Intrapartum Care: The third stage of labour

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: The third stage of labour

  1. 1. 5 The third stage of labourBefore you begin this unit, please take the THE NORMAL THIRDcorresponding test at the end of the book toassess your knowledge of the subject matter. You STAGE OF LABOURshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned 5-1 What is the third stage of labour? The third stage of labour starts immediately Objectives after the delivery of the infant and ends with the delivery of the placenta and membranes. When you have completed this unit you 5-2 How long does the normal should be able to: third stage of labour last? • Define the third stage of labour. • Manage the third stage of labour. The normal duration of the third stage of labour lasts less than 30 minutes, and mostly • List the observations needed during the only two to five minutes. third stage of labour. • Examine a placenta after delivery. 5-3 What happens during the • Manage a patient with prolonged third third stage of labour? stage of labour. 1. Uterine contractions continue, although • Manage a patient with retained less frequently than in the second stage. placenta. 2. The uterus contracts and becomes smaller • List the causes of postpartum and, as a result, the placenta separates. haemorrhage. 3. The placenta is squeezed out of the upper • Manage a patient with postpartum uterine segment into the lower uterine segment and vagina. The placenta is then haemorrhage. delivered. • Prevent infection of the staff with HIV at 4. The contraction of the uterine muscle delivery. compresses the uterine blood vessels and this prevents bleeding. Thereafter, clotting (coagulation) takes place in the uterine blood vessels due to the normal clotting mechanism.
  2. 2. THE THIRD STAGE OF LABOUR 915-4 Why is the third stage 1. Blood loss is less than when the activeof labour important? method is used. Therefore the active method reduces the incidence ofExcessive bleeding is a common complication postpartum haemorrhage.during the third stage of labour. Therefore, 2. There is less possibility that oxytocin willthe third stage, if not correctly managed, be needed to contract the uterus followingcan be an extremely dangerous time for the the third stage of labour.patient. Postpartum haemorrhage is thecommonest cause of maternal death in some Disadvantages:developing countries. 1. The person actively managing the third stage of labour must not leave the patient. The third stage of labour can be a very dangerous Therefore, an assistant is needed to give the time and, therefore, must be correctly managed. oxytocic drug and examine the newborn infant, while the person conducting the delivery continues with the management of the third stage of labour.MANAGING THE THIRD 2. The risk of a retained placenta is increasedSTAGE OF LABOUR if the active method is not carried out correctly, especially if the first two contractions after the delivery of the infant5-5 How should the third stage are not used to deliver the placenta.of labour be managed? 3. Excessive traction on the umbilical cord can result in inversion of the uterus,There are two ways of managing the third especially if the fundus of the uterus is notstage of labour: supported by placing a hand above the1. The active method. bladder on the abdomen.2. The passive method.Whenever possible, the active method should Blood loss during the third stage of labour is lessbe used. However, midwives conducting when the active management is used.deliveries alone, without an assistant, in amidwife obstetric unit or level 1 hospitalmay use the passive method. Midwives who 5-6 What is the active managementchoose to use the passive method of managing of the third stage of labour?the third stage of labour MUST also be able 1. Immediately after the delivery of theto confidently use the active method, as this infant, an abdominal examination is donemethod may have to be used in some patients. to exclude a second twin. 2. An oxytocic drug is given if no second twin is present. Everybody conducting a delivery must be able 3. When the uterus contracts controlled cord to use the active method of managing the third traction must be applied: stage of labour. • Keep steady tension on the umbilical cord with one hand.5-6 What are the advantages and • Place the other hand just above thedisadvantages of the active method of symphysis pubis and push the uterusmanaging the third stage of labour? upwards. Controlled cord traction is also called theAdvantages: Brandt–Andrews method (manoeuvre).
