Third stage of labour
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Anatomy and applied physiology
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Third stage of labour
- 1. Third stage of labour
- 2. Definitions and Principles Third stage â From birth of the baby, until complete expulsion of placenta and membranes, and control of haemorrhage. Physiological v Active management
- 3. Definitions and Principles Physiological management â˘Leave cord intact â˘Placenta expelled by normal physiological processes aided by gravity/maternal effort Active management â˘administration of prophylactic uterotonic, â˘clamping and cutting of umbilical cord â˘delivery of the placenta by Controlled Cord Traction (CCT) / modified Brandt Andrews.
- 4. Definitions and Principles Delayed cord clamping â Recent interest in delaying cord clamping to enable neonate to obtain extra blood and prevent anaemia. Lotus birth â cord is kept attached to placenta until it separates from umbilicus http://sarahbuckley.com/lotus-birth-a-ritual-for-our-times
- 5. Separation and descent of the placenta Mechanical factors ⢠Retraction during second stage results in reduction in size of placental bed by 75% ⢠Placenta becomes compressed ⢠Blood in intervillous spaces forced back into decidua ⢠Oblique muscle fibres clamp down on blood vessels ⢠Vessels become tense, congested
- 6. ⢠With next contraction vessels burst, blood seeps between spongy layer of decidua and the placenta ⢠Placenta separates and falls into LUS ⢠Uterus contracts strongly and placenta expelled
- 7. Schultze method of separation (A) ⢠Placenta separates usually centrally first forming retroplacental clot ⢠Increased weight continues separation process and peeling of membranes off uterine wall. ⢠Clot enclosed in membranous bag and expelled fetal surface first ⢠Associated with less blood loss and complete membranes
- 8. Matthews Duncan method of separation (B) ⢠Placenta separates from a lateral border ⢠Blood escapes, no clot to aid process ⢠Placenta descends by slipping down uterine wall ⢠Placenta expelled maternal surface first Associated with ragged, incomplete membranes and increased blood loss
- 9. Haemostasis Potential blood loss through placental site 500-800mls per minute! Haemostasis achieved by ⢠Ligature action of oblique muscle fibres (living ligatures) ⢠Direct pressure from uterine walls with contraction ⢠Activation of coagulation cascade â rapid clot formation ⢠Oxytocin â neonate nuzzling, breastfeeding
- 10. Physiological/expectant management Normal physiological processes expel placenta. Takes 10 â 60 mins, occasionally longer Calm, quiet environment Put baby to the breast Upright position - gravity aids process Watch and wait Contraction with pressure felt by mother Maternal effort will deliver placenta/ may need gentle assistance/twist to remove membranes
- 11. Signs of separation Contracted uterus â fundus rises, narrows, becomes mobile Small fresh blood loss Cord lengthens
- 12. Active management Oxytocic drug given with anterior shoulder or soon after birth Early cord clamping? Observe for signs of separation Counter traction above symphysis pubis Deliver by Controlled Cord Traction (CCT) / modified Brandt Andrews. Takes 5-15 mins Mother plays passive role
- 13. Uterotonic drug choices Syntocinon â IV/IM 5iu â drug of choice Ergometrine â IV 0.25 â 0.5mg, not used routinely Syntometrine â IM 1ml contains syntocinon 5iu plus 0.5mg ergometrine Misoprostol (prostaglandin analogue) â Oral/vaginally/rectally 400-600 microgrammes. Useful where no refridgeration facilities NB Use of ergometrine in any combination not recommended if raised BP
- 15. Midwifeâs role Be aware! Maintain asepsis - laceration/bruising/open placental site Observation of mother and baby After expulsion of placenta and membranes â˘Cord blood if required â˘Check fundus well contracted â˘Examine birth canal for lacerations (?PR) â˘Estimate and continue to observe blood loss â˘Examination of placenta and membranes
- 16. Cord Blood Sampling Required â˘When motherâs blood group is Rhesus Negative â˘When atypical maternal antibodies are present â˘Where haemoglobinopathy is suspected â˘When there has been concern about the neonate during labour or immediately after birth (NICE 2014) Taken from fetal surface of placenta or cord
- 17. Paired cord sampling âPaired samplesâ - both arterial and venous samples taken from the cord. Carried out routinely in some units Selectively for circumstances such as â˘Babies having had fetal blood sampling in labour â˘Instrumental/Caesarean/Vaginal breech births â˘Babies with Apgar under 5 at 1min â˘Babies with severe growth restriction â˘Babies >24 wks<37 wks
- 19. Examination of the Placenta and Membranes
- 20. The placenta at term Flat, round/oval Approximately 20cm diameter, 2.5 cm deep Weighs approx. 1/6th weight of fetus Usually situated in Upper Uterine Segment. Two surfaces â maternal, fetal
- 22. Maternal surface Embedded into decidua Deep â red appearance Surface composed of 16-20 cotyledons, divided by sulci
- 23. Fetal surface Lies adjacent to the fetus White, glistening appearance Umbilical cord joins, usually centrally Cord vessels radiate out across surface Cord and fetal surface covered by amnion.
