During a full-term vaginal delivery, an obstetrics resident is seen applying counterpressure above the pubic symphysis with one hand while gently pulling on the umbilical cord with the other. Which maneuver is being demonstrated in the image?

Explanation

## Correct Answer: A. Controlled cord traction Controlled cord traction (CCT) is the gold-standard technique for safe delivery of the placenta in the third stage of labour, as per WHO and Indian guidelines (NRHM, FOGSI protocols). The maneuver described—applying **counterpressure above the pubic symphysis** (to prevent uterine inversion) with one hand while **gently pulling the umbilical cord** with the other—is the textbook definition of CCT. The counterpressure hand stabilizes the uterus and prevents inversion, which is a life-threatening complication. The traction hand applies gentle, steady downward pull on the cord, allowing the placenta to separate naturally from the uterine wall via the plane of cleavage. This technique reduces blood loss, shortens the third stage, and decreases the risk of retained placenta compared to expectant management. CCT is now the standard of care in all Indian delivery units and is part of the AMTSL (Active Management of Third Stage of Labour) protocol, which includes uterotonic administration, early cord clamping, and CCT. ## Why the other options are wrong **B. Manual removal of placenta** — Manual removal is an **invasive procedure** performed only when the placenta fails to deliver within 30 minutes despite CCT, or in cases of retained placenta. It requires anesthesia, carries high infection and hemorrhage risk, and is not a routine maneuver. The clinical scenario describes a normal delivery with gentle traction—not manual intrauterine exploration. **C. Bimanual uterine compression** — Bimanual compression involves placing one hand **inside the vagina** and the other on the abdomen to compress the uterus against the symphysis pubis. This is a **hemorrhage control maneuver** used when the uterus is atonic and bleeding is uncontrolled, not a routine placental delivery technique. The described maneuver uses external counterpressure only. **D. Uterine massage** — Uterine massage (fundal massage) is performed **after placental delivery** to stimulate uterine contraction and control postpartum hemorrhage. It is not used during placental separation. The described maneuver specifically involves cord traction during the active phase of third-stage labour, before the placenta is delivered. ## High-Yield Facts - **Controlled cord traction** is the standard technique for placental delivery in the third stage of labour, combining counterpressure and gentle cord pull. - **Counterpressure above the pubic symphysis** prevents uterine inversion, the most feared complication of aggressive cord traction. - **AMTSL (Active Management of Third Stage of Labour)** includes uterotonic (oxytocin 10 IU IM), early cord clamping, and CCT—reduces PPH by 60% vs expectant management. - **Manual removal of placenta** is reserved for retained placenta (>30 min) and requires anesthesia; it is NOT a routine maneuver. - **Bimanual compression** is a hemorrhage control technique for uterine atony, not a placental delivery method. ## Mnemonics **CCT = Counter + Cord** **Counter**pressure (one hand above pubic symphysis to prevent inversion) + **Cord** traction (other hand pulls gently on umbilical cord). Use this to remember the two-handed technique during third-stage labour. **AMTSL: Oxy-Early-Traction** **Oxy**tocin (uterotonic), **Early** cord clamping, **Traction** (controlled cord traction). This is the WHO/FOGSI protocol for active third-stage management in Indian delivery units. ## NBE Trap NBE may lure students who confuse third-stage maneuvers by offering "manual removal" or "bimanual compression"—both are hemorrhage/retention management techniques, not routine placental delivery. The key discriminator is the **two-handed external technique with counterpressure**, which is pathognomonic for CCT. ## Clinical Pearl In Indian delivery units, CCT is the standard taught at all levels (ASHA, ANM, nurse, doctor) because it is simple, safe, and reduces postpartum hemorrhage—the leading cause of maternal mortality in India. A single mistake (aggressive traction without counterpressure) can cause uterine inversion and shock; hence the emphasis on the two-handed technique. _Reference: DC Dutta's Textbook of Obstetrics (8th ed.), Ch. 8 (Third Stage of Labour); FOGSI Guidelines on Active Management of Third Stage of Labour_