Tuesday, February 14, 2012


Third stage is a stage of labour that is so delicate and needs to be handled with care. In it lurks more unheralded treachery than in both the other stages combined together.A sucessful delivery can within splits of seconds become abnormal or turn swiftly to disaster(Donald, 1979).Because of the complications that can arise after this stage. Some authorities have advocated a fourth stage of labour which is from the delivery of placenta to an arbitrary period afterward ie 1-4hrs after delivery.Lenght of 3rd stage of labour 5-15mins.
Poor management of this stage can lead to complications such as PPH leads to anaemia due to poor iron reserve and this leads to weakness and fatigue delayed establishment of breastfeeding.It may also lead to transfusion of blood that can cause transfusion reaction and sepsis.PPH can sometimes strain the resources of the best blood bank.Other complications that can be observed in 3rd stage are uterine inversion, retained placenta etc.


Management of this stage starts from the time a pregnant mother books in the hospital.
The midwife tries to find out from the patient and her partner their preferences of the method of delivery process with an open dialogue regarding any risk factors present. Ask the couple of their concerns and educate them on the various management options. They should also know the risk implications of limited management options.

A patient who is in labour can be prepared well when is still in the latent phase of first stage so as to reduce and avoid complications in the third stage of labour. She can be prepared :
a. Adequate history taking to know if there are complications in third stage of previous deliveries or not.
b.Psychologically by reminding her of all she was taught during ante-natal concerning breathing exercise during labour,
c. Medically by making sure that all the drugs that this patient will receive during and after delivery are made available.

Third stage of labour can be managed based on the school of thought that you believe in and also considering the risk of the chosen approach of management.There are different approaches taken into consideration in the management of this stage. These are :-
*physiological approach
*active approach

This is a school of thought which is of the opinion that this approach is a natural process with less complications because here the placenta seperates and is delivered normally by uterine contraction and maternal expulsive effort.They also believe that active approach can lead to :increase risk of PPH,uterine inversion due to CCT or even rupture due to entrapment caused by uterotonic agents and it may also cause serious problem in case of an undiagnosed twin.

The steps include:
a.Do not give any utero-tonic at the delivery of the anterior shoulder or give after the delivery of the placenta.
b.Check for bulkiness of the uterus ie size and also the uterine tone( note if uterus is well contracted) or not.
c.Allow placenta to seperate on its own and deliver it when it is visible at the vulva. Do not apply traction on the cord ie.CCT.
d.You may or may not clamp the cord.

-Reduces the risk of PPH.
-Reduces the incidence of uterine inversion.
-Prevents entrapment of the placenta.
-Prevents retension of second twin.

This is an approach that supports the management of third stage of labour actively. This active management entails the administration of uterotonic agents at the delivery of the anterior shoulder of the baby. Prophylatic use of these agents promotes strong uterine contractions which results to faster retraction of the uterine muscles and placental seperation / delivery.

These include :
a.Give uterotonic with the delivery of the anterior shoulder or after the delivery of the baby.
b.Asses the size and tone of the uterus( note whether uterus is contracted or not ).
c.Use CCT to deliver the placenta when the uterus is contracted ie. Gently apply downward cord traction with countertraction on the body of the uterus.
d.Clamp cord early ie immediately the baby comes out.

-It promotes strong uterine contractions and leads to faster retraction and placenta seperation and delivery.
-Decreases the amount of maternal blood loss at the delivery.
-Reduces the rate of PPH at least by 60%.
-Reduces the incidence of retained placenta.
-Reduces anaemia which results to weakness and fatigue after delivery in some patient.
-Need for blood transfusion is reduced and the incidence of blood transfusion reaction,sepsis is also reduced.
-Need for therapeutic uterotonic agent is also reduced by 80%.
-Increases the establishment of breastfeeding.

a.Late clamping of the cord
-increases the haematocrit values in the neonate and brings down the incidence of neonatal anaemia and increased iron stor
-reduces neonatal intraventricular haemorrhage and sepsis.
-increases neonatal polycytemia and jaundice.
b.Administration of uterotonics
-in active management of third stage of labour, care should be taken in the use of drugs like:
*calcium antagonists eg Nifedipine, mgso4 which may inhibit uterine
*nitroglycerine or other inhalational anaesthetic agents.
c.Gentle cord traction which is only done :
-when the uterus is well contracted with a countertraction ( trapping of the body of the uterus) above the level of the symphysis pubis.

