3rd stage OF LABOUR

UNIT 4

1. MANAGEMENT OF THIRD STAGE OF LABOUR

2. THIRD STAGE OF LABOR

3. INTRODUCTION THIRD STAGE IS MOST CRUCIAL STAGE OF LABOR. Previously uneventful first and second stage can become abnormal with in a minute with disastrous consequences.

4. SIGNS OF EXPULSION OF PLACENTA ( IIIrd STAGE OF LABOUR) Lengthening of cord. Gush of bleeding. Uterus becomes full OR boggy uterus .

5. EVENTS: The third stage of labour stage of labour consist of following phases: PLACENTAL SEPARATION ITS DESCEND TO LOWER SEGMENT PLACENTAL EXPULSION

6. A) Placental Separation: At the beginning of the labour , the placental attachment is roughly corresponds to an area of 20cm in diameter. In the first stage of labour , there is no decrease in the surface area of placental attachment. In second stage of labour , there is slight but progressive decrease in surface area because of retraction. There is marked decrease or attain its peak, immediately following the birth of the baby. After the birth of the baby, uterine measures about 20cm vertically and 10cm antero - posteriorly , shape become discoid.

7. Mechanism of separation: There are 2 ways of separation of placenta: CENTRAL SEPARATION MARGINAL SEPARATION .

8. Central separation (Schultz mechanism) Detachment of placenta from its uterine attachment starts at the centre resulting in opening up of few uterine sinuses and accumulation of blood behind the placenta ( retroplacental hematoma), with increasing the contractions, more and more detachment occurs facilitated by weight of placenta and retroplacental blood until whole of the placenta get detached.

9. Marginal separation (Mathew’s Duncan Mechanism): Separation starts at its margins as it is mostly unsupported with progressive uterine contractions, more and more areas of the placenta get separated. Marginal separation is found more frequently.

10. B)Descend of the Placenta: After the placenta has separated, it descends into the lower uterine segment by effective contractions and retraction of uterus These are as follows: Sudden trickle or gush of blood. Lengthening of the amount of umbilical cord visible at the vaginal introitus . Change in the shape of the uterine from a discoid to globular. Change of the position of the uterus as it rises in the abdomen, because the bulk of placenta is in the lower uterine segment or at upper vaginal vault.

11. C)Expulsion of the Placenta: After complete separation of the placenta and descend of the placenta. Thereafter, it is expelled out by either voluntary contractions of the abdominal muscles (bearing down efforts) or by manipulative procedure.

12. Mechanism of control of bleeding: After the placental separation there are so many torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be removed. The occlusion is effected by complete retraction where by arterioles, as they pass twistedly through the interlacing intermediate layer of the myometrium , are literally clamped. It is the principle mechanism to prevent bleeding. Thrombosis occurs to occlude the torn sinuses, a phenomenon which is facilitated by hyper- coagulable state of pregnancy. Constriction of the walls of uterus following expulsion of the placenta also contributes to minimize the blood loss.

13. MANAGEMENT OF IIIrd STAGE OF LABOR Expectant management Active Management

14. Expectant management In this management, the placental separation and its descent into the vagina are allowed to occur spontaneously. Minimal assistance may be given for the placental expulsion if it needed.

15. Contd … Constant watch To note features of placental separation To assess the amount of blood loss A hand is placed over the fundus (a) To recognize the signs of separation of placenta (b) To note the state of uterine activity

16. Expulsion of the placenta When the features of placental separation and its descent into the lower segment are confirmed, the patient is asked to bear down simultaneously with the hardening of the uterus . If the patient fails to expel, one can wait safely up to 10 minutes if there is no bleeding. as the placenta passes through the introits, it is grasped by the hands and twisted round and round with gentle traction so that the membranes are stripped intact.

17. Contd … Placenta is separated within minutes following the birth of the baby. A watchful expectancy can be extended up to 15-20 minutes. The patient is expected to expel the placenta within 20 minutes with the aid of gravity. 'no touch' or 'hands off' policy

18. ASSISTED EXPULSION Control Cord Traction Never apply cord traction (pull) without applying counter traction (push) above the pubic bone with the other hand. 

19. FUNDAL PRESSURE : the pressure must be given only when the uterus becomes hard.

20. Examination of the placenta membranes and cord The placenta is placed on a tray and is washed out in running tap water to remove the blood and clots : MATERNAL SURFACE THE MEMBRANES

21. Contd … THE MARGIN OF THE GAP INDICATES A MISSING SUCCENTURIATE LOBE. THE CUT END OF THE CORD IS INSPECTED FOR NUMBER OF BLOOD VESSELS

22. PALPATION OF THE FUNDUS OF UTERUS FOR CONTRACTILITY Midwife/Nurse should assess sustained contractions of the uterus. Ideally the fundus should lie on the mid-plane of the pelvis at or below the umblicus .

