006 management of the third stage of labor

1. DR NIPON POOMTHANAWIT

2.  The third stage of labor ----- interval from the
delivery of the baby to the separation and expulsion of the
placenta
 Normally the delivery of placenta will take about 5-10
minutes after delivery of the baby regardless of the parity
 The major complication associated with this period is
postpartum hemorrhage (PPH)---- the most common cause
of maternal morbidity and mortality in developing
countries.

3.  In developed countries common cause of maternal
death ( beyond 20 weeks.preg)
 Thromboembolic disease
 Hypertensive disease
 PPH
FOOT NOTE

4.  Placental separation occurs due to shearing of the placental surface
when the uterus contracts after the infant is delivered
THIRD STAGE PHYSIOLOGY
Normal placental separation

5. After delivery of
the baby
Decrease in size of
the uterine cavity
Uterine contraction
Marked decreased
placental site
Marked decreased
placental site
The placenta
cannot decrease in
size as the attached
placental site
Uterine contraction
Decrease in size of
the uterine cavity
Placenta
is rigid
and
inelastic

6. Shearing force
cause cleavage
The placenta cannot
decrease in size as the
attached placental site
Tearing of spongiosa
layer of decidua basalis
Damage of decidual
vessels forming
retroplacental hematoma
Shearing
force cause
cleavage

7. DECIDUA
BASALIS

8. Decidualized endometrium covers the early embryo. Three portions of the
decidua (basalis, capsularis, and parietalis) also are illustrated.

10. Full-term placenta

11. Myometrial contraction compresses the
spiral arteries and veins, thereby
obliterating their lumina
Spiral arterioles
Interlacing myometrial fibers
Perpendicular
to the uterine
wall in between
the interlacing
muscle fibers
Veins are parallel to the
uterine wall

12. Full-term placenta
After the 30th week, a prominent venous
plexus separates the decidua basalis from the
myometrium, thus participating in providing a
plane of cleavage for placental separation.
There are about 120 spiral
arterial entries into the
intervillous space at term

13. Uterine relaxation
Uterine contraction
Oxygenated
blood
Spiral aeteries Veins
Intervillous space
Oxygenated
blood Intervillous space
VeinsSpiral aeteries
Placental blood flow

15. Optimal uterine
contraction during active
labor
Adequate oxygenated
blood to supply the
placental bed(intervillous
space)
Tetanic uterine
contraction
No new oxygenated blood
from the occluded spiral
arteioles
The blood in the intervillous
space is gradually
deoxygenated
No oxygen exchange with
the villous vessels
Hypoxic umbilical vessels
Fetal
hypoxia

16. Placental
separation
Strong uterine
contraction
Spiral arterioles
collapsed
Vein collapsed
Hemostasis
Poor uterine
contraction
Bleeding from spiral
arterioles and veins
PPH
Uterine
atony
Incomplete
separation of
placenta
Thirdstageoflabor

17. Principles in the management of third stage of labor to prevent PPH
Rapid and complete
separation of placenta
Strong uterine
contraction
Prevent from
PPH
Occlude spiral
arterioles and veins
Stop bleeding
Uterotonic drugs

18.  Uterine contractions play the major role
 Placental separation takes place in spongiosa
layer…..( decidua basalis)
 Defect in the decidua basalis in conjunction with an
imperfect development of the Nitabuch membrane ( a
fibrinoid layer that separates the decidua basalis from the
placental villi). resulting in abnormally invasive implantation
of the placenta… PLACENTA ACRETA
Placental separation from the placental site

19. Placental adherens

21. Tearing of blood vessels
in spongiosa layer lead
to retroplacental
hematoma which will
facilitate placental
separation
Multiple uterine
contractions will cause
more and more
spongiosa cleavage until
complete separation

22. Placental separation from
the uterus(placental site )
Lower uterine cavity
or upper vagina
Complete
delivery from
the vagina
Placental separation from
the uterus(placental site )
Lower uterine cavity or
upper vagina
Complete delivery
from the vagina
More uterine
contractions
Steps of placental delivery

23.  Gush of blood (VULVA SIGN)
 Does not signify complete separation
 Lengthening of the umbilical cord (CORD SIGN)
 Anterior-cephalad movement of the uterine fundus, which
becomes firmer and globular after the placenta detaches
(UTERINE SIGN)
Signs of placental separation

