Active management of third stage of labour

1. ACTIVE MANAGEMENT OF
THIRD STAGE OF LABOUR
Dr Faseyosan V.T
Supervisor : Dr Ojo

2. Objectives
• Background
• To understand third stage
• Complications
• Active management
• Harmful practices

3. BACKGROUND
• The leading causes of maternal mortality are haemorrhage, infection,
hypertension, unsafe abortion and obstructed labour
• One quarter of these deaths are caused by haemorrhage and
preventable by simple measures; one of them is Active Management
of Third Stage of Labour (ATMSL)
• ATMSL is an effective measure to prevent PPH.

4. THIRD STAGE
• Delivery of the foetus to delivery of placenta and membranes
• Up to thirty minutes
• Average 5 to 15 minutes
• Shorter in multi, slightly longer in primi

5. KEY EVENTS IN THIRD STAGE
• Separation of placenta
• Expulsion/Delivery of Placenta
• Haemstasis

6. SEPARATION OF PLACENTA
Central separation
Marginal separation
Signs of placental separation
• Uterus becomes contracted, hard and globular
• Uterus rises just above umbilicus
• Extra vulval lengthening of umbilical cord
• A gush of blood frequently appears
• On pushing the uterus up in the abdomen, the cord does not
recedeback

7. Complications of third stage
• PPHs
• Retained Placenta
• Inversion
• Post-partum shock

8. METHODS OF THIRD STAGE MANAGEMENT
1. PHYSIOLOGIC OR EXPECTANT MANAGEMENT
Oxytocics are not used
Placenta is delivered by gravity and maternal effort
Cord is clamped after delivery of the placenta
2. ACTIVE MANAGEMENT
Oxytocic is given
Cord is clamped
Placenta delivered by controlled cord traction(CCT) with counter
traction on the fundus
Fundal massage

9. ACTIVE MANAGEMENT
• Administration of an oxytotic during or immediately after delivery of
the baby by any route
• Early or immediate clamping and cutting of cord without awaiting
cessation of cord pulsation
• Delivery of the placenta by controlled cord traction without waiting
for the signs of separation of the placenta
• Uterine massage
N.B : ACOG has recommended delayed cord clamping (for at least thirty
to 60 secs) for both term and preterm infants

10. Oxytotics
• Oxytocin(safe,cheap, no contraindication, effective<quick action>, 10
units IM , less heat labile)
• Ergometrine(cheapest, side effects, has contraindications, 0.2mg
IM/IV, heat labile)
• Prostaglandin(costly, contraindications, effective , 125 – 520mcg IM,
highy heat labile)
• Misoprostol(less costly, no significant CI or side effects, 600mcg
orally/per rectal, highly heat labile)

11. Comparative study of various oxytocics in
AMTSL
• A study by Gaddapa SN et al in 2018
• 160 patients were randomly given one of following oxytocics a)
tablet misoprostol 600 µg per rectal b) Inj. Oxytocin 10 IU IM c) Inj.
Methylergometrine 0.2 mg IM d) Inj. PGF2α
• Duration for the delivery of placenta and amount of blood loss was
measured, side effects were noted, and comparison of haemoglobin
and blood loss done.
• No significant difference in mean blood loss in all group with respect
to parity and type of labour. In present study it seems that no
oxytocic is superior to other in reducing the blood loss. Misoprostol
has variable onset of action. Mean duration of 3rd stage in various
groups is same. In respect to side effects HTN is common with
methylergometrine, shivering and fever with misoprostol and
diarrhoea with PGF2α.

12. Inappropriate practices
• Non use of active management
• Manipulating uterus (fundal pressure , squeezing)
• Inappropriate cord traction
• Inappropriate use of oxytotic
• Uterine lavage
• Non examining birth canal/after births

13. References
• Current testbook of OnG
• Agboola
• International Journal of Reproduction, Contraception, Obstetrics and
Gynecologydoi = {10.18203/2320-1770.ijrcog20184125}