03 Active management of third stage of labour

Training UDJ

1. ACTIVE MANAGEMENT ACTIVE MANAGEMENT
OF THIRD STAGE OF OF THIRD STAGE OF
LABOURLABOUR
Dr. Md. AlauddinDr. Md. Alauddin
Professor & HeadProfessor & Head
Dept. of G&ODept. of G&O
MMCMMC

2. SESSION OBJECTIVESSESSION OBJECTIVES
To understand 3To understand 3
rdrd
stage stage
ComplicationsComplications
Active ManagementActive Management
Inappropriate/Harmful PracticesInappropriate/Harmful Practices
Best PracticesBest Practices

3. Third StageThird Stage
Delivery of the Foetus to delivery of placenta Delivery of the Foetus to delivery of placenta
and membranes.and membranes.
Upto Thirty MinutesUpto Thirty Minutes
Average 5-15 MinutesAverage 5-15 Minutes
Shorter in multi, slightly longer in primiShorter in multi, slightly longer in primi

4. KEY EVENTS IN THIRD KEY EVENTS IN THIRD
STAGESTAGE
Separation of PlacentaSeparation of Placenta
Expulsion/Delivery of PlacentaExpulsion/Delivery of Placenta
HaemostasisHaemostasis

5. SEPARATION OF PLACENTASEPARATION OF PLACENTA
Central SeparationCentral Separation
Marginal SeparationMarginal Separation
Signs of Placental separationSigns of Placental separation
Uterus becomesUterus becomes contracted, hard and globular;contracted, hard and globular;
Uterus rises just above umbilicus;Uterus rises just above umbilicus;
Extra vulval lengthening of umbilical cord;Extra vulval lengthening of umbilical cord;
A gush of bloodA gush of blood frequently appears;frequently appears;
On pushing the uterus up in the abdomen, the cord On pushing the uterus up in the abdomen, the cord
does not recede back.does not recede back.

6. EXPULSION/DELIVERY OF EXPULSION/DELIVERY OF
PLACENTAPLACENTA
Natural expulsion – Bearing down effortsNatural expulsion – Bearing down efforts
Controlled cord traction.Controlled cord traction.

7. HAEMOSTASISHAEMOSTASIS
Contraction and Retraction of MyometriumContraction and Retraction of Myometrium
– Ligature effect.– Ligature effect.
ThrombosisThrombosis
Apposition of uterine walls.Apposition of uterine walls.

8. COMPLICATIONS OF THIRD COMPLICATIONS OF THIRD
STAGESTAGE
PPHPPH
Retained PlacentaRetained Placenta
InversionInversion
Post-partum ShockPost-partum Shock

9. ACTIVE MANAGEMENT OF ACTIVE MANAGEMENT OF
THIRD STAGE OF LABOURTHIRD STAGE OF LABOUR
PRINCIPLES:PRINCIPLES:
Enhance separation of placentaEnhance separation of placenta
Safe and complete delivery of placentaSafe and complete delivery of placenta
Minimize bleedingMinimize bleeding

10. ACTIVE MANAGEMENT OF ACTIVE MANAGEMENT OF
THIRD STAGE OF LABOURTHIRD STAGE OF LABOUR
COMPONENTS:COMPONENTS:
Use of oxytocicsUse of oxytocics
Delivery of placenta by controlled cord tractionDelivery of placenta by controlled cord traction
Massage of uterus after placental deliveryMassage of uterus after placental delivery
Examination of birth canal and afterbirthsExamination of birth canal and afterbirths
Repair of tears/episiotomyRepair of tears/episiotomy

11. OXYTOCICSOXYTOCICS
OxytocinOxytocin
Ergometrine/MethylergometrineErgometrine/Methylergometrine
ProstaglandinProstaglandin
MisoprostolMisoprostol