24.  SCHULTZ’s method….70%
 DUNCAN’s method……30%
Types of placental separation

25.  Separation starts in the middle portion of the placental bed
 The entrapped retroplacental blood will facilitate the placental
separation so the separation is more complete and rapid
 The placenta is delivered like a parachute presenting the glossy
surface of the amniotic sac
 Initially there is little gush of blood
 Flow of blood will be evidenced after delivery of the placenta
Schultze’s method of placental separation

26.  The placental separation starts at the edge of the placenta
 Bleeding will be evidenced in the early phase of separation
 No retroplacental clot to facilitate placental separation
 The separation is slower and less complete
 More blood loss
 The maternal edge of the placenta is first evidenced
maternal edge of the
placenta
maternal edge of
the placenta
Duncan’s method of placental separation

27.  Spontaneous uterine contractions,
 Downward pressure from the developing retroplacental
hematoma
 An increase in maternal intraabdominal pressure
Placental expulsion follows as a result of

29.  The changes in the uteroplacental unit during placental
separation

 From delivery of the fetus to the beginning of myometrial contractions
 Placental separation
 The longest phase of third stage
 Myometrial contraction at the placental site
 Detachment phase
 Shearing of the placenta off of the uterus.
 Expulsion phase
 The separated placenta is extruded from the uterus into the vagina
SUMMARY
Latent phase
Detachment phase
Expulsion phase
Contraction phase

30.  Vulva sign means only placental separation is going on but does not
signify complete separation
 Cord lengthens for more than 3 inches (8-10 cms)
 When pushing the uterus upward the cord will not follow
Tests for complete placental separation

31.  Longer duration----more PPH
 Average 5-6 mins
 90% placenta delivered in 15 mins
 97% in 30 mins
 Preterm---longer duration
 Retained placenta---more likely in very early GA
Duration of the third stage of labor

32.  Expectant management
 Spontaneous delivery of the placenta without the use of
uterotonic agents or cord traction
 Delivered by maternal expulsive force and gravitational force
 The placenta may be incomplete separated or entrapped in the
lower uterine segment or upper vagina
 Takes more time
 More bleeding
 Active management
MANAGEMENT OF THIRD STAGE OF LABOR
Expectant management
Active management

33.  Early cord clamping
 Administration of a uterotonic agent prior to placenta
separation.
 Controlled cord traction
 Uterine massage
 Reduced risks of maternal blood loss
Active management
MANAGEMENT OF THIRD STAGE OF LABOR
Urinary bladder should be emptied in all cases

34.  Administration of a uterotonic agent is recommended
during the third stage to reduce maternal blood loss
 Uterotonic agents should not be given until after
delivery of the anterior fetal shoulder to ensure that
shoulder dystocia is not exacerbated.
 The clinician should also be certain that there is no
undiagnosed and undelivered twin

35. DRUGS USED FOR ACTIVE MANAGEMENT
ERGOT alkaloid
Prostaglandin
Oxytocin

36.  There are insufficient data to determine whether
administration of the uterotonic agent is more
effective
 If it is given after delivery of the anterior shoulder but
before separation of the placenta
 Or immediately upon expulsion of the placenta

37.  Modified crede maneuver
 Brandt-Andrews maneuver
 Controlled cord traction (recommended by WHO)
Maneuver to facilitate placental delivery

38. Modified crede maneuver
Crede maneuver

39. Brandt-Andrews maneuver

40. Sudden gush of blood

41. Lengthening of the cord

43. Expression of the Placenta

44. Delivery of the placenta

45. Controlled cord traction
recommended by
WHO

46. After birth of baby, the cord stops pulsating and is cut, severing the baby from
the mother. Follow the cord and grasps it at the vaginal opening, taking up any
cord slack, pulling it straight out the vaginal opening

47. A large ring forceps is clamped onto the cord at the entrance to the vagina
and let it hang down by its own weight

48. Checking for placental separation and release along with uterine tone and
contraction by placing a hand on the uterus. Do not massage the uterus. Allow it to
contract on its own. When the uterus contracts, it will form a hard globular ball
which rises slightly under your hand. Tell the mother to let you know when she begins
to have contractions again
Do not massage
the uterus

49. Checking placental separation and release from the uterus by placing a
hand on the uterus and using the other hand for cord traction. Uterine
firmness is noted.

