03 active management of third stage of labour

ACTIVE MANAGEMENT ACTIVE MANAGEMENT OF THIRD STAGE OF OF THIRD STAGE OF

LABOURLABOUR

Dr. Md. AlauddinDr. Md. AlauddinProfessor & HeadProfessor & Head

Dept. of G&ODept. of G&OMMCMMC

SESSION OBJECTIVESSESSION OBJECTIVES

To understand 3To understand 3rdrd stage stage ComplicationsComplications Active ManagementActive Management Inappropriate/Harmful PracticesInappropriate/Harmful Practices Best PracticesBest Practices

Third StageThird Stage

Delivery of the Foetus to delivery of placenta Delivery of the Foetus to delivery of placenta and membranes.and membranes.

Upto Thirty MinutesUpto Thirty Minutes Average 5-15 MinutesAverage 5-15 Minutes Shorter in multi, slightly longer in primiShorter in multi, slightly longer in primi

KEY EVENTS IN THIRD KEY EVENTS IN THIRD STAGESTAGE

Separation of PlacentaSeparation of Placenta Expulsion/Delivery of PlacentaExpulsion/Delivery of Placenta HaemostasisHaemostasis

SEPARATION OF PLACENTASEPARATION OF PLACENTA

Central SeparationCentral Separation Marginal SeparationMarginal Separation Signs of Placental separationSigns of Placental separation

Uterus becomesUterus becomes contracted, hard and globular;contracted, hard and globular; Uterus rises just above umbilicus;Uterus rises just above umbilicus; Extra vulval lengthening of umbilical cord;Extra vulval lengthening of umbilical cord; A gush of bloodA gush of blood frequently appears;frequently appears; On pushing the uterus up in the abdomen, the cord On pushing the uterus up in the abdomen, the cord

does not recede back.does not recede back.

EXPULSION/DELIVERY OF EXPULSION/DELIVERY OF PLACENTAPLACENTA

Natural expulsion – Bearing down effortsNatural expulsion – Bearing down efforts Controlled cord traction.Controlled cord traction.

HAEMOSTASISHAEMOSTASIS

Contraction and Retraction of MyometriumContraction and Retraction of Myometrium – Ligature effect.– Ligature effect.

ThrombosisThrombosis Apposition of uterine walls.Apposition of uterine walls.

COMPLICATIONS OF THIRD COMPLICATIONS OF THIRD STAGESTAGE

PPHPPH Retained PlacentaRetained Placenta InversionInversion Post-partum ShockPost-partum Shock

ACTIVE MANAGEMENT OF ACTIVE MANAGEMENT OF THIRD STAGE OF LABOURTHIRD STAGE OF LABOUR

PRINCIPLES:PRINCIPLES: Enhance separation of placentaEnhance separation of placenta Safe and complete delivery of placentaSafe and complete delivery of placenta Minimize bleedingMinimize bleeding

ACTIVE MANAGEMENT OF ACTIVE MANAGEMENT OF THIRD STAGE OF LABOURTHIRD STAGE OF LABOUR

COMPONENTS:COMPONENTS: Use of oxytocicsUse of oxytocics Delivery of placenta by controlled cord tractionDelivery of placenta by controlled cord traction Massage of uterus after placental deliveryMassage of uterus after placental delivery

Examination of birth canal and afterbirthsExamination of birth canal and afterbirths Repair of tears/episiotomyRepair of tears/episiotomy

OXYTOCICSOXYTOCICS

OxytocinOxytocin Ergometrine/MethylergometrineErgometrine/Methylergometrine ProstaglandinProstaglandin MisoprostolMisoprostol

OXYTOCINOXYTOCIN

SafeSafe CheapCheap No contraindicationNo contraindication Effective – quick actionEffective – quick action 10 units IM10 units IM Less heat labileLess heat labile

ERGOMETRINEERGOMETRINE

CheapestCheapest Has contraindicationsHas contraindications Side effects – sometimes seriousSide effects – sometimes serious EffectiveEffective 0.2 mg IM/IV0.2 mg IM/IV Heat labileHeat labile

PROSTAGLANDINPROSTAGLANDIN

CostlyCostly ContraindicationsContraindications Some side effectsSome side effects EffectiveEffective 125-250 mcg IM125-250 mcg IM Highly heat labileHighly heat labile

MISOPROSTOLMISOPROSTOL

Less costlyLess costly No significant contraindicationNo significant contraindication No significant side-effectNo significant side-effect EffectiveEffective 600 mcg orally600 mcg orally Highly heat stableHighly heat stable

WHICH OXYTOCIC?WHICH OXYTOCIC?

Oxytocin - first choiceOxytocin - first choice Misoprostol - has a promiseMisoprostol - has a promise Prostaglandin – effective but costlyProstaglandin – effective but costly

DELIVERY OF PLACENTADELIVERY OF PLACENTA

Controlled cord tractionControlled cord traction Raising the uterus gently upward by Raising the uterus gently upward by

abdominal handabdominal hand Traction when placenta is separated/Uterus Traction when placenta is separated/Uterus

contractedcontracted

UTERINE MASSAGEUTERINE MASSAGE

Immediately after placental delivery till uterus Immediately after placental delivery till uterus is hardis hard

Repeat intermittently for 1-2 hrs.Repeat intermittently for 1-2 hrs.

IMMEDIATE POST-PARTUM IMMEDIATE POST-PARTUM CARECARE

Closely monitor for first 6 hours.Closely monitor for first 6 hours. - Pulse, respiration, temperature, - Pulse, respiration, temperature,

B.P., G.CB.P., G.C - Vaginal bleeding.- Vaginal bleeding. - Uterine hardness.- Uterine hardness. @ Every 15 mins. for 1 hour.@ Every 15 mins. for 1 hour. @ Every 30 mins. For 2 hours.@ Every 30 mins. For 2 hours. @ Every hour for 3 hours.@ Every hour for 3 hours. Massage the uterus every 15 mins. to maintain Massage the uterus every 15 mins. to maintain contraction.contraction. If stable give her something to drink/eat when If stable give her something to drink/eat when thirsty/hungry.thirsty/hungry.

INAPPROPRIATE/HARMFUL INAPPROPRIATE/HARMFUL PRACTICESPRACTICES

Non-use of active managementNon-use of active management Manipulating uterus (fundal pressure, Manipulating uterus (fundal pressure,

squeezing)squeezing) Inappropriate use of oxytocicInappropriate use of oxytocic Inappropriate cord tractionInappropriate cord traction Routine catheter/MRP/exploration of uterusRoutine catheter/MRP/exploration of uterus Uterine lavageUterine lavage Not examining birth canal/after birthsNot examining birth canal/after births

BEST PRACTICESBEST PRACTICES

Cleanliness: IPPCleanliness: IPP Complication readinessComplication readiness Support personSupport person Active management FOR ALLActive management FOR ALL

Oxytocic : Oxytocic : OXYTOCIN 10 U IM – FIRST CHOICEOXYTOCIN 10 U IM – FIRST CHOICE CControlled tractionontrolled traction Uterine massageUterine massage

Examination of birth canal and after birthsExamination of birth canal and after births To remain vigilant for 6 hoursTo remain vigilant for 6 hours

MAKE IT AN ISSUEMAKE IT AN ISSUE

T H A N K Y O U !!!T H A N K Y O U !!!