gynecology and obstetrics
Management of Normal Delivery
Delivery of the Placenta
Active management of the 3rd stage of labor reduces the risk of Postpartum Hemorrhage , which is a leading cause of maternal morbidity and mortality. Active management includes giving the woman a uterotonic drug such as , the clinician gently pulls on the cord and places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. The mother can usually help deliver the placenta by bearing down. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to Uterine Inversion . If this procedure is not effective, the umbilical cord is held taut while a hand placed on the abdomen pushes upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. If the placenta has not been delivered within 45 to 60 minutes of delivery, manual removal may be necessary; appropriate analgesia or anesthesia is required. For manual removal, the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. In such cases, an abnormally adherent placenta ( Placenta Accreta ) should be suspected. The placenta should be examined for completeness because fragments left in the uterus can cause hemorrhage or infection later. If the placenta is incomplete, the uterine cavity should be explored manually. Some obstetricians routinely explore the uterus after each delivery. However, exploration is uncomfortable and is not routinely recommended. 