1.Presented by Reshma suzen

2. Third stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. 3. normally 5 to15 minutes. 30 minutes have been suggested if there is no evidence of significant bleeding. The risk of complications continues for some period after delivery of the placenta. 4. Placental separation Separation of membranes Placental separation Mechanism of control of bleeding 5. Central separation (Schultze): Detachment of placenta from its uterine attachment starts at the centre resulting in opening up of few uterine sinuses and accumulation of blood behind the placenta (retro placental hematoma). With increasing contraction, more and more detachment occurs facilitated by weight of the placenta and retro placental blood until whole of the placenta gets detached. 6. The separation is facilitated partly by uterine contractions and mostly by weight of the placenta as it descends down from the active part 7. Separated placenta is expelled out by either voluntary contraction of abdominal muscles (bearing down efforts) or by manipulative procedure. 8. 1. The uterus becomes globular and as a rule, firmer 2. There is often a sudden gush of blood 3. The uterus rises in the abdomen because the placenta, having separated, passes down into the lower uterine segment and vagina. Here, its bulk pushes the uterus upward 4. The umbilical cord protrudes farther out of the vagina, indicating that the placenta has descended. 9. PAINS: experiences no pain, intermittent discomfort in the lower abdomen disappears, corresponding with uterine contractions. BEFORE SEPARATION Per abdomen uterus become globular firm and ballottable. The fundus height is slightly raised as the separated placenta comes down in the lower segment and the contracted uterus rest on the top of it. There may be slight bulging in the supra pubic region due to distension of the lower segment by the separated placenta. 10. EXPULSION OF PLACENTA AND MEMBRANES The expulsion is achieved either by voluntary bearing down effort or more commonly aided by manipulative procedures. The after birth is soon followed by slight to moderate bleeding amounting to 100-250ml. MATERNAL SIGNS There may be chills and occasional shivering. Slight transient hypotension is not unusual. 11. After placental separation, innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterated. The occlusion is effected by complete retraction where by the arterioles, as they pass tortuously through the interlacing intermediate layer of the myometrium, are literally clamped. It is the principal mechanism to prevent bleeding; however, thrombosis occurs to occlude the torn sinuses, a phenomenon which is facilitated by hypercoagulable state of pregnancy. Apposition of the walls of the uterus following expulsion of the placenta, (myotamponade) also contributes to minimize blood loss. 12. To promote natural separation of the placenta and membranes and their complete expulsion To arrest haemorrhage To secure good and permanent contraction and retraction of the uterus 13. Expectant management Active management 14. Advantages are To minimize blood loss in third stage approximately to 1/5th To shorten the duration of third stage to half disadvantage is slight incidence of retained placenta and consequent increased incidence of manual removal. Of course accidental administration during delivery of the first baby in undiagnosed twins produces grave danger to the unborn second baby caused by asphyxia due to tetanic contraction of the uterus, thus, it is imperative to limit its use in twins only during the delivery of the second baby. 15. Inj. Ergometrine 0.25 mg or methergin 0.2mg is given intravenously following the birth of anterior shoulder. 16. The palmar surface of the fingers of the left hand is placed approximately at the junction of upper and lower uterine segment. The body of the uterus is pushed upwards and backwards, towards the umbilicus while by the right hand steady tension is given in downward and backward direction holding the clamp until the placenta comes outsides the introitus. It is thus more a uterine elevation which facilitates expulsion of the placenta. The procedure is to be adopted only when the uterus is hard and contracted. 17. The fundus is pushed downwards and backwards after placing four fingers behind the fundus and the thumb in front using the uterus as a sort of piston. The pressure must be given only when the uterus become hard. If it is not, then make it hard by gentle rubbing. The pressure is to be withdrawn as soon as the placenta passes through the introitus. 18. Steps-1: the operation is done under general anaesthesia. The patient is placed in lithotomy position. With all aseptic measures the bladder is catheterized. 19. Steps-II: one hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped manner following the cord, which is made taut by the other hand. While introducing the hand, the labia are separated by the fingers of the other hand. The fingers of the uterine hand should locate the margin of the placenta. 20. counter pressure on the uterine fundus is applied by the other hand placed over the abdomen. The abdominal hand should steady the fundus and guide the movements of the fingers inside the uterine cavity till the placenta is completely separated 21. Steps-IV: as soon as the placenta margin in reached, the fingers are insinuated between the placenta and the uterine wall with the back of the hand in contact with the uterine wall. The placenta is gradually separated with a side ways slicing movements of the fingers, until whole of the placenta is separated. 