Controlled cord traction involves traction on the umbilical cord, combined with counterpressure upwards on the uterine body by a hand placed immediately above the symphysis pubis. CCT is used on conjunction with drugs that speed up the seperation process i.e. syntometrine.


After the syntometrine is given (with consent) - intramuscularly in the upper outer quadrant of the buttock - you MUST wait for signs of seperation, this will be blood loss and lengthening of the umbilical cord, use the clamps as a guide to cord lengthning.




Maintain your abdominal hand over the uterus, using your flattened fingers just above the pubic bone to aid the placenta as it exits the cervical os into the vagina. Instead of pressure with flattened fingers, the Brandt Andrews manuver may also be used, but this is more uncomfortable for the mother.



Place your fingers in the clamp at the point where the cord is attached, and apply steady cord traction with a downward motion, STOP IF YOU FEEL RESISTANCE. Wait a minute or two and then try again, gently, if you do not feel resistance then continue traction but upward along the curve of Carus as the placenta becomes visible at the the introitus.



When the placenta is visable at the introitus, lift it partially through with the hand holding the clamp.



Remove your other hand from the abdomen and let the placenta fall into your hands. At this point drop the cord and the clamp.



Move the placenta up and down and rotate it gently to bring it through the os. This has been called 'feathering'.



Continue to rotate the placenta to make a thick cord of the trailing membranes, if necessary.



If this is not sufficent, grasp the membranes with the clamp to encompass them laterally.



Rotate the ring forceps to make a thicker cord of membranes and then gently tease the membranes through the introitus by a slight up and down movement.


Important Note: Remember: slow controlled delivery to avoid tearing the cord or membranes.

See the video on delivery of the placenta (model)
(REQUIRES REAL PLAYER TO VIEW)





In two controlled trials this procedure has been compared with less active approaches, sometimes entailing fundal pressure (Bonham 1963, Kemp 1971). In the controlled traction groups a lower mean blood loss and shorter third stages were found, but the trials do not provide sufficient data to warrant definite conclusions about the occurrence of postpartum haemorrhage and manual removal of the placenta.


In one trial patient discomfort was less if controlled traction was used. However, in 3% the cord was ruptured during controlled cord traction.


A rare but serious complication associated with controlled cord traction is inversion of the uterus. Although the association might be with a wrong application of the method, the occurrence of inversion of the uterus still is a matter of concern.


The above mentioned trials have apparently gathered data on women in a supine position. The impression of midwives attending deliveries with the woman in the upright position during the second and third stage is that the third stage is shorter and placental separation is easier, although the loss of blood is more than in the supine position. However, apart from blood loss, these aspects have not been investigated in randomized trials. Presumably controlled cord traction as described in the textbooks would be more difficult to perform in the upright position.


http://www.who.int/reproductive-heal...apter5.en.html

http://www.cochrane.org/reviews/en/ab005462.html

http://www.maqweb.org/techbriefs/tb13activemgmt.shtml

http://library.med.utah.edu