2b amtsl

1
Active Management of Third
Stage of Labor (AMTSL)
Session 2b
Trainee Handbook Pg 21
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
BEMoC - Presentation 2 (b)

ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMTSL)
Government of India
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Session Objectives
To learn about
 Active management of third stage of labour
(AMTSL)
 Care of the mother immediately after delivery

Government of India
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What does Active Management of the
Third Stage of Labor include?
 Administration of uterotonic drug
 Controlled cord traction
 Uterine massage

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Active Management of Third Stage of Labor
Uterotonic drugs
 Enhance contraction of the uterus
 Facilitate expulsion of the placenta
 Decrease blood loss and are
 Given after delivery of baby, after ruling out
presence of another baby

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Uterotonic Drugs
Uterotonic
Agent
Route
Dosage
Action
Onset of
action
Duration
of action
Contraindication
Storage
(o
C)
Oxytocin IM 10 Units 2 - 4 mins 20 mins
Never give IV
bolus
15 – 30 o
C
Misoprostol Oral 600 mcg
12 -15
mins
20 -40
mins
Nil
Room
Temp.

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Controlled Cord Traction (CCT)
 Technique to assist in expulsion of placenta.
 Helps to reduce the chances of a retained
placenta and subsequent bleeding i.e. PPH.
How do you perform CCT?
Third Stage of labour (AMTSL)

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Heading???

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Third Stage of Labour (AMTSL)
Controlled Cord Traction (CCT)
 Ensure that placenta is delivered complete with
all membranes.
 If the placenta is not delivered after 30 minutes of
delivery - refer the woman to FRU.
 Give information regarding drugs given, their dose
and time of administration on referral slip.
 Never apply cord traction (pull) without a
contraction and without applying counter-
traction (push) above the pubic symphysis with
the other hand.

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Third Stage of Labour (AMTSL)
Uterine massage
 Immediately after delivery of the placenta,
massage the fundus of the uterus through the
woman’s abdomen until it is well contracted.
 Helps in contraction of the uterus and thus
prevents PPH.
 Ensure that the uterus does not become relaxed
(soft) after the massage.
 Watch for vaginal bleeding.

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Examination of placenta
Examine the placenta and the membranes for
completeness

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Retained Placenta
 Give information on referral slip regarding
 If the placenta is not delivered after 30 minutes
of delivery - refer the woman to FRU
• drugs given
• the dose
• time of administration
 To be discussed in detail in later slides

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Disposal of Placenta
 Disposal of the placenta should be done in a
correct, safe and culturally appropriate manner.
 Use gloves while handling the placenta.
 Put the placenta into a leak-proof bag
containing bleach.
 Incinerate the placenta or bury it at least 10
meters away from a water source in a 2 meter
deep pit.

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Uterine Massage
 Immediately after delivery of the placenta,
massage the fundus of the uterus through the
woman’s abdomen until it is well contracted
 Helps in contraction of the uterus and thus
prevents PPH
 Ensure that the uterus does not become relaxed
(soft) after the massage
 Watch for vaginal bleeding

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Uterine Massage
 Massage the uterine fundus in a circular
motion with the cupped palm until the
uterus is well contracted.
 When well contracted, place your fingers
behind the fundus and push down in one
swift action to expel clots.
 Repeat the massage every 15 minutes for
the first 2 hours.

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Care of the mother
 Examine the perineum, lower vagina and
vulva for tears
 If present manage as per management of
vaginal and perineal tears
 Clean the woman and the area beneath her
 Put a sanitary pad / folded cloth under her
buttocks
 Pads/ cloths soaked can be counted to
estimate the blood loss

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Fourth Stage of Labor
Fourth stage: First one-hour after delivery of
placenta.
 Aim: Observation and care of the mother and
newborn
 Do not separate mother and the baby, unless
essential

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Care of the mother
 Check every 10 minutes if the uterus is well
contracted and observe for vaginal bleeding
 If the uterus - not well-contracted / bleeding
is excessive, massage the uterus
 If bleeding persists – manage as PPH

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 Check the following every 10 minutes for the
first 30 minutes, then every 15 minutes for
next 30 minutes and then every 30 minutes for
the next 3 hours:
• General condition
• BP, pulse, temperature
• Uterus, whether well-contracted or not
• Amount of vaginal bleeding
 Observe the woman for 24 hours

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 Encourage the woman to eat and drink, and
rest.
 Encourage the woman to pass urine. If the
woman has difficulty in passing urine, or the
bladder is full and she is uncomfortable, help
her pass urine by gently pouring water over
her vulva.

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 Weigh the baby
 Ask the birth companion to stay with the
mother. Do not leave the mother and the
newborn alone. Ask the companion to watch
the woman and call for help if any of the
following signs appear

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 The bleeding increases.
 The woman feels dizzy
 The woman has severe headache
 The woman has visual disturbances
 The woman has epigastric distress
 The woman complains of breathlessness
 The woman complains of increased
abdominal or perineal pain

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 Do not discharge the woman before 24 hours
after delivery. This is a crucial period for the
occurrence and management of PPH. The
woman must be kept under observation during
this time.

Government of India
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Key Messages
 Active management of 3rd
stage of labour.
 Postpartum care and contraception
counseling
 Ensure timely referral

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