Original Articles

By Ms. Judy S Cohain
Corresponding Author Ms. Judy S Cohain
Independent Researcher, Alon Shvut 37 - Israel 90433
Submitting Author Ms. Judy S Cohain

PPH, Third Stage Management, Active managment, Expectant management, Retained placenta

Cohain JS. Judys 3-4-5 Protocol: Combining the Best Parts of Active and Expectant Management of Third Stage of Labor for Lowest PPH > 500 cc and no PPH >1000 cc. WebmedCentral OBSTETRICS AND GYNAECOLOGY 2012;3(3):WMC002993
doi: 10.9754/journal.wmc.2012.002993

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 04 Mar 2012 02:56:56 PM GMT
Published on: 05 Mar 2012 01:33:59 PM GMT


Objectives: To find a third stage protocol that is easy to perform consistently, that results in lower  PPH rates than active management.
Methods: Judy’s 3,4,5 protocol was tested in 425 consecutive births.
Results: 0.7% PPH rate > 500 cc and 0% PPH > 1000 cc, 0% blood transfusions, 1 placenta accreta removed by manual extraction at 30 minutes postpartum.
Conclusions: Judy’s 3,4,5 combines the expedience of active management, delayed cord cutting of expectant management with the use of gravity and the abdominal and diaphragm muscles, to obtain the lowest PPH rates as well as the lowest retained placental rates reported to date.


The primary advantages to attended over unattended births is having a trained attendant to prevent or treat postpartum hemorrhage (PPH), prevent tearing, and resuscitate newborns. Despite the fact that preventing PPH is one of the three primary functions of attendants at the time of birth, there has been a paucity of research into how to prevent PPH.
The Cochrane Review of Randomized Controlled Trials of third stage management found Active Management of the Third Stage to result in 5% PPH rates (>500 cc) compared to  14% PPH rates(>500 cc) for expectant management at hospital births(1). This was the foundation that led to the use of active management for millions of women. However all studies reviewed had varying definitions for active and expectant management. Noncompliance to expectant management protocol ranged up to 66%. (2) Evidence justifying either the use of active OR expectant management for low risk women is lacking. (2) The lack of quality evidence results in practitioners not knowing the best way to deliver the placenta in the case of low risk women. Active management involves uterotonics which can cause intense abdominal pain which delays the initiation of nursing. Expectant management has higher rates of PPH and thereby interferes with bonding and postpartum recovery. A survey from Canada found only 77% of obstetricians, 60% of family practitioners and 80% of midwives think Active management of 3rd stage of labor is evidence based.(3) Another 8% of obstetricians, 20% of family practitioners and 39% of midwives think that expectant management of 3rd stage of labor should be routine in low-risk women.(3) Practices varied widely in this survey. Popular techniques for delivering the placenta were: Controlled cord traction (75%), Waiting for signs of spontaneous separation (66%) or Expectant waiting for placenta (31%). Popular techniques used to facilitate placenta delivery was: Mother actively pushing (57%); Nipple stimulation (37%); None (24% ); Emptying the Bladder (23%); Woman in upright position ( 22%). Almost 90% said they agree with the SOGC (Society of OBGYN Canada) guideline for active management of third stage management, but most did not adhere to it as described in the guideline. (3)
Is 5% the lowest obtainable PPH rate?
The Cochrane review (1) recommended active management because it resulted in the  lower  PPH rate of 5%, and lower PPH decreases short and long term maternal morbidity.  Is 5% the lowest possible PPH rate or can this be improved upon with a better protocol?    
Rates of PPH lower than 5% have been recorded in four studies among low risk women who planned to deliver at home, but none of these used a reproducible third stage management protocol making it impossible to know if it was due to low risk women or a protocol that was used or a combination of both:
4.4% PPH >1000 cc of 862 women with 0.3% blood transfusions (5);
3.8% PPH >500 mL for vaginal births among  2899 women who planned to have a homebirth(6);
2.8% rate of PPH (1.9% >500 mL & 0.6% > 1000 mL & 0.3% >1,500 mL) (7). 2.5% PPH among 15,198 low risk women. (8)  All of the above studies use a conglomerate of protocols for third stage management that cannot be replicated.
There are no studies, other than my own, on Medline reporting on delivering the placenta in squatting position. In 2010, I reported a 0.6% PPH rate > 500 mL;  0% PPH> 1000 mL among 350 planned attended homebirths delivering the placenta in squatting at 5 minutes protocol described below.  Expectant management in a matched sample of 800 births resulted in 2.2% PPH > 500 cc and 0.5% PPH >1000.(9) The exclusive use of this method has now provided  0.7% PPH rate >500 (3/425), 0% > 1000 cc for 425 births with no blood transfusions given. Exclusion and inclusion criteria are listed in Table 1. Women at higher risk of PPH such as fetal macrosomia > 4000 g, previous CS, anemia, and Prolonged first and second stages composed 20% of the study group, yet the PPH rate was the lowest reported to date. This implies that the 3,4,5 protocol may be beneficial to women in all risk categories.


