Management of the 3rd stage of Labor By: Ihab Hassan Abdel Fattah MD Prof of Ob. & Gyn.

The 3rd stage of labor The baby is delivered and handled to the Neonatologist, nurse or assistant. End by delivery of the placenta and exploration of the lower genital tract.

The 4th stage of Labor The next 2 hours after delivery of both the baby and the placenta. It is a very critical time in the developing, and prevention of postpartum Hemorrhage.

The 3rd stage of labor The placenta separates as a result of capillary hemorrhage and the sharing effect of uterine muscle contraction and retraction. The degree of blood flow associated with placenta separation and delivery depends on how quickly the placenta separates from the uterine wall and how effectively uterine muscles contracts around the placental bed during and after separation.

2 different approaches to the management of the 3rd stage Expectant Management Active Management

Expectant Management ( Physiological or Passive ) Waiting for signs of placental separation and allowing the placenta to deliver spontaneously or aided by gravity or nipple stimulation.

Step By step Active management of the 3rd stage.

1 Palpate the uterus to make sure that there is no second twin and massage the uterus to contract. Assure the patient and tell her the sex and condition of her baby.

2- Administer a Uterotonic Agent (Also called Oxytocic or Ecbolic Agent)

2 Uterotonic Agent Oxytocin 10 IU IM. Oxytocin 5 IU IV. Ergometrin 0.25mg Syntometrine (5IU of Oxtocin and 0.5mg ergometrine.

3 Controlled cord traction

3 Controlled cord traction If the cord is elongated, continue the maneuver till the placenta is delivered If not, repeat after 30 seconds till you fell that the cord is elongated.

4 Examine the placenta The placenta should be examined from the Maternal Surface. Fetal Surface. Uterine massage after delivery of the placenta should be done

5 Lower Genital tract exploration Estimate the amount of fresh bleeding. Explore the vagina and perineum. Repair episiotomy and any vaginal or perineal tear. Clean the perineum, patients legs and back. Return the women to the dorsal position, massage calf muscles.

6 Examine the women before transfer her to postnatal ward. Amount of vaginal bleeding. Uterus is contracted Pulse, Blood pressure, Temp. Record all data in the patient record. Assure the women and advice for early breast feeding.

7 Examine the women During the 4th Stage Amount of vaginal bleeding. Uterus is contracted Pulse, Blood pressure, Temp. Every 15 mins for 2 hours. Record all data in the patient record. Make sure the women started breast feeding.

Revision: Early cord clamping and cutting of the cord Early cord clamping is no longer included in the International Federation of Gynecology and Obstetrics (FIGO) definition of active management of the third stage of labor, and uterine massage after delivery of the placenta has been added.

Revision Cred’s and brandt Andrews These maneuvers and names are not used and replaced by Controlled cord traction

Clinical recommendation Active management of the third stage of labor decreases postpartum blood loss and the risk of postpartum hemorrhage by 68 percent (number needed to treat=12). Evidence A 2

Clinical recommendation Active management of the third stage of labor does not increase the risk of retained placenta. Evidence A 2

Clinical recommendation Oxytocin (Pitocin) is the first choice for prevention of postpartum hemorrhage because it is as effective or more effective than ergot alkaloids or prostaglandins and has fewer side effects. Prophylactic administration of oxytocin reduces rates of postpartum hemorrhage by 40 percent; this reduction also occurs if oxytocin is given after placental delivery Evidence A 2

Clinical recommendation Misoprostol (Cytotec) may be used when other oxytocic agents are not available for prevention of postpartum hemorrhage (number needed to treat=18). Misoprostol may be used for treatment of postpartum hemorrhage, Evidence A

Clinical recommendation Misoprostol (Cytotec) is inexpensive, heat and light-stable, and requires no syringes. This agent is associated with more side effects than conventional uterotonic drugs. Evidence A

Clinical recommendation Routine episiotomy increases anal sphincter tears and blood loss. Evidence A

Step By step Active management of the 3rd stage Palpate and massage the uterus. Administer a Uterotonic Agent. Controlled cord traction. Examine the placenta and massage the Uterus. Lower Genital tract exploration. Examine the women before transfer her to postnatal ward. Examine the women during the 4th Stage.

All through the 3rd and 4th stage Assure the women and advice for early breast feeding. Keep the patient covered in a decent way. Record all data in the patient record. Stick to infection control recommendations.

Thank you