Third stage of labourThird stage of labour

Dr.Roaa H. GadeerDr.Roaa H. GadeerMDMD

DefinitionDefinition

commences with the delivery of the fetus and ends with commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes.delivery of the placenta and its attached membranes.

The length of the third stage is 5-15 minutes. 30 minutes The length of the third stage is 5-15 minutes. 30 minutes have been suggested if there is no evidence of significant have been suggested if there is no evidence of significant bleeding.bleeding.

The risk of complications continues for some period after The risk of complications continues for some period after delivery of the placenta. delivery of the placenta.

Fourth stage of labor: begins with the delivery of the Fourth stage of labor: begins with the delivery of the placenta and lasts for 1 hourplacenta and lasts for 1 hour

SignificanceSignificance

Postpartum haemorrhagePostpartum haemorrhage (PPH) : It is a leading cause of (PPH) : It is a leading cause of maternal mortality.maternal mortality.

Maternal death: The maternal mortality rate in the United Maternal death: The maternal mortality rate in the United States is approximately 7-10 women per 100,000 live births; States is approximately 7-10 women per 100,000 live births; 8% of these deaths are caused by PPH. The maternal mortality 8% of these deaths are caused by PPH. The maternal mortality rates in developing world exceeded 1000 women per 100,000 rates in developing world exceeded 1000 women per 100,000 live births, 25% of these deaths are due to PPH.live births, 25% of these deaths are due to PPH.

AnemiaAnemia: PPH may cause anemia or poor iron. Anemia may : PPH may cause anemia or poor iron. Anemia may cause weakness and fatigue. prolonged hospitalization may cause weakness and fatigue. prolonged hospitalization may affect the establishment of breastfeeding. affect the establishment of breastfeeding.

transfusion reaction and infectiontransfusion reaction and infection: Due to blood transfusion. : Due to blood transfusion. Emergency anesthetic interventionEmergency anesthetic intervention: due to severe PPH, : due to severe PPH,

retained placenta, and uterine inversion. retained placenta, and uterine inversion. SepsisSepsis: due to exploration or instrumentation of the uterus.: due to exploration or instrumentation of the uterus.

What to do before delivery of the placenta ?What to do before delivery of the placenta ?

Inspect the cervix and vagina for lacerations.Inspect the cervix and vagina for lacerations. Look for signs of placental separation.Look for signs of placental separation.

Mechanism of placental separationMechanism of placental separation Uterine contractions and retractionUterine contractions and retraction reduce the surface reduce the surface

area area →→ placental detachment and expulsion into the placental detachment and expulsion into the lower uterine segment.lower uterine segment.

Retro placental hematoma. Retro placental hematoma.

* Agents causing uterine contraction (uterotonic): * Agents causing uterine contraction (uterotonic): oxytocinoxytocin, , ergometrinergometrin and and prostaglandinsprostaglandins enhance enhance placental separation and expulsion .placental separation and expulsion .

* Agents * Agents (tocolytics/n(tocolytics/nitroglycerinitroglycerin and some and some inhalation inhalation anestheticsanesthetics) cause uterine relaxation and delay of ) cause uterine relaxation and delay of placental separation causing placental separation causing dangerous bleeding dangerous bleeding

following deliveryfollowing delivery..

What to do before delivery of the placenta?What to do before delivery of the placenta?

1. Look for signs of placental separation:1. Look for signs of placental separation: lengthening of the umbilical cord outside.lengthening of the umbilical cord outside. The uterus becomes firm and globular. The uterus becomes firm and globular. The uterus rises in the abdomen. The uterus rises in the abdomen. A gush of blood. A gush of blood.

2. Assess the uterus:2. Assess the uterus:

To exclude an undiagnosed twinTo exclude an undiagnosed twin To determine a baseline fundal heightTo determine a baseline fundal height to detect the signs of placenta separation to detect the signs of placenta separation to detect an atonic uterusto detect an atonic uterus

Delivery of the placentaDelivery of the placenta

Physiological or expectant managementPhysiological or expectant management: : --Wait for the signs of placental separationWait for the signs of placental separation - Make sure that the uterus is contracted.- Make sure that the uterus is contracted. - - Controlled Cord tractionControlled Cord traction: the body of the uterus is supported above the : the body of the uterus is supported above the

symphysis pubis by the left hand directed upward and backward. Then cord symphysis pubis by the left hand directed upward and backward. Then cord traction is applied continuously downward with the right hand. traction is applied continuously downward with the right hand.

active managementactive management: : - - By using 1 of 3 uterotonic agents: ergometrine, oxytocin, or ergometrine- By using 1 of 3 uterotonic agents: ergometrine, oxytocin, or ergometrine-

oxytocin (Syntometrineoxytocin (Syntometrine

- - Given at theGiven at the delivery of anterior shoulder or after delivery of the baby. delivery of anterior shoulder or after delivery of the baby. - Immediate delivery of the cord with CCT.- Immediate delivery of the cord with CCT.

