Third stage of labor events management Prophylaxis of

Third stage of labor: events & management Prophylaxis of PPH Dr. Renu Singh

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

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

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

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: 4 T’s – Tone – Trauma – Tissue – Thrombosis

Primary PPH: causes

PPH : risk factors

Prophylaxis of PPH • • Improvement of health status of mother(Hb>11 gm%) Identify high risk women Plan for institutional delivery /SBA Strict vigilance of all women in 3 rd 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 • Give uterotonics routinely during 3 rd 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 (<1 min of birth): not recommended until the neonate is asphyxiated & needs immediate resuscitation

MCQ 1 • Labor is said to be normal if all are present except: 1. At term 2. Breech presentation 3. Spontaneous in onset 4. Healthy mother & neonate after delivery

MCQ 2 • Regarding the third stage of labor, following is not true: 1. Most crucial stage of labor 2. Duration is 15 minutes 3. Uterine inversion is most common complication 4. AMTSL is routine in all

MCQ 3 • The uterotonic of choice for prophylaxis of PPH in third stage of labor is 1. Syntometrine 2. Oxytocin 3. Misoprostol 4. carboprost

MCQ 4 • • • 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

MCQ 4 • All are true in relation to AMTSL except: 1. 10 IU of Oxytocin , IM 2. Uterine massage 3. Reduces the duration of third stage 4. Perform in only high risk cases

MCQ 5 • Complications during third stage of labor are all except 1. PPH 2. Chronic Uterine inversion 3. Retained placenta 4. Amniotic fluid embolism

MCQ 6 • The most frequently observed method of placental separation : 1. Marginal separation 2. Central separation 3. None 4. both

MCQ 7 • The most important method to control uterine bleeding following delivery 1. Myotamponade 2. Thrombosis 3. Contraction& retraction of uterine muscle 4. none

MCQ 8 • Following are true regarding misoprostol, except 1. Low cost 2. Easy storage 3. Administered rectally 4. Drug of choice for AMTSL

MCQ 9 • Following is true regarding Oxytocin 1. Given as IV bolus dose 2. Thermolabile 3. Contraindicated in cardiac patient 4. Causes hypertension

MCQ 10 • Prevention of PPH, all are true except 1. Treatment of anemia in antenatal period 2. Practice AMTSL in all 3. Home delivery in high risk cases 4. In forceps delivery, explore uterovaginal canal

MCQ 10 • Prevention of PPH, all are true except 1. Treatment of anaemia in antenatal period 2. Practice AMTSL in all 3. Home delivery in high risk cases 4. In forceps delivery, explore uterovaginal canal