-Postpartum Haemorrhage.
-Retained Placenta.
-Uterine Inversion.
-Placenta Accreta and its var


Sweating is a normal function of the body. Sweating is a regulatory function of the body which helps in regulation of body temperature and excretes waste products from the body. Sweat can come out from any part of the body where there are skin pores.
Armpit sweating is the main topic of discussion because of its effects on people who over sweat from there. It can be embarrassing and can also affect an individual socially. It is an experience that starts from the age of puberty and throughout life. During puberty, alot of changes occur in the body which often leads to over-sweating from the armpit. The armpit produce sweat from two major sweat glands called :
i. Apocrine (which secrets an oil-like protein ) and
ii. Eccrine (which produces the watery sweat).
Part of the changes that occur in the body during puberty is development of more sweat glands in the armpit which becomes more active. These active glands at this period produce more oilier and smellier sweat which makes the individual to have a very bad body odour.Sweat on its own does not smell but when its not cleaned, micro-organisms will act on the protein and fatty content of sweat which in turn produces the bad odour.

There are many causes of body odour and they include :
i.poor hygiene.
iii.inborn errors of metabolism.
iv. uncontrolled diabetes mellitus.
v. eating of certain foods.
Vi.tooth and oral conditions eg periodontal disease,gingivitis etc.
vii.psychological conditions.
viii.Drugs, herbs, toxins eg arsenic poison.
ix.Infections like lung abscess, STD,UTI etc.
x.Liver or kidney failure.
xi.Tumour/cancer of cervix/uterus.

a. Social effects :
i. Withdrawal of friends.
ii.withdrawal of the individual from social activities.
iii.it can lead to inferiority complex.
iv.it makes the person to be angry always
v.always ashamed and frustrated.
vi.can lead to depression.
b. It can also lead to mental retardation and death depending on the cause of the body odour.

Body odour generally can be prevented based on the aforementioned cause which include
i. monitoring of blood sugar level.
ii. treatment of the various infections etc.
But for the purpose of this discussion, the preventive measure for people who have body odour due to over-sweating from the armpit include:
i. regular shaving of hairs of the armpits.
ii. treatment of the cause of the body odour.
iii. avoid wearing dirty clothes.
iv. regular and adequate washing of the armpit with soap and sponge.
v. use of good body sprays.

a. wash regularly with soap and clean water.
b. adequate personal hygiene eg regular shaving.
c. use of deodorants with an antipersperant to help prevent sweating.
d. taking of balanced diet.


Postpartum haemorrhage(PPH) is a condition whereby a woman starts bleeding immediately or 4-6wks after delivery. It is an excessive loss of >500mls of blood after vaginal delivery, or 1000mls of blood following ceaserean section or any blood loss that will affect the general condition of the woman even if it is not upto 500mls.
Fluid loss is extremely difficult to measure with any degree of accuracy, especially when a mixture of blood and fluid has soaked into delivery couch and spilled onto the floor. It should also be taken into consideration that measurable solid clots represents only half the total fluid loss,therefore the best way to diagnose PPH is by watching out for any blood loss that adversely affects the mother’s general wellbeing. In addition, if the blood loss is upto 500mls,it must be treated as PPH, irrespective of the maternal condition.
Postpartum haemmorrhage as we all know is one of the complications of third stage of labour and a leading causes of maternal mortality(ie one quarter of maternal death) and may occur in any woman especially those already compromised by anaemia or other illnesses during pregnancy.

The incidence of postpartum haemorrhage is 5-8%.It is the most commonest cause of maternal death in the developed countries and a major cause of maternal morbidity worldwide.

There are so many causes of PPH which include uterine atony, vaginal/cervical lacerations, retained placental tissue, coagulation defects.The causes of postpartum haemorrhage has been grouped into 4T’s +1 which are:

a.Uterine atony :-is the inability of the uterus to contract and may lead to continuous bleeding. Postpartum haemorrhage is physiologically controlled by constriction of the living ligatures that surround the blood vessels supplying the placenta site. This atony occurs when the myometrium refuses to contract after the delivery of the placenta. This atony causes about 50% of PPH.

