Management of third stage of labour

Introduction

The third stage of labour is defined as the period extending from the birth of the baby to the complete expulsion of the placenta and membranes, the control of bleeding from the placental site, and the initiation of breastfeeding.

Nowadays, many different parts of the world, including Nepal, use active management for the third stage. Active management is associated with lower blood loss compared to physiological management. Nepal, most maternal mortality is attributed to post partum hemorrhage (PPH) caused by uterine atony and placenta retention, conditions that can be prevented through active management of the third stage.

There are two methods for managing the third stage of labour:

• Active management
• Physiological (expectant) management.

Active management of third stage of labour

1. Administer oxytocin immediately within 1 minute of delivering the baby, palpate the abdomen to check for the presence of an additional baby, and administer 10 units of oxytocin intramuscularly. If oxytocin is unavailable, administer 0.2 mg of ergometrine intramuscularly or prostaglandin after checking blood pressure.
2. Employ controlled cord traction (CCT) to facilitate the delivery of the placenta.
3. Perform uterine massage after delivering the placenta, continuing until the uterus contracts. Repeat the massage every 15 minutes for the first 2 hours.

Methods of placenta delivery

There are three methods of placenta delivery

1. Controlled cord traction (CCT) (modified Brandt –Andrews) method
2. Fundal pressure
3. Maternal effort

Control cord transmission (Modified Brandt-Andrews method)

The Modified Brandt-Andrews method for controlled cord traction involves several pre-procedure checks:

1. Administering an oxytocin drug.
2. Allowing sufficient time for the drug to take effect.
3. Ensure that the uterus is well-contracted.
4. Applying counter traction.
5. Confirming the presence of signs indicating placental separation and descent.

Method of Controlled Cord Traction

1. Place the left hand above the level of the symphysis pubis with the palm surface facing toward the umbilicus to apply upward pressure.
2. Displace the body of the uterus upward toward the umbilicus using the left hand.
3. With the right hand, steadily apply traction in a downward and backward direction along the birth canal, holding onto the clamp positioned on the cord at the vulva.
4. It is important to pull the cord firmly while maintaining a steady traction.
5. Pause until another contraction is palpated before making further attempts.

Complication of Controlled cord traction

• Inversion of the uterus
• Partial separation of the placenta
• Hemorrhage
• Detachment of the cord

Advantages of Controlled cord traction

1. Reduced blood loss
2. Reduction in third stage of labour

Fundal pressure

1. Place four fingers of the hand behind the fundus and the thumb in  front of the fundus to use as a piston.
2. The uterus is made to contract by gentle rubbing.
3. When the uterus is hard it is pushed downwards and backwards.
4. The pressure is to be withdrawn as soon as the placenta passes through the introitus.

Maternal effort

Steps of the placental delivery

1. A hand is placed over the fundus to feel for the signs of placental separation
2. When the features of placental separation and its descend into the lower segment are confirmed, the client asked to bear down simultaneously with the hardening of the uterus.
3. As soon as the placenta passes through the introitus, it is grasped by both hands and twisted round and round or slightly up and down with gentle traction applied as the membranes are stripped off intact.
4. If the membranes are threatened to tear, they are to be held by an artery forceps and gentle traction is applied to deliver the rest of the membranes.

Examination of birth canal after delivery

Inspection of vulva, vagina and perineum carefully after child birth for any injuries or trauma is called as examination of birth canal.

Importance

• To identify any laceration or injuries on the birth canal.
• To repair or suture on episiotomy or trauma.
• To prevent postpartum hemorrhage (PPH) by identifying the site and source of bleeding.

Process of birth canal examination

1. Gently separate the labia and inspect the lower vagina for lacerations.
2. Inspect the perineum for lacerations, tears, and hematomas.
3. Gently clean the perineum with boiled water and a gauze piece, and press to check for bleeding.
4. If there is trauma and oozing of blood, repair it immediately.
5. Apply a clean pad to the vulva.
6. Continuously observe and monitor for bleeding.
7. Keep the woman in a comfortable position.

