CCT THIRD STAGE LABOUR OSCE
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Active management of 3rd stage of labor MMMC
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CCT THIRD STAGE LABOUR OSCE
- 1. ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR OSCE BY afiqi fikri
- 2. The patient is a multigravida who has successively delivered a health baby. case scenario 02
- 3. Identify the procedure in the pictures 03
- 4. Controlled cord traction in the third stage of labor 4
- 5. State THREE prerequisites for the procedure Lengthening of the cord Fresh gush of recent blood A rise of the uterine fundus 04 The uterus becomes globular in shape and feels firm
- 6. Describe the correct conduct of the procedure • Immediately after the delivery of the baby, palpate the uterus so as to determine it is firm 05 • Ensure there is no excessive bleeding (PPH) • Check for signs of separation and ensure the patient has been administered IM oxytocin at delivery of the anterior shoulder of the fetus.
- 7. CCT - involves traction on the umbilical cord, combined with counter pressure upwards on the uterine body by the other hand placed immediately above the symphysis pubis. The patient is not left till no active bleeding is seen at the introitus. 06 An artery clamp which has seen placed on the umbilical cord close to the vulva is observed for some descent denoting separation (also look for other signs of separation) Then firm continues pressure is given till entire placenta is delivered. The uterus is massaged till it is firm Any perineal tear is the repaired The delivered placenta is checked for completeness
- 8. State TWO benefits of the procedure in conduct of the third stage. 07 Shortens third stage Less bleeding post partum
- 9. What further action is taken with regards to the placenta after its delivery? 08 It is checked for completeness , no cotyledons should be missing and the membrane should be complete too Obtain instructions with regards to disposing the placenta (incineration or packaging to be sent back to the mother for cultural reasons)
- 10. State TWO complications that may occur in improper management of the procedure. 09 Postpartum hemorrhage Uterine inversion
- 11. References 1. Pamela M. Spencer. Controlled cord traction in management of third stage of labour.British Medical Journal June 1962, pp 1970 2. Begley CM, Gyte GML, Devane D, McGuire W, Weeks A .Delivering the placenta, expectant or mixed management in the third stage of labour. Cochrane Summary Nov. 2011 available on line http ://summaries.cochrane.org/ CD007412/ delivering-thepl a centa-with-a ctive-expecta nt-or-m ixed-ma na gem e nt-i n-the-th i rd-sta ge-of-1 a bo u r 16
- 12. Xie Xie
Editor's Notes
- Delivery of the placenta and membranes (the third stage of labour) is potentially the most hazardous part of childbirth for the mother, mainly because of the risk of primary postpartum haemorrhage (PPH, defined as estimated maternal blood loss of 500 ml or more within 24 h of delivery) and its subsequent morbidity. This stage of labour can be managed actively or expectantly. Acti ve management generally involves routine prophylactic administration of an uterotonic agent, early cord clamping and cutting, and control led cord traction (CCT) . In expectant management uterotonic drugs are not given prophylactically, the cord is neither clamped nor cut early and the placenta is expelled by maternal effort. The third stage is conducted as described by Margaret Spencer (1962). 1. Intravenous oxytocin 10 units is given with delivery of the anterior shou lder. The baby is delivered slowly. The cord is divided and the baby passed to an assistant.
- A sterile towel is placed over the lower abdomen and the uterus palpated to ensure that it has contracted firmly in response to the oxytocic. The placenta is then delivered by C.C.T. as follows. The attendant stands on the right of the patient. The left hand is placed over the lower abdomen so as to grasp the lower segment between the index finger and thumb an) steady pressure is exerted in an upward and backward direction. \ At the same time the cord is taken in the right hand and a grip secured with a pair of artery forceps at the level of the introitus. Steady tension on the cord is maintained by traction on the forceps in a backward and downward direction, exactly countered by the upward pressure of the left hand so that the position of the uterus remain~ unchanged. Traction is gentle at first and then slowly increased; in this fashion the placenta is usually delivered quite easily.
- The placenta and membranes are then examined carefully for completeness . Failure to del iver the placenta within 30 minutes after the birth of the baby or if the blood loss exceeds 250 ml . early assessments by experienced staff is warranted so that immediate resuscitation may be given and a pathologically adherent placenta excluded. Whether active management of the third stage of labour should be advocated or conservative approaches are sufficient should be guided by ward protocol.
- The Cochrane Review states that there is a lack of high quality evidence. However active management reduced the risk of hemorrhage greater than lOOOml in women who are at risk of excessive bleeding. Hence this approach should be advocated in population where PPH has a high prevalence. The review also refers to increased adverse effects which includes increases in blood pressure, after pains and vomiting. In view of the high prevalence of PPH and anemia in pregnancy in Malaysia administration of oxytocin is routinely practiced in third stage of labour.