active management of 3rd stage of labour
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Slide 1 :
DR. SUGUNA. R . KUMAR. PROFESSOR OF OBG, AL- AMEEN MEDICAL COLLEGE BIJAPUR. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR
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Delivery of the fetus to complete expulsion of the placenta Relatively little thought or teaching devoted to 3rd stage compared to the 1st or 2nd stage. “This indeed is the unforgiving stage of labor and in it lurks more unheralded treachery than in both the other stages combined. The normal case can, within a minute, become abnormal and unsuccessful delivery can turn swiftly to disaster.” --Donald I. Postpartum hemorrhage. Prac Obst Problems. 5th ed. 1979:748-94 III stage of labor
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The length of 3rd stage – 5-15min, but periods ranging from 30-60min suggested as the time limit. Thus 4th stage, chosen duration is 1hr but as long as 4hrs have been suggested. The most common complication is PPH – a leading cause of maternal mortality WHO statistics suggest – 25% of maternal death are due to PPH accounting for >100000 maternal death /year. 36,000 (25.7%) contributed by India – the highest by a Single country.
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PPH - > anemia, poor iron reserve, weakness, fatigue, failed lactation, BT - > Transfusion reaction and infection, strains the resources of Blood bank Emergency anesthetic service for PPH, retained placenta and inversion Increased risk of sepsis in exploration and instrumentation of Ut 3rd stage complication Morbidity
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All delivering women are at risk of complications of 3rd stage - > PPH, retained placenta and uterine inversion Preventable. Avoid mismanagement switch from physiological management to AMTSL Caregivers and institutions must have a management strategies to deal with these problems promptly.
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Preparation Well before the delivery of the baby Antenatal period – discuss regarding risk factors present and the implication and potential risks involved Draw up the uterotonic before the delivery in order to facilitate rapid administration Avoid fundal fiddling before placental delivery. Management of 3rd stage
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Management Management : Physiological VS Active management
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Meta-analysis of 7 trials in the Cochrane database systemic review on Active management Reduced risk of maternal primary hemorrhage(>1000ml) and reduced Hb <9g/dl following birth, Decrease in primary blood loss ( >500ml), BT and use of therapeutic uterotonic. No difference in the incidence of neonatal admission or infant jaundice. Increase in maternal DBP, vomiting, after pains, analgesia use -Begley CM et al, Active vs expectant management for women in 3rd stage of labor, Cochrane Database Syst Rev, Nov 9 2011:11: CD007412
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CHOICE OF UTEROTONICS
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Early cord clamping – least important, indicated to facilitate newborn resuscitation Delayed cord clamping until the cord pulseless – higher Hb in the newborn and greater iron store profound in preterm – fewer transfusions and lower neonatal intraventricular hemorrhage and sepsis I-A - Mercer J S et al, Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late onset sepsis, a randomised controlled trial. Peadiatric Apr 2006: 117(4):1235-42 Early cord clamping
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BE ACTIVE BUT NOT HASTY. AMTSL can prevent 60% of uterine atony and an evidence based feasible, low cost intervention AMTSL recommended to all delivering women I-A 100 AMSTL can prevent 12 PPH But III stage complications can still occur Anticipation Preparedness Action required
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Overdistended uterus Grand muiltipara Abnormal labor pattern Chorioamnionitis Placenta previa/ accreta Coagulopathy On anticoagulate Large myoma p/h of PPH At risk for PPH
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