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.
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The Women's policy is to use active management of the third stage of labour1,2.
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- References (Evidence table)
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Active management
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Active management involves:
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- Administration of a prophylactic oxytocic agent
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- Prepare to birth the placenta and membranes
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- Controlled cord traction of the umbilical cord.
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- Birth of the placenta and membranes.
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Advantages of active management:
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- Reduction in the incidence of post partum haemorrhage. Refer to CPG: Postpartum Haemorrhage (PPH).
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- Reduction in maternal morbidity.
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Process
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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.
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In order to minimise the inadvertent administration of an oxytocic drug, the clinician conducting or assisting with the birth:
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2. Early cord clamping
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Clamp and cut umbilical cord close to the perineum within 2-3 minutes of administration of oxytocic.
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3. Prepare to birth the placenta and membranes
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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.
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Note: Collect cord blood at this time if required. Refer to Procedure: Cord Blood Collection (Intranet only)
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4. Controlled cord traction (CCT)
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- 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.
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- 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.
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- During CCT you will observe signs of separation of the placenta, including:
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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.
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5. Birth the placenta and membranes
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Once the placenta is visible:
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- Release counter traction on the fundus
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- 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.
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- 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.
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6. Following birth of placenta and membranes
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- Immediately massage the fundus of the uterus to make sure it is well contracted².
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- 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.
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- Ensure the uterus does not relax after you stop uterine massage².
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- Examine placenta and membranes for completeness.
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Physiological Management
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- Physiological management allows placental separation and expulsion to occur spontaneously without intervention.
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- This precludes the administration of oxytocic drugs.
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- This process may take from fifteen minutes to one hour.
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Management
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The accoucheur waits for signs of separation and descent of the placenta:
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- Fundus becomes rounded and smaller
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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.
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- If the placenta and membranes remain insitu after 30 minutes, notify RMO. Refer to CPG: Retained Placenta: Management
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Following birth of placenta and membranes
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- Immediately massage the fundus of the uterus to make sure it is well contracted².
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- 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.
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- Ensure the uterus does not become relaxed (soft) after you stop uterine massage².
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- Examine placenta and membranes for completeness.
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NOTE: If there are any signs of significant bleeding administer oxytocic agent.
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Summary
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| | Administer oxytocic
| - With the anterior shoulder
| - Within 1 minute of the birth
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| Wait for signs of separation
| - Slight PV bleeding - monitor
| - Heavy PV bleeding - administer oxytocic and active management
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| Clamp and cut the umbilical cord close to the perineum within 2-3 minutes of administration of oxytocic.
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| Allow placenta and membranes to be birthed by maternal efforts
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| Prepare to birth the placenta and membranes
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| Placenta birthed
| - If placenta remains insitu after 30 minutes, notify RMO
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| | | Birth the placenta and membranes
| - If the placenta remains insitu after 30 minutes, notify RMO
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|  | 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
| | - Examine placenta and membranes
| - Consider whether there are indications for:
|  | - The placenta requiring histopathological examination
| - Collection of cord bloods
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| 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
| | - Examine placenta and membranes
| - Consider whether there are indications for:
|  | - The placenta requiring histopathological examination
| - Collection of cord bloods
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References
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