2. AIMS
• Understand the process of normal labour
• Understand what Active Management of the
Third Stage of Labour (AMTSL) is and it’s
importance
• Knowledge of evidence based practices
3. When is a Woman in Labour?
• Diagnosis of Labour
2-3 uterine contractions in 10mins
Progressive shortening and thinning of the
cervix during labour and
Cervical dilatation
4cm or more dilated
4. Normal Labour
• Stages of Labour
First Stage: onset of labour pains to full dilatation
of the cervix
Second Stage: full dilatation of the cervix to the
delivery of the baby
Third Stage: starts after the delivery of the baby
ending with the delivery of the placenta
Immediate postpartum (‘Fourth Stage’): frequent
monitoring in the one hour following delivery
5. Supportive Care
• Many providers continue to use, untimely,
inappropriate and/or unnecessary interventions,
leading to complications
• Example: immobilising women, not allowing
eating and drinking
6. Supportive Care
• Supportive care during labour is the most
important thing to help the woman tolerate
labour pains and facilitate the progress of
labour
7. Supportive Care
• Support from a birth partner or companion.
• Good communication and building trust with
staff.
• Encourage walking around and changing
positions frequently.
• Encourage adequate intake of food and drinks
• Monitor maternal and fetal wellbeing using
the partograph
8. Care that is of no proven benefit
• Routine shaving of the pudendal area.
• Giving an enema.
• Routinely cutting episiotomy for delivery.
• Application of fundal pressure
10. • Not in active labour
(cx 0-3cm, contraction <2/10)
- Monitor every hour: contractions, FHR
- Monitor every 4 hours: HR, BP, temp
11. • In active labour
(cx 4cm or more)
- START partograph
- Monitor every 30 min: contractions, FHR,
presence of any danger signs
- Monitor every 4 hours: cervical dilatation, HR,
BP, temp
12. Assessing Progress in Labour
- Assessing changes in cervical dilatation and
effacement (PV examination)
- Foetal descent (PV and Abdominally)
15. Second Stage
• Once the cervix is fully dilated, encourage the
woman to assume the position she prefers to
push only with a contraction.
Squatting, sitting and standing positions may
make pushing easier
Avoid routine catheterization which may lead to
infections.
When delivery is imminent the women may be
put in dorsal lithotomy position for the actual
conduct of delivery
16. Second Stage
Delivery of the head:
Control birth of the head to keep it flexed.
Gently support the perineum as the baby’s
head delivers.
Feel around the baby’s neck for the umbilical
cord:
- if the cord is loose, slip it over the baby’s head
- if the cord is tight clamp and cut it.
[!] NO routine episiotomy
17. Second Stage
Completion of delivery :
• Allow the baby’s head to turn spontaneously.
• Deliver one shoulder at a time - anterior then
posterior.
• Support the rest of the baby’s body as it slides out.
• Dry and wrap baby, assess breathing
• Ensure the baby is kept warm and in skin-to-skin
contact on the mother’s chest/abdomen.
19. The classical expectant management
• Wait for the natural forces of labor to bring
about 3rd
stage contraction and placental
separation
• Look for the signs of placental separation
• Controlled cord traction to expel the placenta
and membranes
• Optional administration of Oxytocics
20. Active management of 3rd
stage
• Oxytocic administration immediately after
delivery of the baby so that the uterine
contractions and placental separation is not
left to the natural uncertain forces of labor
• Controlled cord traction on perception of a
strong uterine contraction with out waiting for
the actual signs of placental separation
• Uterine massage to maintain the contraction
21. Active Management of the Third
Stage
As practiced
• Palpate the abdomen to rule out the presence of
an additional baby(s)
• Give Oxytocin: 10 units
• Clamp and cut the umbilical cord
• Controlled cord traction on perception of a
strong uterine contraction with out waiting for
the actual signs of placental separation
• Uterine massage to maintain the contraction
22. Controlled Cord Traction
• Should be done only when the uterus is
felt to have contracted strongly
• Make sure the bladder is empty
• Hold the clamped cord in one hand and
with the other hand apply counter
traction on the uterus. Keep slight
tension on the cord and await a
contraction.
23. Controlled Cord Traction
Cont
• Pull downward on the cord to deliver the
placenta, applying counter traction to the
uterus with the other hand
• If it does not succeed at first attempt wait for
some more time for a stronger uterine
contraction
• Stress on a complete examination of the
placenta for any retained placental fragments
24. Third Stage
• As the placenta delivers, gently turn it until
the membranes are twisted and slowly pull
to complete the delivery.
• Check the placenta to be sure none of it is
missing.
• Examine the woman carefully and repair any
tears to the cervix or vagina or repair the
episiotomy.
[ ! ] NO routine packing of vagina while attempting a repair.
25. Immediate PNC - Mother
• Routine observations
• Regular checks for vaginal bleeding and contraction of
uterus.
• Examine perineum for tears.
• Pain relief
• Encourage the mother to eat, drink and rest
• Consider IUD insertion
• Identify any signs of complications, stabilise and REFER
26. Observations
• 1-2 hours: every 15 minutes
• 3-5 hours: every 30 minutes
• >5 hours: every 4 hours
• Length of stay in health facility: Advise
observation for 24hours
27. Immediate PNC - Newborn
• Encourage early breastfeeding
• Keep warm, check temp every 15min by feeling the feet
• Examine for any malformation or abnormality > REFER
• Care of the cord, check for bleeding
• Give VIT K 1mg IM.
• Delay baby’s first bath to beyond 24 hours of birth
[!] Avoid separating mother from baby whenever possible. Do not leave
mother and baby unattended at any time.
[!] NO routine suction of throat and nose