12. OXYTOCINOXYTOCIN
SafeSafe
CheapCheap
No contraindicationNo contraindication
Effective – quick actionEffective – quick action
10 units IM10 units IM
Less heat labileLess heat labile

13. ERGOMETRINEERGOMETRINE
CheapestCheapest
Has contraindicationsHas contraindications
Side effects – sometimes seriousSide effects – sometimes serious
EffectiveEffective
0.2 mg IM/IV0.2 mg IM/IV
Heat labileHeat labile

14. PROSTAGLANDINPROSTAGLANDIN
CostlyCostly
ContraindicationsContraindications
Some side effectsSome side effects
EffectiveEffective
125-250 mcg IM125-250 mcg IM
Highly heat labileHighly heat labile

15. MISOPROSTOLMISOPROSTOL
Less costlyLess costly
No significant contraindicationNo significant contraindication
No significant side-effectNo significant side-effect
EffectiveEffective
600 mcg orally600 mcg orally
Highly heat stableHighly heat stable

16. WHICH OXYTOCIC?WHICH OXYTOCIC?
Oxytocin - first choiceOxytocin - first choice
Misoprostol - has a promiseMisoprostol - has a promise
Prostaglandin – effective but costlyProstaglandin – effective but costly

17. DELIVERY OF PLACENTADELIVERY OF PLACENTA
Controlled cord tractionControlled cord traction
Raising the uterus gently upward by Raising the uterus gently upward by
abdominal handabdominal hand
Traction when placenta is separated/Uterus Traction when placenta is separated/Uterus
contractedcontracted

18. UTERINE MASSAGEUTERINE MASSAGE
Immediately after placental delivery till uterus Immediately after placental delivery till uterus
is hardis hard
Repeat intermittently for 1-2 hrs.Repeat intermittently for 1-2 hrs.

19. IMMEDIATE POST-PARTUM IMMEDIATE POST-PARTUM
CARECARE
 Closely monitor for first 6 hours.Closely monitor for first 6 hours.
- Pulse, respiration, temperature, - Pulse, respiration, temperature,
B.P., G.CB.P., G.C
- Vaginal bleeding.- Vaginal bleeding.
- Uterine hardness.- Uterine hardness.
@ Every 15 mins. for 1 hour.@ Every 15 mins. for 1 hour.
@ Every 30 mins. For 2 hours.@ Every 30 mins. For 2 hours.
@ Every hour for 3 hours.@ Every hour for 3 hours.
Massage the uterus every 15 mins. to maintain Massage the uterus every 15 mins. to maintain
contraction.contraction.
If stable give her something to drink/eat when If stable give her something to drink/eat when thirsty/hungry.thirsty/hungry.

20. INAPPROPRIATE/HARMFUL INAPPROPRIATE/HARMFUL
PRACTICESPRACTICES
Non-use of active managementNon-use of active management
Manipulating uterus (fundal pressure, Manipulating uterus (fundal pressure,
squeezing)squeezing)
Inappropriate use of oxytocicInappropriate use of oxytocic
Inappropriate cord tractionInappropriate cord traction
Routine catheter/MRP/exploration of uterusRoutine catheter/MRP/exploration of uterus
Uterine lavageUterine lavage
Not examining birth canal/after birthsNot examining birth canal/after births

21. BEST PRACTICESBEST PRACTICES
Cleanliness: IPPCleanliness: IPP
Complication readinessComplication readiness
Support personSupport person
Active management FOR ALLActive management FOR ALL
Oxytocic : Oxytocic : OXYTOCIN 10 U IM – FIRST CHOICEOXYTOCIN 10 U IM – FIRST CHOICE
CControlled tractionontrolled traction
Uterine massageUterine massage
Examination of birth canal and after birthsExamination of birth canal and after births
To remain vigilant for 6 hoursTo remain vigilant for 6 hours

22. MAKE IT AN ISSUEMAKE IT AN ISSUE
T H A N K Y O U !!!T H A N K Y O U !!!