Required Equipment: Digital watch that displays hours, minutes and seconds, bowl.
At the 36-week prenatal visit, the midwife squats in front of the client to demonstrate exactly how the woman will deliver her placenta 5 minutes after the birth. The client’s consent is obtained. After birth, immediate continuous skin-to-skin contact with the baby is initiated for the first 3 1 ? 2 minutes postpartum. At 3 minutes, using 2 fingers other than the thumb, the cord is checked to see if it has it is pulsing, has a pulse. The nonpulsing cords are cut at 3 minutes postpartum while the baby is in her mother’s arms unless mother chooses for it not to be cut. The midwife keeps hands off the fundus. At 4 minutes: The midwife directs the mother into a squatting position on the floor or on the floor of an empty bathtub, over a plastic bowl on a plastic sheet. If the mother has agreed to the cord being cut, the mother hands the baby to someone. The midwife waits until 5 minutes postpartum for the placenta to be born without intervention other than verbal encouragement to push without feeling a contraction.  If the placenta is not born by 5 minutes, the midwife assists the cord to come further out by gently pulling it down about5 cmin 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 to put on an absorbent pad and underwear, assisted into bed, and immediately given the baby. The uterus is then immediately massaged to check for clots. If bleeding fills 10 X20 cmabsorbent pad 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 encouraged and initiated asap, and generally takes place between 10 and 45 minutes postpartum depending on the baby. In the case of a woman with a history of PPH > 1000 mL on previous birth(s), or delivering twins, methergine 0.4 cc IM is given as soon as placenta is delivered.

Why Judy

1. Lower PPH rates than active management
2. Lower retained placenta rates
3. Lower rates of incomplete placental delivery
4. Expedient
5. Physiological
6. No cord cutting required
7. Optimizes bonding time between mother and newborn
8. Avoids uterotonics whenever possible
9. Bonding takes place in clean, dry bed
10. Easily reproduced with sign language or 385 word explanation
11. Simple equipment
Published evidence supporting Judy’s 3,4,5 comes from Magann. Magann(4) elucidated the exact rate at which PPH increases related to passage of time after the birth. Using strict active management protocol, delivering the placenta at 5 minutes results in the lowest percent of postpartum hemorrhage (PPH) where PPH is defined as bleeding > 500 cc in the first 20 minutes postpartum. Delivering the placenta at 10 minutes involved twice as many PPH and delivering the placenta at 20 minutes involved six times as many PPH.   From this study, it appears that expedience is the critical factor in preventing PPH.  
Support for Judy’s 3,4,5 also comes from the physiology of third stage. The baby takes up most of the space in the uterus, being about 5 times the size of the placenta. The top or fundus of the uterus is pulled down by the vacuum formed as the baby exits, since air is unable to rush into the uterus as the baby is born.  As the baby leaves the uterus, the uterus becomes much smaller, by folding and contracting down. As the uterus changes shape, the placenta is shorn off the wall by this dramatic change in the shape and size of the uterus. In about 1% of cases, the placenta separates completely simultaneously with the birth and delivery of the placenta follows immediately after the baby with no time in between the two. This is more usual with the aid of gravity when the birth took place in squatting position. In the other 99% of cases, within 3 minutes of the birth, the placenta is completely separated from the wall of the uterus. If the woman is laying or sitting, the placenta is sitting or laying down also. The placenta is large and sticky and the opening of the uterus is smaller than the placenta. That is why it does not fall out while she is sitting, and cannot deliver until the uterus and/or woman pushes it out or it is pulled out.  If the woman gets into squatting position, at 4 minutes, gravity and the diaphragm pulls and pushes the placenta down towards the opening of the uterus and it delivers. Once the placenta is delivered, the uterus is able to contract completely, preventing excessive blood loss.  Bleeding uses up clotting factors, therefore bleeding begets more bleeding as clotting factors are diminished, which explains why delay of the delivery of the placenta of even 5 minutes is the most common cause of PPH > 1000 mL. Preventing PPH > 1000 mL is much easier and more effective than treating it.
Previous protocols teaching the attendant to wait for a gush of blood ignore the fact that when the placenta is ready to deliver, bleeding may not be apparent because the heavy, sticky placenta blocks blood from going out the opening of the uterus (os). Tragically in these cases, bleeding accumulates in the uterus above the placenta, forming into large clots. The amount of blood loss only becomes apparent after the placenta is delivered. At delivery, the placenta may be accompanied by a large clot.    One can quickly calculate blood loss by estimating the diameter of the clot if it were rounded into a ball. Practitioners are used to estimating measurements between 3 and10 cm. when they estimate dilation. If the clot is the equivalent of a5 cmdiameter ball it equals 65 cc of blood because we know from math that Volume = 4/3 X 3.14 X radius³. If it is a clot the equivalent of an8 cmdiameter ball, it equals 267 cc of blood loss. If the clot is the equivalent of a10 cmdiameter ball, then it is equivalent to 522 cc blood loss i.e. PPH because > 500 cc is the definition of a PPH. Instead of waiting and discovering a large clot after the placenta delivers, it is more logical to deliver the placenta at 5 minutes before such a large clot forms in the uterus.
Instructions to wait for contractions after birth ignore the fact that Immediately after birth of the baby, the cervix begins to close. It is unknown how long this process takes but it begins immediately after the baby exits the cervix. Retained placenta is a result either of placenta accreta or delayed delivery of the placenta. Retained placenta can be caused by the placenta being trapped behind a closed cervix. Delivering the placenta expediently avoids most incidences of retained placenta.  Except for the rare case of placenta accreta, retained placenta can be prevented with expedient delivery of the placenta.
Common, non-evidence based, objections to Judy’s 3-4-5:
1. Resistance to change. Resistance to trying new things. Resistance to calculating and documenting one’s PPH rates.
2. The once familiar physiological position of squatting position is no longer familiar.
3. Interferes with bonding for the minute between 4 and 5 minutes postpartum.
NB. Science to support a critical bonding period between at exactly 4 minutes postpartum that is different from other minutes is lacking. On the contrary, most women are not strongly bonding at 4 minutes but rather recovering from the physical experience/pain of vaginal stretching and/or have low tolerance for sitting in the puddle of amniotic fluid, urine, blood, and feces. Although research is lacking, it is plausible that the majority of women bond better with their uterus well contracted in a clean bed with the third stage completed.
4. The suggestion that cords are still pulsing at 4 minutes is not a problem. Cutting the cord is a voluntary step in this protocol.


