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Third stage of labor: events & management
Prophylaxis of PPHDr. Renu Singh
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Labor
• Physiological process• The products of conception passed form uterus to
outside world• Normal labour: spontaneous in onset, at term, vertex
presentation, natural termination without any complications affecting health of mother &/or newborn
• Three stages of labor
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Stages of labour
• First stage : onset of true labour pains to full dilatation of cervix
• Second stage: full dilatation of cervix to expulsion of fetus from birth canal
• Third stage: after expulsion of fetus to expulsion of placenta & membranes (afterbirths)
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Third stage: events
• After expulsion of fetus to expulsion of placenta & membranes (afterbirths)
• Duration :15 min.(primigravida multigravida)• AMTSL:5 minutes
• Placental separation• Placental expulsion
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Placental separation
• Sudden diminution in uterine size following delivery of fetus
• Limited placental elasticity• Creates disproportion between two• Placenta buckles : placental separation• Spongy layer of decidua basalis• 2 ways : central, marginal separation
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Methods of placental separation
Central ( Schultze) separation Marginal (Mathews Duncan) separation
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Expulsion of placenta
• Contraction & retraction of Upper Uterine Segment
• Placenta forced to lie in LUS/upper vagina• Voluntary contraction of abdominal muscles• Expulsion of placenta
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Mechanisms to control bleeding
1. Effective retraction of uterine muscles : Living ligatures
2. Thrombosis of torn sinuses
3. Myotamponade: apposition of walls of the uterus
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Management of third stage
• Most crucial stage• Strict vigilance• Follow protocols
• Expectant management• Active management
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Expectant management
• Look for 3 classic signs of placental separation– Lengthening of U. cord– A gush of blood from vagina signifying separation
of placenta from uterine wall– Change in shape of uterine fundus from discoid to
globular with elevation of fundal height
• Spontaneous/Controlled cord traction (CCT)• Expulsion of placenta :20 minutes
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Expectant management
• Massage the uterus• Intramuscular Oxytocin : 10 IU• Examination of placenta ,membranes, cord• Inspect vulva, vagina & perineum
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CCT
• Modified Brandt Andrews method• Left hand: palmar surface of fingers placed above
pubic symphysis. Body of uterus pushed upwards & backwards
• Right hand: cord traction in downward & backward direction
• Uterus feels hard, contracted
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Examination of placenta ,membranes
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Examination of membranes, cord
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Active management
• AMTSL: Active Management of Third Stage of Labour– Prophylactic uterotonic after delivery of baby ( Oxytocin 10 IU ,IM)– cord clamping, cutting & Controlled cord traction
of U cord– Uterine massage
• Excites powerful uterine contractions ,aid in early placental separation, minimises blood loss & duration of third stage (5 min.)
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Third stage
• Most crucial• Life threatening complications
• PPH(postpartum haemorrhage)• Retained placenta• Inversion of uterus• Pulmonary embolism
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Prophylaxis of PPH
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PPH: hard facts
• Globally in 10-11% women having live births• Duration between onset of massive bleeding
& death: 2 hours• 14 million women worldwide• 1.4 million women die annually
• India : 15-25% of maternal deaths due to PPH
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stage Approximate blood loss(ml)
Volume loss(%)
Signs & symptoms
0 <500 <10 none
ALERT LINE
1 500-1000 15 None/minimal
ACTION LINE
2 1000-1500 20-25 ↓ urine output,↑ PR,↑ RR, postural hypotension, narrow pulse pressure
3 1500-2000 30-35 Hypotension, tachycardia, cold clammy extremities ,tachypnea
4 >2000 >40 Profound shock
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PPH• Primary PPH
– Haemorrhage <24 hrs of birth
• Secondary PPH– Haemorrhage >24 hrs till 6 weeks of birth
• Primary PPH: 4T’s– Tone– Trauma– Tissue– Thrombosis
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Primary PPH:causes
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PPH : risk factors
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Prophylaxis of PPH