50. Cord traction is applied, using the ring forceps to obtain a firm hold (the cord is very
slippery), taunt traction is done, pulling gently but firmly away from the vagina. The
mother should be having contractions at this point. There is usually a little gush of
blood as the placenta begins to pull away from the uterine wall. Placenta separation
may be apparent by the increasing cord length between the forceps and the vaginal
opening

51. Placenta Delivery: Controlled cord traction. Have the mother begin
pushing with her contractions. If there is a gush of blood and lengthening
of the cord, have the mother push whether or not there is a contraction.

52. Placenta Delivery: Using one hand to apply suprapubic pressure against the
fundus of the uterus with your cupped hand, and your thumb placed just above
the pubic bone to keep the uterus from entering the pelvis and causing
spurious cord lengthening or other false evidence of separation, or even
inverting the uterus. Provide some steady cord traction to not whether there is a
sense of "give" as the placenta moves into the vagina and the cord lengthens, or
conversely, does not progress, in which case cease your maneuvers and wait. If
you are uncertain whether the placenta has actually separated, you may follow
the cord with your hand in the vagina, up to the cervix, to determine if the
placenta is trapped in the cervical os, or whether the cord disappears into the
uterus.

53.  There is no hurry to deliver the placenta
 It is normal and safe, if there is no bleeding, to wait up
to an hour, checking for separation periodically
 The placenta has been known to stay attached to the
uterine wall for days after a delivery. If this occurs
because there is acreta, this is the safe state until the
problem can be evaluated more completely.
In the absence of heavy bleeding

54.  If the placenta has separated without your knowledge
and it is not delivered , then the uterus may be silently
filling with blood.
 This is another reason for keeping your abdominal
hand over the uterus at all times until the delivery of
the placenta is imminent at the introitus

55. Placenta Delivery : Use maternal efforts to deliver the placenta, assisted by the
following maneuvers, as needed, when you believe the separation has occurred.
Maintain your abdominal hand over the uterus, using your flattened fingers just above
the pubic bone to aid the placenta as it exits the cervical os into the vagina. Instead of
pressure with flattened fingers, the Brandt Andrews maneuver may also be used, but this
is more uncomfortable for the mother. Place your fingers around the ring forceps at the
point where the cord is attached, and apply steady cord traction with a downward
motion. The Upward Placental Lift: then upward along the curve of Carus as the
placenta traverses the vagina to the introitus. When the placenta is visible at the
introitus, lift it partially through with the hand holding the ring forceps.

56. Placenta Delivery: Remove your other hand from the abdomen and let the
placenta fall into your hands. At this point, drop the cord and ring forceps.
Encompass the placenta using both hands to support it during delivery,
making sure the membranes do not tear.

57. Placenta Delivery: Using an Up-Down-
Rotation method to bring it through the os.

58. Placenta Delivery: Once the placenta is delivered, continue to
rotate it and the membranes to form a thicker cord of membranes
help the membranes release intact without tearing or shredding.

59. Placenta Delivery: Grasping the membranes with the ring forceps to help in
delivery and to aid in making a thicker cord of membranes.

60. Placenta Delivery of the Membranes: Rotating the ring
forceps to "tease" the membranes loose from the uterine lining
without shredding them by a slight up and down movement. NOTE:
Slow controlled delivery is necessary to avoid tearing of the cord or
membranes.

61. Placenta Delivery Cleanup: Once the placenta is out, massage the
belly once or twice above the uterus to get the uterus to contract and
form a grapefruit size firm ball under your hand. Wipe out the blood
from the introitus (vaginal opening) after the delivery of the placenta
to determine if you have additional bleeding.

62.  Rapid infusion of intravenous oxytocin
(20 units in 1000 mL crystalloid) upon
delivery of the anterior shoulder (to
limit the risk of shoulder dystocia).
 After delivery of the baby and when
signs of placental separation are evident,
we employ the Brandt maneuver and put
gentle traction on the umbilical cord to
facilitate delivery of the placenta.
 Perform manual uterine massage and
continue the oxytocin infusion after
delivery of the placenta
PRACTICALLY
Anterior shoulder
delivered
Rapid synyto
infusion
Signs of placental
separation
Brandt-Andrew
Placenta completely
delivered
Manual uterine
massage

63.  Oxytocin can be infused (20 units in 1000 mL
crystalloid) into a maternal vein
 Injected into the umbilical vein (20 units)
 Both routes are effective
 IV bolus may cause hypotention ,cardiac arrest
Oxytocin