It is thrilling as a midwife, to minimize blood loss and start an uninterrupted bonding and nursing period, (not interrupted by PPH or delivery of placenta and subsequent clean up) by delivering the placenta which is sitting in the uterus, waiting to come out, at 5 minutes. A desire to have women start motherhood with the least possible blood loss is a logical motivation for finding the best way to deliver the placenta. Practitioners are encouraged to calculate their PPH rates and if they are over 1%, to consider trying this protocol or engaging in research that will find a protocol that provides a PPH rate under 1%.

Table 1: Inclusion and Exclusion factors for 425 consecutive births

Exclusion criteria:

CS (1), forceps, vacuum  (0)
Oxytocin in labor (2)
Epidural or spinal in labor (0)
Renal disease (0)
Antepartum hemorrhage (1), Placenta previa (0)
Fetal growth restriction (1)

Inclusion Criteria (some births included in more than one factor)

Parity = or >6                                8%
Fetal macrosomia > 4000               7%
1,2, or 3 Previous Cesareans          8%
Labor stage 1 >13                         7%
Labor stage 2 >3 h                       1.5%
Anemia in pregnancy = < 100 g/L = 1%, between 100-110 g/L =93%
Second degree tear = 22, third degree = 0
Polyhydramnios AFI>50 = 2
Oligohydramnios AFI< 5 = 2
Gestational diabetic = 4
Twin birth = 1
>42 weeks = 2
serious Shoulder dystocia = 2  (4300 g,4700 g)
PROM > 24 hours = 2
Breech = 5
Medical problem = 1 Anorexic, 1 CAH, 1 serious vestibulitis NVA, Hx of PPH >1000 mL = 2, Hx of 4 miscarriages and low Factor 5, CMV +
Placenta accreta requiring manual extraction =1
Surgery this pregnancy = 0
BMI 40+  =0       BMI 31 = 3


1. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database
Systematic Rev 2000;3:CD000007.
2. Fahy KM. Third stage of labour care for women at low risk of postpartum haemorrhage. J Midwifery Womens Health 2009;54(5):380–386.
3.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.
4. 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.
5 Janssen PA, Lee SK, Ryan EM, et al. Outcomes of planned home births versus planned hospital births after regulation of midwifery inBritish Columbia. CMAJ 2002;166(3):315–323.
6. 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.
7. Fahy K, Hastie C, Bisits A, Marsh C, Smith L, Saxton A. Holistic ‘physiological’ care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study. Women Birth. 2010;23(4):146-52.
8. Malabarey O, Almog B, Brown R, Abenhaim HA, Shrim A. Postpartum hemorrhage in low risk population. J Perinat Med. 201;39(5):495-8.    
9. Cohain JS. A Proposed Protocol for Third Stage Management- the 3,4,5,10 minute method. Birth 2010: 37(1)84-5.

Source(s) of Funding


Competing Interests



This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)