Active management of third stage of labour

1. GROUP 4

2. AMTSL (Active Management of Third Stage of
Labour)
AMTSL refers to a set of interventions performed during the third
stage of labor to prevent postpartum hemorrhage (PPH). It typically
involves administering uterotonic drugs, controlled cord traction, and
uterine massage.

3. IMPORTANCE
• AMTSL helps reduce the risk of postpartum hemorrhage, which is a
leading cause of maternal mortality worldwide. By facilitating the
prompt delivery of the placenta and promoting uterine contraction,
AMTSL helps minimize blood loss and prevent complications.
• Shorter third stage of labor, By efficiently facilitating placental
delivery and uterine contraction, AMTSL leads to a quicker
completion of the third stage of labor.
• Decreased need for intervention, The proactive approach of AMTSL
helps reduce the likelihood of needing additional interventions to
manage PPH

4. IMPORTANCE
• Improved maternal bonding: A shorter and less complicated delivery
experience can positively impact the mother’s emotional well-being
and contribute to better maternal-infant bonding.
• Potential reduction in maternal mortality: While further research is
needed, some studies suggest a potential link between AMTSL
implementation and a decrease in maternal mortality rates,
particularly in low-resource settings.
• Standardized approach: AMTSL provides a clear and evidence-based
protocol for managing the third stage of labor, ensuring consistency
and reducing the risk of errors or missed interventions.

5. • Administration of uterotonic drugs (e.g., oxytocin,
misoprostol) immediately after the birth of the baby or
delivery of the anterior shoulder
• Controlled cord traction: gentle traction applied to the
umbilical cord while supporting the uterus to aid in the
expulsion of the placenta
• Uterine massage: gentle massage of the uterus through the
abdominal wall to stimulate contractions and prevent atony.

6. CHARACTERISTICS OF NORMAL LABOUR
• Regular contractions of the uterus that increase in frequency,
duration, and intensity over time.
• Progressive cervical dilation and effacement.
• Descent of the fetus through the birth canal.
• Rupture of membranes (water breaking) may occur spontaneously or
artificially.
• Maternal instinctive urge to push (bearing down) during the second
stage of labor.
• Delivery of the baby followed by the delivery of the placenta and
membranes.

7. Differentiate between placenta Previa and
Abruptio Placenta.
-Placenta Previa: In placenta previa, the placenta is implanted abnormally
low in the uterus, partially or completely covering the cervix. This can cause
painless vaginal bleeding in the third trimester. Diagnosis is typically made
via ultrasound. Management involves close monitoring and may include
cesarean section delivery if bleeding is severe or persistent.
-Abruptio Placenta: Abruptio placenta occurs when the placenta
prematurely separates from the uterine wall before delivery of the baby. This
can result in painful vaginal bleeding, uterine tenderness, and fetal distress.
Diagnosis is based on clinical signs and symptoms, including abdominal pain
and vaginal bleeding. Management involves stabilizing the mother and
delivering the baby, often via emergency cesarean section if the condition is
severe.

8. APH Placenta previa Abruptio Placenta
Definition Implantation of placenta in the lower
uterine segment, encroaching on/
covering internal cervical os in T3
Premature separation of a normally
sited placenta associated with the
highest fetal morbidity and mortality
rate wrt APH
Pathophysiology Occurs due to decreased uterine
vasculature from endometrial damage
resulting in scarring
Vasospasm of uterine vessels followed
by rupture of arterioles into decidua
basalis. Blood beneath decidua dissects
under placenta, extending degree of
separation and appears through vagina
or amniotic cavity toward serosa. This
causes uterus to contract and look
bruised, purple and motties-
COUVELAIRE UTERUS

9. Risk factors • Multiparity & Multigravidae
• Previous C-section
• Uterine Structural Anomalies
• Previous D&C
• Abortion
• Increased maternal age
• Maternal Smoking
• Hypertension
• Cigarette smoking
• Sudden uterine decompression (delivery
of twin A, SROM/AROM esp with
polyhydramnios)
• External physical trauma or ECV
• PPROM
• Short umbilical cord
• Thrombophilia
• Retroplacental leiomyoma and increased
AFP
Types TYPE 1 (Lateral) placenta lies mainly in upper uterine segment and now begins encroaching on
lower segment
TYPE 2 (Marginal) edge of placenta reaches margin of internal cervical os
TYPE 3 (Central)-partially covers os TYPE 4 (Central)-completely covers os
MINOR: Type 1 ant & post, Type 2 ant
MAJOR: Type 2 post, Type 3, Type 4
Type 2 posterior is major because results in decreased AP diameter of pelvic inlet-> compressed
between fetal head and sacrum causing decreased fetal blood flow and hindrance of descent of
head in labour.
• Revealed
• blood dissects downwards to cervix
and pv bleed
• Concealed
• blood dissects upwards to fetus
• presents as uterine pain, Maternal
• Shock, Fetal distress , fetal death
• Mixed

10. Presentation • Painless bright red vaginal bleeding
(don’t base Dx on colour only though)
3 trimester/ onset usually 30-32 wks
• Spontaneous/precipitated by coitus/
small painless bleeds a few weeks
earlier called Warning Hemorrhage.
• Weakness (due to anemia depending
on proportion of blood loss and
possible hypovolemic shock)
• Pale, tachycardic, hypotension, cold
and clammy (Hypovolemic Shock).
• Painful sudden onset, localizes to
back and uterus, increases in
intensity
• Vaginal bleeding (not if concealed)
• Uterine tenderness
• Uterine contractions (uterus tries
to stop the bleeding)
• Usually before labour
• Premature Labour due to
contractions
• Weakness (due to anemia
depending on proportion of blood
loss and possible hypovolemic
shock)
• Pale, tachycardic, hypotension,
cold and clammy (Hypovolemic
Shock)