Is the Crede's (controlled cord traction) method safe for placental delivery?

Safety of Crede's Method for Placental Delivery

Crede's method (controlled cord traction) is not recommended for placental delivery as it is associated with increased risk of uterine inversion, hemorrhage, and maternal trauma.

Understanding Placental Delivery Methods

Placental delivery is a critical component of the third stage of labor. Several methods exist:

• Controlled cord traction: Applying gentle traction on the umbilical cord while providing counter-pressure on the uterus 1
• Manual removal: Direct removal of the placenta using the operator's hand 1, 2
• Spontaneous delivery: Allowing the placenta to separate and deliver without intervention 2
• Placental drainage: Allowing blood to drain from the placenta, which may reduce third stage duration 3

Evidence Against Crede's Method

Risks and Complications

• Crede's method (controlled cord traction with excessive fundal pressure) can lead to acute uterine inversion, a rare but potentially life-threatening complication 4
• In documented cases of uterine inversion following Crede's maneuver, patients have experienced:
  • Severe hemorrhage (up to 2500 ml blood loss)
  • Shock
  • Severe coagulopathy requiring intervention 4

Preferred Approaches for Placental Delivery

For Vaginal Deliveries:

• Placental drainage significantly reduces the duration of the third stage of labor compared to controlled cord traction (3.24 minutes vs. 8.57 minutes in primigravidas) 3
• When controlled cord traction is used, it should be performed with gentle traction while providing counter-pressure on the uterus to prevent inversion 1

For Cesarean Deliveries:

• Current recommendations suggest against manual removal of the placenta during cesarean delivery 1
• Spontaneous delivery of the placenta is associated with:
  • Lower mean drop in hematocrit (2.65% vs. 5.57% with manual removal)
  • Significantly lower risk of postpartum infectious morbidity 2
• However, a more recent study found clinically insignificant differences between controlled cord traction and manual removal during cesarean section 5

Clinical Recommendations

1. For vaginal deliveries: Consider placental drainage as a preferred method for placental delivery, as it significantly reduces third stage duration 3

2. For cesarean deliveries: Allow for spontaneous placental delivery when possible, as it results in less blood loss and lower infection risk 2

3. Avoid aggressive Crede's maneuver with excessive fundal pressure, as this increases the risk of uterine inversion 4

4. When using controlled cord traction:

   • Apply gentle, steady traction on the cord
   • Always provide counter-pressure on the uterus
   • Discontinue if resistance is encountered 1, 5

Important Considerations

• Clinicians should be trained in managing complications of placental delivery, including uterine inversion, as these are rare but potentially life-threatening 4
• The ideal method of placental delivery may vary based on clinical circumstances, but safety should always be prioritized 1, 5
• Excessive force during any placental delivery method should be avoided to prevent maternal trauma 4, 2