**Question:** A 24-year-old woman underwent a normal vaginal delivery of a term infant. After the delivery, the placenta does not deliver even after 30 minutes. Which of the following would be the next step for this patient:

A. Observation
B. Oxytocin infusion
C. Manual removal of the placenta (Posterior shoulder impaction)
D. Infection screening and treatment

**Core Concept:**

The process of placental delivery after vaginal delivery is a crucial step to ensure maternal wellbeing and prevent complications. Normally, the placenta is expelled within 10-30 minutes after delivery due to uterine contractions induced by oxytocin, a hormone secreted by the posterior pituitary gland. If the placenta does not deliver spontaneously even after 30 minutes, it indicates a delay in placental delivery, which can lead to complications such as postpartum hemorrhage (PPH), retained placental fragments, and sepsis.

**Why the Correct Answer is Right:**

In this scenario, the correct course of action is to manually remove the placenta (manual vacuum extraction or MVE), also known as the posterior shoulder impaction method. This technique involves manually guiding the placenta out of the uterus by gently pulling on cord and applying traction to the placenta while the mother continues to contract. This method increases the effectiveness of uterine contractions and helps in expelling the placenta, preventing potential complications of delayed placental delivery.

**Why Other Options are Incorrect:**

A. Observation: This option is too simplistic and does not address the potential complications arising from delayed placental delivery.

B. Oxytocin infusion: While oxytocin is a key hormone involved in uterine contractions, providing additional oxytocin infusion may not be necessary or effective in this case, as the primary issue is the delay in placental delivery.

D. Infection screening and treatment: Although infection screening is essential after delivery, it is too broad and does not directly address the issue of delayed placental delivery, which is the primary concern in this scenario.

**Clinical Pearl:**

In cases of delayed placental delivery, it is crucial to promptly employ manual removal techniques like posterior shoulder impaction to prevent complications such as PPH, retained placental fragments, and sepsis. Observation and routine oxytocin infusion may not be effective in addressing the primary issue and can lead to misdiagnosis and delayed intervention. It is essential to prioritize the specific issue at hand, which is delayed placental delivery, and focus on specific interventions to resolve the problem.