Examination of placenta, membranes and cord

Perform the examination of the placenta and membranes as soon as possible. It helps to address any doubts about their completeness before the woman leaves the room.

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Purpose

1. To identify any abnormalities in the placenta and membranes.
2. To examine for the presence of a retro-placental clot.
3. To verify the completeness of cotyledons and membranes.
4. To measure the weight of the placenta and the length of the umbilical cord.

Articles

• Placenta in a bowl
• Large kidney basin
• Weighing scale
• Measuring tape
• Clean gloves 1 pair
• Gauze piece

Importance

1. To prevent postpartum hemorrhage (PPH) by identifying placental piece or membrane retention
2. To determine whether placenta/membranes are completely expelled
3. To identify abnormalities of placenta, membrane, and cord

Process of placenta examination

1. Thoroughly inspect to ensure that no part of the placenta or membranes has been retained, as the membranes, in particular, pose a challenge for examination due to their tendency to become torn during delivery, resulting in a potentially ragged appearance.
2. Make every effort to assemble them to create a comprehensive image of completeness, which is more easily achieved by holding the placenta by the cord and allowing the membranes to hang.
3. Hold the placenta in the palm of your hands, keeping the palms flat, with the maternal side facing upward.
4. Remove any clots present on the maternal surface and retain them for measurement.
5. Spread the maternal surface of the placenta across both hands, and inspect to ensure that all the lobules are intact, fitting together seamlessly without any gaps, forming a uniform circle along the edges.
6. The surface typically comprises around 20 lobes, separated by sulci. Carefully reposition any broken fragments of cotyledon before an accurate assessment can be conducted.
7. Hold the umbilical cord in one hand and allow the placenta to hang down. Confirm the completeness of the membranes, ensuring that there is one opening where the baby passed through.
8. Peel the amnion from the chorion all the way to the umbilical cord, enabling a complete view of the chorion. Then, insert the right hand between the two membranes with fingers spread apart to inspect for completeness and to differentiate between the layers of the two membranes.
9. Inspect the cord for the number of blood vessels, cord insertion, and its length.
10. Measure the blood loss.
11. Weigh the placenta, noting that the weight varies depending on when the cord is clamped. Delayed clamping of the placenta results in a weight approximately equal to 1/6th of the baby’s birth weight, while early clamping leads to additional blood volume, increasing the weight to nearly 1/5th of the baby’s birth weight.
12. Dispose of the placenta membrane in the appropriate location. Decontaminate gloves by immersing them in a 0.5% chlorine solution for 10 minutes.
13. Wash hands thoroughly with soap and water.
14. Record all findings on the delivery sheet and report any abnormalities and defects, such as whitish areas indicating infarcts, necrosis, and calcification, as well as anemic regions where the placenta is thinner than normal, and the occasional presence of tumors such as hemangiomata.

Complications of third stage of labour

• Postpartum haemorrhage
• Retention of placenta
• Uterine inversion
• Obstetric shock
• Pulmonary embolism

Cord blood preservation

• When the mother’s blood group is Rhesus negative  or as a precautionary measure if the mother’s Rhesus  type is unknown
• When atypical maternal antibodies found  during an antenatal screening test
• Where a haemoglobinopathy is suspected (e.g. sickle  cell disease)

1. Take a sample  as  soon  as  possible  from  the  fetal  surface  of  the  placenta  where  the  blood  vessels  are  congested  and  easily  visible.
2. If  the  cord  has  not  been  clamped  prior  to  placental  birth  the  fetal  vessels  will  not  be congested, but a sample of sufficient volume may still  be easily obtained, or can be taken by syringe prior to birth of the placenta.
3. In the case of paired cord blood sampling  being  required  for  reasons ,  blood will be obtained from the umbilical cord.
4. To achieve this, an additional clamp will need to be applied resulting  in double-clamping of the cord.
5. The appropriate containers should be used for any investigations requested. These  may include the baby’s blood group, Rhesus type, haemoglobin estimation, serum bilirubin level, cord blood analysis  for  acid  base  status,  Coombs’  test.

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