Management of 3rd stage and PPH

Question 1

Physiological 3rd stage?

Answer 1

• Birth of placenta by maternal effort and gravity
   No routine use of uterotonics
   No fundal massage or controlled cord traction
   Clamp cord only after pulsation ends or placenta is
  delivered

Question 2

Active 3rd stage?

Answer 2

Second midwife draws up uterotonic and
administers it following birth of anterior shoulder of
the baby
 Delay cord clamping for 1 - 3 minutes following
birth
 Wait for signs of separation
 Assess uterine tone but no fundal massage
 Controlled cord traction while guarding the uterus
 Uterine massage - if required after delivery of the
placenta

Question 3

Summary of 2013 cochrane review for use of oxytocin in labour

Answer 3

8 studies, involving 1338 low-risk women in the first stage of spontaneous labour at term

Oxytocin did not reduce:
- CS or assisted delivery rate

Didn’t increase:

• NVD rate
• Uptake of epidural
• harm to mother or baby- but may be because the sample size was too small

It did:
- Shorten labour by 2 hours

Question 4

Summary of the Irish ‘active management regime’

Answer 4

A package of care which included:

• special classes preparing women for labour,
• strict criteria for determining the onset of labour,
• psychological support,
• regular supervision by senior staff,
• routine amniotomy and early recourse to high doses of oxytocin under supervision of a midwife

Found a reduction in CS rate and therefore advocated for this approach in ‘active management’ of labour

Since then, studies using oxytocin alone have failed to replicate these results- thought to be due to supportive package and 1:1 care

Question 5

When should use of oxytocin be particularly cautious?

Answer 5

• FHR abnormality
• Previous CS
• Multip in labour
• Other cause of labour dystocia- not thought to be due to lack of contractions

Question 6

active 3rd stage reeduces risk of PPH by how much?

Answer 6

50%

Question 7

How much blood flows through the placenta at term?

Answer 7

750ml/min

Question 8

How much blood does a woman have in her circulation at the end of pregnancy?

Answer 8

approx 100ml/kg

ie 70kg- 7000ml

Question 9

Mioprostol or oxytocin for active 3rd stage?

Answer 9

Oxytocin more effective with less side effects and so should be 1st line

Question 10

RANZCOG 5 steps to managing a PPH?

Answer 10

1. Recognition- weighing blood loss, calculating EBL, calculating occult loss if suspected
2. Communication - including amongst team members, involving anaesthetics, other specialists e.g. haematologists and communicating to woman and her family
3. Resuscitation
4. Monitoring and Investigation - observation, send bloods,
5. Management of PPH-
   - Atony: mechanical, pharmacological
   - Tissue- remove tissue
   - Trauma - suture any tears
   - Thrombin- TXA and correct any abnormalities
   - Theatre- if above hasn’t worked