  3. 3. 92 INTRAPAR TUM CARE4. Placental separation will take place when Oxytocin is the drug of choice in the the uterus contracts. When controlled cord traction is applied the placenta will be management of the third stage of labour. moved down from the upper segment to the lower segment of the uterus. 5-9 What are the actions of the two5. Once this occurs, continuous light components of syntometrine? traction on the umbilical cord will now 1. Oxytocin causes physiological uterine deliver the placenta from the lower contractions which start two to three uterine segment or vagina. minutes after an intramuscular injection6. If placental separation does not take place and continue for approximately one to during the first uterine contraction after three hours. giving the oxytocic drug, wait until the 2. Ergometrine causes a tonic contraction of next contraction occurs and then repeat the uterus which starts five to six minutes the manoeuvre. after an intramuscular injection andWith the passive method of managing the continues for about three hours.third stage of labour, the patient is askedto bear down only after there are signs of 5-10 What are the contraindicationsplacental separation. An oxytocic drug is only to the use of syntometrine?given after the placenta has been delivered. Syntometrine contains ergometrine and, therefore, should not be used if:5-8 Which oxytocic drug is usually givenduring the third stage of labour? 1. The patient is hypertensive. Ergometrine causes vasospasm which may result in aOne of the following two drugs is generally severe increase in the blood pressure.given: 2. The patient has heart valve disease.1. Oxytocin (Syntocinon ) 10 units. This is Tonic contraction of the uterus pushes a given intramuscularly. It is not necessary large volume of blood into the patient’s to protect this drug against direct light. circulation, which may cause heart failure Although the drug must also be kept in a with pulmonary oedema. refrigerator, it has a shelf life of one month at room temperature.2. Syntometrine. This is given by Make sure that there are no contraindications intramuscular injection. Syntometrine is before using syntometrine. supplied in a 1 ml ampoule which contains a mixture of five units oxytocin and 0.5 5-11 What oxytocic drug should be mg ergometrine maleate. The drug must used if there is a contraindication be protected from direct light at all times to the use of syntometrine? and must be kept in a refrigerator. The ampoules must, therefore, be kept in an Oxytocin (Syntocinon) should be used. An opaque container in the refrigerator. intravenous infusion of 10 units oxytocin in 200 ml normal saline is given at a rate of 30Oxytocin (Syntocinon) is the drug of choice. drops per minute or 10 units oxytocin areHowever, as Syntometrine is still widely given by intramuscular injection.prescribed, the correct use of this drug willalso be explained. 5-12 Should the umbilical cord be allowedThe latest information in the Cochrane Review to bleed before the placenta is delivered?indicates that the best drug and dosage to use 1. The umbilical cord must not be allowed tois oxytocin 10 units. bleed after the delivery of the first infant
  4. 4. THE THIRD STAGE OF LABOUR 93 in a multiple pregnancy. In identical twins • A short note on the suturing of an with a single placenta (monochorionic episiotomy or perineal tear. placenta), the undelivered second twin • The patient’s pulse rate, blood pressure may bleed to death if the umbilical cord and temperature. of the first born infant is allowed to bleed. • The completeness of the placenta Therefore, the forceps should be left in and membranes, and any placental place on the umbilical cord after the abnormality. delivery of the first twin. 3. Recordings made during the first hour2. The umbilical cord should be allowed after the delivery of the placenta: to bleed if the patient’s blood group is • During this time (sometimes called the Rhesus negative (Rh negative) with a fourth stage of labour) it is important single fetus. This will reduce the risk to record whether the uterus is well of fetal blood crossing the placenta to contracted and whether there is any the mother’s circulation and, thereby, excessive bleeding. During the first sensitizing the patient. Nevertheless, anti- hour after the completion of the third D immunoglobulin must always be given stage of labour, there is a high risk of to these patients. postpartum haemorrhage.3. Allowing the umbilical cord to bleed • If the third stage of labour and the during the third stage of labour, reduces observations were normal, the patient’s the placental volume and, thereby, speeds pulse rate and blood pressure should be up the separation of the placenta. As a measured again an hour later. general rule, the umbilical cord should • If the third stage of labour was not be allowed to bleed once a multiple normal, the observations must be pregnancy has been excluded. Recent repeated every 15 minutes, until the research suggest that the umbilical cord is patient’s condition is normal. Thereafter, best clamped and cut three minutes after the observations should be repeated delivery to allow the infant to receive extra every hour for further four hours. blood from the placenta. During the first hour after the delivery it is Allowing the umbilical cord to bleed after essential to ensure that the uterus is well delivering the infant speeds up the separation contracted and that there is no excessive bleeding. of the placenta. 5-14 When should the infant be given to5-13 What recordings must always be made the mother to hold and put to the breast?during and after the third stage of labour? As soon as possible after delivery. Usually1. Recordings made about the third stage of the infant is well dried and then placed labour: on the mother’s abdomen if the infant is • Duration of the third stage. crying or breathing well. Wait three minutes • The amount of blood lost. before clamping the umbilical cord and then • Medication given. give the infant to the mother to hold and • The condition of the perineum and the place to the breast. The nipple stimulation presence of any tears. causes uterine contractions which may help2. Recordings made immediately after the placental separation. delivery of the placenta: • Whether the uterus is well contracted or not. • Any excessive vaginal bleeding.
