Active management of third stage of labo

AMTSL

1. Active Management of the Third Stage of Labour (AMTSL ) Professor

2. OBJECTIVE To prevent postpartum haemorrhage (PPH), it is recommended that active management of third stage of labour (AMTSL), be practiced at all times. AMTSL includes: 1. Prophylactic use of oxytocin 2. Controlled cord traction for delivery of the placenta 3. Uterine massage

3. 1. Prophylactic Oxytocin to Prevent Postpartum Haemorrhage Within one minute of delivery of the baby, palpate the abdomen to rule out the presence of additional baby/babies. Give oxytocin 10 IU intramuscular (IM) Oxytocin is preferred because it is effective 2-3minutes after injection, has minimal adverse effects and can be used in all women . If oxytocin is not available, ergometrine can be used as 0.25mg given IM. However, ergometrine is contraindicated in women with pre- eclampsia / eclampsia , high blood pressure and cardiac disease because it increases blood pressure by peripheral vasoconstriction, and may increase the risk of convulsions and cerebrovascular accidents

4. IM Oxytocin 10 IU

5. 2. Controlled Cord Traction Within one minute of delivery, clamp the cord close to the perineum using sponge forceps. Hold the clamped cord and the end of the forceps with one hand . Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying counter traction during controlled cord traction. This helps prevent uterine inversion. Keep slight tension on the cord and await a strong uterine contraction (2-3 minutes). When the uterus becomes rounded or the cord lengthens very gently pull downwards on the cord to deliver the placenta. Do not wait for a gush of blood.

6. Controlled Cord Traction If the placenta does not descend during 30-40 seconds of controlled cord traction (i.e. there are no signs of placental separation). DO NOT continue to pull on the cord. Gently hold the cord and wait until the uterus is well contracted again. If necessary, roll the cord on the forceps or clamp the cord closer to the perineum as it lengthens.

7. Controlled Cord Traction With the next contraction, repeat controlled cord traction with counter traction. Never apply cord traction without applying counter traction above the pubic bone with the other hand. To reduce the risk of the thin membranes tearing off as the placenta delivers, hold the placenta in two hands and gently turn it until the membranes are twisted. Slowly complete delivery of the placenta. Inspect the maternal surface of the placental lobes for completeness and remove any retained fragments Maintain infection prevention protocols at all times

8. 3.Uterine massage

9. Uterine Massage Immediately after delivery of the placenta, massage the fundus of the uterus through the woman’s abdomen until the uterus is contracted. Repeat uterine massage every 15 minutes for the first 1-hour. Ensure that the uterus does not become relaxed after you stop uterine massage. Ensure the urinary bladder is empty.

10. Examination of the placenta Carefully examine the placenta to ensure completeness and that no lobe is missing. If a portion of the maternal surface is missing or there are torn membranes, suspect retained placental fragments. In such cases examine the upper vagina and cervix and use a sponge forceps to remove any pieces of membranes that are present.

11. Examination of the placenta The midwife must be familiar with the normal and abnormal findings of a placenta at term. The placenta has two sides (fetal and maternal) and both sides need careful examination. Pre-requisite knowledge 1. The normal findings of a placenta, cord and membranes 2. The abnormalities of the placenta, cord and membranes

12. Equipment needed 1. A tray holding the placenta 2. Gauze swabs 3. A scale 4. A measuring jar 5. A pair of unsterile gloves 6. A plastic apron 7. A red disposal bag

13. Procedure 1. The midwife must protect herself/himself against any blood splashes. 2. Put on a plastic apron and unsterile gloves. 3. Place the examining tray holding the placenta on a flat surface with the fetal surface upwards. 4. Commence with a general examination of the placenta - note the shape and the size of the placenta, which is usually round, flat, firm, about 20cm in diameter and 2.5cm in thickness. 5 . A small placenta is indicative of a preterm birth, intra-uterine growth restriction, and intrauterine infections. 6. A large placenta is indicative of a large baby, gestational diabetes and multiple pregnancy. A large , pale and soggy placenta is indicative of a hydrops fetalis condition. 7. An abnormal shape is indicative of an abnormal placenta, such as a succenturiate lobe, a bipartite or tri-partite placenta or multiple pregnancy.