23. CONTD… Fundus of uterus is palpated by placing the side of one hand on top of, Slightly cupped above the fundus , While the other hand is placed suprapubically with the exertion of slight pressure.

24. CONTD… Massage the uterus if it is found boggy on palpation, until it contracts and becomes firm. Avoid Over stimulation as it leads to muscle fatigue with subsequent relaxation of uterus and possible hemorrhage

25. VULVAL, VAGINAL & PERINEAL EXAMINATION Should be inspected for injuries To be repaired, if any injury or laceration because it may lead to pph. Vulva & adjoining part are cleaned with cotton swabs soaked in antiseptic solution.

26. NURSING MANAGEMENT

27. PRINCIPLES Prompt separation and expulsion of the placenta To ensure strict vigilance To follow the management guidelines striclty in practice To prevent the complications “ POSTPARTUM HAEMORRHAGE ”

28. ASSESSMENT Placenta separation is indicated by the following signs : A firmly contracting fundus . The uterus changing from a discoid to globular ovoid shape as the placenta moves into the lower uterine segment

29. CONTD.. A sudden gushing of dark blood from the introitus Apparent lengthening of the umbilical cord as the placenta gets closer to the introitus The finding of a vaginal fullness on vaginal or rectal examination or of fetal at the introitus .

30. MATERNAL PHYSICAL STATUS Cardiac output increases Pulse rate slows

31. PLAN OF CARE & INTERVENTIONS To assist the women in the delivery of the placenta, the nurse or primary health care provider has the woman push when signs of separation have occurred. The placenta should be expelled by maternal effort during a uterine contraction , plus minimum, controlled traction on the umbilical cord may be used to facilitate delivery of the placenta and amniotic membranes

32. Contd.. When the third stage is complete and episiotomy is sutured, the vulval area should be cleansed with warm sterile water or normal saline. Apply a sterile perineal pad. Remove any drapes and /or place dry linen under the woman’s buttocks. Reposition the birthing table or bed.

33. Contd … Lower the mother’s legs simultaneously from the stirrups if she is in a lithotomy position. Assist the woman onto her bed while transferring from the birthing area to the recovery area. Provide the woman with a clean gown and cover with a warmed blanket. Raise the side rails of the bed during transfer.

34. NURSING DIAGNOSIS

35. 1. NURSING DIAGNOSIS RISK FOR FLUID VOLUME DEFICIT RELATED TO : Blood loss occurring following placental separation and expulsion Inadequate contraction of the uterus

36. NURSING INTERVENTIONS Monitor fluid loss ( i.e. blood, urine, perspiration) and vital signs ; inspect skin turgor and mucus membranes for dryness to evaluate hydration status Administer oral/ parenteral fluids per physican / nurse – midwife orders to maintain hydration.

37. CONTD.. Monitor the fundus for firmness after placental separation to ensure adequate contraction & prevent further blood loss. Administer medications per physician / nurse – midwife orders to aid contraction of the uterus.

38. 2. Ineffective individual coping (mother) related to : Lack of preparation for sensations that occur during third stage of labor

39. NURSING INTERVENTIONS Explain to women and labor partner what is expected in the third stage of labor to enlist cooperation. Have woman maintain her position to facilitate delivery of the placenta Ask mother if she wishes to dispose of the placenta in any specific manner to comply with certain cultural customs.

40. 3. Fatigue related to : Energy expenditure associated with childbirth and the bearing down efforts of the second stage

41. NURSING INTERVENTIONS Educate mother & partner about the need for rest and help them to plan strategies; for e.g. restricting visitors, increasing the role of support systems performing functions associated with daily routines. As it allow specific times for rest & sleep to ensure that women can restore depleted energy level in preparation for caring for a new infant. Monitor the woman’s fatigue level and the amount of rest received to ensure restoration of energy.

42. IV th STAGE OF LABOUR Stage of observation for at least 1 hr after expulsion of the after births

43. CONTD…

44. ADAPTATION TO PARENTHOOD & THE NEW FAMILY Encouragement to couples : discuss anxiety & expectations of each others. Transition to parenthood : parent – child relationships Role of fathers : lack of attention Role of family