## Correct Answer: B. Controlled cord traction Controlled cord traction (CCT) is the gold-standard technique for safe delivery of the placenta in the third stage of labor, recommended by WHO, FIGO, and Indian guidelines (NITI Aayog/FOGSI protocols). The maneuver described—applying **counterpressure above the pubic symphysis** (to prevent uterine inversion) while **gently pulling the umbilical cord**—is the pathognomonic description of CCT. This technique reduces postpartum hemorrhage (PPH) by 60–70% compared to expectant management, prevents uterine inversion, and shortens the third stage. The counterpressure (one hand on the lower abdomen above the symphysis pubis) stabilizes the uterus and prevents fundal descent, while the other hand applies gentle, steady traction on the cord only during contractions. This is part of **active management of third stage of labor (AMTSL)**, which includes oxytocin administration (5–10 IU IM/IV), early cord clamping, and CCT. In Indian obstetric practice, CCT is the standard of care in all delivery settings—primary health centers, community health centers, and tertiary hospitals—as it significantly reduces maternal morbidity from PPH, a leading cause of maternal mortality in India. ## Why the other options are wrong **A. Manual removal of placenta** — Manual removal is performed only when the placenta does not separate spontaneously after 30 minutes of active management or in case of retained placenta. It involves inserting a hand into the uterus to separate and remove the placenta—a completely different procedure with higher infection and hemorrhage risk. The described maneuver (external counterpressure + cord traction) is for *facilitating* placental separation, not manual extraction. **C. Replacement of prolapsed cord** — Prolapsed cord is an obstetric emergency where the umbilical cord lies below the presenting part; management involves emergency cesarean delivery or, rarely, replacement and tocolysis. The described maneuver has nothing to do with cord prolapse—it is a routine third-stage technique applied after fetal delivery is complete. This option confuses cord management with cord pathology. **D. Delivery of shoulder using Lovset maneuver** — Lovset maneuver is a specific technique for delivering the shoulders in a breech presentation by rotating the fetus to bring each shoulder into the anteroposterior diameter. It is performed during the second stage (fetal delivery), not the third stage. The question explicitly states the resident is performing a 'normal vaginal delivery' (implying vertex presentation) and is managing the umbilical cord—clearly a third-stage action, not shoulder delivery. ## High-Yield Facts - **Controlled cord traction (CCT)** reduces postpartum hemorrhage by 60–70% and is part of active management of third stage of labor (AMTSL). - **Counterpressure above pubic symphysis** during CCT prevents uterine inversion—a life-threatening complication. - **CCT is applied only during contractions** with gentle, steady traction; jerky or excessive force risks cord breakage and uterine inversion. - **AMTSL components**: oxytocin (5–10 IU IM/IV), early cord clamping (30–60 seconds), and CCT—all three reduce PPH risk. - **Third stage duration** with CCT is typically 5–10 minutes; if placenta not delivered by 30 minutes, manual removal is indicated. ## Mnemonics **CCT = Counter + Cord + Traction** Counter (pressure above symphysis to prevent inversion) + Cord (gentle traction) + Traction (during contractions only). Use this when you see 'counterpressure + cord pulling' in a third-stage scenario. **AMTSL = Oxytocin + Early Clamp + CCT** Active Management Third Stage Labor: give Oxytocin, clamp cord Early, apply Controlled Cord Traction. Remember: all three together reduce PPH by ~60%. ## NBE Trap NBE pairs "manual removal" with "placental delivery" to trap students who confuse active management (CCT) with manual extraction. The key discriminator is the word "gently pulling"—manual removal is forceful and invasive, while CCT is gentle and external. ## Clinical Pearl In Indian primary health centers and ASHA-supported deliveries, CCT is the single most impactful intervention to prevent PPH—a leading cause of maternal death in rural India. Teaching CCT to ANMs and ASHAs has reduced maternal mortality by 15–20% in several state programs. _Reference: DC Dutta's Textbook of Obstetrics (8th ed.), Ch. 12 (Third Stage of Labor); FOGSI/NITI Aayog Guidelines on Prevention of Postpartum Hemorrhage_
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