64.  Hemorrhage
 Uterine inversion
 Retained placenta
Major complications of the third stage of labor

67.  Placenta that has not been expelled by 30 to 60 minutes
after delivery of the baby
 Recommend manual removal of a placenta that has
been retained for at least 30 minutes to
prevent excessive bleeding and infection
 The procedure is done in an operating room, and
ultrasound guidance is suggested
 Intravenous injection of nitroglycerine (50 to 200 mcg)
may facilitate the procedure by relaxing the uterus
Retained placenta

68. DR NIPON POOMTHANAWIT

71.  note general size and shape
 look for any variations or for any abnormalities
 circumvallate placenta (an opaque ring on the fetal surface formed by a
doubling back of the chorion and amnion membranes
 extra placental lobes… vessels running off the edge of the placenta (which
could mean that a placental lobe may still be in the uterus )
Start with the fetal surface since
that is the most common
presentation of the placenta at
birth (shiny schultz).
Placental Exam
Fetal Surface

72.  A normal placenta should have the cord firmly attached into the center or
near the center of the placenta (concentric).
 Eccentric (away from the center of the placenta),
 Rarely a Battledore placenta (the cord at the edge of the placenta).
 Occasionally seen is a velamentous insertion of the cord in which
the umbilical vessels run through the membranes from the cord to the
placenta, without the protection of the gelatinous portion of the cord, which
ends several centimeters above where the vessels insert into the placenta
Note the cord insertion location

73.  Turning the placenta over to the maternal surface,
 pull the membranes up gently to identify the location of the hole which resulted
from the rupture of the membranes.
 Checking for tears in the membranes with a hole near the center of the
membranes indicates a placenta attached to the upper portion of the uterus.
 A hole near the edge of a placenta indicates a low lying placenta (one attached in
the lower uterine segment closer to the cervical os.
 Ideally there should only be one tear - the one the baby came out of.
Placenta Exam of the Membranes:

74.  The Amnion and the Chorion.
Checking membrane for both layers

75.  There should be three in a normal umbilical cord (2 arteries
and 1 vein )
Placental Cord Vessels

76.  After noting whether or not there were tears in the
membranes or blood vessels passing through them, pull the
membranes completely back to expose the maternal surface
of the placenta.
 Look for and note the cotyledons which make up a normally
thick, red surface and ensure that there is not any missing
pieces or sections that may still be in the uterus.
 Note any blood clots
 Calcified infarctions (white, thickened areas), or a pale overall
color. These signs indicate an aging placenta, or one that has
not had a healthy maternal/fetal transfer unit.
 Run your finger around the edge areas of the placenta to
determine whether there are any vessels or succenturiate
lobes in the membranes.
Maternal Surface Inspection.

77.  Any retained uterine fragments may cause severe bleeding
problems (hemorrhage) since the uterus is not able to effectively
contract down to close off open uterine vessels found in the
former placental site.
 This can be life threatening, which is why it is important to do a
proper placental examination.
 The mother may be given oxytocin, methergine, or other
medications if needed. These medications are not usually
required in a normal third stage of labor with minimal bleeding
NOTE:

78.  looking for missing pieces, broken vessels and missing
extra placental lobes.
Maternal Side Inspection of Cotyledons

79.  Maternal side of the placenta.
 Meconium is the blackish-greenish tar-like feces found in the newborn.
 Sometimes during labor, the baby becomes stressed and may lose oxygen.
When this happens, it causes the anal sphincter to relax and the baby releases
the meconium into the amniotic fluid, staining the fluid, the placenta and the
baby.
 If the baby happens to breathe this meconium into the lungs at the time of
birth, it can make the baby very sick and cause severe breathing difficulties and
neonatal lung infections
Checking for meconium

80. Succinturiate Lobes(Maternal Side.)

81. .
Battledore Cord Insertion

82. Placental Circumvallate, Partial and Complete

83. .Placental Abruption With Large Blood Clots

84. Placental Infarction, Calcified Areas of The Placenta.

86.  Begins at the delivery of the placenta and lasts for an
arbitrary period of time afterward.
 This very early postpartum period is associated with
maternal complications from
 Hemorrhage
 Fluid shifts
 Embolism
Fourth stage of labor

87.  Before transferring to the post partum ward, the
patient should be checked for
 Conscious
 Vital signs
 Perineum /bleeding , hematoma
 Uterine fundus /contraction
 Urinary bladder/voiding