Immediately after the delivery of the infant, the umbilical cord is clamped. The placenta should be allowed to separate spontaneously, assisted with gentle traction. This process can take several minutes, and often the mother and baby have already been moved from the ED to the labor and delivery suite before the placenta delivers. Aggressive traction on the cord risks uterine inversion, tearing of the cord, or disruption of the placenta, which can result in severe vaginal bleeding. 12
After the removal of the placenta, the uterus should be gently massaged to promote contraction. Oxytocin (20 U in 1 L of 0.9 normal saline) is infused at a moderate rate to maintain uterine contraction (Table 10.3:2). Uterine atony may follow a precipitous delivery and may lead to excessive vaginal bleeding. Additional oxytocin may be administered, as well as methyl ergonovine (Methergine) 0.2 mg [intramuscularly (IM) only] or prostaglandin F-2 alpha (Hemabate) 0.25 mg IM. With significant postpartum hemorrhage, vigorous bimanual massage should be continued while contractile agents are administered. Episiotomy or laceration repair may be delayed until an experienced obstetrician is able to close the laceration and inspect the patient for fourth-degree (rectovaginal) tears. 13
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