  5. 5. 94 INTRAPAR TUM CAREEXAMINATION OF THE 4. Size: Finally the placenta must be weighed.PLACENTA AFTER BIRTH The weight of the placenta increases with gestational age and is usually 1/6 the weight of the infant, i.e. 450–650 g at term.5-15 How should you examine If the placenta is abnormally large andthe placenta after delivery? heavy, the following possibilities must beEvery placenta must be examined for: considered: • A heavy, oedematous placenta is1. Completeness: suggestive of congenital syphilis. Make sure that both the placenta and the • A heavy, pale placenta is suggestive of membranes are complete after the delivery Rhesus haemolytic disease. of the placenta: • A placenta which is heavier than would • The membranes are examined for be expected for the weight of the completeness by holding the placenta infant, but with a normal appearance, is up by the umbilical cord so that the suggestive of maternal diabetes. membranes hang down. You will see A placenta which weighs less than would the round hole through which the be expected for the weight of the infant, infant was delivered. Examine the is suggestive of fetal intra-uterine growth membranes carefully to determine restriction (IUGR). whether they are complete. • The placenta is now held in both hands All placentas must be carefully examined for and the maternal surface is inspected after the membranes are folded away. completeness and abnormalities after delivery. A missing part of the placenta, or cotyledon, is thus easily noticed.2. Abnormalities: THE ABNORMAL THIRD • Cloudy membranes, or a placenta that smells offensive, suggest the STAGE OF LABOUR presence of chorioamnionitis. Peeling the amnion off the chorion is the best 5-16 What is a prolonged way of examining the amnion over third stage of labour? the placenta for cloudiness caused by chorioamnionitis. If the placenta has still not been delivered • Clots of blood which stick to the after 30 minutes, the third stage is said to be maternal surface suggest that abruptio prolonged. placentae has occurred. • Infarcts can be recognised as firm, pale The third stage is prolonged when the placenta areas on the maternal surface of the placenta. Calcification on the maternal still has not been delivered after 30 minutes. surface is normal.3. Umbilical cord: 5-17 How should a prolonged third Two arteries and a vein should be seen on stage of labour be managed? the cut end of the umbilical cord. If only 1. If the active method has been applied and one umbilical artery is present, the infant failed: must be carefully examined for other • An infusion with 20 units of oxytocin congenital abnormalities. in 1000 ml Basol or normal saline must be started and run in rapidly.
  6. 6. THE THIRD STAGE OF LABOUR 95 • Once the uterus is well contracted, MANAGING A try again to deliver the placenta by controlled cord traction. POSTPARTUM HAEMORRHAGE5-18 What should be done if theplacenta is still not delivered, afterthe routine management of a 5-20 What is a postpartum haemorrhage?prolonged third stage of labour? 1. Blood loss of more than 500 ml within theA vaginal examination must be done: first 24 hours after delivery of the infant. 2. Any bleeding after delivery, which appears1. If the placenta or part of the placenta is excessive. palpable in the vagina or lower segment of the uterus, this confirms that the placenta has separated. By pulling on the umbilical Any excessive bleeding after delivery should be cord with one hand, while pushing the considered to be a postpartum haemorrhage and fundus of the uterus upwards with the managed as such. other hand (i.e. controlled cord traction), the placenta can be delivered.2. If the placenta or part of the placenta is not 5-21 What should be done if a patient palpable in the vagina or lower segment of has a postpartum haemorrhage? the uterus and only the umbilical cord is The management will depend on whether the felt, then the placenta is still in the upper placenta has been delivered or not. segment of the uterus and a diagnosis of retained placenta must be made. 5-22 What is the management of a postpartum haemorrhage, if the A retained placenta is diagnosed if the placenta has not been delivered? management of prolonged labour has failed. 1. If the active method has been used to manage the third stage of labour, a rapid5-19 What is the management intravenous infusion of 20 units oxytocinof a retained placenta? in 1000 ml Basol or normal saline must be started, to ensure that the uterus is1. Continue with the intravenous infusion of well contracted. A further attempt should oxytocin and make sure that the uterus is now be made to deliver the placenta. well contracted. This will reduce the risk of Immediately after the delivery of the postpartum haemorrhage. placenta, make sure that the uterus is well2. While waiting for the theatre to be ready or contracted, by rubbing up the fundus. transfer of the patient, check continuously 2. If the attempt to deliver the placenta fails, whether the uterus remains well contracted the patient has a retained placenta and and for excessive vaginal bleeding. should be managed for a retained placenta. The blood pressure and pulse must be measured and recorded every 30 minutes. The management of a patient with a3. If the patient is at a clinic or a level 1 postpartum haemorrhage before the delivery of hospital without an operating theatre, the placenta is summarised in flow diagram 5-I. she must be transferred to a level 2 or 3 hospital, for manual removal of the placenta under general anaesthesia.4. Keep the patient ‘nil per mouth’.
