This protocol works for all non-vacuum, non-forceps, non-epidural, non-hemophiliac vaginal births in which the woman is in squatting at 2 minutes and pushes the placenta out by 3 minutes.
5% to 10% of women are currently experiencing unnecessary postpartum hemorrhage because they are not getting into a full squat at 2 minutes after normal vaginal births and pushing out the placenta without waiting for a contraction. 0.7% of women will need manual removal of the placenta performed by 15 minutes after birth. Half of those are because the cervix closes before the woman pushes the placenta out, and half are due to placentas fully or partially grown into the wall of the uterus.
N.B. The protocol calls for manual removal being done if the placenta has not delivered by 15 minutes postpartum. If the placenta is right at the cervix, it could be the cervix is closed or the woman is just too tired to squat and push, and expedient manual removal is required because the uterus cannot contract with the placenta inside. If the placenta has not delivered and is not found sitting next to the cervix, then the placenta is likely grown into the wall of the uterus and manual removal must also be done by 15 minutes postpartum because in some of those cases, some of the placenta has separated causing uterine bleeding.
The protocol has yet to be tested on women with rare disorders such as hemophilia. All women should avoid episiotomy, forceps, vacuum, and cesarean births which all cause excess bleeding. Women with epidurals need to be assisted into squatting, but so far only a handful of women have tried it, all successfully.
Women who are sickly, such as hemophiliacs, women with a history of previous severe postpartum hemorrhage, or those with rare blood clotting disorders, should do expedient squatting to deliver the placenta but get into squatting before 2 minutes (such as at 1 minute or 1.5 minutes after the birth). Women with a history of one or more previous cesareans also should squat at 1.5 minutes and start pushing to prevent hemorrhage. Women who deliver vaginally for the first time after one or more cesareans are at risk for postpartum hemorrhage if they are unwilling to get into squatting 2 minutes after the birth. They also have a 1 in 200 risk of the placenta being partially or fully grown into the uterine wall (instead of the usual 1 in 2,000 risk), which makes them need manual removal more often.