Third stage of labor: events & management

Prophylaxis of PPH

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

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)

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

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

Methods of placental separation

Central ( Schultze) separation Marginal (Mathews Duncan) separation

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

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

Management of third stage

• Most crucial stage• Strict vigilance• Follow protocols

• Expectant management• Active management

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

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

Expectant management

• Massage the uterus• Intramuscular Oxytocin : 10 IU• Examination of placenta ,membranes, cord• Inspect vulva, vagina & perineum

Examination of placenta ,membranes

Examination of membranes, cord

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.)

Third stage

• Most crucial• Life threatening complications

• PPH(postpartum haemorrhage)• Retained placenta• Inversion of uterus• Pulmonary embolism

Prophylaxis of PPH

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

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

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

Primary PPH:causes

PPH : risk factors

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

WHO GUIDELINES FOR PROPHYLAXIS OF PPH

WHO guidelines

WHO guidelines

WHO guidelines

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

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

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

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

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

MCQ3

• The uterotonic of choice for prophylaxis of PPH in third stage of labor is

1.Syntometrine2.Oxytocin3.Misoprostol4.carboprost

MCQ3

• The uterotonic of choice for prophylaxis of PPH in third stage of labor is

1.Syntometrine2.Oxytocin3.Misoprostol4.carboprost

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

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

MCQ5

• Complications during third stage of labor are all except

1.PPH2.Chronic Uterine inversion3.Retained placenta4.Amniotic fluid embolism

MCQ5

• Complications during third stage of labor are all except

1.PPH2.Chronic Uterine inversion3.Retained placenta4.Amniotic fluid embolism

MCQ6

• The most frequently observed method of placental separation :

1.Marginal separation2.Central separation3.None4.both

MCQ6

• The most frequently observed method of placental separation :

1.Marginal separation2.Central separation3.None4.both

MCQ7

• The most important method to control uterine bleeding following delivery

1.Myotamponade2.Thrombosis3.Contraction& retraction of uterine muscle4.none

MCQ7

• The most important method to control uterine bleeding following delivery

1.Myotamponade2.Thrombosis3.Contraction& retraction of uterine muscle4.none

MCQ8

• Following are true regarding misoprostol, except

1.Low cost2.Easy storage3.Administered rectally4.Drug of choice for AMTSL

MCQ8

• Following are true regarding misoprostol, except

1.Low cost2.Easy storage3.Administered rectally4.Drug of choice for AMTSL

MCQ9

• Following is true regarding Oxytocin1.Given as IV bolus dose2.Thermolabile3.Contraindicated in cardiac patient4.Causes hypertension

MCQ9

• Following is true regarding Oxytocin1.Given as IV bolus dose2.Thermolabile3.Contraindicated in cardiac patient4.Causes hypertension

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

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