Predisposing factors to uterine atony
This can be classified into:
i.fatigued uterus which can be caused by
*excessive manipulation of the uterus during operative delivery/
mismanagement of the third stage of labour (fundus fiddling) may
trigger contractions which are retraction.
*general anaesthesia( especially with halogenated compounds or
cyclopropane causes relaxation of the uterine muscles)
*prolonged labour resulting to uterine inertia due to muscle
*precipitate labour – causes insufficiency of the uterine muscles
to contract
ii.obstructed uterus caused by
* presence of uterine leiomyoma
*full bladder
*incomplete seperation of placenta –interrupts efficient
contraction and retraction but an adherent placenta may not
cause bleeding
*retained cotyledon, placenta fragments or membranes – impedes
efficient uterine action.
*placenta praevia/abruption
iii.induction and augumentation of labour with oxytocin –causes
uterine inertia which inhibits uterine muscles from providing
strong and sustained contraction and retraction of the empty
iv.other causes:
*previous history of PPH –detailed history is necessary because
there may be risk of recurrence in subsequent pregnancies.
*intrinsic myometrial dysfuntion
*uterine infections
v.overdistension of the uterus caused by
*high parity /grand multiparity(5 or more birth)-there is
formation of fibrous tissue which replaces muscle fibres with
each successive pregnancy and this reduces the contratilityof
the uterus and makes the blood vessels more difficult to compress.

i.Vaginal/cervical lacerations and haematoma
This may occur as a result of precipitous or uncontrolled delivery. Bleeding from episiotomy and laceration is the 2nd most frequent cause of over 20% of PPH. Laceration of the vagina, cervix and uterus most commonly occurs in assisted or surgical delivery due to the fact that these parts of the body are highly vascularised.
Predisposing factors are :-
*delivery of a macrosomic baby.
*vaginal birth after caeserean section
*instrumental delivery or intrauterine manipulation

C.Tissue (retained placenta)
This occurs in cases where the placenta has an accessory lobe, in preterm delivery or where there is placenta accreta.
Predisposing factors:-
*previous uterine surgeries
*premature delivery
*difficult or prolonged placenta delivery

D.Thrombosis(clotting disorder)
This occurs when there is failure of blood to clot and this occurs when there is delay in uterine contractions which gives room for liqour to enter into the blood stream causing coagulopathy.
Predisposing factors:-
*platelet dysfunction eg thrombocytopenia.This may be as a result of HELLP syndrome( haemolysis, elevated liver enzymes and low platelet count).
*inherited coagulopathy
*Hiv/Aids (immunosupression lowers platelet count)
*use of anticoagulants
*disseminated intravascular coagulation(DIC)-occurs from intrauterine fetal death,placenta abruption, amniotic fluid embolism.
*physiologic factors eg hypocalcemia acidemia and hypothermia.

E.Traction(uterine inversion)
This occurs when the weight of a partially seperated placenta pulls on an atonic uterus or excessive traction of the cord during controlled cord traction.

Obvious signs:-
-visible bleeding.
-maternal collapse.
Other subtle signs
-rising pulse rate
-falling blood pressure.
-altered level of consciousness with restlesnes or drowsiness.
-fundal height above the umblicus ie enlarged uterus as it is filled with blood
clots(it feels boggy on palpation).Uterus is soft and distended due to lack of
tone and there may be no visible bleeding.

This type of haemorrhage occurs immediately after the delivery of the placenta.
The patient bleeds abnormally and looses blood that may affects the general condition of the patient.

This is a bleeding from the vaginal occuring between 24hrs and12weeks postnatally. This occurs due to retention of some products of conception like pieces of placenta, membrane or even blood clots. When it occurs the lochia is usually heavy and will change from a serous pink or brownish to a bright red blood loss, the lochia may even be offensive if the patient has infection.There may be subinvolution, pyrexia, and tachycardia etc.


