Which is the appropriate method to use to deliver the placenta after a precipitate delivery?
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The normal third stage of labour11-1 What is the third stage of labour?The third stage of labour starts immediately after the delivery of the infant and ends with the delivery of the placenta and membranes. 11-2 How long does the normal third stage of labour last?The normal duration of the third stage of labour depends on the method used to deliver the placenta. It usually lasts less than 30 minutes, and mostly only 2 to 5 minutes. 11-3 What happens during the third stage of labour?
11-4 Why is the third stage of labour important?Excessive bleeding is a common complication during the third stage of labour. Therefore, the third stage, if not correctly managed, can be an extremely dangerous time for the patient. Postpartum haemorrhage is the most common cause of maternal death in many low and middle income countries.
Managing the third stage of labour11-5 How should the third stage of labour be managed?There are two ways of managing the third stage of labour:
Whenever possible, the active method should be used. However, a midwife working on her own may need to use the passive method. Midwives who choose to use the passive method of managing the third stage of labour must also be able to confidently use the active method, as this method may have to be used in some patients.
11-6 What is the active management of the third stage of labour?
11-7 Which oxytocic drug is usually given during the third stage of labour?One of the following two drugs is generally given:
Oxytocin (Syntocinon) is the drug of choice. However, as Syntometrine is still sometimes used, the correct use thereof will also be explained. NoteThe latest information in the Cochrane Library indicates that the best drug and dosage to use is oxytocin 10 units.11-8 What are the actions of the two components of Syntometrine?
11-9 What are the contraindications to the use of Syntometrine?Syntometrine contains ergometrine and, therefore, should not be used if:
11-10 What oxytocic drug should be used if there is a contraindication to the use of Syntometrine?Oxytocin (Syntocinon) should be used. An intravenous infusion of 10 units oxytocin in 200 ml normal saline is given at a rate of 30 drops per minute (20 drops per ml dropper) or 10 units oxytocin are given by intramuscular injection. 11-11 What is the passive method of managing the third stage of labour?
11-12 What are the signs of placental separation?
Separation of the placenta can now be confirmed by applying suprapubic pressure. The placenta has definitely separated if the umbilical cord does not shorten when the uterus is pushed up (no cord retraction). 11-13 What are the advantages and disadvantages of the active method of managing the third stage of labour?Advantages:
Disadvantages:
11-14 What are the advantages and disadvantages of the passive method of managing the third stage of labour?Advantages:
Disadvantages:
11-15 When should the active method be used and when should the passive method be used in the management of the third stage of labour?The active method:
The passive method:
11-16 How long can you safely wait for signs of placental separation, if the passive method of managing the third stage is used?If the signs of placental separation have still not appeared 30 minutes after the start of the third stage of labour, then an oxytocic drug must be given and the active management of the third stage must be used. 11-17 Should the umbilical cord be allowed to bleed before the placenta is delivered or should the forceps be left in place on the umbilical cord?
11-18 What recordings must always be made during and after the third stage of labour?
11-19 When should the infant be given to the mother to hold and put to the breast?If the labour and delivery were normal and the infant appears to be healthy and normal, the infant should be dried and put on the mother’s abdomen. If the infant is breathing well the infant should be put to the breast. The nipple stimulation causes uterine contractions which may help placental separation. Examination of the placenta after birth11-20 How should you examine the placenta after delivery?Every placenta must be examined for:
The abnormal third stage of labour11-21 What is a prolonged third stage of labour?If the placenta has still not been delivered after 30 minutes, the third stage is said to be prolonged. 11-22 How should a prolonged third stage of labour be managed?If the active or passive method has been applied and failed:
11-23 What should be done if the placenta is still not delivered, after the routine management of a prolonged third stage of labour?A vaginal examination must be done:
11-24 What is the management of a retained placenta?
Managing postpartum haemorrhage11-25 What is a postpartum haemorrhage?
11-26 What should be done if a patient has a postpartum haemorrhage?The management will depend on whether the placenta has been delivered or not. 11-27 What is the management of a postpartum haemorrhage if the placenta has not been delivered?
The management of a patient with a postpartum haemorrhage before the delivery of the placenta is summarised in Figure 11-1.
