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THIRD STAGE OF LABOR

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Undergraduate course lectures in Obstetrics &Gynecology Prepared by dr Manal Behery – PowerPoint PPT presentation

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Title: THIRD STAGE OF LABOR


1
DR MANAL BEHERY Assistant Professor Zagazig
University 2013
2
  • Defintion
  • 3rd stage of labor commences with the
    delivery of the fetus and ends with delivery of
    the placenta and its attached membranes.
  • Duration
  • - normally 5 to15 minutes.
  • - 30 minutes have been suggested if there is no
    evidence of significant bleeding.

3
Cause of placental separation
  • After delivery of the fetus,
  • the uterus retracts and the
  • placental bed diminished.
  • As the placenta is inelastic
  • and does not diminish in
  • size it separates.

4
Uterine Retraction and Placental Separation
5
Placental Site during Separation
6
Placental Site during Separation
7
Separation and Descent of Placenta
  • Non-elastic placenta has detached from the
    shrinking uterine wall
  • Primary mechanism is the reduction in surface
    area of placental site as the uterus shrinks
  • Secondary mechanism is the formation of haematoma
    due to venous occlusion and vascular rupture in
    the placental bed caused by uterine contractions

8
Methods of Placental Separation
9
Schultze Method
  • Placenta separates in the centre and folds in on
    itself(80), as it descends into the lower part
    of uterus
  • Fetal surface appears at vulva
  • with membranes trailing behind
  • Minimal visible blood loss as
  • retroplacental clot contained within membranes
    (inverted sac)

10
Duncan Method
  • separation starts at the
  • lower edge of placenta
  • (20) lateral border separates.
  • maternal surface appears first at vulva
  • Usually accompanied by more bleeding from
    placental site due to slower separation and no
    retro placental clot.

11
Signs of Separation and Descent
  • lengthening of the
  • umbilical cord outside.
  • The uterus becomes
  • firm and globular (Descent).
  • The uterus rises in the
  • abdomen.
  • A gush of blood(separation ).
  • 2

12
Assess the uterus
  • 1-To exclude an undiagnosed
  • twin
  • 2-To determine a baseline
  • fundal height
  • 3-to detect the signs of placenta separation
  • 4- to detect an atonic uterus.

13
Control of Bleeding
  • 1. Normal blood flow through placenta site is
    500-800 ml/minute (10-15 of cardiac output)
  • 2.Strong contraction/retraction of uterus
    constrict blood vessles by interlacing muscle
    fibres in myometrium (living ligature)
  • 3. Pressure exerted on placental site by walls
    of contracted uterus
  • 4. Blood clotting mechanism (sinuses and torn
    vessels)

14
Management of the Third Stage of Labour
15
Physiologic or Active
16
Active vs physiologic management
  • Active management includes a prophylactic
    oxytocic drug,early clamping and cutting of cord
    and controlled cord traction
  • Physiological management involves no prophylactic
    oxytocic drugs, no cord clamping until after
    placental delivery and no cord traction

17
Physiological Active
Placental delivery By gravity and maternal effort By controlled cord traction with counter traction on funds
Uterotonic after placenta delivery With birth of anterior Shoulder
Uterus Assessment of size and tone Assessment of size and tone
Cord Clamping Variable Early
18
Active Management
  • reduces length of 3rd stage and incidence of PPH
    (blood loss and need for transfusion)
  • Oxytocic given after birth of
  • shoulder (check for a twin/
  • no shoulder dystocia)
  • Cord clamped and cut
  • Placenta delivered by
  • Controlled Cord Traction

19
Guarding the Uterus
20
Controlled cord traction
21
Placental delivery
22
Delivering the Membranes
23
Controlled Cord Traction CHECKS FIRST!
  • Check that an oxytocic (uterotonic) has been
    given Why?
  • Check that the uterus is well contracted Why?
  • Check that countertraction is applied (Brandt-
    Andrews manoeuvre) Why?
  • Check for signs of separation descent Why?
  • Check that cord traction is released before
    countertraction is stopped Why?

24
Physiological Management1
  • Passive or expectant management
  • Allows placenta to separate and
  • descend without interference
  • No prophylactic oxytocics
  • Cord clamped after delivery of placenta
  • No Controlled Cord Traction (CCT)

25
Physiological Management2
  • Upright/kneeling/squatting position best- easy
    to observe blood loss
  • Hands off just check uterus contracted and
    observe PV loss
  • waits and watches for signs of separation and
    descent
  • Mother expels placenta when she feels contraction
    and placenta in vagina

26
Which is better active or physiologic management ?
  • Active management is superior to physiological in
    terms of blood loss
  • Physiological management is only appropriate for
    women with low risk of PPH and who have normal
    physiological labour
  • If physiological management is attempted but
    intervention is subsequently required ( the
    placenta is retained after one hour) active
    management should be considered.

27
Manual removal of retained placenta
28
After Care Before leaving to check placenta and
membranes
  • Check the uterus is well contracted
  • Check that PV loss is minimal
  • Inspect perineum, vulva and vagina in good light
    (? Repair)
  • Baby should be pink (respirations heart rate)
    warm, fed, cord clamp secure

29
check placenta and membranes
  • for completeness
  • and normality

30
Abnormal placenta (accessory lobe)
  • Succentriate
  • lobe

31
Effects of labor on the mother
32
  • 1 st stage anxiety mild tachycardia.
  • 2 nd stage
  • Pulse up to 100 b.p.m.
  • Temp mild increase (37.5 - 37.7).
  • B.P. systolic increased during pains.
  • Conjunctiva edematous congested.
  • Birth canal minor lacerations in the cervix or
    perineum especially in PG.

33
3rd Stage
  • Blood loss from
  • ? Placental site 200-300 C.C due to placental
    separation.
  • ? Lacerations or episiotomy about 100 - 200 C.C

34
Effects of labor on the Fetus
35
Moulding
  • Overlap of the flat bones
  • of the vault of the skull
  • due to compression of
  • the head during labour
  • leading to alteration in
  • its shape

36
Types Degrees
  • a. Physiological
  • "beneficial decreases
  • the size of head
  • facilitates its passage
  • through the birth canal.
  • 1. First degree
  • 2. Second degree

37
Pathological may lead to intracranial hemorrhage
  • 3 rd degree
  • Overriding of one parietal
  • bone over the other with
  • Contractions but it is not
  • Reducible inbetween.
  • 4 th degree overriding of the 2 parietal bones
    over each others both override the occipital

38
Caput Succedaneum
39
Types
  • A Natural
  • Cervical
  • with cervical dystocia.
  • Pelvic
  • with obstructed labour
  • usually formed in prolonged labour
  • after rupture of membranes.

40
Cehalnematoma
41
Cehalhematoma(subperiostealhemorrhage
42
  • Thank You
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