AMTSL

2. PRESENTED BY:
LAMNUNNEM HAOKIP
MSC (N) 1ST YEAR
UNDER THE SUPERVISION OF
SHILPY MA’AM
ACTIVE MANAGEMENT OF THIRD
STAGE OF LABOUR

3. Post partum haemorrhage is potentially life
threatening, albeit preventable, condition that
persists as a leading cause of maternal and
fetal mortality and morbidity rate.
AMTSL is a recommended series of steps by
the World Health Organization, including the
provision of uterotonic drugs immediately upon
fetal delivery, controlled cord traction, and
massage of the uterine fundus.
INTRODUCTION

4. Post partum haemorrhage
It is defined as the excessive bleeding
from the genital tract at any time
following the baby’s birth up to 6
weeks after delivery. The amount of
blood loss is more than 500 ml.
Third stage of labour
The third stage of labour begins upon
the completion of birth of baby and
ends with the expulsion of placenta. It
is also known as the placental stage of
labour.
DEFINITION

5. After expulsion of fetus to expulsion of
placenta and membranes.
Duration is 15 minutes in primigravida and 10
minutes in multi-gravida .
Active management of third stage of labour
takes around 5 – 10 minutes.
Placental separation
Placental expulsion.
THIRD STAGE OF LABOUR

6. META
CARDS
 Enhance the separation of placenta.
 Safe and complete delivery of placenta.
 Minimize bleeding.
 Prevention from infection.
PRINCIPLES OF THIRD STAGE OF
LABOUR

7. There are two methods of management
which are currently in practice, they are:
Expectant management:
 In expectant management, uterotonic
drugs are not given prophylactically, the
cord may or may not be clamped early
and the placenta is delivered by
maternal efforts.
STEPS OF MANAGEMENT OF THIRD
STAGE OF LABOUR

8. Active management
 In active management, uterotonic drugs
are given before delivery of placenta,
the cord is usually cut 2 – 3 minutes
after birth and the placenta is
delivered by controlled cord traction
(CCT).

9. The third stage of labour consist of two phase,
they are:
Placental separation
It is the result of abrupt decrease in size of
the uterine cavity during following delivery of the
baby.
As the uterine cavity empties progressively,
the retraction process accelerates.
PHYSIOLOGICAL PROCESS OF
PLACENTAL SEPARATION AND
EXPULSION

10. The separation of placenta takes place in the
spongiosa layer of the decidua's.
Clinical Signs Of Placental Separation
Sudden trickle or gush of blood.
Lengthening of the cord.
Change in the shape of the uterus from discoid
to globular.
Change in the position of the uterus as it rises
in the abdomen, because the bulk of placenta is in
the lower uterine segment or upper vaginal vault.

11. Placental expulsion
Placental expulsion begins with the
descend of the placenta into the lower
uterine segment.
It then passes through the cervix into
the upper vaginal vault where it is
expelled.
Expulsion of the placenta is by one of
the two mechanisms.
The Schultz Mechanism (80%)
Mathews Duncan Method (20%)

13. CHART
 Administration of uterotonic agents.
 Controlled Cord Traction.
 Uterine massage after delivery of the
placenta as appropriate.
COMPONENTS OFACTIVE
MANAGEMENT THIRD STAGE OF
LABOUR

14. Administration of Uterotonic Drug:
Within one minute of the delivery of
the baby, palpate the abdomen to rule
out the presence of additional fetus, if
not give Oxytocin 10 units IM for 60
seconds i.e 1 minute.
Oxytocin is preferred over other
uterotonic drugs due to its effective 2 –
3 minutes after administration and has
minimal side effects and can be use in
all women.
ACTIVE MANAGEMENT OF THIRD
STAGE OF LABOUR

15. In the absence of Oxytocin, give 600μg of
Misoprostal orally / Ergometrine 0.2 mg IM,
syntometrine (1 ampoule) IM within one minute
after child birth.
Uterotonic require proper storage:
Ergometrine 2 -8 degree Celsius and protect
from light and freezing. Misoprostal room
temperature, protect from freezing. Oxytocin
15 -30 degree Celsius and protect from
freezing.

16. Clamp the cord close to the perineum and hold
in one hand.
Place the other hand just above the woman’s
pubic bone and stabilize the uterus by applying
counter-pressure during controlled cord traction.
Keep slight tension on the cord and wait for
strong uterine contraction (2-3 minutes).
CONTROLLED CORD TRACTION
( BRANDT-ANDREWS METHOD)

17. VIDEO

18. With the strong uterine contraction,
encourage the mother to push and very gently
pull downward on the cord to deliver the
placenta. Continue to apply counter-pressure
to the uterus.
If the placenta does not descend during 30 –
40 seconds of CCT do not continue to pull on
the cord.

19. Gently hold the cord and wait until the
uterus is well contracted again.
With the next contraction, repeat CCT with
the counter pressure

20. Massage the uterus immediately after the
delivery of the placenta and membranes until
it is firm.
During recovery, assist the woman to
breastfeed if this is her choice.
Monitor the newborn and woman closely.
UTERINE MASSAGE

21. Palpate the uterus through the abdomen
every 15 minutes for 2 hours to make sure it is
firm and monitor the amount of vaginal bleeding.
Provide prevention of mother to child-
prevention care as needed.

22. VIDEO

23. Placenta: the placenta, membranes
and umbilical cord should be examined
for completeness and for anomalies.
Perineum: At the same time, the
perineum region, vulva outlet, vaginal
canal and he cervix should be carefully
examined for lacerations.
If the perineum has been torn or an
episiotomy done, tear or incision should
be repair immediately.
EXAMINATION OF PLACENTA AND
PERINEUM

25. BIBLIOGRAPHY / REFERENCE
Mudaliar and Menon’s. Clinical Obstetrics 12th Edition.
Universities Press. pp 95 – 97.
Annamma Jacob. A Comprehensive Textbook of
Midwifery and Gynaecological Nursing Fourth Edition.
Jaypee The Health Science Publishers. pp 211 – 219.
DC Dutta, Hiralal Konar. Textbook of Obstetrics. 8th
Edition. Jaypee The Health Science Publishers. pp 162 –
165.
https://youtu.be/_TXv2jGnzhU
Microsoft Word - PPH Briefer (AMTSL) (who.int)
https://www.glowm.com/pdf/AMTSL_WallChart.pdf
https://youtu.be/FJFXYDP8N7M