Third stage of labour

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Third stage of labour

• Dr.Roaa H. Gadeer
• MD

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Definition

• commences with the delivery of the fetus and ends
  with delivery of the placenta and its attached
  membranes.
• The length of the third stage is 5-15 minutes.
  30 minutes have been suggested if there is no
  evidence of significant bleeding.
• The risk of complications continues for some
  period after delivery of the placenta.
• Fourth stage of labor begins with the delivery
  of the placenta and lasts for 1 hour

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Significance

• Postpartum haemorrhage (PPH) It is a leading
  cause of maternal mortality.
• Maternal death The maternal mortality rate in
  the United States is approximately 7-10 women per
  100,000 live births 8 of these deaths are
  caused by PPH. The maternal mortality rates in
  developing world exceeded 1000 women per 100,000
  live births, 25 of these deaths are due to PPH.
• Anemia PPH may cause anemia or poor iron. Anemia
  may cause weakness and fatigue. prolonged
  hospitalization may affect the establishment of
  breastfeeding.
• transfusion reaction and infection Due to blood
  transfusion.
• Emergency anesthetic intervention due to severe
  PPH, retained placenta, and uterine inversion.
• Sepsis due to exploration or instrumentation of
  the uterus.

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What to do before delivery of the placenta ?

• Inspect the cervix and vagina for lacerations.
• Look for signs of placental separation.

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Mechanism of placental separation

• Uterine contractions and retraction reduce the
  surface area ? placental detachment and expulsion
  into the lower uterine segment.
• Retro placental hematoma.
• Agents causing uterine contraction
  (uterotonic) oxytocin, ergometrin and
  prostaglandins enhance placental separation and
  expulsion .
• Agents (tocolytics/nitroglycerin and some
  inhalation anesthetics) cause uterine relaxation
  and delay of placental separation causing
  dangerous bleeding following delivery.

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What to do before delivery of the placenta?

• 1. Look for signs of placental separation
• lengthening of the umbilical cord outside.
• The uterus becomes firm and globular.
• The uterus rises in the abdomen.
• A gush of blood.
• 2. Assess the uterus
• To exclude an undiagnosed twin
• To determine a baseline fundal height
• to detect the signs of placenta separation
• to detect an atonic uterus

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Delivery of the placenta

• Physiological or expectant management
• -Wait for the signs of placental separation
• - Make sure that the uterus is contracted.
• - Controlled Cord traction the body of the
  uterus is supported above the symphysis pubis by
  the left hand directed upward and backward. Then
  cord traction is applied continuously downward
  with the right hand.
• active management
• - By using 1 of 3 uterotonic agents
  ergometrine, oxytocin, or ergometrine- oxytocin
  (Syntometrine
• - Given at the delivery of anterior shoulder
  or after delivery of the baby.
• - Immediate delivery of the cord with CCT.
• Avoid uterine massage before placental delivery.

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Delivery of membrane

• by rotating the placenta about the insertion
  site as it descends or grasping the membranes
  with a clamp.

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Umbilical cord management

• cord clamping Delayed until the cord is
  pulseless, usually 2-4 minutes, ??Hb, ?iron
  stores in the newborn and ?levels of early
  childhood anemia.
• Method of cord clamp

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Physiological Versus Active Management
Physiological Management Active management
Uterotonic agent None or after placenta delivered With delivery of anterior shoulder or baby
Uterus Assessment of size and tone after delivery Assessment of size and tone after delivery
Cord traction None controlled cord traction when uterus contracted
Cord clamping Variable Early
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Mode of uterotonic administration

• Oxytocin dose is 10 IU, intramuscularly. with
  intravenous access in place, 10-20 IU is placed
  in 500-1000 mL of crystalloid and run quickly.
  With cesarean deliveries, 5 IU is administered as
  an intravenous bolus, followed by a similar
  infusion.
• Ergometrine dose is 0.2-0.25 mg, some used 0.5
  mg IM or IV.
• Syntometrine (contains 0.5 mg of ergometrine with
  5 IU of oxytocin) IM, 2 mg.

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What to do after delivery of the placenta?

• Determine the fundal position and size of the
  uterus. why?
• Ensure that the uterus is contracted (can be
  enhanced with oxytocin and uterine massage).
• Examine the placenta for completeness and
  detection of abnormalities.
• Suturing of lacerations.
• Uterine exploration
• - No longer recommended for normal deliveries
  or those following previous cesarean delivery.
• - Is justified in patients with bleeding
  originating high in the genital tract.
• - The cervix should be visualized after all
  forceps deliveries

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Fourth stage

• Observe the vital signs.
• palpate the abdomen to assess and monitor uterine
  tone and size.
• Do uterine massage.
• Ensure continuous infusion of oxytocin.
• Encourage early breastfeeding to promote
  endogenous oxytocin release.
• assess the lower genital tract for bleeding.
• assess the placenta for completeness.
• repair of an episiotomy or any lacerations.
• Close observation every 15 minute for the next
  hour.

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COMPLICATIONS

• Postpartum hemorrhage.
• Retained placenta.
• Uterine inversion.

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