  7. 7. 96 INTRAPAR TUM CAREFlow diagram 5-1: The management of a patient with a postpartum haemorrhage before the delivery of theplacenta5-23 What is the management of a patient If the bleeding persists following rubbing upwith a postpartum haemorrhage, if the the uterus, bleeding must be controlled byplacenta has already been delivered? bi-manual compression of the uterus. A fist is inserted in the vagina or four fingers with theThis is a dangerous complication, which must palm upwards in the posterior fornix of thebe rapidly and correctly managed, according vagina, with the other hand pushing down onto a clear plan: the fundus of the uterus abdominally.Step 1 Step 3Call for help. One cannot manage a A rapid intravenous infusion of 20 unitspostpartum haemorrhage alone. Someone oxytocin in 1000 ml Plasmalyte B or normalneeds to get the oxytocin, cannulas, infusion saline must be started. Once again, makesets and intravenous fluids while the other sure that the uterus is well contracted, byperson is controlling the bleeding. massaging it.Step 2 Step 4The uterus must immediately be rubbed up, The patient’s bladder must be emptied. Ai.e. massaged. This will cause the uterus to full bladder can cause the uterus to contractcontract and stop bleeding in most cases. poorly, with resultant haemorrhage.
  8. 8. THE THIRD STAGE OF LABOUR 97These four steps must always be carried out, Bleeding from an atonic uterus occurs in episodesirrespective of the cause of the postpartumhaemorrhage. The cause of the haemorrhage and consists of dark red blood clots.must now be diagnosed. 5-26 What are the possible NOTE Bleeding can also be controlled by causes of an atonic uterus? aortic compression. The aorta can be compressed abdominally by pressing down 1. A uterus full of blood clots is the at the level of the umbilicus. Compression commonest cause. of the aorta is particularly useful during a 2. A full bladder. laparotomy for postpartum haemorrhage. 3. Retained placental cotyledons. 4. Factors during the pregnancy, which resulted in an abnormally large uterus: A postpartum haemorrhage is a dangerous • A large infant. complication and must be managed according to • A multiple pregnancy. a definite plan. • Polyhydramnios. 5. A prolonged first stage of labour.5-24 What are the main causes of 6. The intravenous infusion of oxytocinpostpartum haemorrhage? during the first stage of labour. 7. General anaesthesia.The two main causes of postpartum 8. Grande multiparity.haemorrhage are: 9. Abruptio placentae.1. Haemorrhage due to an atonic (poorly contracted) uterus. The commonest causes of an atonic uterus are a2. Haemorrhage due to trauma, usually in the form of tears (lacerations). uterus full of blood clots and a full bladder.It is very important that they are differentiatedfrom one another as this will determine the 5-27 What is the correct managementcorrect management. of postpartum haemorrhage, if the clinical signs indicate bleeding from an atonic uterus? The two main causes of postpartum 1. Rub up the uterus, empty the patient’s haemorrhage are an atonic uterus and trauma. bladder and start a fast intravenous infusion of 20 units oxytocin in 1000 mlThe management of a patient with a postpartum Basol or normal saline.haemorrhage after the delivery of the placenta 2. If the uterus still tends to relax, examineis summarised in flow diagram 5-II. the placenta again, to check whether it is complete.5-25 What clinical signs indicate that the 3. If the placenta is not complete, manage thebleeding is caused by an atonic uterus? patient as detailed in section 5-28. 4. If the placenta is complete and the uterus1. The uterus is atonic (feels soft and spongy), remains poorly contracted, the patient or tends to become atonic after it is rubbed must be referred to a hospital with theatre up or after an oxytocin infusion is given. facilities. This is an extremely serious2. The bleeding is intermittent and consists complication, which could result in the mainly of dark red clots. patient’s death. While waiting for the3. If the uterus is rubbed up and becomes theatre or arranging transfer, the following well contracted, a large amount of dark red management must be followed: blood clots escapes from the vagina.