22. Steps-V: when the placenta is completely separated, it is extracted by traction of the cord by the other hand. The uterine hand is still inside the uterus for exploration of the cavity to be sure that nothing is left behind. 23. Steps-VI: intravenous ergometrine 0.25mg is given and the uterine hand is gradually removed while massaging the uterus by the external hand to make it hard. After the completion of manual removal, inspection of the cervico-vaginal canal is to be made to exclude any injury. 24. Steps-VII: the placenta and membranes are to be inspected for completeness and be sure that the uterus remains hard and contracted. 25. Hour glass contraction leading to difficulty in introducing the hand Morbid adherent placenta which may cause difficulty in getting to cleavage of placental separation. 26. The maternal surface is first inspected for incompleteness and anomalies. The maternal surface is covered with grayish decidua (spongy layer of the deciduas basalis). Normally the cotyledons are placed in close approximation and any gap indicates a missing cotedyldon. The membrane chorion, amnions are to be examined carefully for completeness and presence of abnormal vessels indicative of succenturiate lobe. 27. The cut end of the cord is inspected for number of blood vessels. Normally there are two umbilical arteries and one umbilical vein. An oval gap in the chorion with torn ends of blood vessels running up to the margin of the gap indicates a missing succenturiate lobe. The absence of a cotyledon or evidence of a missing succenturiate lobe or evidence of significant missing membranes demands exploration of the uterus urgently. 28. hemostasis Anatomical restoration 29. Vaginal and submucosa - continuous suture 30. 31. In the third or fourth degree of perineal lacerations, in which the anal sphincters and the anterior rectal wall are torn, it is first necessary to isolate the torn ends of the sphincter after which the tear in the anterior rectal wall is closed with fine interrupted catgut sutures tied within the lumen of the bowel. The end of the rectal sphincter are reapproximated with interrupted catgut sutures. Then the laceration in the more superficial structures 32. Haemorrhage Shock Injury to uterus Infection Inversion Subinvolution Thrombophlebitis Embolism 33. Risk for deficient fluid volume related to : - Blood loss occurring after placental separation and expulsion. - Inadequate contraction of the uterus. Anxiety related to : -Lack of knowledge regarding separation and expulsion of the placenta. -Occurrence of perineal trauma and the need for repair. Fatigue related to : -energy expenditure associated with childbirth and the bearing-down efforts of the second stage. 34. BLOOD PRESSURE Measure blood pressure every 15 mts. PULSE Assess rate and regularity. Measure every 15 mts for first hour. TEMPERATURE Determine the temperature at the beginoing of the recovery period and after the first hour of recovery period and after the first hour of recovery. 35. Just below the umbilicus, cup the hand and press firmly in to the abdomen. At the same time, stabilize the uterus at the symphisis with opposite hand. If the fundus is firm, with uterus in midline, measure its position relative to womens umbilicus. Lay finger flat on abdomen under the umbilicu; measure howmany finger breadths or centimeters fit between the umbilicus, the value is plus(+) if the fundus is above the umbilicus and if below it is valued as (-). The fundus is not firm, massage it gently to contract Expel clots while keeping handsplaced. With upper hand , firmly apply pressure downward toward vagina, observe the perineumfor amount and size expelled clots. 36. Assess the distention by noting the location and firmness of the uterine fundus and by observing and palpating the bladder. A distended bladder is seen as suprapubic rounded bulge that is dull to percussion and fluctuates similar to a water filled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the womans right side. Assist the woman to void spontaneously. Measure the amount of urine voided. Catheterize if the bladder is distented and woman is unable to void spontaneously. Reassess after voiding or catheterization to make sure the bladder is not palpable and the fundus is firm and in the midline. 37. LOCHIA Observe lochia on perineal pads and on linen under mothers buttocks. Determine the amount and colour ; note the size and number of clots; note any odour. Observe the perineum for source of bleeding (e.g, episiotomy, lacerations) PERINEUM Ask or assist the woman to turn on her side and flex the upper leg on the hip. Lift the upper buttocks Observe the perineum 9in good lighting Assess episiotomy or laceration repair for intactness, heamatoma, edema, bruising, red ness and drainage. Assess the presence of hemorrhoids. 38. Acute Pain related to physiological response to Labour Deficient fluid volume related to uterine atony after child birth. Deficient Knowledge related to information about birth process Ineffective coping related to labour and delivery Anxiety related to hospitalization and birth process.