Third stage of labour (Normal & abnormal). Dr. Abdalla H. Elsadig MD. Definition : 3 rd 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.
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Dr. Abdalla H. Elsadig
3rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes.
- normally 5 to15 minutes.
- 30 minutes have been suggested if there is no evidence of significant bleeding.
- Maternal mortality.
. 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 causes anemia or poor iron. Anemia causes weakness and fatigue. prolonged hospitalization affects the establishment of breastfeeding.
- Blood transfusion→ transfusion reaction and infection.
- Emergency anesthetic intervention: due to severe PPH, retained placenta, and uterine inversion.
- Sepsis: due to exploration or instrumentation of the uterus.
* Oxytocin, ergometrin and prostaglandins enhance placental separation and expulsion by causing uterine contraction .
* Tocolytics/nitroglycerin and some inhalation anesthetics cause uterine relaxation and delay of placental separation causing dangerous bleeding following delivery.
1. Look for signs of placental separation:
2. Assess the uterus:
1. 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 and forward with the right hand.
2. Active management:
- By using one of the following: Ergometrine, Oxytocin, or Syntometrine (ergometrine + oxytocin ).
- Given at the delivery of anterior shoulder or after delivery of the baby.
- Immediate delivery of the placenta with CCT.
- 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.
The dose is 2 mg and given IM only.
By rotatingthe placenta about the insertion site as it descends or grasping the membranes with a clamp or artery forceps and drawn down.
- 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
- Inherited coagulopathy.
- Abruptio placentae.
- Retained dead fetus.
- Amniotic fluid embolism.
Over-distension of the uterus: multiple pregnancy, poly-hydramnios or fetal macrosomia.
Retained products of conception: the placenta , placental cotyledon or fragments or a large amount of membranes.
large placental site: multiple pregnancy.
Prolonged labor: weak or incoordinate uterine action or mechanical difficulty will leading to uterine exhaustion and atony.
Placenta praevia: inability of the lower uterine segment to contract and retract.
Abruptio placentae: interstitial uterine hemorrhage and later hypofibrinogenaemia.
Grand-multiparity: (a parity of 5 or more) ↑ fibrous tissue of the uterus ↓ muscular tissue.
Operative deliveries: C/S & general anaesthesia that relax the myometrium, such as Halothane and Cyclopropane.
multiple fibromyomata (leiomyomata), especially of the interstitial type resulting in ineffective uterine contraction and retraction.
full bladder.Uterine Atony
- Due to abnormal development of decidua basalis.
- Causes: previous CS, placenta previa, manual removal of placenta or uterine curettage.
2) in 3rd stage: commonly
- Uterotonics: IV ergometrine (0.5 mg), IV Syntocinon (5 iu) or IM syntometrin ( 1ml) + 30-40 units of syntocinon in 40 ml of normal saline run at 10 ml/hr.
- Acute complete inversion: absent uterus on abdominal examination.
- Incomplete inversion: presence uterine dimpling on abdominal examination.