KEY STEPS IN THE SAFE DELIVERY AND INSPECTION OF THE PLACENTA

The third stage of labor, which begins immediately after the birth of the infant and ends with the delivery of the placenta and fetal membranes, is a critical period in childbirth. Meticulous management of this stage and a thorough subsequent inspection of the placenta are paramount for maternal and neonatal well-being. These procedures are fundamental skills for obstetricians, midwives, and labor and delivery nurses, as they are crucial for preventing and identifying postpartum hemorrhage (PPH), retained placental tissue, and other potential complications.

The Delivery of the Placenta (Third Stage of Labor)

The management of the third stage of labor can be approached in two primary ways: active management or physiological (expectant) management. The choice of method often depends on institutional protocols, the provider’s assessment of maternal risk factors for hemorrhage, and the patient’s preferences.

A. Active Management of the Third Stage of Labor (AMTSL)

AMTSL is a series of interventions recommended by the World Health Organization (WHO) and other leading obstetric bodies to reduce the incidence of PPH, the leading cause of maternal mortality worldwide. It is the preferred method in most clinical settings due to its proven efficacy in reducing blood loss and shortening the duration of the third stage. AMTSL consists of three core, sequential steps:

1. Administration of a Uterotonic Agent: The cornerstone of AMTSL is the prompt administration of a prophylactic uterotonic drug. The most commonly used agent is oxytocin (typically 10 IU administered intramuscularly). This is given within one minute of the baby’s birth, often as the anterior shoulder is being delivered or immediately after the birth is complete. The purpose of the uterotonic is to stimulate strong, sustained uterine contractions, which constrict the spiral arteries at the placental site and facilitate placental separation while minimizing bleeding.
2. Controlled Cord Traction (CCT): Once signs of placental separation are evident, CCT is performed to assist in the delivery of the placenta. It is vital that this is only done after a uterotonic has been given and the uterus is well-contracted.
   • Step-by-Step CCT:
     • Place one hand on the maternal abdomen just above the pubic symphysis. Apply firm, upward pressure on the uterine body (suprapubic counter-pressure). This technique, known as the Brandt-Andrews maneuver, stabilizes the uterus and prevents uterine inversion, a rare but life-threatening emergency where the uterus turns inside out.
     • With the other hand, grasp the umbilical cord clamp close to the perineum.
     • Apply gentle, steady downward and backward traction on the cord, following the curve of the birth canal. Never pull or jerk the cord. Traction should be paused if there is resistance or if the mother experiences significant pain.
     • As the placenta emerges from the introitus, gently cup it in both hands and use a slight twisting motion to guide the trailing membranes out, preventing them from tearing.
3. Uterine Massage: Immediately following the delivery of the placenta, the uterine fundus should be massaged vigorously through the abdominal wall until it feels firm and contracted (often described as feeling like a grapefruit or a hard ball). This ensures uterine atony does not develop and helps expel any remaining clots from the uterus. The fundus should be assessed for tone regularly in the immediate postpartum period.

B. Physiological (Expectant) Management

Physiological management involves waiting for spontaneous placental separation and delivery without the routine use of uterotonics or CCT. It is often chosen by women who desire minimal intervention during their birth experience and who are at low risk for PPH.

1. Awaiting Signs of Separation: The provider waits for natural signs of placental separation to occur. These classic signs include:
   • A sudden gush of blood from the vagina.
   • Lengthening of the visible portion of the umbilical cord.
   • The uterus becoming firmer, more globular, and rising in the abdomen.
   • A palpable suprapubic bulge as the detached placenta descends into the lower uterine segment.
2. Maternal Effort and Gravity: Once signs of separation are present, the mother is encouraged to bear down (push) with the next contraction. Gravity can also be used to assist delivery by having the mother in an upright or squatting position. The placenta is then delivered by this maternal effort. If the membranes are trailing, they can be gently guided out.

The Inspection of the Placenta

A meticulous and systematic examination of the placenta, umbilical cord, and membranes is a non-negotiable step following every birth. Its primary goals are to ensure completeness, thereby ruling out retained products of conception, and to identify any abnormalities that may have implications for the mother or the infant.

Preparation: The inspection should be performed in a well-lit area on a clean, flat surface, such as a designated tray or an absorbent pad. The examiner should wear appropriate personal protective equipment, including gloves.

