Management of 3rd stage of labor

3rd stage of labor management

1. PRESENTER: RITU CHAHAL 2017033

2. LABOR Series of events that take place in the genital organs in an effort to expel the viable product of conception ( fetus , placenta and the membranes) out of the womb, through the vagina into the outer world is called labor .

3.  The third stage of labor ----- interval from the delivery of the baby to the separation and expulsion of the placenta Normally the delivery of placenta will take about 5-10 minutes after delivery of the baby regardless of the parity The major complication associated with this period is postpartum hemorrhage (PPH)---- the most common cause of maternal morbidity and mortality in developing countries .

4. THIRD STAGE PHYSIOLOGY Normal placental separation  Placental separation occurs due to shearing of the placental surface when the uterus contracts after the infant is delivered

5. After delivery of the baby Decrease in size of the uterine cavity Uterine contraction Marked decreased placental site Marked decreased placental site The placenta cannot decrease in size as the attached placental site Uterine contraction Decrease in size of the uterine cavity Pla c ent a is rigid and i n elastic

6. cause cleavage The placenta cannot decrease in size as the attached placental site Tearing of spongiosa layer of decidua basalis Damage of decidual vessels forming retroplacental hematoma Shearing force cause cleavage

7. Placental sepa r at i on Strong uterine contraction Spiral arterioles collapsed Vein collapsed Hemostasis Poor uterine contraction Bleeding from spiral arterioles and veins PPH U t e r i n e atony Incomplete separation of placenta Third stage of labor

8. Principles in the management of third stage of labor to prevent PPH Rapid and complete separation of placenta Prevent from PPH Strong uterine contraction Occlude spiral arterioles and veins Stop bleeding Uterotonic drugs

9. Uterine contractions play the major role Placental separation takes place in spongiosa layer….. ( decidua basalis) Placental separation from the placental site

10. the uterus( placental site ) Placenta separates from the uterus(placental site ) Lower uterine cavity or upper vagina C o m p l e t e d e l i v e r y f r o m t h e v a g i n a More uterine contractions Steps of placental delivery

11. Gush of blood ( VULVA SIGN )  Does not signify complete separation Lengthening of the umbilical cord ( CORD SIGN ) Uterine fundus palpable beyond the umbilicus Uterus become round in shape Signs of placental separation

12. Vulva sign means only placental separation is going on but does not signify complete separation Cord lengthens for more than 3 inches (8-10 cms) When pushing the uterus upward the cord will not follow Tests for complete placental separation

13. Spontaneous uterine contractions, Downward pressure from the developing retroplacental hematoma An increase in maternal intraabdominal pressure Placental expulsion follows as a result of

14. Sudden gush of blood

15. Lengthening of the cord

16. Expression of the Placenta

17. Delivery of the placenta

18. Longer duration----more PPH Average 5-6 mins 90% placenta delivered in 15 mins 97% in 30 mins Preterm---longer duration Retained placenta---more likely in very early GA Duration of the third stage of labor

19.  Ex pectant m ana g ement MANAGEMENT OF THIRD STAGE OF LABOR Expectant management Spontaneous delivery of the placenta without the use of uterotonic agents or cord traction Delivered by maternal expulsive force and gravitational force The placenta may be incomplete separated or entrapped in the lower uterine segment or upper vagina Takes more time More bl eeding 

20. Active management Early cord clamping Administration of a uterotonic agent prior to placenta separation. Controlled cord traction Uterine massage Reduced risks of maternal blood loss MANAGEMENT OF THIRD STAGE OF LABOR Urinary bladder should be emptied in all cases

21. Administration of a uterotonic agent is recommended during the third stage to reduce maternal blood loss Uterotonic agents should not be given until after delivery of the anterior fetal shoulder to ensure that shoulder dystocia is not exacerbated. The clinician should also be certain that there is no undiagnosed and undelivered twin

22. DRUGS USED FOR ACTIVE MANAGEMENT Methergine Oxy t ocin

23.  There are insufficient data to determine whether administration of the uterotonic agent is more effective If it is given after delivery of the anterior shoulder but before separation of the placenta Or immediately upon expulsion of the placenta

24. Maneuver to facilitate placental delivery Brandt-Andrews maneuver Controlled cord traction ( recommended by WHO ) Fundal Pressure

25. Controlled cord traction recommended by WHO

26. After birth of baby, the cord stops pulsating and is cut, severing the baby from the mother. Follow the cord and grasps it at the vaginal opening, taking up any cord slack, pulling it straight out the vaginal opening

27. A large ring forceps is clamped onto the cord at the entrance to the vagina and let it hang down by its own weight

28. Checking for placental separation and release along with uterine tone and contraction by placing a hand on the uterus. Do not massage the uterus . Allow it to contract on its own . When the uterus contracts, it will form a hard globular ball which rises slightly under your hand. Tell the mother to let you know when she begins to have contractions again Do not massage the uterus

29. Checking placental separation and release from the uterus by placing a hand on the uterus and using the other hand for cord traction. Uterine firmness is noted .

