Active Management of 3rd Stage of Labour

Cases for CME

December 10-12/08

Lao P.D.R.

• A healthy 22-year old woman has had an uneventful pregnancy and labour. Just seconds ago an approximately 3 kg girl has been delivered. Perineum is intact. Baby cried immediately and the birth assistant is drying the baby while the nurse is preparing an oxytocic for injection. You are taking cord blood samples and about to clamp and cut the umbilical cord.

• What is important to confirm before injecting oxytocics (uterotonic)?

• Which of the following can be given? Is one or another best?– Oxytocin 10 U IM

– Oxytocin infusion 20 U in 1000 cc NS at 100-150 cc/hr

– Ergotamine 0.2 mg IM

– Misoprostol 800 mcg rectally

• Should oxytocics be given as soon as possible after delivery of the anterior shoulder or within a minute or two of delivery?

• Within 3 minutes of Oxytocin 10 U IM there is a small gush of blood at the perineum. What are 2 other signs that the placenta has separated from the uterine wall?

• The placenta delivers spontaneously with gentle traction on the cord and counter traction suprapubically. Following this what else needs to be done?

• Discussion• Active management 3rd stage allows placenta to deliver

spontaneously and the uterus to contract and decreases blood loss or need for manual removal of placenta

• Active management:– Skilled attendant

– Use of Oxytocics (Uterotonics)

– Delayed clamping of umbilical cord (1-2 minutes)

– Take cord samples

– Palpate uterus and confirm it is contracted

– Wait for signs of placental separation

– Gentle traction on the cord with counter- traction on uterus above pubis (why?)

– If placenta not delivered by 15 minutes and Oxytocic not given with delivery, it can still be given

– Some evidence that injection of Oxytocin or Misoprostol into umbilical cord may reduce need for MROM

• Discussion continued:• After placenta delivered

– Ensure fundus is well contracted

– Inspect placenta to ensure it is intact

– Consider need for ongoing Oxytocin infusion

– Inspect lower genital tract

– Inspect upper vagina and cervix with all operative vaginal births

– Repeat uterine massage q 15 minutes for the 1st 2 hours: uterus must stay contracted.

– Consider need for emptying bladder if patient unable to void

• A 30 year old woman has delivered a 2.8 kg boy 14 minutes ago. Her pregnancy was complicated by PIH. There was no Oxytocin in the delivery room and the 2nd stage of labour was unexpectedly rapid so she did not receive any uterotonic drug with the delivery. It is now well into the 3rd stage of labour and the placenta has not delivered despite uterine massage and gentle traction on the cord. There is a steady but very light flow from the vagina and the uterus feels soft.

• Why not give her Ergotamine?

• What else could you give her if Oxytocin is not available?

• What is the risk of PPH with a prolonged 3rd stage?

Oxytocin is located and 10 U given IM immediately. Fortunately the placenta delivers without complication at 19 minutes of 3rd stage.

• Would you start an Oxytocin infusion for this lady?

• What dose would be correct?

• Discussion:

• Consider other options for 3rd stage management– Oxytocin– Ergotamine– Misoprostol– Infusion Ocytocin– Injection of Oxytocin 10 U in 30 cc NS OR Misoprostol 800 mcg in 30 cc NS into

umbilical vein (Pipingas Technique) for prolonged 3rd stage lasting >30 minutes

• Risk of PPH with prolonged 3rd stage: increases after 10 minutes and 6 x more likely after 15 minutes

• Complications of Manual Removal of Placenta (MROM)– Infection– Uterine perforation– Hemorrhage– Maternal discomfort