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Defintion: Defintion  3rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta...
Cause of placental separation After  delivery of the fetus,the uterus retracts and theplacental bed diminished. As the p...
primary and secondarymechanism for placental      separation
 Primary  mechanism is the reduction in surface area of placental site as the uterus shrinks
 Secondary mechanism is the formation of haematoma due to venous occlusion and vascular rupture in the placental bed caus...
Placental Site during    Separation
Methods of Placental    Separation
Schultze MethodPlacenta  separates in the centre and folds in on itself as it descends into the lower part of uterus (80%...
Duncan Method separation starts at thelower edge of placentalateral border separates (20%). maternal surface appears fir...
Signs of Separation and Descent  lengthening of theumbilical cord outside. The uterus becomesfirm and globular (Descent)...
Assess the uterus1-To exclude an undiagnosed twin2-To determine a baselinefundal height3-to detect the signs of placenta  ...
Control of Bleeding   1. Normal blood flow through placenta site is    500-800 ml/minute (10-15% of cardiac output) 2.St...
Management of the Third   Stage of Labour
Physiologic   or   Active
Active vs physiologic          managementActive  management includes a prophylactic oxytocic drug,early clamping and cutt...
Physiological                  ActivePlacental      By gravity and            By controlled corddelivery       maternal ef...
Physiological Management Passive or expectant management No prophylacticoxytocics Cord clamped afterdelivery of placent...
Physiological Management Upright/kneeling/squatting   position best-  easy to observe blood loss Hands  off just check u...
Active Management Reduceslength of 3rd stage and incidence of PPH (blood loss and need for transfusion)Oxytocic given aft...
Guarding the Uterus
Controlled cord traction
Placental delivery
Delivering the Membranes
Controlled Cord Traction         CHECKS FIRST! Check that an oxytocic (uterotonic) has been  given Why? Check that the u...
Which is better active or physiologic           management ? Active management is superior to physiological in  terms of ...
Manual removal of retained         placenta
After Care: Before leaving to check      placenta and membranes Check   the uterus is well contracted Check  that PV los...
check placenta and          membranesfor completeness   and normality
Abnormal placenta (accessory            lobe)Succentriatelobe
Effects of labor on the       mother
 1 st stage: anxiety & mild tachycardia. 2 nd stage Pulse: up to 100 b.p.m. Temp: mild increase (37.5 - 37.7). B.P. s...
3rd StageBlood loss from  Placental site = 200-300 C.C due to placental separation. Lacerations or episiotomy = about ...
Effects of labor on the         Fetus
Moulding Overlap of the flat bonesof the vault of the skull due  to compression ofthe head during labourleading to alte...
Types & Degrees a. Physiological: "beneficial“ decreases the size of head & facilitates its passage through the birth...
Pathological : may lead to   intracranial hemorrhage3 rd degree:Overriding of one parietalbone over the other withContrac...
Caput Succedaneum:
Types A: Natural Cervical: with cervical dystocia. Pelvic: with obstructed labour usually formed in prolonged labour...
Cehalnematoma
Cehalhematoma(subperiosteal       hemorrhage
Thank You
Third stage of labor for undergraduate
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Third stage of labor for undergraduate

Undergraduate course lectuers in Obstetrics&Gynecology,Faculty of medicine ,Zagazig UNIVERSIRY ,Prepared by DR MANAL BEHERY

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Third stage of labor for undergraduate

