Management of third stage - Management of patient in labour

Management of third stage

The uterus usually rest for a few minutes after the delivery of the baby. But normal contractions soon start again to separate the placenta and push it to the lower uterine segment or vagina. While the placenta separate there may be slight blood loss. The midwife must observe the woman’s condition as she wait for signs of placenta separation.

The woman lies in dorsal position. The midwife places her left hand on the uterus to know that it is well contracted. When well contracted the uterus feels hard like a cricket ball. Also to note the size of the uterus. The hand must not meddle with the uterus. Signs of placenta separation are also observed for. Asepsis and antisepsis must be maintained throughout this stage.

Signs of placenta separation

1.           Cord lengthens

2.           Uterus becomes harder and mobile.

3.           Small gush of blood.

4.           Fundus rises.

Methods of delivery of placenta

Controlled cord Traction; this method is becoming commonly used now a days because of its advantages of reducing the risk of post partum Haemorrhage, shortens the third stage of labour.

It is done by administration of sytometrine 2 mls, 5 unit Oxytocin ,0.5mg Ergometrine with the birth of the anterior shoulder or the after coming head. The success of the method depends on good knowledge of pharmacological action of the oxytocic drug used and proper timing of the procedure. A downward and outward traction is applied on the cord following birth canal while the left hand braces the uterus backwards to provide counter-traction. The uterus must be well contracted. Mayor forceps could be applied to give a firmer grip on the cord. This method must not be combined with fundal pressure to prevent inversion of the uterus. A sterile kidney should be placed against the perineum to collect blood loss and receive the placenta

Contraindications

1.           Preterm baby

2.           Macerated fetus

Fundal pressure

With this method the placenta must have separated and lying in the lower uterine segment or vagina. The uterus must be well contracted. The woman must relax her abdominal muscles by breathing through her mouth gently. The well contracted uterus is used to push the placenta out as the piston is used to push fluid out of the syringe.

The midwife standing on the patient’s right hand, grasp the fundus with her left hand with her fingers behind the uterus and her thumb in the front. She then applies a pressure with the palm of her hand towards the pelvic outlet in a downward and backward

direction. The right hand receives the placenta at the vulva then the left hand joins it when the placenta is almost completely expelled. Give Ergometrine 05mg i.m.

Maternal Effort:

Good uterine contraction will separate the placenta. When the placenta has separated and descended into the lower segment signs of placental separation are present with the next contraction the woman is asked to push as she did for the delivery of the baby. The placenta is received into a cupped hand, twisting the membranes into a rope to prevent it breaking. If membranes are adherent then apply a gentle up and down traction using a forceps.

Brandt Andrews maneuver:

In this method the placenta must also have separated and the uterus well contracted. The midwife places her left hand on the uterus over the symphysis pubis. A forceps is applied on the cord or cord wound round the right hand twice, a gentle traction is applied while the left hand applied on upward pressure on the uterus. If properly used it is a safe method.