judy’s 3,4,5.</div>