Third stage of labor: events & management

1. Third stage of labor: events & management Prophylaxis of PPH

2. 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

3. 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)

4. 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

5. 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

6. Methods of placental separation Central ( Schultze) separation Marginal (Mathews Duncan) separation

8. 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

9. Mechanisms to control bleeding Effective retraction of uterine muscles : Living ligatures Thrombosis of torn sinuses Myotamponade: apposition of walls of the uterus

10. Management of third stage • Most crucial stage • Strict vigilance • Follow protocols • Expectant management • Active management

11. 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

12. 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

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

14. Examination of placenta ,membranes

15. Examination of membranes, cord

16. 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.)

17. Third stage • Most crucial • Life threatening complications • PPH(postpartum haemorrhage) • Retained placenta • Inversion of uterus • Pulmonary embolism

18. Prophylaxis of PPH

19. 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

21. 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

22. Primary PPH:causes

23. PPH : risk factors

24. 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

25. WHO guidelines for Prophylaxis of PPH

26. WHO guidelines

27. WHO guidelines

28. WHO guidelines

29. 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

30. MCQ1 • Labor is said to be normal if all are present except: • At term • Breech presentation • Spontaneous in onset • Healthy mother & neonate after delivery

31. MCQ1 • Labor is said to be normal if all are present except: • At term • Breech presentation • Spontaneous in onset • Healthy mother & neonate after delivery

32. MCQ2 • Regarding the third stage of labor, following is not true: • Most crucial stage of labor • Duration is 15 minutes • Uterine inversion is most common complication • AMTSL is routine in all

33. MCQ2 • Regarding the third stage of labor, following is not true: • Most crucial stage of labor • Duration is 15 minutes • Uterine inversion is most common complication • AMTSL is routine in all

34. MCQ3 • The uterotonic of choice for prophylaxis of PPH in third stage of labor is • Syntometrine • Oxytocin • Misoprostol • carboprost

35. MCQ3 • The uterotonic of choice for prophylaxis of PPH in third stage of labor is • Syntometrine • Oxytocin • Misoprostol • carboprost

36. 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

37. 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

38. MCQ5 • Complications during third stage of labor are all except • PPH • Chronic Uterine inversion • Retained placenta • Amniotic fluid embolism

39. MCQ5 • Complications during third stage of labor are all except • PPH • Chronic Uterine inversion • Retained placenta • Amniotic fluid embolism

40. MCQ6 • The most frequently observed method of placental separation : • Marginal separation • Central separation • None • both

41. MCQ6 • The most frequently observed method of placental separation : • Marginal separation • Central separation • None • both

42. MCQ7 • The most important method to control uterine bleeding following delivery • Myotamponade • Thrombosis • Contraction& retraction of uterine muscle • none

43. MCQ7 • The most important method to control uterine bleeding following delivery • Myotamponade • Thrombosis • Contraction& retraction of uterine muscle • none

44. MCQ8 • Following are true regarding misoprostol, except • Low cost • Easy storage • Administered rectally • Drug of choice for AMTSL

45. MCQ8 • Following are true regarding misoprostol, except • Low cost • Easy storage • Administered rectally • Drug of choice for AMTSL

46. MCQ9 • Following is true regarding Oxytocin • Given as IV bolus dose • Thermolabile • Contraindicated in cardiac patient • Causes hypertension

47. MCQ9 • Following is true regarding Oxytocin • Given as IV bolus dose • Thermolabile • Contraindicated in cardiac patient • Causes hypertension

48. MCQ10 • Prevention of PPH, all are true except • Treatment of anemia in antenatal period • Practice AMTSL in all • Home delivery in high risk cases • In forceps delivery, explore uterovaginal canal

49. MCQ10 • Prevention of PPH, all are true except • Treatment of anaemia in antenatal period • Practice AMTSL in all • Home delivery in high risk cases • In forceps delivery, explore uterovaginal canal