• Improvement of health status of mother(Hb>11gm%)• Identify high risk women• Plan for institutional delivery /SBA• Strict vigilance of all women in 3rd stage labor• Practice AMTSL in all• Examination of afterbirths ,should be a routine• Explore Uterovaginal canal following difficult/
instrumental, destructive delivery
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WHO GUIDELINES FOR PROPHYLAXIS OF PPH
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WHO guidelines
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WHO guidelines
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WHO guidelines
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WHO guidelines • Give uterotonics routinely during 3rd stage labor, in
all births• Oxytocin 10 IU IM is drug of choice• Use other uterotonics only when Oxytocin is not
available• Late cord clamping( 1-3 min after birth) is
recommended• Early cord clamping (<1min of birth): not
recommended until the neonate is asphyxiated & needs immediate resuscitation
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MCQ1
• Labor is said to be normal if all are present except:
1.At term2.Breech presentation 3.Spontaneous in onset4.Healthy mother & neonate after delivery
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MCQ1
• Labor is said to be normal if all are present except:
1.At term2.Breech presentation 3.Spontaneous in onset4.Healthy mother & neonate after delivery
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MCQ2
• Regarding the third stage of labor, following is not true:
1.Most crucial stage of labor2.Duration is 15 minutes3.Uterine inversion is most common
complication4.AMTSL is routine in all
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MCQ2
• Regarding the third stage of labor, following is not true:
1.Most crucial stage of labor2.Duration is 15 minutes3.Uterine inversion is most common
complication4.AMTSL is routine in all
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MCQ3
• The uterotonic of choice for prophylaxis of PPH in third stage of labor is
1.Syntometrine2.Oxytocin3.Misoprostol4.carboprost
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MCQ3
• The uterotonic of choice for prophylaxis of PPH in third stage of labor is
1.Syntometrine2.Oxytocin3.Misoprostol4.carboprost
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MCQ4
• All are true in relation to AMTSL except:• 10 IU of Oxytocin , IM• Uterine massage• Reduces the duration of third stage• Perform in only high risk cases
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MCQ4
• All are true in relation to AMTSL except:1.10 IU of Oxytocin , IM2.Uterine massage3.Reduces the duration of third stage4.Perform in only high risk cases
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MCQ5
• Complications during third stage of labor are all except
1.PPH2.Chronic Uterine inversion3.Retained placenta4.Amniotic fluid embolism
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MCQ5
• Complications during third stage of labor are all except
1.PPH2.Chronic Uterine inversion3.Retained placenta4.Amniotic fluid embolism
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MCQ6
• The most frequently observed method of placental separation :
1.Marginal separation2.Central separation3.None4.both
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MCQ6
• The most frequently observed method of placental separation :
1.Marginal separation2.Central separation3.None4.both
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MCQ7
• The most important method to control uterine bleeding following delivery
1.Myotamponade2.Thrombosis3.Contraction& retraction of uterine muscle4.none
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MCQ7
• The most important method to control uterine bleeding following delivery
1.Myotamponade2.Thrombosis3.Contraction& retraction of uterine muscle4.none
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MCQ8
• Following are true regarding misoprostol, except
1.Low cost2.Easy storage3.Administered rectally4.Drug of choice for AMTSL
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MCQ8
• Following are true regarding misoprostol, except
1.Low cost2.Easy storage3.Administered rectally4.Drug of choice for AMTSL
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MCQ9
• Following is true regarding Oxytocin1.Given as IV bolus dose2.Thermolabile3.Contraindicated in cardiac patient4.Causes hypertension
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MCQ9
• Following is true regarding Oxytocin1.Given as IV bolus dose2.Thermolabile3.Contraindicated in cardiac patient4.Causes hypertension
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MCQ10
• Prevention of PPH, all are true except1.Treatment of anemia in antenatal period2.Practice AMTSL in all3.Home delivery in high risk cases4.In forceps delivery, explore uterovaginal canal
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MCQ10
• Prevention of PPH, all are true except1.Treatment of anaemia in antenatal period2.Practice AMTSL in all3.Home delivery in high risk cases4.In forceps delivery, explore uterovaginal canal