03 Active management of third stage of labour

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03 Active management of third stage of labour

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

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