  9. 9. 98 INTRAPAR TUM CAREFlow diagram 5-2: The management of a patient with a postpartum haemorrhage after the delivery of theplacenta • Start a second, rapidly running, bleeding, until the patient is in theatre intravenous infusion and take a sample or until she reaches a level 2 hospital. of blood for urgent cross-matching. A • Lie the patient flat, or in the head- blood transfusion must be started as down position and give oxygen by soon as possible. means of a face mask. • The uterus must be bi-manually 5. Place three misoprostol (Cytotec) tablets compressed as explained in Step 2 of (one tablet = 200 μg) in the patient’s rectum. section 5-23. This should control the
  10. 10. THE THIRD STAGE OF LABOUR 995-28 What is the further management of is clamped. The balloon catheter is used inpostpartum haemorrhage due to an atonic conjunction with oxytocics or misoprostol.uterus if the initial management fails? It is important to note that the clinician mustAll patients that did not respond to the initial progress to the next step without delay until itemergency management should be transferred is certain that the bleeding has stopped.as acute emergencies to an appropriate level of If the bleeding persists a laparotomy (midlinecare, which will be at least level 1 hospitals with incision) is required:theatre facilities and emergency blood available. 1. If the patient has completed her family orProstaglandin F2-alpha is a potent uterotonics is of high parity, proceed directly with aagent. The drug may be injected into the total abdominal hysterectomy.myometrium. 5 mg is added to 20 ml saline 2. If the patient is primiparous or of low parity,and 2 ml injected into various sites in the the following steps could be followed:myometrium being careful not to inject • The patient is draped in the lithotomyintravascularly. Alternatively 5 mg may be position with the legs angled slightlyadded to a litre of the crystalloid infusion. downwards at about 30 degrees.If the uterus continues to relax, the patient This allows the surgeon more roomneeds to be taken to theatre in a level 2 hospital. during the operation. This will allowFour units of blood and a person with the skills immediate inspection to assess theto do an emergency hysterectomy need to be result of intra-abdominal measures toavailable if required. While waiting for theatre reduce blood loss.bi-manual compression of the uterus should be • Compression sutures are insertedapplied to reduce further blood loss. (B-Lynch sutures). The bladder peritoneum is opened. A Vicryl 1 sutureIn theatre an examination under general is passed through the lower segmentanaesthetic (EUA) is done: 2–3 cm from the lateral border of the1. Inspect the vagina and cervix for tears. uterus. These sutures are tied as tight as2. A bi-manual examination and exploration possible on top for the uterus 3–4 cm of the uterine cavity with two fingers for medial to the uterine cornu. retained placental tissue and a possible 3. If the bleeding persists systematic laceration. devascularisation of the uterus is required.3. The uterus is further emptied with a large Number one absorbable suturing material is ovum forceps and then firmly curetted used on a large round bodied (taper) needle. with a Baum’s curette. • First, ligate the uterine artery. A suture is inserted through full thicknessTrans-abdominal ultrasound in theatre is of myometrium just above the deflectionvalue to confirm that the uterus is empty. of the broad ligament on the pelvicInserting a balloon cather could be valuable to floor. This will be at the level of thereduce the bleeding while waiting for theatre internal os of the cervix. The anterioror if the patient is primiparous or of low entry and posterior exit point of theparity, where a hysterectomy after evacuation needle will be 2 cm medial to thewould be a last option. The balloon cather lateral insertion of the broad ligament.is made by using a large Foley’s catheter and Pass the needle back from posterior tosurgical latex glove. The glove is tied around anterior through an avacular portion ofthe Foley’s catheter above the bulb. Any suture the broad ligament and tie a tight knot.material can be used. Saline is infused under If bleeding persists a similar suture ispressure into the glove either by injecting with inserted on the other side of the uterus.a syringe or by squeezing a vacolitre. Once • If bleeding persists the anastomosis of500 ml of saline has been infused the catheter the ovarian and uterine artery is ligated