11-28 What is the management of a patient with a postpartum haemorrhage, if the placenta has already been delivered?This is a dangerous complication which must be rapidly and correctly managed according to a clear plan:
These four steps must always be carried out, irrespective of the cause of the postpartum haemorrhage. The cause of the haemorrhage must now be diagnosed.
11-29 What are the main causes of postpartum haemorrhage?The cause of the haemorrhage must now be diagnosed. The two main causes of postpartum haemorrhage must be differentiated from one another:
It is very important that the two causes are differentiated from one another as this will determine the correct management.
The management of a patient with a postpartum haemorrhage after the delivery of the placenta is summarised in Figure 11-2.
11-30 What clinical signs indicate that the bleeding is caused by an atonic uterus?
11-31 What are the possible causes of an atonic uterus?
11-32 What is the correct management of postpartum haemorrhage if the clinical signs indicate bleeding from an atonic uterus?
11-33 What should be done if the membranes or placenta are not complete after delivery and the patient is not bleeding?
11-34 What can be done to reduce the risk of postpartum haemorrhage?In patients who are at high risk of postpartum haemorrhage (e.g. multiple pregnancy, polyhydramnios or grande multiparity) the following should be done:
11-35 What clinical signs indicate that the bleeding is from a tear?
11-36 What is the correct management if the clinical signs indicate that the bleeding is from a tear?The patient should be placed in the lithotomy position and examined as follows:
11-37 What is the correct management for bleeding from an episiotomy?
11-38 Which patients are at high risk of a cervical tear?
11-39 How can you recognise an inverted uterus?
11-40 What is the management of a patient with an inverted uterus?
Protecting the staff from HIV infection11-41 What should be done during labour to prevent the staff from becoming infected with the human immunodeficiency virus (HIV)?All patients should be regarded as being potentially infected with HIV, the virus which causes AIDS (Acquired Immune Deficiency Syndrome). The virus is present in blood, liquor and placental tissue. Contamination of the eyes or cuts on the hands or arms, and pricks by contaminated needles carry a small risk of causing infection. Therefore, the following precautions should be taken for all deliveries:
Case study 1Following normal first and second stages of labour, the third stage of labour is actively managed. The patient was not hypertensive during her pregnancy and does not have a history of heart valve disease. Syntometrine is given by intramuscular injection and the patient is observed for signs of placental separation. 1. Were the necessary precautions taken before giving the Syntometrine?No. A second twin must be excluded before giving the Syntometrine. 2. Is the third stage of labour being correctly managed by the active method?No. The placenta must be delivered when the uterus contracts. If the active method of managing the third stage is used, it is incorrect to wait for signs of placental separation. 3. How soon after giving the Syntometrine does the uterus contract?Syntometrine includes oxytocin which causes uterine contractions 2 to 3 minutes after intramuscular administration. 4. What should have been done as soon as the uterus contracted?The umbilical cord should have been steadily pulled with one hand while the other hand was pushing upwards on the uterus, i.e. controlled cord traction. Placental separation and then placental delivery occur with the uterine contraction. 5. What should be done if placental separation does not take place with the first uterine contraction?A second uterine contraction will occur 5 to 6 minutes after giving Syntometrine by intramuscular injection due to the action of the ergometrine. A second attempt must now be made to deliver the placenta by controlled cord traction. Most placentas which are not delivered with the first contraction will be delivered with the second contraction. Case study 2A patient with normal first and second stages of labour has been delivered by a midwife working alone at a peripheral clinic. A second twin is excluded on abdominal examination and the passive method is used to manage the third stage of labour. After 30 minutes there has been no sign of placental separation. A diagnosis of retained placenta is made and the patient is referred to the nearest hospital for a manual removal of the placenta. 1. Is the diagnosis of a retained placenta correct?No. The diagnosis of retained placenta can only be made if the placenta is not delivered after the active method of managing the third stage of labour has been used. The correct diagnosis is a prolonged third stage of labour. 2. What should have been done in this case of a prolonged third stage of labour?The placenta should have been delivered by the active method of managing the third stage of labour, i.e. by giving oxytocin 10 units intramuscular and using controlled cord traction. 3. What should be done in a peripheral clinic if the placenta is retained?The patient should be transferred to a hospital with theatre facilities for the manual removal of the placenta under general anaesthesia. Before the transfer repeat the vaginal examination. If the placenta or part of the placenta is palpable in the vagina or lower segment of the uterus, the largest possible portion of the placenta is grabbed and the placenta delivered. 