Management of postpartum haemorrhage starts from the day a pregnant mother books in the hospital. The midwife that books the pregnant mother applies some
preventive screening so as to identify those who are at greater risk and recognise causative factors.Thorough and accurate history taking of previous obstetric
experience will identify risk factors eg previous PPH or precipitate labour. This will also help in planning for the delivery of the index pregnancy in a hospital that has facilities for dealing with emergencies. All mothers who are identified as being at risk
should be advised to do series of blood test eg blood typing and cross-matching.Mothers at risk should provide a pint of blood that will be reserved in the blood bank till 24hrs after delivery.
Early detection and treatment of anaemia will help the woman enter into labour with haemoglobin that is greater than 10g/dl.The midwife should make sure that the patient’s blood test is done regularly,results recorded and explained to the woman.If the woman’s haemoglobin is less than normal, arrangement should be made to restore it before birth by transfusion with 1pint of blood.
Autologous blood donation has also been advocated mainly for patients who has been identified to be at risk of postpartum haemorrhage.


i.First and second stage
During labour, good pratices should be applied in the first and second stage of labour to prevent prolonged labour (by the use of partogragh) and ketoacidosis. A woman should not go into second stage with full bladder. Intramuscular or intravenous administration of uterotonic as prophylaxis is recommended.
After the delivery of the baby,the uterus is massaged in a circular or back-and-forth motion for contractions until the myometrium becomes firm and well contracted. Remember that excessive massage of the uterus will also cause PPH by interferring with normal contraction of the myometrium.

ii.Third stage of labour
The placenta is usually delivered 5mins after the delivery of the baby. Do not be in a hurry to force it out because it is of no benefit and may succeed in causing more harm.Before delivering the placenta, make sure that the signs of placenta seperation(gush of blood from the vagina,lenghtening of the cord, uterus becomes firm and rises in the abdomen)are there.
The placenta can be delivered by a gentle traction on the umblical cord ie using controlled cord traction (CCT) or by using Brandt-Andrews manoeuver ie applying a gentle steady traction on the cord combined with an upward pressure on the lower uterine segment. Placenta is thoroughly inspected to check for completeness.
Adherent membrane can be removed by manual removal or by using a gloved hand wrapped with sterile gauze to sweep the myometrium.
If the bleeding continues, suture the episiotomy if there is any and check clotting time give inj VIT K 1 ampoule stat if clotting time is more than normal ie over 8seconds.


After the delivery of a baby, there are two patients to observe ie the mother and baby. These two should be observed closely using the ABC of acute life support ie airway,breathing and circulation.

Midwife’s responsibility:-
It is an emergency condition therefore it requires immediate and prompt attension.
*reassure the woman and her support person.
*check the patient’s vital signs.
*do a general examination using ABC.
*do perineal examination to check for source of bleeding.
*rub up uterine contraction ie rubbing the fundus to increase contractions and reduce bleeding.
*encourage the woman to empty her bladder.
*keep all pads and linen so as to assess the volume of blood loss.
*set up an IV infusion with crystalloids + oxytocin.
*pack any visible tear with sterile gauze.
*transfer the patient to the hospital where there are facilities for emergency care.

*start resuscitation measure with taking of history, physical examination
according to acute life support algorithm.
*do ABC emergency care ie primary survey:-
-place patient in a recumbent position(patient will lie on her back with her head
turned to one side and with one pillow under her head)
-monitor her vital signs.
-set up IV infusions ie 1L 0.9% normal saline + 40iu oxytocin.
-laboratory investigations
*secondary survey:-
Address the 4T’s plus 1
i.Tone :-if the cause of the bleeding is atonic uterine contraction, do
-uterine massage
-empty the bladder with a sterile urinary catheter.
-remove blood clots from the uterus
-reduce excessive uterine manipulation especially the fundus.
-give uterotonics eg oxytocin [(bolus(im or iv)or added in a crystalloid )], ergometrine ( 0.5mg if BP is not high) or misoprostol (400mcg sublingually or 800mcg rectally)
-if bleeding continues do bimanual compression for 20-30mins

-repair episiotomy or lacerations of the vagina or cervix.
-pack uterine cavity with sterile gauze.
-put blakemore(barkri) balloon in the uterus and fill it with normal
saline to act as tamponade.
-disrupt any haematoma
-resuscitate patient if bleeding has stopped.

