MANAGEMENT OF THIRD STAGE OF LABOR IN ENGLISH

                                                       

                   MANAGEMENT OF THIRD STAGE OF LABOR IN ENGLISH

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MANAGEMENT OF THIRD STAGE OF LABOR-

Ø  Third stage is very crucial stage of labor. Previously normal first and second stage can become abnormal within a minute with serious complications. 

Ø  The main aims in the management of third stage are to ensure strict vigilance and to follow  guidelines strictly in practice so as to prevent the complications, and  the important one is postpartum hemorrhage.

STEPS OF MANAGEMENT:

Two methods of management of third stage of labor are currently in practice.

Ø  Expectant management

Ø  Active management (preferred)

Expectant management

Ø  In this management, the placental separation and its descent into the vagina are allowed to occur spontaneously. Minimal assistance may be given for the placental expulsion if it needed.

Ø  The patient should not be left alone, A watchful continue monitoring should be done.

Ø  The mother should be kept in dorsal recumbent position

Ø  Fundus should be palpated-

Ø  (a) to recognize the signs of separation of placenta,

Ø  (b) to note the state of uterine activity—contraction and relaxation and

Ø  (c) to detect, though rare, cupping of the fundus which is an early evidence of inversion of the uterus.

Ø  Placenta is separated within minutes following the birth of the baby. A watchful expectancy can be extended up to 15–20 minutes

Ø   Watch for signs of placenta separations such as- uterine contraction and signs pain is seen on women’s face, gush of blood which stops in 10-20 seconds and cord may lengthen .  

Ø  At appearance of signs of placental serpration the women is asked to bear down simultaneously with the hardening of the uterus. The raised intra-abdominal pressure is often adequate to expel the placenta. most women will push the placenta out as soon as they feel pressure, with little effort.

Ø  As soon as the placenta passes through the introitus, it is grasped by the hands and twisted round and round with gentle traction so that the membranes are stripped intact.

Ø  If the membranes threaten to tear, they are caught hold of by sponge-holding forceps and in similar twisting movements the rest of the membranes are delivered

Ø  If the spontaneous expulsion fails, the palmar surface of the fingers of the left hand is placed (above the symphysis pubis) approximately at the junction of upper and lower uterine segment. The body of the uterus is pushed upward and backward, toward the umbilicus while by the right hand steady tension

Active management (preferred)

Ø  The Main principle in active management is to excite powerful uterine contractions within 1 minute of delivery of the baby (WHO) by giving parenteral oxytocic. This facilitates not only early

Ø  separation of the placenta but also produces effective uterine contractions following its separation. 

Ø  The advantages of AMTSL are—

Ø  (a) to minimize blood loss in third stage  approximately to one-fifth and

Ø  (b) to shorten the duration of third stage to half.

Ø   The only disadvantage is slight increased incidence of retained placenta (1–2%) and consequent increased incidence of manual removal.

Ø  In active management of third stage of labor Injection oxytocin 10 units IM (preferred) or methergine 0.2 mg IM is given within 1 minute of delivery of the baby (WHO).

Ø  The placenta is expected to be delivered soon following deliveryof the baby.

Ø  If the placenta is not delivered thereafter, it should be delivered forthwith by controlled cordtraction (Brandt-Andrews) technique after clamping the cord while the uterus still remains contracted.

Ø  If the first attempt fails, another attempt is made after 2–3 minutes failing which another attempt is made at 10 minutes.

Ø  If this still fails, manual removal is to be done.

Ø  it should be applied in proper time and followed by rapid delivery of the placenta. It may be an ideal procedure while conducting delivery in an equipped

Ø  Examination of the placenta membranes and cord: - The placenta is placed on a tray and is washed out in running tap water to remove the blood and clots. The maternal surface is first inspected for its completeness and anomalies.

Ø  The maternal surface is covered with grayish decidua

Ø  Check membranes of fetal surface

Ø  examine the maternal surface to ensure there are no gaps, a gap would indicate a retained piece.

Ø   Look for accessory lobes (succenturiate lobes), placental infarcts, hemorrhages, tumors, or nodules

Ø  Weigh the Placenta: The weight of the placenta is often recorded

Ø  The membranes—chorion and amnion are to be examined carefully for completeness and presence of abnormal vessels indicative of succenturiate lobe

Ø  Assess the Umbilical Cord: 

Ø  Vessels: Count the number of arteries and veins (typically two arteries and one vein). 

Ø  Insertion: Note where the cord inserts into the placenta. 

Ø  Knots and Thrombi: Look for true knots or other blockages in the cord. 

Ø  Constrictions: Check for any constricting bands or webs along the cord.