  11. 11. 100 INTRAPAR TUM CARE with a similar suture inserted above 5-30 What can be done to reduce the the level of the insertion of the ovarian risk of postpartum haemorrhage? ligament to the uterus and below the In patients who are at high risk of postpartum uterine tube. Both anastomoses need to haemorrhage (e.g. multiple pregnancy, be ligated with persistent bleeding. polyhydramnios or grande multiparity) the • If bleeding persists proceed with following should be done: a hysterectomy as a life saving procedure. A less experienced 1. An intravenous infusion should be started surgeon should perform a subtotal during the active phase of the first stage hysterectomy, by amputating the uterus of labour. above the cervix following the ligation 2. Twenty units of oxytocin in 1000 ml of the uterine arteries. Basol or normal saline should be given by rapid infusion after the placenta has beenAs a general principle the decision to do a delivered.hysterectomy must not be postponed too 3. Make sure that the uterus is welllong. Continued blood loss requiring the contracted during the first hour after thetransfusion of five or more units of blood delivery of the placenta and make sure thatcompromise blood clotting and increase the the patient empties her bladder frequently.risk of a maternal death. 5-31 What clinical signs indicate5-29 What should be done if the that the bleeding is from a tear?membranes or placenta are notcomplete after delivery and the 1. The uterus is well contracted.patient is not bleeding? 2. A continuous trickle of bright red blood comes from the uterus in spite of a well1. Incomplete membranes usually do not contracted uterus. cause any complications.2. An incomplete placenta with one or more cotyledons missing can cause a postpartum Bleeding from a tear causes a continuous trickle haemorrhage due to an atonic uterus. of bright red blood in spite of a well contracted Therefore, manage as follows: uterus. • An intravenous infusion of 20 units oxytocin in 1000 ml Basol or normal saline must be started to make sure that 5-32 What is the correct management the uterus is well contracted. if the clinical signs indicate that • Arrange for an evacuation of the uterus the bleeding is from a tear? or transfer the patient to a hospital with The patient should be placed in the lithotomy theatre facilities to evacuate the uterus. position and examined as follows: • Keep the patient ‘nil per mouth’ as a general anaesthetic will be necessary. 1. First the perineum must be examined for bleeding from a a tear or episiotomy. Repair any tear or episiotomy. An evacuation of the uterus under general 2. Thereafter, the vagina must be examined anaesthesia is required if placental cotyledons for a tear using the index finger of each are retained in the uterus. hand to hold the vagina open. If available, a retractor (a Werdheim’s retractor) is helpful in examining the vagina. If a tear is found it must be sutured.
  12. 12. THE THIRD STAGE OF LABOUR 1013. If a perineal or vaginal tear cannot be require a laparotomy and in most cases a found, a cervical tear or even a ruptured hysterectomy. uterus may be present. 5-34 What is the correct management5-33 What will the further management for bleeding from an episiotomy?be once a perineal and vaginal tear has 1. If the episiotomy has not yet been stitched,been excluded and the bleeding persists? it should be repaired. Make sure that allThe patient is put into the Lithotomy position. bleeding stops.A good light and a cervical suturing pack must 2. If the episiotomy has already been repaired,be available. The cervical suturing pack contains the stitches must be removed and thethree swab holders, a Sims speculum (or bleeding vessels must be identified and tiedAuvard’s speculum) and a Werdheim retractor. off. Then the episiotomy must be resutured.The postpartum cervix is very floppy and it canbe difficult to orientate oneself. Also there is 5-35 Which patients are at highoften a lot of blood making vision difficult. risk of a cervical tear?1. The vagina is held open with a posterior 1. Patients who bear down and deliver an inserted Sims speculum (or Auvard’s infant before the cervix is fully dilated. speculum) and an anterior inserted 2. Patients with a rapid labour when the cervix Werdheim retractor. A swab holder is dilates very quickly (a precipitous delivery). placed on the cervix at 12 o’clock to serve 3. Patients who have an instrument delivery. as a marker. A second swab holder is placed next to it. The part of the cervix 5-36 How can you recognise between the swab holders is inspected for an inverted uterus? a tear. A third swab holder is placed next to the second swab holder