4. What complication is this patient at high risk of developing?A postpartum haemorrhage due to an atonic uterus. 5. What should have been done in this case to make the patient’s transfer to hospital safer?An intravenous infusion is commenced with a side infusion containing of 20 units oxytocin in 1000 ml Basol or normal saline. She should also have been carefully observed to make sure that the uterus was well contracted. Make sure that the uterus remains well contracted, and measure the blood pressure and pulse rate every 15 minutes until the patient is transferred. Case study 3After normal first and second stages of labour in a grande multipara, the placenta is delivered by the active management of the third stage of labour. There are no complications. Half an hour later you are called to see the patient as she is bleeding vaginally. You immediately measure her blood pressure which indicates that she is shocked. 1. Was the patient’s third stage of labour correctly managed?No. As the patient falls into a high-risk group for postpartum haemorrhage, an intravenous infusion should have been started during the first stage of labour. Twenty units of oxytocin should have been added as a side infusion after the placenta was delivered. The patient should also have been carefully observed to make sure that the uterus remained well contracted. 2. Do you agree that the first step in the management of postpartum haemorrhage is to measure the blood pressure?No. The first step should be to call for help and to rub up the uterus in order to stop the bleeding. 3. What should be the further management of this patient?A rapid intravenous infusion is commenced with a side infusion containing of 20 units oxytocin in 1000 ml Basol or normal saline. Make sure that the uterus is well contracted. Then check for vaginal tears and that the patient’s bladder is empty as a full bladder can cause relaxation of the uterus. 4. What additional management is needed for this patient?The cause of the bleeding must now be found. The two important causes of postpartum haemorrhage are an atonic uterus or a tear. 5. What is the most probable cause of this patient’s postpartum haemorrhage?As she is a grande multipara the most likely cause is an atonic uterus. 6. What are the clinical signs of bleeding due to an atonic uterus?The uterus will not be well contracted and will tend to relax after it is rubbed up. In addition, the bleeding is not continuous but occurs in episodes, and the blood consists of dark red clots. Case study 4A primigravida patient who did not co-operate well during the first stage of labour delivers soon after a vaginal examination. At the examination the cervix was found to be 7 cm dilated and paper thin. When observations were made an hour after delivery of the placenta, the patient was found lying in a pool of blood. Her uterus was well contracted and her bladder was empty. 1. What should be the next step in the management of this patient?A rapid intravenous infusion is commenced with a side infusion containing of 20 units oxytocin in 1000 ml Balsol or normal saline and you should make sure that the uterus is well contracted. 2. In spite of this management a continuous trickle of bright red blood is observed. What is the most likely cause of the bleeding?A tear. 3. Why is this patient at high risk of a cervical tear?Because the infant was delivered through an incompletely dilated cervix. 4. What should be the next step in the management of this patient?The patient must be placed in the lithotomy position and be examined for a vaginal or perineal tear. Any tear must be sutured. 5. The midwife who is managing this patient does not find either a vaginal or perineal tear. What should be the next step in the management of this patient?A doctor should examine the patient for a cervical tear. The most likely site of a tear is the cervix as this patient probably delivered before full cervical dilatation. Which observation would indicate that the placenta has separated and is ready for delivery?Separation of the placenta from the uterine interface is hallmarked by three cardinal signs, including a gush of blood at the vagina, lengthening of the umbilical cord, and a globular shaped uterine fundus on palpation. [1] Spontaneous expulsion of the placenta typically takes between 5 to 30 minutes.
When are the placenta and the umbilical cord delivered quizlet?During stage 2 of labor, the placenta and umbilical cord are delivered. The first trimester is the most critical time for an embryo or fetus.
When examining the umbilical cord immediately after birth which blood vessels are present in a normal umbilical cord select all that apply?It has three blood vessels: one vein that carries food and oxygen from the placenta to your baby and two arteries that carry waste from your baby back to the placenta. A substance called Wharton's jelly cushions and protects these blood vessels.
How does a placenta abruption happen?Placental abruption occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery. This can decrease or block the baby's supply of oxygen and nutrients and cause heavy bleeding in the mother.
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