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Third stage of labour

Third stage of labour. Dr.Roaa H. Gadeer MD. Definition. commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes.

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Third stage of labour

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  1. Third stage of labour Dr.Roaa H. Gadeer MD

  2. Definition • commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. • The length of the third stage is 5-15 minutes. 30 minutes have been suggested if there is no evidence of significant bleeding. • The risk of complications continues for some period after delivery of the placenta. • Fourth stage of labor: begins with the delivery of the placenta and lasts for 1 hour

  3. Significance • Postpartum haemorrhage (PPH) : It is a leading cause of maternal mortality. • Maternal death: The maternal mortality rate in the United States is approximately 7-10 women per 100,000 live births; 8% of these deaths are caused by PPH. The maternal mortality rates in developing world exceeded 1000 women per 100,000 live births, 25% of these deaths are due to PPH. • Anemia: PPH may cause anemia or poor iron. Anemia may cause weakness and fatigue. prolonged hospitalization may affect the establishment of breastfeeding. • transfusion reaction and infection: Due to blood transfusion. • Emergency anesthetic intervention: due to severe PPH, retained placenta, and uterine inversion. • Sepsis: due to exploration or instrumentation of the uterus.

  4. What to do before delivery of the placenta ? • Inspect the cervix and vagina for lacerations. • Look for signs of placental separation.

  5. Mechanism of placental separation • Uterine contractions and retractionreduce the surface area → placental detachment and expulsion into the lower uterine segment. • Retro placental hematoma. * Agents causing uterine contraction (uterotonic): oxytocin, ergometrin and prostaglandins enhance placental separation and expulsion . * Agents (tocolytics/nitroglycerinand some inhalation anesthetics) cause uterine relaxation and delay of placental separation causing dangerous bleeding following delivery.

  6. What to do before delivery of the placenta? 1. Look for signs of placental separation: • lengthening of the umbilical cord outside. • The uterus becomes firm and globular. • The uterus rises in the abdomen. • A gush of blood. 2. Assess the uterus: • To exclude an undiagnosed twin • To determine a baseline fundal height • to detect the signs of placenta separation • to detect an atonic uterus

  7. Delivery of the placenta • Physiological or expectant management: -Wait for the signs of placental separation - Make sure that the uterus is contracted. - Controlled Cord traction: the body of the uterus is supported above the symphysis pubis by the left hand directed upward and backward. Then cord traction is applied continuously downward with the right hand. • active management: - By using 1 of 3 uterotonic agents: ergometrine, oxytocin, or ergometrine- oxytocin (Syntometrine - Given at the delivery of anterior shoulder or after delivery of the baby. - Immediate delivery of the cord with CCT. • Avoid uterine massage before placental delivery.

  8. Delivery of membrane: by rotating the placenta about the insertion site as it descends or grasping the membranes with a clamp.

  9. Umbilical cord management • cord clamping: Delayed until the cord is pulseless, usually 2-4 minutes, →↑Hb, ↑iron stores in the newborn and ↓levels of early childhood anemia. • Method of cord clamp:

  10. Physiological Versus Active Management

  11. Mode of uterotonic administration • Oxytocin dose is 10 IU, intramuscularly. with intravenous access in place, 10-20 IU is placed in 500-1000 mL of crystalloid and run quickly. With cesarean deliveries, 5 IU is administered as an intravenous bolus, followed by a similar infusion. • Ergometrine dose: is 0.2-0.25 mg, some used 0.5 mg ; IM or IV. • Syntometrine (contains 0.5 mg of ergometrine with 5 IU of oxytocin); IM, 2 mg.

  12. What to do after delivery of the placenta? • Determine the fundal position and size of the uterus. why? • Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine massage). • Examine the placenta for completeness and detection of abnormalities. • Suturing of lacerations. • Uterine exploration: - No longer recommended for normal deliveries or those following previous cesarean delivery. - Is justified in patients with bleeding originating high in the genital tract. - The cervix should be visualized after all forceps deliveries

  13. Fourth stage • Observe the vital signs. • palpate the abdomen to assess and monitor uterine tone and size. • Do uterine massage. • Ensure continuous infusion of oxytocin. • Encourage early breastfeeding to promote endogenous oxytocin release. • assess the lower genital tract for bleeding. • assess the placenta for completeness. • repair of an episiotomy or any lacerations. • Close observation every 15 minute for the next hour.

  14. COMPLICATIONS • Postpartum hemorrhage. • Retained placenta. • Uterine inversion.

  15. thanks

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