Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Mother Initiative Tutorial Normal labor: The third stage – physiological and active management Alison James Midwifery Lecturer Margaret Fisher Associate Professor in Midwifery Plymouth University and The Royal College of Midwives, United Kingdom This tutorial is designed to re-inforce previous training – and should, therefore, not be regared as sufficient guidance by itself 1 To find out more about the first and second stages of labor, see the two separate tutorials on these topics Normal labor: “The first stage” tutorial describes labor progress and maternal care until cervix is fully dilated Normal labor: “The second stage” tutorial describes the birth of the baby 2 The third stage of labor Third stage of labor Starts from when the baby is born Third stage of labor: Finishes when the placenta (afterbirth) has come away from the mother, and when her bleeding stops 3 Typical duration of the third stage The third stage of labor can take 20-60 minutes and sometimes longer if no intervention is used and the placenta delivers naturally (physiological or expectant management) If active management (uterotonic and controlled cord traction) is used the placenta should be delivered within 5-30 minutes Physiological Management Active Management 4 How the placenta separates from the womb This diagram shows what happens when the placenta (afterbirth) separates from the uterus (womb): Step 1 – The placenta is still attached to the uterus Step 2 – The muscles in the uterus tighten and clamp down on the blood vessels, causing them to burst (rupture), forcing the placenta off the wall of the uterus. Step 3 – The placenta separates from the uterus as the muscles tighten more and a clot forms behind the placenta (retroplacental clot). Step 2 Step 1 Step 3 5 Illustrating the third stage of labor After birth, the placenta at first remains attached to the top of the uterus Later the uterine muscles contract tightly, expelling the placenta The lower picture shows the uterine muscles tightly contracted, pushing the placenta out. Note how the fundus (top) of the uterus becomes rounder and firmer and lower in the woman’s abdomen as the placenta separates 6 Skin-to-skin contact Place the baby in skin-to-skin contact on the abdomen of the mother, dry the baby, assess the baby’s breathing and perform resuscitation if needed Cover the baby’s head with a cloth or, preferably a hat/bonnet Cover the woman and baby 7 There are two alternative options for the management of the third stage of labor Option 1: Physiological management Physiological (expectant) management – where contraction of the uterus, separation of the placenta and delivery of the placenta and membranes takes place naturally 8 Physiological management (1) Clamp and cut the cord after cord pulsations have ceased It is not necessary to clamp and cut it until after the placenta and membranes have been fully delivered if the cord is long enough for the baby to reach the mother’s breast Cover the cord with a piece of gauze when cutting the cord to avoid splashing blood 9 Physiological management (2) The mother may be encouraged to stand, squat, pass urine or breastfeed to help this to happen. The cord must NOT be pulled, but the mother should be encouraged to push the placenta and membranes out. Stand Squat Pass urine Breastfeed 10 There are two alternative options for the management of the third stage of labor Option 2: Active management Reason for considering the active management of the third stage of labour (AMTSL) This option is recommended to reduce the risk of postpartum haemorrhage but can only be performed by a skilled birth attendant and if the uterotonic drugs are available 11 Active management Step 1: Uterotonic Administer a uterotonic (oxytocin or misoprostol) within 1 minute after the baby’s birth and after ruling out the presence of another baby (the uterotonic of choice is oxytocin 10 IU IM)* OR Give 600 μg of misoprostol by mouth within 1 minute after the baby’s birth and after ruling out the presence of another baby OR Give synometrine 1 ampoule IMI or ergometrine 0.2mg IMI * IM = intramuscular 12 Active management Step 2: Controlled cord traction (1) To perform controlled cord traction (CCT): Place the clamp near the woman’s perineum to make CCT easier. Hold the cord close to the perineum using a clamp. Place the palm of the other hand on the lower abdomen just above the woman’s pubic bone to assess for uterine contractions. If a clamp is not available, CCT can be applied by encircling the cord around the hand When performing controlled cord traction, at the same time, support the uterus by applying external pressure on the uterus in an upward direction towards the woman’s head 13 Active management Step 2: Controlled cord traction (2) When there is a contraction, apply external pressure on the uterus in an upward direction (toward the woman’s head) with the hand just above the pubic bone. At the same time with your other hand, pull with firm, steady tension on the cord in a downward direction (follow the direction of the birth canal). Avoid jerky or forceful pulling. Do not release support on the uterus until the placenta is visible at the vulva. Deliver the placenta slowly and support it with both hands Only release support of the uterus when the placenta is visible at the vulva 14 Active management Step 3: Delivery of the Placenta As the placenta is delivered, hold and gently turn it with both hands until the membranes are twisted Slowly pull to complete the delivery Gently move membranes up and down until delivered 15 Massage Massage the uterus immediately after delivery of the placenta and membranes until it is firm During recovery, assist the woman to breastfeed if this is her choice, monitor the newborn and woman closely, palpate the uterus through the abdomen every 15 minutes for 2 hours to make sure it is firm and monitor the amount of vaginal bleeding. Provide prevention of mother-to-child transmission care as needed 16 What else should the midwife do? 1. Check that the mother’s uterus stays firm – check this every 15 minutes for 2 hours and show the mother how to do this too 2. Check that the vaginal blood loss is normal – it should not be trickling or flowing and she should not be passing clots. 3. Check that the mother’s blood pressure, pulse and temperature are normal See the tutorial ‘Postpartum hemorrhage’ for management if there are concerns. The woman may need to be transferred urgently to a place where medical aid is available. 17 What else should the midwife do? 4. Check the placenta to see if it is complete. If there is a piece missing, the woman will need to be transferred to a place where medical aid is available. See tutorial on ‘Postpartum hemorrhage’ 18 What else should the midwife do? 5. Check the mother’s perineum for labial, vaginal wall or perineal tears. If these involve the muscle (are 2nd degree tears or more) or bleeding they should be sutured as soon as possible 3rd and 4th degree tears (involving the anal sphincter) should only be sutured by a highly skilled midwife or doctor trained to do this 6. Check that the mother is able to pass urine within 6 hours of the birth 19 Summary of third stage of labour It should not last more than about 1 hour if physiological/ expectant management and 30 minutes if active management (AMTSL) Vaginal blood loss should not be more than 500 ml and the mother should feel well. If any concerns, see tutorial on ‘Postpartum haemorrhage’ AMTSL with controlled cord traction must only be performed by a skilled birth attendant Suture any perineal or labial tears quickly Feel the woman’s uterus frequently to see that it stays firm Help the mother to feed and care for her baby Provide PTMCT* care as needed * PTMCT = Preventing Mother To Child Transmission 20