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Cohain JS: A Proposed Protocol for Third Stage Management- the 3,4,5,10 minute method. Birth 2010;37(1)84-5.

A Proposed Protocol for Third Stage Management

Although postpartum hemorrhage is often touted as a supposed priority on the agendas of maternity practitioners, as well it should be, the first report of a postpartum hemorrhage rate in low-risk women, who represent most women in the Western world, in any medical journal was published in 2002 (1). This study (1) reported a rate of 4.4 percent among 862 home births, and it was followed by a 2009 report of 3.8 percent among 2,899 planned home births (2). Before the second report appeared, the largest randomized controlled trial group studied, which subsequently justified the use of active management on millions of women, was only 849 women, and the postpartum hemorrhage rates varied from 5 to13 percent (3). Unfortunately, due to the dearth of research, not only does very little evidence exist about postpartum hemorrhage in low-risk women, but there is no evidence-based protocol to prevent postpartum hemorrhage for third stage in low-risk women (4). Thus, it is certainly not surprising to find that no accepted protocol exists for third stage management among doctors and midwives (5). I wish to suggest consideration of the protocol I have used for 281 consecutive planned home births, resulting in a 0 percent postpartum hemorrhage rate (>500 ml). My partner has delivered 732 women using „expectant“ management, that is, hands off the fundus, await signs of separation, upright sitting position, and placenta born spontaneously. This management has resulted in a consistent 2,2 percent (16/732) postpartum hemorrhage rate in a population medically and socially identical to the 281 women in my practice. The „3,4,5,10 minute third stage management“ protocol proposed by Judy Cohain is as follows:

3,4,5,10 Minute Protocol for Third Stage Management

Equipment required: Digital watch with hour, minute, and seconds displayed; bowl.

At the 36-week prenatal visit, the midwife squats in front of the client to teach and demonstrate to her exactly how she will deliver her placenta 5 minutes after the birth. The client’s consent is obtained. Immediate continuous skin-to-skin contact with the baby is initiated for the first 3 1/2 minutes postpartum.

The cord is cut at exactly 3 minutes postpartum while the baby is in her mother’s arms. The midwife keeps hands off the fundus. At 4 minutes: The midwife assists or directs the mother, as necessary, into a squatting position on the floor or on the floor of an empty bathtub, over a plastic bowl, by 4 minutes postpartum. The mother generally hands the baby to her partner or midwife. The midwife waits until 4 3/4 minutes (5 minutes) postpartum for the placenta to be born without intervention other than verbal encouragement to push. If the placenta is not born, the midwife assists the cord to come further out by gently pulling it down about 5 cm in length in order to bring the placenta low enough to give the woman an urge to push. The woman is in a squatting position while she pushes out and births the placenta. The time of delivery is noted. A bowl is used to catch the placenta to measure blood loss afterward. Immediately after delivery of the placenta, the mother is assisted into bed, dressed with a sanitary pad, and immediately given the baby.

The uterus is massaged to check for clots.

If bleeding is above average during the next 5 minutes, a shot of either 10 u Pitocin, 0.2 mg methergine intramuscularly, or both is given at 10 minutes postpartum. Early suckling at the breast is initiated, which generally takes place between 10 and 45 minutes postpartum depending on the baby.

The preceding protocol eliminates the drawbacks of routine administration of prophylactic Pitocin (e.g., extremely painful afterbirth pains that disturb the initiation of breastfeeding); early cord clamping (increased newborn anemia); and routine cord traction (increased need for manual extraction). The protocol takes advantage of the forces of gravity, the forces of the diaphragm muscles to assist in delivery, and perhaps the separation of the placenta, and it does so in a timely fashion. As recently as 2005 (6), it was found that the risk of postpartum hemorrhage (>1,000 mg) was twice as high for third stages more than 10 minutes compared with those less than 10 minutes, 4 times as high for third stages more than 20 minutes compared with less than 20 minutes; and 6 times as high for third stages more than 30 minutes compared with less than 30 minutes. The authors concluded that the critical factor in lowering the postpartum hemorrhage rate was the length of the third stage and not routine administration of Pitocin, since every woman received Pitocin on delivery of the shoulder but 5.1 percent of women with vaginal deliveries lost over 1 liter of blood (6). The concept of assisting the woman to take charge in a timely fashion was not suggested. Questions from practitioners about the above protocol are invited. The „3,4,5,10 minute protocol“ may provide a future direction for third stage management of low-risk childbearing women.


1. 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.

2. 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.

3. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Systematic Rev 2000;(3):CD000007.

4. Fahy KM. Third stage of labour care for women at low risk of postpartum haemorrhage. J. Midwifery Womens Health 2009;54(5):380-386.

5. Tan WM, Klein MC, Saxell L, et al. How do physicians and midwives manage the third stage of labor? Birth 2008;35(3):220-229.

6. Magann EF, Evans S, Chauhan SP, et al. The length of the third stage of labor and the risk of postpartum hemorrhage. Obstet. Gynecol. 2005;105(2):290-293.

I dont always get a bowl from the kitchen to deliver placenta, but when i do, I do measure it afterwards in a measuring cup. The 2 women who came closest to 500 cc, I did have a bowl and measured it. 350 and 450. The others usually lose 50-100 cc at birth, including first 10 minutes postpartum. So there is no real need for a bowl.

About 20-30% are in a bathtub without water, so then I can pick it up the clots and measure in measuring cup.

The problems I have found is that sometimes, if not often, I see amniotic fluid flowing into bowl, that follows (remarkably slowly) after the birth of the baby.

Then how do I know how much is blood and how much is amniotic fluid?

Can I only measure clotted blood and spill off the clear stuff that rises to the top, and consider that amniotic fluid? I don’t break the membranes during labor, so maybe this happens more in my practice.

Also, when I was working in the hospital, last year, the midwives unclamp the cord before the placenta delivers and say this makes it easier to deliver the placenta.

I don’t know if this is true.

But it gives one something to do while waiting patiently for a placenta – to watch the blood come out of the cord. I think about 20 cc of deep red blood, negligible really, comes out. Also once there isn’t a metal clamp so conveniently attached to the end of it, less tempting to tug on the cord.

Do you ask because you have found problems measuring in the bowl also?