- 24. Umbilical cord Approximately 50cm long, 2cm thick, spiral twist Contains two umbilical arteries, one vein Vessels enclosed in Wharton's jelly Covered by amniotic membrane continuous with that covering fetal surface
- 25. Fetal membranes Chorion ⢠Formed from the trophoblast of the embryo ⢠Opaque in appearance, thick, friable ⢠Continuous with edge of placenta Amnion ⢠Secretes amniotic fluid ⢠Smooth, transparent ⢠Covers fetal surface of placenta
- 26. Amniotic fluid Also known as liquor amnii â˘Produced continuously by the amnion â˘Clear straw coloured fluid â˘99% water and 1% solid matter â˘Made up of proteins, carbohydrates, lipids, and phospholipids, electrolytes, urea, uric acid, and creatinine, enzymes and placenta hormones. â˘Contains fetal epithelial cells, vernix caseosa and laguno - makes liquid milky
- 27. Amniotic fluid â˘Fetus recycles it â swallowing/urinating â˘Approximately 1000ml at term â˘Maintains a constant temperature â˘Cushions fetus â˘From uterine walls â˘From the noises of body systems â˘From the pressure of the cervix during labour
- 28. Why examine the placenta and membranes? To rule out any abnormalities which may indicate fetal anomalies To ensure placenta and membranes expelled complete ⢠Retained placenta/membranes lead to haemorrhage or infection
- 29. Process Maintain universal precautions Hold by cord â may indicate where membranes ruptured and whether membranes are complete
- 30. Lay on flat surface and examine both surfaces â˘Maternal surface â missing cotyledons, infarctions, position of blood vessels â˘Fetal surface â insertion of cord, â˘Presence of two membranes Check umbilical cord for three vessels, 2 arteries, 1 vein Dispose appropriately
- 31. Placental anomalies Succenturiate lobe ⢠Extra segment may be retained leading to infection/haemorrhage ⢠Cord in membranes â vasa praevia
- 32. Velamentous insertion of cord ⢠Vasa praevia ⢠Cord separates from placenta during third stage Mamabirth.com
- 33. Battledore placenta ⢠Cord attached to edge of placenta ⢠May separate during third stage Mamabirth.com
- 34. Circumvallate placenta ⢠Membranes doubled back at the edge ⢠No clinical significance Fetalultrasound.com
- 35. Bi/Tripartite placentae ⢠Two or three separate lobes ⢠?Vasa praevia Minnesotaplacenta.com
- 36. Cord anomalies Vasa praevia â˘Blood vessels from the placenta lie over the cervical os â˘Risk of rupture and haemorrhage if artificial rupture of membranes â˘Spontaneous rupture usually follows more friable membrane route Absence of blood vessels
- 37. Knots in the cord True False
- 38. Immediate care Skin to skin â maintain infant temperature Dispose of all equipment appropriately including placenta (mother may wish to keep this) Carry out postnatal observations including blood loss Carry out neonatal examination Make mother comfortable Encourage breastfeeding Documentation Observe mother and baby for one hour
- 39. Sources National Institute for Health and Care Excellence 2014 Guideline CG 190 Intrapartum care for healthy women and babies. NICE, London Marshall J, Raynor M (eds) 2014 Mylesâ Textbook for Midwives 16th ed Elsevier, Edinburgh MacDonald S, Maguill â Cuerden J (eds) 2011 Mayesâ Midwifery 14th ed. Elsevier, Edinburgh Wylie L 2005 Essential Anatomy and Physiology in Maternity Care 2nd ed. Elsevier, Edinburgh
Editor's Notes
- Uterotonic â causes smooth muscle of uterus to contract
- Cochrane review In this updated version of the review we have included 15 trials (involving a total of 3911 women and infant pairs) carried out in a number of countries over a long timeframe. There were no significant differences seen between early and late cord clamping groups for the primary maternal outcome of severe postpartum haemorrhage or for the secondary outcomes of postpartum haemorrhage of 500 mL or more or mean blood loss. No included trials reported on maternal death or severe maternal morbidity. Maternal haemoglobin values were not significantly different between women in the early and late cord clamping groups in the days after giving birth. No significant difference between early and late cord clamping was seen for the primary outcome of neonatal mortality or for most other neonatal morbidity outcomes. There was a significant (101 g mean) birthweight increase seen with late, compared with early, cord clamping. However, significantly fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group. Haemoglobin concentration in infants at 24 to 48 hours was increased in the late cord clamping group. This difference in haemoglobin concentration was not seen at subsequent assessments. However, improvement in iron stores was significant (with infants in the early cord clamping over twice as likely (risk ratio (RR) 2.65 95% confidence interval (CI) 1.04,6.75) to be iron deficient at three to six months compared with infants whose cord clamping was delayed. In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences between early and late clamping were identified at four months.
- 75% Baldock 2006
- Stables 40.3
- Maternal choice
- Given with anterioe shoulder, after birth, after placenta is expelled Ergo â no BP or if not checked either alone or in syntometrine Misoprostol â unpleasant side effects â not used routinely in the UK
- Such as sickle cell
- All babies of diabetic mothers, i.e. insulin, metformin and diet controlled ⢠All cases of shoulder dystocia ⢠All cases with intrapartum fever >38 ⢠All multiple pregnancies ⢠All babies of mothers with thyroid disease ⢠All babies with intrapartum pathological CTG trace. ⢠All babies with severe growth restriction ⢠All preterm babies greater than 24 weeks. ⢠All babies with thick meconium during labour.
- The water in amniotic fluid is exchanged as often as every 3 hours. It is swallowed by the fetus â absorbed through the intestines into the circulation, carried to the placenta where it passes to maternal blood. Total volume of amniotic fluid increases throughout pregnancy until 38weeks 1000-1500ml. It then diminishes until term until 800ml remain
- https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to%E2%80%A6-perform-an-examination-of-the-placenta