Avoid uterine massage before placental delivery.Avoid uterine massage before placental delivery.

Delivery of membrane :

by rotating the placenta about the insertion site as it descends or grasping the membranes with a clamp.

Umbilical cord managementUmbilical cord management

cord clampingcord clamping: Delayed until the cord is pulseless, : Delayed until the cord is pulseless, usually 2-4 minutes, usually 2-4 minutes, →↑→↑Hb, Hb, ↑↑iron stores in the iron stores in the newborn and newborn and ↓↓levels of early childhood anemia.levels of early childhood anemia.

Method of cord clamp:Method of cord clamp:

Physiological Versus Active ManagementPhysiological Versus Active Management

Physiological Physiological ManagementManagement

Active Active managementmanagement

Uterotonic agentUterotonic agent None or after placenta None or after placenta delivereddelivered

With delivery of With delivery of anterior shoulder or anterior shoulder or babybaby

UterusUterus Assessment of size Assessment of size and tone after deliveryand tone after delivery

Assessment of size Assessment of size and tone after deliveryand tone after delivery

Cord tractionCord traction NoneNone controlled cord controlled cord traction when uterus traction when uterus contractedcontracted

Cord clampingCord clamping VariableVariable EarlyEarly

Mode of uterotonic administrationMode of uterotonic administration

Oxytocin Oxytocin dose is 10 IU, intramuscularly. with intravenous dose is 10 IU, intramuscularly. with intravenous access in place, 10-20 IU is placed in 500-1000 mL of access in place, 10-20 IU is placed in 500-1000 mL of crystalloid and run quickly. With cesarean deliveries, 5 IU crystalloid and run quickly. With cesarean deliveries, 5 IU is administered as an intravenous bolus, followed by a is administered as an intravenous bolus, followed by a similar infusion.similar infusion.

ErgometrineErgometrine dose: is 0.2-0.25 mg, some used 0.5 mg dose: is 0.2-0.25 mg, some used 0.5 mg ; IM ; IM or IV.or IV.

SyntometrineSyntometrine (contains 0.5 mg of ergometrine with 5 IU of (contains 0.5 mg of ergometrine with 5 IU of oxytocin); IM, 2 mg.oxytocin); IM, 2 mg.

What to do after delivery of the placenta?What to do after delivery of the placenta?

Determine the fundal position and size of the uterus. why?Determine the fundal position and size of the uterus. why? Ensure that the uterus is contracted (can be enhanced with Ensure that the uterus is contracted (can be enhanced with

oxytocin and uterine massage).oxytocin and uterine massage). Examine the placenta for completeness and detection of Examine the placenta for completeness and detection of

abnormalities.abnormalities. Suturing of lacerations.Suturing of lacerations. Uterine exploration: - No longer recommended for normal deliveries or those

following previous cesarean delivery. - Is justified in patients with bleeding originating high in the

genital tract. - The cervix should be visualized after all forceps deliveries

Fourth stageFourth stage Observe the vital signs.Observe the vital signs. palpate the abdomen to assess and monitor uterine palpate the abdomen to assess and monitor uterine

tone and size. tone and size. Do uterine massage.Do uterine massage. Ensure continuous infusion of oxytocin.Ensure continuous infusion of oxytocin. Encourage early breastfeeding to promote Encourage early breastfeeding to promote

endogenous oxytocin release.endogenous oxytocin release. assess the lower genital tract for bleeding.assess the lower genital tract for bleeding. assess the placenta for completenessassess the placenta for completeness.. repair of an episiotomy or any lacerations.repair of an episiotomy or any lacerations. Close observation every 15 minute for the next hour.Close observation every 15 minute for the next hour.

COMPLICATIONSCOMPLICATIONS

Postpartum hemorrhagePostpartum hemorrhage..Retained placenta.Retained placenta.Uterine inversion.Uterine inversion.