03 Active management of third stage of labour

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  • 1. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR Dr. Md. Alauddin Professor & Head Dept. of G&O MMC
  • 2. SESSION OBJECTIVES
    • To understand 3 rd stage
    • Complications
    • Active Management
    • Inappropriate/Harmful Practices
    • Best Practices
  • 3. Third Stage
    • Delivery of the Foetus to delivery of placenta and membranes.
    • Upto Thirty Minutes
    • Average 5-15 Minutes
    • Shorter in multi, slightly longer in primi
  • 4. KEY EVENTS IN THIRD STAGE
    • Separation of Placenta
    • Expulsion/Delivery of Placenta
    • Haemostasis
  • 5. SEPARATION OF PLACENTA
    • Central Separation
    • Marginal Separation
    • Signs of Placental separation
      • Uterus becomes contracted, hard and globular;
      • Uterus rises just above umbilicus;
      • Extra vulval lengthening of umbilical cord;
      • A gush of blood frequently appears;
      • On pushing the uterus up in the abdomen, the cord does not recede back.
  • 6. EXPULSION/DELIVERY OF PLACENTA
    • Natural expulsion – Bearing down efforts
    • Controlled cord traction.
  • 7. HAEMOSTASIS
    • Contraction and Retraction of Myometrium – Ligature effect.
    • Thrombosis
    • Apposition of uterine walls.
  • 8. COMPLICATIONS OF THIRD STAGE
    • PPH
    • Retained Placenta
    • Inversion
    • Post-partum Shock
  • 9. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR
    • PRINCIPLES:
      • Enhance separation of placenta
      • Safe and complete delivery of placenta
      • Minimize bleeding
  • 10. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR
    • COMPONENTS:
      • Use of oxytocics
      • Delivery of placenta by controlled cord traction
      • Massage of uterus after placental delivery
    • Examination of birth canal and afterbirths
    • Repair of tears/episiotomy
  • 11. OXYTOCICS
    • Oxytocin
    • Ergometrine/Methylergometrine
    • Prostaglandin
    • Misoprostol
  • 12. OXYTOCIN
    • Safe
    • Cheap
    • No contraindication
    • Effective – quick action
    • 10 units IM
    • Less heat labile
  • 13. ERGOMETRINE
    • Cheapest
    • Has contraindications
    • Side effects – sometimes serious
    • Effective
    • 0.2 mg IM/IV
    • Heat labile
  • 14. PROSTAGLANDIN
    • Costly
    • Contraindications
    • Some side effects
    • Effective
    • 125-250 mcg IM
    • Highly heat labile
  • 15. MISOPROSTOL
    • Less costly
    • No significant contraindication
    • No significant side-effect
    • Effective
    • 600 mcg orally
    • Highly heat stable
  • 16. WHICH OXYTOCIC?
    • Oxytocin - first choice
    • Misoprostol - has a promise
    • Prostaglandin – effective but costly
  • 17. DELIVERY OF PLACENTA
    • Controlled cord traction
    • Raising the uterus gently upward by abdominal hand
    • Traction when placenta is separated/Uterus contracted
  • 18. UTERINE MASSAGE
    • Immediately after placental delivery till uterus is hard
    • Repeat intermittently for 1-2 hrs.
  • 19. IMMEDIATE POST-PARTUM CARE
    • Closely monitor for first 6 hours.
    • - Pulse, respiration, temperature, B.P., G.C
    • - Vaginal bleeding.
    • - Uterine hardness.
    • @ Every 15 mins. for 1 hour.
    • @ Every 30 mins. For 2 hours.
    • @ Every hour for 3 hours.
    • Massage the uterus every 15 mins. to maintain
    • contraction.
    • If stable give her something to drink/eat when thirsty/hungry.
  • 20. INAPPROPRIATE/HARMFUL PRACTICES
    • Non-use of active management
    • Manipulating uterus (fundal pressure, squeezing)
    • Inappropriate use of oxytocic
    • Inappropriate cord traction
    • Routine catheter/MRP/exploration of uterus
    • Uterine lavage
    • Not examining birth canal/after births
  • 21. BEST PRACTICES
    • Cleanliness: IPP
    • Complication readiness
    • Support person
    • Active management FOR ALL
        • Oxytocic : OXYTOCIN 10 U IM – FIRST CHOICE
        • C ontrolled traction
        • Uterine massage
    • Examination of birth canal and after births
    • To remain vigilant for 6 hours
  • 22. MAKE IT AN ISSUE T H A N K Y O U !!!