Management of 3rd Stage of labour

Active care in the third stage aids in the prevention of postpartum hemorrhage. Active management of the third stage of labor includes the following:

1. Immediate oxytocin
   Within one minute of the infant's birth, palpate the abdomen to rule out the presence of another baby and administer oxytocin 10 units intramuscularly. If Oxytocin is not available, administer 0.2 mg IM ergometrine or prostaglandin after monitoring blood pressure.
2. Controlled cord traction to deliver the placenta.
3. Uterine massage

• Massage the fundus of the uterus through the abdomen immediately until the uterus is constricted.
• Uterine repetition
• For the first two hours, massage every 15 minutes.
• Make sure the uterus does not relax when you stop massaging it.

Methods of Placenta Delivery

The placenta should be entirely removed from the uterus before delivery, and the bladder should be empty.

There are three methods of placenta delivery:

1. Controlled cord traction (CCT)
2. Fundal pressure
3. Maternal effort

Controlled Cord Traction

CCT is thought to reduce blood loss, shorten the third stage of labor, and hence limit the time during which the mother is at risk of hemorrhaging. Before using CCT, there are various tests that must be made:

• That an oxytocin medication was administered.
• It has been given the opportunity to act.
• The uterus is fully contracted.
• This counter-traction is used.
• There is evidence of placental separation and descent.

Method of placenta delivery by CCT

1. A sterile towel is used to drop the abdomen.
2. Within one minute of delivery, use sponge forceps to clamp the chord near the perineum. With one hand, grasp the pinched cord and the end of the force.
3. Place the second hand right over the women's pubic bone, palm towards the umbilicus, and provide upward pressure to stabilize the uterus. Counter-traction is used during controlled cord traction.
4. Maintain slight stress on the chord while waiting for a powerful uterine contraction.
   When the uterus rounds up or the cord lengthens. To deliver the placenta, gently draw the chord downward. Do not apply traction on the cord until there is a gush of blood.
5. Maintain counter-traction on the uterus.
6. If the placenta does not descend within 30-40 seconds of CCT, stop pulling on the cord.
7. Hold the cord gently and wait until the uterus has fully contracted again. If necessary, clamp the cord closer to the perineum with sponge forceps and repeat CCT with counter traction.
8. Repeat CCT with counter traction with the following contraction.
9. The thin membranes can tear as the placenta births. Gently turn the placenta in two hands until the membranes are twisted.
10. If the membranes tear, gently check the upper vagina and cervix using a high-level disinfectant glove and sponge forceps to remove any remaining membrane pieces.
11. Examine the placenta carefully to ensure that nothing is missing. If a component of the material surface is absent or there are ruptured membranes with vessels, retained placental fragments should be suspected.
12. If the cord is severed, the placenta may have to be manually removed.
13. To collect the blood loss and placenta, insert a sterile receiver against the perineum.

Fundal pressure

Using the uterus as a sort of piston, the fundus is pushed downward and backward by inserting four fingers behind the fundus and the thumb in front. Only when the uterus gets hard should pressure be applied. If it isn't, rub it lightly to make it hard. As soon as the placenta passes through the introitus, the pressure is to be released. This approach is superior to cord traction if the baby is macerated or preterm.

Maternal effort

When uterine contractions continue, a woman is urged to hold her breath and bear down, just like she did during the baby's birth. Some multiparous women have slack abdominal muscles that are incapable of breaking down. In such circumstances, the midwife could help by placing both hands, palms down, over the woman's abdomen below the umbilical to offer a brace against which the ladies could push. The genital tract, placenta, membranes, and cord are all examined.

Importance

1. To detect any laceration or injury on the delivery canal.
2. Suture out the vagina and perineum as needed.
3. To avoid PPH, find the placental component or membrane retainer and remove blood clots.
4. To determine whether or not the placenta or membrane has been entirely evacuated.
5. To detect problems in the placenta, membrane, and cord.

Examination of genital tract

1. Separate the labia gently and check the lower vagina for laceration or tears.
2. Examine the perineum for laceration, tear, or hematoma.
3. Cleanse the perineum gently with warm water and a clean cloth, then press hard on the back wall of the vagina with gloved dominant fingers to view deep into the vagina.
4. Tear bleeding may seep slowly or spurt from an artery.
5. Cleanse the vulva with a clean pad or towel.
6. Remove any soiled or wet bed linen and dispose of it properly.
7. Assess for bleeding on a regular basis. If there is a trickle of blood, a rapid burst of blood, or clots, evaluate the vagina carefully.
8. Make sure the woman is comfortable and wrap her in a blanket.

Steps of Placenta Examination

The examination should be performed as soon as possible after birth so that if there is any uncertainty regarding their completeness, further action can be taken before the mother leaves the labor room.

1. A measuring jug should be used to measure the blood. While measuring the lost blood, the bloodstreams in bed, the clothes are soiled, and the perineal pad soakage should be assessed.
2. To remove the blood and clots, the placenta is placed on a tray and rinsed under running water.
3. The maternal surface is first examined by removing the placenta with two hands. It is preferable to examine the placenta convex over both hands' backs. Grayish decidua covers the maternal surface. The cotyledons are normally arranged in close proximity, with any indicating a missing cotyledon.
4. The location should be checked for an infraction, which is common in toxemic and post-mature mothers. It is unimportant, but it may yield relevant evidence.
5. The color of the placenta should be examined; it is generally greenish, but a yellowish hue suggests jaundice, light color shows hemolytic disorders, and white areas indicate infraction.
6. The membrane - The cord holds the placenta in place, enabling the membranes to dangle. Typically, the hole through which the infant was delivered is recognized, and a hand is spread out inside the membrane to help inspection. The amnion should be peeled from the chlorine all the way up to the umbilical cord so that the chorion can be seen clearly. Amnion is gleaming. The hole in the membrane becomes spherical if the membrane is complete.
7. The number of blood vessels in the umbilical cord is counted. If there are two umbilical arteries and one umbilical vein, a doctor should be notified. A missing succenturiate lobe is indicated by an oval space in the chorion with the form ends of blood vessels reaching up to the gap's boundary.
8. Cord insertion is most usually done centrally, however, it can also be done bilaterally, as in blattedore insertion.
9. Placenta weight should be 1/5 or 1/6 of the baby's weight. The cord measures 50cm in length.
10. All discoveries must be carefully documented and reported.

Safe disposal of Placenta

1. When handling the placenta, use gloves.
2. Place the placenta in a leak-proof container and transport it.
3. Place the placenta in a pit at least 2 meters deep and burn it or bury it.
4. Pour liquid waste down a drain or into a flushable toilet.
5. After disposing of a placenta and infectious trash, wash your hands.