thirdstageoflabour-140413065917-phpapp01.pptx

third stage of labour

1. THIRD STAGE OF LABOUR

2. DEFINITION The third stage of labor lasts from the birth of the baby until the placenta is expelled. It is known as the placental stage of labour.

3. Signs of third stage of Labor Pain: Due to uterine contraction, intermittent discomfort may be felt in the lower abdomen Separation of the placenta: Uterus is discoid in shape Feels firm Nonballotable Fundus is below the umbilicus Slight oozing of blood per vagina Length of umbilical cord as visible outside remains static

4. After separation Uterus becomes globular in shape Feels firm Nonballotable Fundus is found in between symphysis pubis and umbilicus Permanent lengthening of cord Sudden gush of vaginal bleeding

5. Expulsion of placenta and membrane By bearing down effort Uterine contractions If required, gentle tractions may be given on tags of membranes using hemostat or Kocher’s clamp

6. Maternal signs Sudden chills Shivering Raised pulse rate Increased BP

7. PHYSIOLOGICAL PROCESSES OF PLACENTAL SEPERATION AND EXPULSION Placental separation. Descend of the placenta. Expulsion of the placenta.

8. PLACENTAL SEPERATION Result of the abrupt decrease in size of the uterine cavity . The retraction process accelerates. The formation of retro placental clot.

9. BEFORE SEPARATION Per abdomen : Uterus become discoid in shape, firm in feel and ballottable . Fundal height reaches slightly below the umbilicus and raised. Slight bulging in the suprapubic region Per vaginum : There may be slight trickling of blood. Length of the umbilical cord as visible from outside remains static.

10. AFTER SEPARATION Per abdomen: Uterus become globular, firm and ballottable . Fundal height is slightly raised. Supra pubic bulging

11. Per vaginum : Slight gush of vagina bleeding. Permanent lengthening of the cord.   Expulsion of placenta and membrane Maternal signs -Chills -Shivering -Slight transient hypotension

12. EXPULSION OF THE PLACENTA The Schultz mechanism(central separation} Mathew Duncan mechanism(marginal separation)

13. Central separation(Schulze method) Detachment of the placenta from its uterine attachment starts at the centre resulting in the opening up of a few uterine sinuses and accumulation of blood behind the placenta (retroplacental haematoma ) . With increasing contraction, more and more detachment occurs facilitated by the weight of the placenta and retroplacental blood until whole of the placenta gets detached.

14. Marginal separation(Mathew-Duncan) Separation starts at the margin as it is mostly unsupported. With progressive uterine contraction, more and more areas of the placenta get separated.

15. Separation of membranes The membranes which are attached loosely in the active part are thrown into multiple folds. Those attached to the lower segment are already separated during its stretching. The separation is facilitated partly by uterine contraction and mostly by the weight of the placenta as it descends down from the active part.

16. Expulsion of placenta After complete separation of the placenta, it is forced down into the flabby lower uterine segment or upperpart of the vagina by effective contraction and retraction of the uterus. Thereafter, it is expelled out by either voluntary contraction of abdominal muscles or by the manipulative procedure.

17. After placental separation, innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterated . The occlusion is effected by complete retraction where by the arterioles, as they pass tortuously through the interlacing intermediate layer of the myometrium, are literally clamped . It is the principal mechanism of hemostasis .

18. However, thrombosis occurs to occlude the torn sinuses, a phenomenon which is facilitated by hypercoaguable state of pregnancy. Apposition of the walls of the uterus following expulsion of the placenta (myotampoade) also contributes to minimize blood loss.

19. Physiological management of third stage of labor Mismanaged third stage is the largest single cause of postpartum hemorrhage and also causes uterine inversion and shock.

20. Steps of management Expectant management Active management

21. EXPECTANT MANAGEMENT In this method, placental separation and descending into vagina are allowed to occur spontaneously. Mother’s efforts are used to help in expulsion.

22. MANAGEMENT OF THIRD STAGE OF LABOUR Do not pull on the umbilical cord before the placenta separates or ever with an uncontracted uterus. Do not try to deliver the placenta prior to its complete separation unless in the emergency of third stage haemorrhage. Wait for the natural process to occur and do not interfere.

