Dear Judy

I appreciative your clear description of delivery of placenta at home, delivery is a physiological process , yes any mother can be delivered alone. But postpartum hemorrhage is a leading cause for maternal death all over the word and it can occur in cases who has no risk factors for postpartum hemorrhage, for that reason active management of third stage of labor is used in most of hospitals and delivery sites, so sorry I am with the idea that physiological delivery of placenta should be bounden and active management of placenta should be used in any area where delivery of a mother is conducted

I wonder how familiar you are with the research. Active management, which you say you practice, results in 5% PPH > 500 cc. Expectant management results in 13% PPH > 500 cc. Both result in almost 1% of women needing a blood transfusion. My protocol results in 0.6% PPH = not more than 500 cc and no severe hemorrhages requiring blood transfusion. The only reason you use your protocol is because you have lost the habit of squating. If you are interested in lowering PPH rates in your practice you would at least TRY a protocol like mine which promises to improve outcomes. It only takes one try to see the logic in it. Judy

I also wonder how familiar are you with researches to gain the scientific base to the degree it could be used insetting to decrease postpartum heamorrhge

You have to have a randomized controlled trial comparing your method to ordinary active management of labour , and may be with physiological placental delivery. the trial should be conducted in a multicenteric labour wards , with a large sample size may be thousends women deliverd vaginally. then the reults to be analzed statistically that will give us the idea if the your method is reliable or not. Percents dose not give any idea about the significance of any method .

Thank you for your good nondescript of a method which may replace the ordinary applied methods to prevent postpartum haemorrhage .

I absolutely agree ! I am looking for multicenter wards to try it.

I think active management of the third stage of labour is the best way to prevent postpartum hemorrhage

Dear Dr Entisar Murad. I appreciate your comment, but if you have never tried Judy's 3,4,5 even once, is your preference for active management truly objective?

Isn't it better for accoucher to encourage pushing down of placenta by mother during uterine contractions instead of it being done randomly?

The question is more complicated than it appears. Perhaps the mother is having contractions 3 minutes after birth but is not aware of them because of the amazing miracle of seeing her baby for the first time.

But the real answer is- if you can get 0 PPH using that method, than it would be better. However, if you measure blood loss accurately, using that method results in 1 in 200 PPH > 1000 cc. That can be avoided by directing the woman to push without a contraction in squatting at 4 minutes PP.

I think that blood loss is likely to be less if expulsion of placenta occurs along with uterine contractions when living ligature of myometrial muscle fibers acts at its best.

-I see you are not relating to my observation that often women have contractions and dont feel them immediately after birth.

-My protocol is based on the fact that the placenta separates at 1 minute postpartum and then the uterus continues bleeding more than it needs to, until it can contract after the placenta is delivered. There is no theory for why waiting until the woman FEELS a contraction would decrease blood loss and the research on expectant management shows that waiting for a contraction increases blood loss. Therefore, your thinking is neither supported by theory or research. However, I understand that only a handful of people base obstetric practice on theory or research.