14. Procedure 8. Note the color of the placenta, membranes and cord . The fetal side appears shiny and consists of the membranes and the cord, and appears bluish red in color. In the presence of meconium, the placenta may appear yellowish to light green in color . There are many blood vessels present and visible on the fetal side. The course of blood vessels are thickest near the insertion of the cord and taper towards the edges of the placenta. Check that vessels are not continuing into the membranes ( velamentosa ), or the presence of a hole, or a missing piece as this may indicate a missing accessory lobe (known as succenturiate lobe). Amnion nodosum is a rare condition associated with oligohydramnios , sometimes found during the examination of the placenta

15. Procedure 11 . A cord less than 45cms identifies as a short cord and may be the reason for placental separation before the birth of the baby (placenta abruption). 12. A long cord measures more than 60cms and maybe the cause of cord around the neck, or cord prolapse . 13. A very thick cord should be observed because the clamp may re -open , resulting in hemorrhage

16. Procedure 14. Examine the end of the cord for the presence of blood vessels. Use a gauze swab to wipe the edge of the cord so you can see the vessels clearly. There should be two rod-shaped arteries, which are partly closed and one large open vein present, which bleeds. The presence of only two vessels (one artery and one vein) indicates fetal abnormalities, such as genito -urinary or gastro-intestinal system . 15. The placenta has two membranes, which are closely adjacent to each other. The amnion is the fetal sac, which contains the fetus and the liquor amnii during pregnancy. It is a thin, shiny translucent but tough membrane, which separates from the chorion up to the insertion of the cord. The chorion is a thickish , friable, opaque membrane and is continuous with the edge of the placenta; it is attached to the decidua vera during pregnancy

17. Procedure…. 15. The placenta has two membranes, which are closely adjacent to each other. The amnion is the fetal sac, which contains the fetus and the liquor amnii during pregnancy . It is a thin, shiny translucent but tough membrane, which separates from the chorion up to the insertion of the cord. The chorion is a thickish , friable, opaque membrane and is continuous with the edge of the placenta ; it is attached to the decidua vera during pregnancy.

18. Procedure 16. Examine the membranes for its completeness or any missing parts. Pick the placenta up to examine the membranes and note the opening, called the fenestra, through which the baby was removed . Start separating the amnion from the chorion. Ensure no missing parts of the membrane has remained in the uterus. Also , note the presence of two amnions and two chorions in binovular twin pregnancy, or the presence of one chorion and two amnions in a uni -ovular twin pregnancy 17 . Note any double folding around the edge of the placenta, known as placenta circumvallate - usually associated with antepartum and post-partum hemorrhage. 18. Now, turn the placenta and examine the maternal surface carefully

19. Procedure 19. The maternal surface appears dark purplish red in color. It consist of chorionic villi (fetal tissue) and decidua basalis (maternal tissue) embedded into the maternal uterine wall. The maternal surface separates from the decidua at the postage stamp layer of Nitabuch . The maternal side of the placenta has an average of 20 cotyledons. Each cotyledon separates by grooves called sulci. Note any missing cotyledons that may have remained in the uterus . If the maternal surface is too bloody for the examination, use gauze swabs to wipe the surface to complete the examination thoroughly . 20. A very dark clot (almost black) indicates a retro-placental clot and indicates an abruption placenta. Other defects include: • Infarcts: necrosis and calcifications, seen as whitish anemic areas (the placental site appears thinner than the rest of the placenta • Fibrin deposits, seen as greyish gritty areas on the maternal surface • Tumors such as hemangiomas • Placenta membranacea - placenta attached to the membranes

20. Procedure 21. On completion of the examination, remove the placenta from the tray and place it in a red disposal bag. Pour the excess blood from the tray into a measuring jar (Measure clotted and liquid blood separately ).Take note of the amount of blood loss and then discard . 22 . Weigh the placenta using a scale (the average weight of the placenta is 1/6th of the baby’s weight). Attach a label to the bag containing the placenta and enter the details in the ‘ placental disposal book’ as per hospital protocol. Discard the placenta as per hospital policy for disposal of human tissue. Complete the procedure by entering your findings in the patient’s notes and inform the registered midwife of any abnormalities