30. Cord traction is applied, using the ring forceps to obtain a firm hold (the cord is very slippery), taunt traction is done, pulling gently but firmly away from the vagina. The mother should be having contractions at this point . There is usually a little gush of blood as the placenta begins to pull away from the uterine wall. Placenta separation may be apparent by the increasing cord length between the forceps and the vaginal opening .

31. Placenta Delivery: Controlled cord traction . Have the mother begin pushing with her contractions. If there is a gush of blood and lengthening of the cord, have the mother push whether or not there is a contraction .

32. Placenta Delivery : Using one hand to apply suprapubic pressure against the fundus of the uterus with your cupped hand, and your thumb placed just above the pubic bone to keep the uterus from entering the pelvis and causing spurious cord lengthening or other false evidence of separation, or even inverting the uterus. Provide some steady cord traction to not whether there is a sense of "give" as the placenta moves into the vagina and the cord lengthens, or conversely, does not progress , in which case cease your maneuvers and wait . If you are uncertain whether the placenta has actually separated, you may follow the cord with your hand in the vagina, up to the cervix, to determine if the placenta is trapped in the cervical os, or whether the cord disappears into the uterus.

33. There is no hurry to deliver the placenta It is normal and safe, if there is no bleeding, to wait up to an hour, checking for separation periodically The placenta has been known to stay attached to the uterine wall for days after a delivery. If this occurs because there is acreta , this is the safe state until the problem can be evaluated more completely. In the absence of heavy bleeding

34. If the placenta has separated without your knowledge and it is not delivered , then the uterus may be silently filling with blood. This is another reason for keeping your abdominal hand over the uterus at all times until the delivery of the placenta is imminent at the introitus

35. Placenta Delivery : Use maternal efforts to deliver the placenta, assisted by the following maneuvers, as needed, when you believe the separation has occurred. Maintain your abdominal hand over the uterus, using your flattened fingers just above the pubic bone to aid the placenta as it exits the cervical os into the vagina . Instead of pressure with flattened fingers, the Brandt Andrews maneuver may also be used, but this is more uncomfortable for the mother . Place your fingers around the ring forceps at the point where the cord is attached, and apply steady cord traction with a downward motion. The Upward Placental Lift : then upward along the curve of Carus as the placenta traverses the vagina to the introitus. When the placenta is visible at the introitus, lift it partially through with the hand holding the ring forceps .

36. Placenta Delivery : Remove your other hand from the abdomen and let the placenta fall into your hands. At this point, drop the cord and ring forceps. Encompass the placenta using both hands to support it during delivery, making sure the membranes do not tear .

37. Placenta Delivery : Using an Up-Down- Rotation method to bring it through the os.

38. Placenta Delivery : Once the placenta is delivered, continue to rotate it and the membranes to form a thicker cord of membranes help the membranes release intact without tearing or shredding.

39. Placenta Delivery : Grasping the membranes with the ring forceps to help in delivery and to aid in making a thicker cord of membranes .

40. Placenta Delivery of the Membranes: Rotating the ring forceps to "tease" the membranes loose from the uterine lining without shredding them by a slight up and down movement. NOTE: Slow controlled delivery is necessary to avoid tearing of the cord or membranes .

41. Placenta Delivery Cleanup : Once the placenta is out, massage the belly once or twice above the uterus to get the uterus to contract and form a grapefruit size firm ball under your hand. Wipe out the blood from the introitus (vaginal opening) after the delivery of the placenta to determine if you have additional bleeding .

42.  Rapid infusion of intravenous oxytocin ( 1 units) upon delivery of the anterior shoulder (to limit the risk of shoulder dystocia).  After delivery of the baby and when signs of placental separation are evident , we employ the Brandt maneuver and put gentle traction on the umbilical cord to facilitate delivery of the placenta.  Perform manual uterine massage and continue the oxytocin infusion after delivery of the placenta P R A CTICAL L Y Anterior shoulder delivered Rapid synyto infusion Signs of placental separation B r and t - An d r ew Placenta completely delivered Manual uterine massage

43. Fundal pressure maneuver The fundus is pushed downward and backward after placing 4 fingers behind the fundus and the thumb in front using the uterus as a sort of piston. Pressure must be given only when the uterus becomes hard. Uterus is massaged to make it hard, which facilitates expulsion of retained clots if any.

44. Hemorrhage Uterine inversion Retained placenta Major complications of the third stage of labor