and the part 1. The diagnosis must be considered if a of the cervix between the swab holders patient suddenly becomes shocked during is inspected for a tear. The second swab the third stage of labour without excessive holder is then placed next to the third vaginal bleeding. swab holder and the cervix between them 2. No uterus is palpable on abdominal examined. The process of alternating examination. the second and third swab holders and 3. The uterus lies in the vagina or may even examining the cervix in between is repeated hang out of the vagina. around the cervix until one reaches the first ‘marker’ swab holder. The entire cervix will 5-37 What is the management of a then have been thoroughly examined. patient with an inverted uterus?2. If a cervical tear is found, two swab holders 1. Two fast running intravenous infusions are placed on both sides of the tear and if must be started to treat the shock. downward traction allows the full length 2. The patient must be transferred to a level 2 of the tear to be seen, the tear is sutured. or 3 hospital as an emergency. If the apex of the tear cannot be seen the patient needs to be taken to theatre and Bleeding disorders can also result in consent signed and preparations made for postpartum haemorrhage. Placental abruption a possible hysterectomy. is the commonest cause of a bleeding disorder3. In theatre a bi-manual examination and in the third stage of labour. In this situation exploration of the uterine cavity with two it is extremely important to ensure that the fingers for retained placental tissue is done. uterus is well contracted after the delivery of If the apex of the cervical laceration is the placenta. The powerful contraction of the seen, the tear is sutured. Larger tears will
  13. 13. 102 INTRAPAR TUM CAREuterus plays a greater role than blood clotting Procedures aimed at preventing the infection ofin the prevention of bleeding. staff with HIV must be strictly enforced.PROTECTING THE STAFF CASE STUDY 1FROM HIV INFECTIONDURING LABOUR Following normal first and second stages of labour, the third stage of labour is actively managed. The patient was not hypertensive5-38 What should be done during during her pregnancy and does not have alabour to prevent the staff from history of heart valve disease. Syntometrine isbecoming infected with the human given by intramuscular injection and the patientimmunodeficiency virus (HIV)? is observed for signs of placental separation.All patients should be regarded as beingpotentially infected with HIV, the virus which 1. Were the necessary precautions takencauses AIDS (acquired immunodeficiency before giving the Syntometrine ?syndrome). The virus is present in blood, No. A second twin must be excluded beforeliquor and placental tissue. Contamination giving the Syntometrine.of the eyes or cuts on the hands or arms, andpricks by contaminated needles carry a small 2. Is the third stage of labour beingrisk of causing infection. correctly managed by the active method?Therefore, the following precautions should be No. The placenta must be delivered whentaken for all deliveries: the uterus contracts. If the active method of1. The person conducting the delivery must managing the third stage is used, it is incorrect wear gloves and a plastic apron. A face to wait for signs of placental separation. mask and goggles are recommended. People wearing glasses need only a mask to 3. How soon after giving the Syntometrine protect their face. does the uterus contract?2. Any person who resuscitates the infant or cleans the labour ward after the delivery Syntometrine includes oxytocin which causes must wear gloves. uterine contractions two to three minutes after3. The umbilical cord must be squeezed intramuscular administration. to empty it of blood before applying the second clamp. This will prevent blood 4. What should have been done as spurting out when the cord is cut. soon as the uterus contracted?4. Injection needles must be placed in a The umbilical cord should have been steadily sharps container immediately after being pulled with one hand while the other hand was used. Needles must not be replaced into pushing upwards on the uterus, i.e. controlled their sheaths. cord traction. Placental separation and then5. When an episiotomy is repaired, the needle placental delivery occur with the uterine must only be held with needle holder and contraction. the tissues with forceps.6. The needle should be cut loose from the suture material and replaced in the dish as soon as possible. When the needle is to be used again, it must be held in a safe manner with forceps.
