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labour: third stage management

Labour: Third Stage Management CPG

The third stage of labour refers to the period of time following the birth of the baby, to the separation and expulsion of the placenta and membranes.

The Women's policy is to use active management of the third stage of labour

1,2

.

Active management

Process

Physiological management

Management

Summary

References (Evidence table)

Active management

Active management involves:

Administration of a prophylactic oxytocic agent

Early cord clamping

Prepare to birth the placenta and membranes

Controlled cord traction of the umbilical cord.

Birth of the placenta and membranes.

Advantages of active management:

Reduction in the incidence of post partum haemorrhage. Refer to CPG: Postpartum Haemorrhage (PPH).

Reduction in maternal morbidity.

Process

1. Administer a prophylactic oxytocic agent

- Syntocinon 10 units (IV or IM) to the mother with the anterior shoulder, or within one minute of the birth of the baby2,3.

In order to minimise the inadvertent administration of an oxytocic drug, the clinician conducting or assisting with the birth:

Does not draw up the oxytocic drug until the woman has commenced the active phase of the second stage of labour, having checked the contents and expiry date of the vial

Draws up the contents into a 2 mL syringe, and

Keeps the checked drug vial and syringe containing the oxytocic away from the neonatal resuscitator and/or cot to minimise inadvertent administration to the neonate.

Refer to the Women's policy and procedure (intranet access only): Medication Policy and Medication management procedure.

2. Early cord clamping

Clamp and cut umbilical cord close to the perineum within 2-3 minutes of administration of oxytocic.

3. Prepare to birth the placenta and membranes

Immediately after cord clamping place one hand on the uterine fundus and await the onset of a strong uterine contraction2. This is likely to occur within 2-3 minutes after oxytocic administration4.

Note: Collect cord blood at this time if required. Refer to Procedure: Cord Blood Collection (Intranet only)

4. Controlled cord traction (CCT)

Place one hand above the level of the symphysis pubis, applying counter pressure in an upward direction, thus stabilising the uterus during CCT. Do not manipulate the uterus².

With the strong uterine contraction (2-3 minutes after administration of oxytocic), very gently pull downward on the cord following the direction of the birth canal until the placenta appears at the vulva. Continue to apply counter-pressure to the uterus2.

During CCT you will observe signs of separation of the placenta, including:

Lengthening of cord

Small amount fresh blood loss, and

The uterine fundus becomes rounded and smaller.

Note:

1. If the placenta does not descend during 20 - 30 seconds of CCT or if there is resistance to CCT, do not continue to pull on the cord:

Hold the cord loosely (i.e without any pulling / traction) and wait until the uterus is well contracted again, and

With the next contraction, repeat controlled cord traction with counter-pressure2.

2. Never apply CCT (pull) without applying counter traction (push) above the pubic bone on a well-contracted uterus2(i.e. Downward traction on the cord must be released before uterine counter-traction is relaxed).

3. Do not encourage CCT in conjunction with maternal effort.

5. Birth the placenta and membranes

Once the placenta is visible:

Release cord traction

Release counter traction on the fundus

THEN

the placenta may be taken into two hands and twisted, or an upward and downward movement used to ease the membranes slowly out of the vagina.

If the placenta and membranes remain insitu and the woman is not bleeding, consider bladder management - either bedpan or indwelling catheter. Notify medical officer if placenta and membranes remain insitu after 30 minutes.

6. Following birth of placenta and membranes

Immediately massage the fundus of the uterus to make sure it is well contracted².

Palpate for a contracted uterus every 15 minutes for first hour following birth of placenta and membranes. Repeat uterine massage as needed during the first 2 hours following birth².

Ensure the uterus does not relax after you stop uterine massage².

Monitor PV bleeding.

Examine placenta and membranes for completeness.

Physiological Management

Physiological management allows placental separation and expulsion to occur spontaneously without intervention.

This precludes the administration of oxytocic drugs.

This process may take from fifteen minutes to one hour.

Management

The accoucheur waits for signs of separation and descent of the placenta:

Small fresh blood loss

Lengthening of cord

Fundus becomes rounded and smaller

Allow the placenta and membranes to be delivered by maternal efforts. Maternal positioning, such as squatting or sitting, by utilising the forces of gravity, will aid expulsion.

If the placenta and membranes remain insitu after 30 minutes, notify RMO. Refer to CPG: Retained Placenta: Management

Following birth of placenta and membranes

Immediately massage the fundus of the uterus to make sure it is well contracted².

Palpate for a contracted uterus every 15 minutes for first hour following birth of placenta and membranes. Repeat uterine massage as needed during the first 2 hours following birth².

Ensure the uterus does not become relaxed (soft) after you stop uterine massage².

Monitor PV bleeding.

Examine placenta and membranes for completeness.

NOTE: If there are any signs of significant bleeding administer oxytocic agent.

Summary

Active

Physiological

Administer oxytocic

With the anterior shoulder

Within 1 minute of the birth

Wait for signs of separation

Slight PV bleeding - monitor

Heavy PV bleeding - administer oxytocic and active management

Clamp and cut the umbilical cord close to the perineum within 2-3 minutes of administration of oxytocic.

Allow placenta and membranes to be birthed by maternal efforts

Prepare to birth the placenta and membranes

Placenta birthed

If placenta remains insitu after 30 minutes, notify RMO

Controlled cord traction

Birth the placenta and membranes

If the placenta remains insitu after 30 minutes, notify RMO

Following birth of placenta and membranes

Immediately massage the fundus2

Palpate for a contracted uterus every 15 minutes for first hour. Repeat uterine massage as needed during the first 2 hours2

Monitor PV bleeding

Examine placenta and membranes

Consider whether there are indications for:

The placenta requiring histopathological examination

Collection of cord bloods

Following birth of placenta and membranes

Immediately massage the fundus2

Palpate for a contracted uterus every 15 minutes for first hour. Repeat uterine massage as needed during the first 2 hours2

Monitor PV bleeding

Examine placenta and membranes

Consider whether there are indications for:

The placenta requiring histopathological examination

Collection of cord bloods

References

Refer to Evidence Table

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