Third Stage Flashcards
What is the third stage of labor?
From delivery of fetus > expulsion of placenta
What is the normal duration for third stage of labor?
5-10 min but can be up to 30 minutes
When is third stage of labor considered prolonged
> 30 minutes
What is the main event in third stage of labor
Palcenta seperation and expulsion
What are the signs for placenta seperation?
1- gush of blood from vagina
2- umbilical cord lengthening
3- fundus of the uterus raises and firms (starting to contract)
What are the two types of managemend for 3rd stage of labor?
1- physiological: waiting
2- active: cord traction + uterogenic agent
Why is active management of third stage of labor is indicated?
To reduce the risk of PPH
What is the expectant method to treat third stage of labor
Observe, massage uterus, and examine placenta, membrane and cord
What is the active management of third stage of labor?
- Oxytocin after delivery of posterior shsoulder of the feuts
- brandt-andrews maneuver to tract the umbilical cord
- uterine massage
How to do controlled cord traction?
Pulling the cord gently with pressing on the uterus to prevent uterine inversion
What are the major complications of third stage of labor
1- hemorrhage
2- lacerations
3- retained placenta
4- uterine inversion
Define PPH:
1- excessive genital bleeding (>500ml in vaginal - >1000 in CS)
2– signs of hypovoulmeic stature
What is early PPH and what is late PPH
- early: within 24 hours
- late: 24hours > 6 weeks
What are the causes for early PPH (Four Ts)
1- Tone (atony)
2- trauma (episiotomy & laceration),
3- tissue (retain placenta\membrane),
4- thromboplastin (IUFD, PET, Sepsis, abruptio)
What is the most common cause for eaerly PPH?
Uterine atony
what is the pathogenesis of atony? How does it cause bleeding
The muscle fibers surround blood vessels, if they contract they stop bleeding.
Atony, loss of contraction
What are the predisposing factors for uterine atony?
- general anesthesia
- uterine overdistension (polyhydraminous or multipara)
- prolonged labor
- uterine leiomyoma
- operative delivery
- oxytocin
- infections
What is the general approach for managing PPH?
- adquate circulation (IVF + blood)
- adquate oxygenation
- reverse or prevent coagulopathy
- elimentation of obstetric causes (laceration or RPOC)
Why is insuring tissue oxygenation in the management of PPH is important?
To prevent end organ damage which is the most important complication of PPH
How to manage PPH?
- immediate: [2] large bors (IVs) & infuse isotonic crystalloid + compress & massage uterus
- inspect vagina\cervix for trauma or suture
- explore uterus to remove RPOC
- examine for coagulation
How to treat atony
Uterine massage, tonic drugs, blood or blood products, surgicall if needed
What are the uterine tonic drugs?
Oxytocin, ergomertine, misoprostol
What are the surgical treatment options for atony?
1- Balloon temponade
2-Uterine artery embolization
3- hysterectomy
When to opt for hysterctomy in aton
If all other options have failed
What is the most common cause for late PPH?
Subinvolution of the uterus
What are the signs of lat PPH
1- fever
2- foul smelling vaginal bleeding
3- anemia
4- uterus is soft and larger than expected
What are other causes of late PPH?
- Retained placenta\blood clots
- Infection (endometritis)
What is the microbial cause for endometritis?
Polymicrobial (give broad spectrum AB)
How to treat PPH secondary to endometritis?
1- admit
2- adminster broad spec AB
3- + or - evacuation (RPOC)
What is puerperium?
From delivery of baby > 6-8 weeks postpartum
What happens during the puerperium period
Reproductive organs return to the pre-pregnancy state
How long does uterus return to its pre-pregnancy state?
6 weeks
When will the uterus be impalpable post delivery?
“Returns to the pelvic organ”
2 weeks post delivery
What will happen to the uterus immidiatly after birth?
Reach the umbilical level (20wks)
What is the weight of the uterus immediately post partum and after the periperurum period?
- postpartum: 1kg
- periperum: <100g
What is the involution of uterus
process by which the post partum uterus weighing 1KG
returns to its pre pregnancy state of less than 100 g.
What physiological action acceleraets the involution of uterus
Oxytocin release by breastfeeding
What happens to the cervix post delivery?
Lose its elasticity & closed by 2nd weeks.
Does the vagina return to the nulliparous dimensions
No
What happens to the decidua 2-3days postpartum?
Differentiated into two layers
- superifical> necrotic forming lochia
- basal > the new endometrium
What is lochia
Blood stained uterine discharge that consist of blood and necrotic decidua
What are the types of lochia
1- rubra: red (1-3d)
2- serosa: pink & pale (4-10)
3- alba: yellow (>11)
How does the abdominal wall change in pureperium state
Returns to prepregnancy appearance but the silver stria presist
Describe leukocytosis:
- during birth:
- after birth:
- after 1 week postpartum:
- during & after: leukocytosis (30,000)
- 1 week: return to pre-pregnancy state
What happens to the CVS after delivery
- Increase peripheral vascular resistance
- increase in CO
When is the most critical period for pregnant women with cardiac disease
48 hours following delivery due to increase cardiac output
What happens to the urinary tract post-delivery
Increase capacity and insensitive to overdistension > incomplete emptying & excessive residual urine
How long does it take to return to normal body weight after delivery
6 months *may retain 1.4kg of excess weight
How many kg is lost following delivery?
Almost 5-6kg due to uterine evacuation and normal blood loss
How long does it take to return of menesturation after delivery
- breast feeding: lactational amenorrhea
- not breast feeding: 6-8 weeks
What does colustrum contain?
Protein, fat, mineral and IgA
How does breastfeeding occurs
1- drop in estrogen
2- suckling stimulate prolactin + oxytocin
3- production of colostrum (3-6d) & mature milk
What is puerperal pyrexia
Fever >39 on [2] occasions at least [4] hrs apart for up to 10days postpartum
“Excluding the first 24 hours post partum”
Why do we exclude the first 24 hours post partum from puerperal pyerxia?
Increase inflammatory mediators causing fever
What are the 7Ws of maternal fever
0: wind
1: water
2-3: womb
4-5: wound
5-6: walk
7-21: wean
Anytime: wonder drug
What is the most important risk factor for postpartum endometritis?
C\S
Name predisposing factors for postpartum endometritis (5)
1- anemia 2- prolonged labor 3- PROM 4- C\S 5- DM & SLE
What type of infection is endometritis considered?
Ascending infection
What is the clinical presentation for endometritis
Fever - pelvic pain - bleeding\discharge - abnormal smell and delay in uterine involution
How to manage endometritis
- admit
- IV or oral fluids
- antipyretics
- IV antibiotics (Clinda + genta)
Which tissue in the breast is responsible for producing the milk
(Glandular vs lactiferous)
Glandular tissue (alveolar cells)
What are the changes that happen during pregnancy for the breast
1st trimester: ductal proliferation
2nd trimester: lobular formation
What are the mechanisms of lactation?
1- mammogenesis
2- lactogensis
3- galactopoeisis
What is the mammogenesis?
Development of breast tissue during pregnancy
What are the stages of lactogenesis?
Stage1: 2nd half of pregnancy
Stage 2: immediately after delivery
(Stage 1: progestrone inhibits milk - stage 2: progestrone is gone)
What maintains the galactopoesis
Suckling which increases production of oxytocin & prolactin
What is the role of
Oxytocin, prolactin, progestrone
In breastfeeding
- oxytocin: letdown (contract muscle surrounding the alveoli to eject milk)
- prolactin: production of milk
- progestrone: inhinit milk production
What is sheehan syndrom and what does it most commonly affects?
ant Pituitary ischemia
