1. Third stage of labor: events & management
Prophylaxis of PPH

2. Labor Physiological process
The products of conception passed form uterus to outside world
Normal labour: spontaneous in onset, at term, vertex presentation, natural termination without any complications affecting health of mother &/or newborn
Three stages of labor

3. Stages of labour
First stage : onset of true labour pains to full dilatation of cervix
Second stage: full dilatation of cervix to expulsion of fetus from birth canal
Third stage: after expulsion of fetus to expulsion of placenta & membranes (afterbirths)

4. Third stage: events
After expulsion of fetus to expulsion of placenta & membranes (afterbirths)
Duration :15 min.(primigravida multigravida)
AMTSL:5 minutes
Placental separation
Placental expulsion

5. Placental separation
Sudden diminution in uterine size following delivery of fetus
Limited placental elasticity
Creates disproportion between two
Placenta buckles : placental separation
Spongy layer of decidua basalis
2 ways : central, marginal separation

6. Methods of placental separation
Central ( Schultze) separation
Marginal (Mathews Duncan) separation

8. Expulsion of placenta
Contraction & retraction of Upper Uterine Segment
Placenta forced to lie in LUS/upper vagina
Voluntary contraction of abdominal muscles
Expulsion of placenta

9. Mechanisms to control bleeding
Effective retraction of uterine muscles : Living ligatures
Thrombosis of torn sinuses
Myotamponade: apposition of walls of the uterus

10. Management of third stage
Most crucial stage
Strict vigilance
Follow protocols
Expectant management
Active management

11. Expectant management Look for 3 classic signs of placental separation
Lengthening of U. cord
A gush of blood from vagina signifying separation of placenta from uterine wall
Change in shape of uterine fundus from discoid to globular with elevation of fundal height
Spontaneous/Controlled cord traction (CCT)
Expulsion of placenta :20 minutes

12. CCT Modified Brandt Andrews method
Left hand: palmar surface of fingers placed above pubic symphysis. Body of uterus pushed upwards & backwards
Right hand: cord traction in downward & backward direction
Uterus feels hard, contracted

13. Expectant management Massage the uterus Intramuscular Oxytocin : 10 IU
Examination of placenta ,membranes, cord
Inspect vulva, vagina & perineum

14. Examination of placenta ,membranes

15. Examination of membranes, cord

16. Active management AMTSL: Active Management of Third Stage of Labour
Prophylactic uterotonic after delivery of baby
( Oxytocin 10 IU ,IM)
cord clamping, cutting & Controlled cord traction of U cord
Uterine massage
Excites powerful uterine contractions ,aid in early placental separation, minimises blood loss & duration of third stage (5 min.)

17. Third stage Most crucial Life threatening complications
PPH(postpartum haemorrhage)
Retained placenta
Inversion of uterus
Pulmonary embolism

18. Prophylaxis of PPH

19. PPH: hard facts Globally in 10-11% women having live births
Duration between onset of massive bleeding & death: 2 hours
14 million women worldwide
1.4 million women die annually
India : 15-25% of maternal deaths due to PPH

20. stage
Approximate blood loss(ml)
Volume loss(%)
Signs & symptoms
<500
<10
none
ALERT LINE 1 15
None/minimal
ACTION LINE 2
20-25
↓ urine output,↑ PR,↑ RR, postural hypotension, narrow pulse pressure 3
30-35
Hypotension, tachycardia, cold clammy extremities ,tachypnea 4
>2000
>40
Profound shock

21. PPH Primary PPH Secondary PPH Primary PPH: 4T’s
Haemorrhage <24 hrs of birth
Secondary PPH
Haemorrhage >24 hrs till 6 weeks of birth
Primary PPH: 4T’s
Tone
Trauma
Tissue
Thrombosis

22. Primary PPH:causes

23. PPH : risk factors

24. Prophylaxis of PPH Improvement of health status of mother(Hb>11gm%)
Identify high risk women
Plan for institutional delivery /SBA
Strict vigilance of all women in 3rd stage labor
Practice AMTSL in all
Examination of afterbirths ,should be a routine
Explore Uterovaginal canal following difficult/ instrumental, destructive delivery

25. WHO guidelines for Prophylaxis of PPH

26. WHO guidelines

27. WHO guidelines

28. WHO guidelines

29. WHO guidelines
Give uterotonics routinely during 3rd stage labor, in all births
Oxytocin 10 IU IM is drug of choice
Use other uterotonics only when Oxytocin is not available
Late cord clamping( 1-3 min after birth) is recommended
Early cord clamping (<1min of birth): not recommended until the neonate is asphyxiated & needs immediate resuscitation

30. MCQ1 Labor is said to be normal if all are present except: At term
Breech presentation
Spontaneous in onset
Healthy mother & neonate after delivery

31. MCQ1 Labor is said to be normal if all are present except: At term
Breech presentation
Spontaneous in onset
Healthy mother & neonate after delivery

32. MCQ2 Regarding the third stage of labor, following is not true:
Most crucial stage of labor
Duration is 15 minutes
Uterine inversion is most common complication
AMTSL is routine in all

33. MCQ2 Regarding the third stage of labor, following is not true:
Most crucial stage of labor
Duration is 15 minutes
Uterine inversion is most common complication
AMTSL is routine in all

34. MCQ3
The uterotonic of choice for prophylaxis of PPH in third stage of labor is
Syntometrine
Oxytocin
Misoprostol
carboprost

35. MCQ3
The uterotonic of choice for prophylaxis of PPH in third stage of labor is
Syntometrine
Oxytocin
Misoprostol
carboprost

36. MCQ4 All are true in relation to AMTSL except: 10 IU of Oxytocin , IM
Uterine massage
Reduces the duration of third stage
Perform in only high risk cases

37. MCQ4 All are true in relation to AMTSL except: 10 IU of Oxytocin , IM
Uterine massage
Reduces the duration of third stage
Perform in only high risk cases

38. MCQ5 Complications during third stage of labor are all except PPH
Chronic Uterine inversion
Retained placenta
Amniotic fluid embolism

39. MCQ5 Complications during third stage of labor are all except PPH
Chronic Uterine inversion
Retained placenta
Amniotic fluid embolism

40. MCQ6 The most frequently observed method of placental separation :
Marginal separation
Central separation
None
both

41. MCQ6 The most frequently observed method of placental separation :
Marginal separation
Central separation
None
both

42. MCQ7
The most important method to control uterine bleeding following delivery
Myotamponade
Thrombosis
Contraction& retraction of uterine muscle
none

43. MCQ7
The most important method to control uterine bleeding following delivery
Myotamponade
Thrombosis
Contraction& retraction of uterine muscle
none

44. MCQ8 Following are true regarding misoprostol, except Low cost
Easy storage
Administered rectally
Drug of choice for AMTSL

45. MCQ8 Following are true regarding misoprostol, except Low cost
Easy storage
Administered rectally
Drug of choice for AMTSL

46. MCQ9 Following is true regarding Oxytocin Given as IV bolus dose
Thermolabile
Contraindicated in cardiac patient
Causes hypertension

47. MCQ9 Following is true regarding Oxytocin Given as IV bolus dose
Thermolabile
Contraindicated in cardiac patient
Causes hypertension

48. MCQ10 Prevention of PPH, all are true except
Treatment of anemia in antenatal period
Practice AMTSL in all
Home delivery in high risk cases
In forceps delivery, explore uterovaginal canal

49. MCQ10 Prevention of PPH, all are true except
Treatment of anaemia in antenatal period
Practice AMTSL in all
Home delivery in high risk cases
In forceps delivery, explore uterovaginal canal