  1. 1. Defintion: Defintion 3rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes.Duration:- normally 5 to15 minutes.- 30 minutes have been suggested if there is no evidence of significant bleeding.
  2. 2. Cause of placental separation After delivery of the fetus,the uterus retracts and theplacental bed diminished. As the placenta is inelasticand does not diminish insize it separates.
  3. 3. primary and secondarymechanism for placental separation
  4. 4.  Primary mechanism is the reduction in surface area of placental site as the uterus shrinks
  5. 5.  Secondary mechanism is the formation of haematoma due to venous occlusion and vascular rupture in the placental bed caused by uterine contractions
  6. 6. Placental Site during Separation
  7. 7. Methods of Placental Separation
  8. 8. Schultze MethodPlacenta separates in the centre and folds in on itself as it descends into the lower part of uterus (80%).Fetal surface appears at vulvawith membranes trailing behindMinimal visible blood loss as retroplacental clot contained within membranes (inverted sac)
  9. 9. Duncan Method separation starts at thelower edge of placentalateral border separates (20%). maternal surface appears first at vulva Usually accompanied by more bleeding from placental site due to slower separation and no retro placental clot.
  10. 10. Signs of Separation and Descent lengthening of theumbilical cord outside. The uterus becomesfirm and globular (Descent). The uterus rises in theabdomen. A gush of blood(separation ).
  11. 11. Assess the uterus1-To exclude an undiagnosed twin2-To determine a baselinefundal height3-to detect the signs of placenta separation4- to detect an atonic uterus.
  12. 12. Control of Bleeding 1. Normal blood flow through placenta site is 500-800 ml/minute (10-15% of cardiac output) 2.Strong contraction/retraction of uterus constrict blood vessles by interlacing muscle fibres in myometrium (“living ligature”) 3. Pressure exerted on placental site by walls of contracted uterus 4. Blood clotting mechanism (sinuses and torn vessels)
  13. 13. Management of the Third Stage of Labour
  14. 14. Physiologic or Active
  15. 15. Active vs physiologic managementActive management includes a prophylactic oxytocic drug,early clamping and cutting of cord and controlled cord tractionPhysiological management involves no prophylactic oxytocic drugs, no cord clamping until after placental delivery and no cord traction
  16. 16. Physiological ActivePlacental By gravity and By controlled corddelivery maternal effort traction with counter traction on fundsUterotonic after placenta delivery With birth of anterior ShoulderUterus Assessment of size Assessment of size and tone and toneCord Clamping Variable Early
  17. 17. Physiological Management Passive or expectant management No prophylacticoxytocics Cord clamped afterdelivery of placenta No Controlled Cord Traction (CCT)
  18. 18. Physiological Management Upright/kneeling/squatting position best- easy to observe blood loss Hands off just check uterus contracted and observe PV loss waits and watches for signs of separation and descent Mother expels placenta when she feels contraction and placenta in vagina
  19. 19. Active Management Reduceslength of 3rd stage and incidence of PPH (blood loss and need for transfusion)Oxytocic given after birth ofShoulder (check for a twin/no shoulder dystocia) Cord clamped and cut Placenta delivered by Controlled Cord Traction
  20. 20. Guarding the Uterus
  21. 21. Controlled cord traction
  22. 22. Placental delivery
  23. 23. Delivering the Membranes
  24. 24. Controlled Cord Traction CHECKS FIRST! Check that an oxytocic (uterotonic) has been given Why? Check that the uterus is well contracted Why? Check that countertraction is applied (Brandt- Andrews manoeuvre) Why? Check for signs of separation & descent Why? Check that cord traction is released before countertraction is stopped Why?
  25. 25. Which is better active or physiologic management ? Active management is superior to physiological in terms of blood loss Physiological management is only appropriate for women with low risk of PPH and who have normal physiological labour If physiological management is attempted but intervention is subsequently required ( the placenta is retained after one hour) active management should be considered.
  26. 26. Manual removal of retained placenta
  27. 27. After Care: Before leaving to check placenta and membranes Check the uterus is well contracted Check that PV loss is minimal Inspect perineum, vulva and vagina in good light (? Repair) Babyshould be pink (respirations; heart rate) warm, fed, cord clamp secure
  28. 28. check placenta and membranesfor completeness and normality
  29. 29. Abnormal placenta (accessory lobe)Succentriatelobe
  30. 30. Effects of labor on the mother
  31. 31.  1 st stage: anxiety & mild tachycardia. 2 nd stage Pulse: up to 100 b.p.m. Temp: mild increase (37.5 - 37.7). B.P. systolic increased during pains.Conjunctiva; edematous & congested. Birth canal: minor lacerations in the cervix or perineum especially in PG.
  32. 32. 3rd StageBlood loss from Placental site = 200-300 C.C due to placental separation. Lacerations or episiotomy = about 100 - 200 C.C
  33. 33. Effects of labor on the Fetus
  34. 34. Moulding Overlap of the flat bonesof the vault of the skull due to compression ofthe head during labourleading to alteration inits shape
  35. 35. Types & Degrees a. Physiological: "beneficial“ decreases the size of head & facilitates its passage through the birth canal. 1. First degree: 2. Second degree
  36. 36. Pathological : may lead to intracranial hemorrhage3 rd degree:Overriding of one parietalbone over the other withContractions but it is notReducible inbetween. 4 th degree: overriding of the 2 parietal bones over each others & both override the occipital
  37. 37. Caput Succedaneum:
  38. 38. Types A: Natural Cervical: with cervical dystocia. Pelvic: with obstructed labour usually formed in prolonged labour after rupture of membranes.
  39. 39. Cehalnematoma
  40. 40. Cehalhematoma(subperiosteal hemorrhage
  41. 41. Thank You

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