Step-by-Step Inspection Process:

1. Examine the Maternal Surface (Decidua Basalis):
   • Lay the placenta flat with the maternal side facing up. This surface is deep red and spongy, divided into 15-20 distinct lobes called cotyledons, which are separated by grooves.
   • Carefully check that all cotyledons are present and fit together like a jigsaw puzzle. A missing or sheared-off portion suggests that placental tissue may have been retained in the uterus, a major risk factor for secondary PPH and infection.
   • Gently palpate the surface for abnormalities such as gritty calcifications, which are common and usually benign, or firm, pale areas indicative of infarction. Examine for any adherent blood clots, particularly a retroplacental clot, which may suggest a placental abruption occurred.
2. Examine the Fetal Surface (Chorionic Plate):
   • Turn the placenta over. The fetal surface is smooth, shiny, and grayish-translucent, covered by the amnion. The umbilical cord typically inserts near the center, and large fetal blood vessels can be seen radiating from the cord insertion site towards the placental edge.
   • Cord Insertion: Note the location of the umbilical cord insertion. While typically central or slightly off-center (eccentric), abnormal insertions are clinically significant.
     • Marginal Insertion (Battledore Placenta): The cord inserts at the very edge of the placenta.
     • Velamentous Insertion: The cord inserts into the fetal membranes, and the umbilical vessels travel unprotected through the membranes before reaching the placental disc. This is a high-risk condition, as these exposed vessels are vulnerable to compression or rupture, potentially leading to fetal hemorrhage (vasa previa).
   • Trace the course of the blood vessels to ensure none appear to have been torn near the placental edge, which could also indicate a succenturiate lobe (see below).
3. Examine the Membranes (Amnion and Chorion):
   • Lift the placenta by the cord and allow the membranes to hang. The amnion and chorion should form a complete sac with a single hole through which the baby passed.
   • Inspect for completeness. Ragged or incomplete-looking membranes may suggest a portion has been retained.
   • Look for vessels running across the membranes that appear to end abruptly in a tear. This is a classic sign of a retained succenturiate lobe—a small accessory lobe of placental tissue that developed separately from the main disc but was connected by fetal vessels. If this lobe is retained, it poses a significant risk for PPH.
   • Note the color and odor of the membranes. Green or yellow staining indicates meconium passage in utero. Foul-smelling, cloudy, or opaque membranes are signs of chorioamnionitis (intra-amniotic infection).
4. Examine the Umbilical Cord:
   • Count the vessels in a freshly cut section of the cord. A normal cord contains two arteries and one vein (AVA). The presence of a single umbilical artery (SUA) occurs in approximately 1% of pregnancies and can be associated with congenital anomalies, particularly renal, cardiac, and gastrointestinal defects.
   • Note the presence of any true knots, which can tighten during labor and compromise fetal blood flow. Differentiate these from more common false knots, which are simply kinks or bulges in the vessels.
   • Assess the cord length. An average cord is 55-60 cm long. An exceptionally short cord may be associated with placental abruption, while an excessively long cord increases the risk of nuchal cords or true knots.

Documentation: Finally, all findings from the placental examination should be meticulously documented in the patient’s medical record. This includes the placenta’s weight and dimensions, the cord insertion site, the number of cord vessels, confirmation of completeness of the placenta and membranes, and a description of any abnormalities found. If significant abnormalities are identified, the placenta should be sent to pathology for further analysis.

In conclusion, the skilled management of placental delivery and the subsequent detailed inspection are foundational components of safe obstetric care. By adhering to these systematic processes, healthcare providers can effectively minimize maternal risk, identify potential postpartum issues, and gather vital information that contributes to the holistic care of both mother and newborn.

References

1. World Health Organization (WHO). (2018). WHO recommendations: uterotonics for the prevention of postpartum haemorrhage. Geneva: World Health Organization.
2. American College of Obstetricians and Gynecologists (ACOG). (2017). Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology, 130(4), e168-e186.
3. Begley, C. M., Gyte, G. M. L., Devane, D., McGuire, W., & Weeks, A. (2019). Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews, (2), CD007412.
4. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Spong, C. Y. (Eds.). (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education.
5. Royal College of Midwives (RCM). (2016). Evidence Based Guidelines for Midwifery-Led Care in Labour: Care of the Woman and Baby in the Third Stage of Labour. London: RCM.