Module 8:The Third and Fourth Stage of Labor Flashcards
Define the third stage of labor.
It begins with birth of the baby and ends with the birth of the placenta
Know the physiologic tasks of the third stage of labor: Placental separation
The uterine cavity abruptly shrinks due to the birth of the baby, and the placenta thickens, and “scrunches” up. I then buckle and separates from the uterus. It separates centrally (schultz-fetal*more common) or peripherally (duncan-maternal)
Know the physiologic tasks of the third stage of labor: Placental expulsion
The placenta descends to the lower uterine segment, then the vaginal vault then delivers
It can sometimes sit just inside the introitus at the curve of karus. Shift position can help.
Know the signs of placental separation.
A small gush or trickle of blood
Lengthening of the umbilical cord
A rise in the fundus
A change in the shape of the uterus from discoid to globular.
What can the patient do to help deliver the placenta?
Adopt an upright position to allow gravity to assist with placental descent.
Stimulate nipples by placing baby to the breast or by using manual stimulation.
Pushing effort to expel placenta if an urge to push is present with a contraction.
Understand techniques to employ during a normal third stage of labor to reduce the risk of complications such as partial separation of the placenta, avulsed cord, or inverted uterus (See Varney’s appendix 30A).
Do NOT massage the uterus, pull on the cord, or try to deliver the placenta until separation. Wait patiently!
Define expectant management of the third stage of labor.
- watchful waiting and observation, 2. attention to the normal and spontaneous physiological process of third stage, and 3. support for the birthing person throughout the process. Both terms also signify a non-pharmacological approach to third stage and require no intervention on the part of the midwife.
Define active management of the third stage of labor.
Administration of a uterotonic medication within one minute of the birth of the baby, after ruling out multiple gestation. Oxytocin is the preferred medication.
Controlled cord traction to assist with placental expulsion.
Uterine massage immediately after placental expulsion, and then as needed. (ICM/FIGO Joint Statement, 2004)
Analyze the evidence regarding outcomes with active management of the third stage of labor.
A reduced risk of postpartum hemorrhage (PPH)
Less overall blood loss
Less postpartum anemia
Less need for therapeutic uterotonics
**A clear and compelling conclusion to draw from the AMTSL evidence is that for birthing people with risk factors for PPH, AMTSL should be the recommended approach for management of third stage.
What are some reasons for active management of third stage?
Past Pregnancy and Medical History:
Coagulopathies
Grand Multiparity
History of PPH
Previous uterine incision
Uterine abnormalities
Current Pregnancy-Related:
Antepartum hemorrhage
Fetal macrosomia
Hypertensive disorders of pregnancy
Anemia
Obesity
Multiple gestation
Placental abnormalities
Polyhydramnios
Labor-Related:
Chorioamnionitis
Induction or augmentation of Labor
Magnesium sulfate use
Precipitous labor and birth
Prolonged labor
Analyze the evidence regarding outcomes with expectant management of the third stage of labor.
When labor and birth are normal, expectant management of third stage results in comparable bleeding outcomes as when AMTSL is implemented with a general population of birthing people at mixed risk for excessive bleeding.
**For birthing people at low risk of PPH having a spontaneous labor and birth without intervention, expectant management of third stage is a reasonable approach.
Define the fourth stage of labor.
The first hour following delivery of the placenta
Know the components and understand the findings of a birthing person’s evaluation during the fourth stage of labor.
Emotional/Psych: attachment/binding, skin-to-skin, BF/latch
Physiologic: VS, fundus, bleeding, bladder, perineum, PO intake, comfort measures
What medication is first line PP for active management?
Pitocin within 1m of birth. 10U IM or 20-60U in 1000ml IV fluid
When should methergine be avoided?
Maternal HTN can cause HTN crisis or stroke
