201_Postdates and Third Stage Flashcards
Define the 3rd stage of labor?
Time period from when baby is born until the placenta and membranes are expelled
How long does the 3rd stage usually last?
5-15 min but up to 1hr may be normal
30 mins AMTSL
60 mins PMTSL (but start helping at 45 mins)
Explain the physiology of the 3rd stage of labor? (8)
- Myometrium continues to contract and retract
- surface area decreases
- buckling occurs shearing placenta from surface
- Retroplacental clot forms
- facilitates separation and expulsion along with continued contractions, aided by gravity
- Longitudinal, circular and oblique muscle fibres become ‘Living ligatures’ cause bleeding cessation
- Continued surge of oxytocin maintains contracted uterus
- Fibrin intensifies clot formation/coagulation; fibrin mesh forms over the placental site
What is shiny ‘Schultze’?
Schultze : begins centrally, “shiny” fetal side visible
What is the Dirty Duncan?
Duncan: seperatation begins on the edge, rougher maternal surface visible. More likely retained amnion.
What are 3 signs of placental separation?
Gush of blood, lengthening of cord, rising fundus in abdomen (becomes globular)
When is a person at most risk for blood loss pp?
Between the delivery of the baby and the delivery of the placenta
What is the definition of a postpartum hemorrhage?
blood loss in excess of 500 mL in a vaginal birth
in excess of 1000 mL in an abdominal delivery….
OR any blood loss that has the potential to produce hemodynamic instability
What is the incidence of postpartum hemorrhage (PPH)?
AOM Guideline 2%-6%
ALARM 10% worldwide and 13% in North America
Third stage management ICD?
The third stage is after your baby is born until the birth of your placenta. This stage can be managed two ways:
- The first is physiological management, which is relying on your body to produce the necessary oxytocin, which is the hormone that contracts your uterus, to shut off the bleeding of the placental site.
Oxytocin production can be encouraged with feelings of safety, skin to skin, breastfeeding, being surrounded by people you trust, low lights, and a quiet atmosphere. We are hands off in this type of management but can encourage you to be in an upright position so gravity can aid you.
- The second is active management of the third stage, which primarily involves administering synthetic oxytocin through IM injection in thigh or arm to encourage the birth of the placenta and control bleeding. This may also involve gentle cord traction.
In both cases we would do delayed cord clamping unless there is a clinical reason not to. (waiting till it stops pulsing usually 1-3 mins at least)
As you make your decision, it’s important to understand we can always switch from physiological management to active management if there’s a concern in the 3rd stage.
The community standard is to recommend active management to all birthing people to reduce to the chance of severe primary postpartum hemorrhage. The Cochrane review says that if you are a low-risk pregnant person and have access to uterotonics and medical care it’s a reasonably safe plan to choose physiological management.
Risks of uterotonics? (4)
increases the risk of hypertension if using ergot compounds
increases afterpains
need for analgesia
bleeding following discharge
Fahy’s criteria for best outcomes for ‘holistic psycho-physiological’ care of the third stage? (10)
-Pregnancy, labour, and birth have been uncomplicated
- safe, secure, cared about, and trusts that their privacy is respected
-Immediate STS and bb kept warm
-Gentle encouragement to birth placena while focusing on NB
-All interactions focused on dyad
-There is “self-attachment” infant feeding.
-Unobtrusively observe for signs of separation of the placenta.
-Avoid fundal “fiddling” or massage.
-Placenta is birthed entirely by bearing down effort and gravity
-The care provider or client gently “checks the fundus” frequently during the first hour post-placental birth to ensure that it is contracted and to ensure haemostasis.
Fahy stated If any part of this “package of care” is missing or discordant, then holistic “psychophysiologic care” was not provided, and active management of the 3rd stage of labour is advisable
Val’s hot takes for physiological management of third stage? (3)
Support Normal physiology throughout labor
Frequent emptying of bladder during labor
Avoiding practices that increase likelihood of tears (eg; epidurals, Valsalva etc)
What is the leading cause of direct maternal death in Canada?
PPH
What is the rate of death from PPH in Canada?
Death from PPH = 1.4/100 000
(ALL DEATHS) 8-10/100 000 births