23. EXPECTANT MANGEMENT Steps A hand is placed over the fundus to feel the signs of placental separation. If the placenta fails to expel, one can wait for upto 10 mts. The client asked to bear down simultaneously with the hardening of the uterus. Soon as the placenta passes through the introitus, it is grasped by both hands and twisted round and round or slightly up and down with gentle traction .

24. If there is danger of the tear of membranes, gentle traction may be given on tags of membranes using hemostat or Kocher’s clamp

25. EXPECTANT MANGEMENT Controlled cord traction [ modified Brandt-Andrews method]:

26. EXPECTANT MANGEMENT EXPRESSION BY FUNDAL PRESSURE This is done by placing four fingers of the hand behind the fundus and thumb in front of the uterus to use as a piston. The uterus is made to contract by gentle rubbing. When the uterus becomes hard, it is pushed downwards and backwards. The pressure should be withdrawn as soon as the placenta passes through the introitus .

27. CONTROLLED CORD TRACTION (MODIFIED BRANDT-ANDREWS METHOD) This method is applied only if uterus is hard and contracted and placenta is separated. In this method, left hand is placed above the symphysis pubis with the palmer surface facing toward the umbilicus to exert pressure in upward direction. The body of uterus is displaced upward and towards the umbilicus, while with the right hand, steady tension is given in a downward and backward direction, by holding the clamp placed on the cord until the placenta comes out of the introitus.

28. ACTIVE MANAGEMENT PRINCIPLE OF ACTIVE MANAGEMENT: Active managements aim to excite powerful uterine contractions within 1 minute of delivery of the baby by giving parenteral oxytocics . This facilitates not only early separation of the placenta but also produces effective uterine contractions following its separation. Advantages Minimizes blood loss in third stage of labor Shorten the duration of third stage to half

29. Disadvantage Risk of retained placenta and consequent increased incidence of manual removal Accidental administration during delivery of the first baby in undiagnosed twins produces grave danger to the unborn second baby caused by asphyxia due to tetanic contraction of the uterus. Thus, in case of twins, always administer following delivery of the second twin.

30. USE OF OXYTOCIC AGENTS Prophylactic use the administration of an oxytocic drug at the time of delivery of the anterior shoulder. Therapeutic administration This method implies the use of an oxytocic either to stop the bleeding once it has occurred or to maintain the uterus in a contracted state when there are indications that excessive bleeding is likely to occur.

31. FUNDAL HEIGHT DURING THIRD STAGE At the end of the third stage following the expulsion of the placenta, the fundus is about 4cm below the umbilicus.

32. COMPLETION OF THIRD STAGE Continuing evaluation ensure that the uterus is well contracted Slight lacerations are usually repaired immediately The vulva and perineum are gently cleansed Mother’s blood pressure, pulse and temperature should be taken Once the mother is comfortable the placenta and membranes is the next priority

33. Examination of placenta and membrane Infarctions that are recent or old Localized calcifications Lobes Blood vessels Insertion of the cord Umbilical vessels Cord length Weight of placenta

34. Care of newborn and mother Care for at least an hour after delivery. The mother should receive cleansing body wash, mouthwash and perineal care. She should be encouraged to empty bladder and bedpan offered. Blood pressure, pulse, uterine contraction and bleeding should be checked every 15 mts.

35. Care of newborn and mother The baby’s general wellbeing and security of the cord clamp needs to be checked. As the baby will chill after birth thoroughly dry and wrap the baby . Mothers intended to breastfeed may be encouraged. Early breastfeeding causes a reflex release of oxytocin from the posterior pituitary and stimulates the uterus to contract.

36. Records All the drugs administered, examination of the placenta, membranes and cord with attention drawn to any abnormalities and the amount of blood loss.

37. COMPLICATIONS OF THE THIRD STAGE Post partum haemorrhage. Hematoma formation. Retained placenta Inversion of uterus. shock

38. SKIN TO SKIN CONTACT Early skin to skin contact begins ideally at birth and involves placing the naked baby, covered across the back with a warm blanket, prone on the mother’s chest.

39. Every baby goes through 9 instinctive stages at the time of skin-to-skin contact: Birth cry Relaxation Awakening Activity Crawling Resting Familiarization Sucking Sleeping

40. Benefits Interaction between mother and infant Opportunity for breastfeeding Better neurodevelopment Thermoregulation Glucose regulation Easier transition to extrauterine life Pain management Prevent infection and other morbidities Leads to early discharge

41. THANK YOU…….