  14. 14. THE THIRD STAGE OF LABOUR 1035. What should be done if placental 3. What should be done in a peripheralseparation does not take place with clinic if the placenta is retained?the first uterine contraction? The patient should be transferred to a hospitalA second uterine contraction will occur five with theatre facilities for a manual removal ofto six minutes after giving Syntometrine by the placenta under general anaesthesia.intramuscular injection due to the action ofthe ergometrine. A second attempt must now 4. What complication is this patientbe made to deliver the placenta by controlled at high risk of developing?cord traction. Most placentas which are notdelivered with the first contraction will be A postpartum haemorrhage due to an atonicdelivered with the second contraction. uterus. 5. What should have been doneCASE STUDY 2 in this case to make the patient’s transfer to hospital safer?A patient with normal first and second stages An intravenous infusion of 20 units oxytocinof labour has been delivered by a midwife in 1000 ml Basol or normal saline shouldworking alone at a peripheral clinic. A second have been started. She should also have beentwin is excluded on abdominal examination carefully observed to make sure that the uterusand the passive method is used to manage the was well contracted. Make sure that the uterusthird stage of labour. After 30 minutes there remains well contracted, and measure thehas been no sign of placental separation. A blood pressure and pulse rate every 15 minutesdiagnosis of retained placenta is made and the until the patient is transferred.doctor in the nearest district hospital phoned.The doctor agrees to accept the patient andarranges ambulance transfer to the hospital. CASE STUDY 31. Is the diagnosis of a retained After normal first and second stages of labourplacenta correct? in a grande multipara, the placenta is deliveredNo. The diagnosis of retained placenta can by the active management of the third stageonly be made if the placenta is not delivered of labour. There are no complications. Halfafter the active method of managing the third an hour later you are called to see the patientstage of labour has been used. The correct as she is bleeding vaginally. You immediatelydiagnosis is a prolonged third stage of labour. measure her blood pressure which indicates that she is shocked.2. What should have been done in thiscase of a prolonged third stage of labour? 1. Was the patient’s third stage of labour correctly managed?The placenta should have been delivered bythe active method of managing the third No. As the patient falls into a high risk groupstage of labour, i.e. by giving oxytocin 10 for postpartum haemorrhage, an intravenousunits intramuscular and using controlled infusion should have been started during thecord traction. first stage of labour. Twenty units of oxytocin should have been added to the infusion after the placenta was delivered. The patient should also have been carefully observed to make sure that the uterus remained well contracted.
  15. 15. 104 INTRAPAR TUM CARE2. Do you agree that the first step in the examination the cervix was found to be 7 cmmanagement of postpartum haemorrhage dilated and paper thin. When observationsis to measure the blood pressure? were made an hour after delivery of the placenta, the patient was found lying in a poolNo. The first step should be to rub up the of blood. Her uterus was well contracted anduterus in order to stop the bleeding. her bladder was empty.3. What should be the further 1. What should be the next step inmanagement of this patient? the management of this patient?A rapid intravenous infusion of 20 units A rapid intravenous infusion of 20 unitsoxytocin in 1000 ml Basol or normal saline oxytocin in 1000 ml Plasmalyte B or normalshould be started. Make sure that the uterus is saline should be started and you should makewell contracted. Then check that the patient’s sure that the uterus is well contracted.bladder is empty as a full bladder can causerelaxation of the uterus. 2. In spite of this management a continuous trickle of bright red4. What additional management blood is observed. What is the mostis needed for this patient? likely cause of the bleeding?The cause of the bleeding must now be found. A tear.The two important causes of postpartumhaemorrhage are an atonic uterus or a tear. 3. Why is this patient at high risk of a cervical tear?5. What is the most probable cause of thispatient’s postpartum haemorrhage? Because the infant was delivered through an incompletely dilated cervix.As she is a grande multipara the most likelycause is an atonic uterus. 4. What should be the next step in the management of this patient?6. What are the clinical signs ofbleeding due to an atonic uterus? The patient must be placed in the lithotomy position and be examined for a vaginal orThe uterus will not be well contracted and perineal tear. Any tear must be sutured.will tend to relax after it is rubbed up. Inaddition, the bleeding is not continuous butoccurs in episodes, and the blood consists of 5. The midwife who is managing thisdark red clots. patient does not find either a vaginal or perineal tear. What should be the next step in the management of this patient?CASE STUDY 4 A doctor should examine the patient for a cervical tear. The most likely site of a tear is theA primigravid patient who did not co-operate cervix as this patient probably delivered beforewell during the first stage of labour delivers full cervical dilatation.soon after a vaginal examination. At the

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