Active management of the third stage of labour

Active management of the third stage of labour


A woman in labour goes through three stages.
In the first stage, the cervix begins to dilate, slowly at the beginning. Once the cervix has
opened to a diameter of 4 cm, it dilates more rapidly, at an average rate of 1 cm per hour,
until it is fully dilated to a diameter of 10 cm. Towards the end of the first stage,
the fetus begins to descend gradually. The second stage of labour begins with the
fully dilated cervix and ends with the delivery of the baby. The third stage of labour begins immediately
thereafter and ends with the delivery of the placenta. The term active management of the third stage
of labour refers to interventions that birth attendants need to make to reduce the risk
of postpartum haemorrhage. Active management of this stage of labour is strongly recommended
in all deliveries because postpartum haemorrhage can occur even in women without any apparent
high-risk factors. This video demonstrates the steps involved in the active management
of the third stage of labour. There are three key steps in the process of
active management: first, administration of an oxytocic drug; second, clamping and cutting
of the umbilical cord; and third, controlled traction of the cord until the placenta is
delivered. Once the baby is delivered, palpate the mother’s
abdomen to rule out the presence of another fetus. Then administer to the mother a 10-international
unit dose of oxytocin intramuscularly. If the mother already has an intravenous line
in place, the oxytocin may be administered intravenously, but in this case the oxytocin
should be injected slowly, such that it takes about 60 seconds to inject the complete dose. Once oxytocin has been administered, or is
in the process of being administered, use two sponge forceps to clamp the umbilical
cord roughly in the middle, leaving a 2 to 3 cm space between the forceps. Now cut the
cord between the forceps. Evidence suggests that a delay of 1 minute before cutting a
cord is advisable. Place one hand just above the mother’s pubic
bone, and while pressing, slightly bring the cord to tension with the other hand. At this
stage, do not start pulling the cord to dislodge the placenta. Maintain tension on a cord and
wait for the next strong uterine contraction. When the uterus contracts and appears to become
rounded, gently pull the cord downwards to deliver the placenta while simultaneously
applying firm pressure upwards on the uterus with the other hand. The force applied to pull the cord should
be only slightly greater than what is needed to keep the cord firm under tension. And a
counterforce supplied on the abdomen should be about equal to the pulling force. The counterforce
on the abdomen helps to prevent uterine inversion. After the placenta is delivered, massage the
abdomen for a few minutes every fifteen minutes for the first two hours. The massage helps
the uterus to continue to contract, which in turns helps to stop the bleeding. Ensure
that there is no active bleeding before transferring the woman to the postnatal ward. If there
is bleeding, check for tears and suture as required. Put the baby to the breast early
to promote breastfeeding.

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