3rd Stage of Labor
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| 3rd stage of labor |
3rd stage is d most crucial stage of labour.
Principles undrlying managment of 3rd stage r
-to ensur strict vigilance
-to folow d managment guidlines strictly in practice
-to prevent complications, d imp one being PPH
A) Expectant managment (Traditional)-
in dis managment, d placental sepration & its descent in2 vagina r alowd 2 ocur spontaneously. Minimal asistanc may b givn for d placental expulsion if it needed
#constant watch is mandatory & patient shudnt b left one
#if mother is delivered in lateral position, she shud b changd 2 dorsal position 2 note features of placental sepration & 2 asses amt of bld loss
a hand is placed ovr fundus
i) to recognise signs of sepration of placenta
ii) to note state of uterine activity-contraction & relax^
iii) to detect cupping of fundus whch is an early evidnc of inversion of uterus
Desire 2 fiddle wid fundus / massage uterus is strongly 2 b condemned
Placenta is seprated widin min folowing birth of baby.
Pt is expected 2 expel placenta widin 20 min wid aid of gravity
Expulsion of placenta- only wen features of placental sepration & its descent in2 lowr segmen r confirmd, pt is askd 2 bear down simultnously wid hardening of uterus.
Raisd intra-abdo presur is often adequat 2 expel placenta.
If pt fails 2 expel, 1 can safely wait upto 10 minutes if der is no bleding.
As soon as placenta pases thru introitus it is graspd by hands & twistd round & round wid gentle traction so dat membranes r stripped intact.
If membranes threaten 2 tear, dey r caught hold of by sponge holding forceps & in similr twisting movts rest of membrans delivrd.
Gentleness, practice & care r prerequisites for complete delivry of membrans.
If spontaneous expulsion fails / is nt practicable, becoz of delivry undr anaesthesia, any 1 of folowing methods can b usd to expedite expulsion
Assisted expulsiön
i) controld cord traction (modified Brandt-Andrews method)
in dis palmar surfac of fingers of left hand is placed abov pubic symphysis approx @ junction of uper & lowr uterine segment. Body of uterus is pushed upwrds & backwrds, 2wrds umbilicus while by rt hand steady tension is givn in downwrd & backwrd dir^ holding clamp until placenta coms outsid introitus. Uterine elev^ facilitats expul^ of placenta. Procedur is 2 b adoptd only wen uterus is hard & contractd
ii)Fundal pressure- fundus is pushd downwrds & backwrds aftr placing four fingers bhind fundus & thumb in front using uterus as a sort of piston
Presur must b givn only wen uterus bcoms hard
If baby is macerated / premature dis methd is prefrable 2 cord traction
uterus is massaged 2 mak it hard, whch facilitates expul^ of retaind clots if any
Inj Oxytocin 5-10units IV or methergin 0.2mg givn IM
Exam of placenta membrans & cord
-Placenta placed on a tray & is washed out in running tap water 2 remov bld & clots
-Maternal surface is first inspected for its completeness & anomalies
-Membranes chorion n amnion r 2 b examind carefuly for completnes n presenc of abno vessels indicativ of succenturiate lobe
-Amnion is shiny but chorion is shaggy
-two umbilicl arteries n one umbilicl vein confirmd
-an oval gap in chorion wid torn ends of bld vessls running up2 margin indicats a missing succenturiate lobe
#Vulva, vagina, perinium inspectd for injuries n 2 b repaired
#4th stage- pulse, BP, behavior of uterus n any abnorml vaginl bledings is 2 b watchd at least for 1 hr aftr delivry
B)Active management of 3rd stage
THE UNDERLYING PRINCIPLE IN ACTIVE MANAGEMENT = it is to excite powerful uterine contractions following birth of anterior shoulder by parenteral oxytocin which facilitates not only early seperation of placenta but produces effective uterine contractions following its seperation.ADVANTAGES=
1)to minimise blood loss approximately to 1/5 th
2)shorten duration of 3rd to half
The only disadvantage is slight increase in incidance of retained placenta nd conseqent increased incidance of manual removal.
Accidental administration during delivery of 1st baby in undiagnosed twins produces grave danger to unborn second baby caused by asphyxia due to tetanic contractions of uterus.Thus it is imperative to limit its use in twins only during delivery of second baby.
PROCEDURES = inj. ergometrine 0.25 mg or methergin 0.2 mg is given i.v.following birth of anterior shoulder.If administered prior to this there is chance of imprisonment of shoulder behind pubic symphysis.This is followed by slow delivery of baby within 2-3 minutes. Placenta expected to be delivered following the delivery of buttocks. If placenta is not delivered instantaneously it should be delivered forthwith by controlled cord traction technique after clamping cord while uterus still remains contracted. He 1st attempt fails another attempt is made after 2-3 minutes failing which another attempt is made at 10 minutes. If still this fails manual removal is to be done.
LIMITATION=It should not be used in cardiac cases or severe pre eclampsia for fear of precipatating cardiac over load in former nd aggravation of bld pressure in latter.
It is certainly of value for cases likely to develope postpartum haemorrhage.
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