If the cause of bleeding is uterine rupture:
-do pelvic ultrasound to look for intra abdominal fluid.
-give broad spectrum antiboitics.
-plan for emergency laparatomy.

If there is breakage of cord, invite the doctor on call to:
manual removal of the placenta but if the placenta has separated it can
be removed by little maternal effort.
If the placenta is adherent;
-do manual removal of the placenta or wrap a sterile gauze around
one hand and sweep the inner wall and gently remove adherent
-if bleeding continues, do manual exploration of the uterus.This will
help to find out if there is uterine rupture or abnormality.
If it is retained placenta( ie placenta stays 1hr following child birth)
-seperate the placenta from the uterine wall digitally.
-curretage can be done using BANJO CURRETE when manual
exploration has failed to control the bleeding.
-if it is accreta, laparatomy is done.

If uterine inversion occurs, push the uterus in position with the hand.

-evaluate the clotting time.
-if hb drops *for anaemia –transfuse with blood.
*for thrombocytopenia –transfuse packed cell of platelets.


When the patient arrives the hospital ,she will be attended to by the midwife in the ward who will inform the obstetrician on duty about the patient. For adequate intervention to be given, quality history and examination should be taken as thus:
A. collect initial vital signs ,this helps to find out the state of the patient on arrival that will help in managing potential circulatory collapse.
* identify cause of PPH.
*ask about severity of bleeding, initial post delivery bleeding and how long the
bleeding has lasted and how heavy it is.
*find out duration of 3rd stage, has placenta been delivered (whether complete or incomplete.
*find out if there is any feeling of dizziness, lightheadedness, palpitations or fainting attack.
B. Enquire of any intervention she has received.
-any history of transfusion, reason and if there is any transfusion reaction.
-take past medical history especially pulmonary, hematologic and cardiovascular history.
-any history of allergies.
C. Ask question about predisposing factors and even potential causes.
-history of PPH.
-parity, gestational age of pregnancy, history of twinning.
D. Any complications:-
-pueperal sepsis.
-postpartum haemorrhage.
-abnormalities of placenta eg praevia /abruption
*ask how placenta was delivered.
*history of vaginal delivery and caeserean section( if emergency or elective).
*other uterine surgeries eg uterine septum removal,myomectomy.
*family history of blood defect or bleeding disorder.
*if patient is on any medication especially platelet inhibitors,anticoagulants,uterine relaxants and antihypertensives.
*where and when delivery was conducted ,who did it.

Postpartum haemorrhage is managed as an emergency and it is important to focus on the cause of the bleeding.There may not be haemodynamic changes
observed immediately due to physiologic maternal hypervolaemia. Examination should centre on some areas of the body. Check if there are:-
*pulmonary oedema.
*heart murmur ,tachycardia.
*check the volume /strenght of the pulse.
*assess mental status.
*check skin for bleeding from infusion sites.This indicates coagulopathy
*take note of the temperature of the skin.
*check for any abdominal,vaginal, uterine haematoma because there may be an internal bleeding which is not seen outside.
Do abdominal palpation. To check:
*for pains
*height of fundus
*check bladder(if empty or full), it may inhibit uterine contractions.
Perineal examination.
*rule out vaginal/cervical lacerations by using speculum
*check for trickling of blood at the vaginal orifice.
*check out for height of fundus and look for haematoma by doing bimanual
*check if cervical os is closed or open.
Examine placenta to check for:
*completeness of placenta to rule out detatched/missing lobe or membrane.

These are some of the investigations that will help in the management of this patient. They include:-
A. complete/full blood count.
*check haemoglobin level and haematocrit.
*do white blood cell count( if it is elevated)
*look for thrombocytopenia.
B. coagulation lab studies
*check raised prothrombin time.
C. check eletrolyte balance.
D. check biliribin level,urea and creatinin –this can identify renal failure
E. grouping and crossmatching.
F. check fibrinogen level
G. do liver funtion test.
H. Imaging studies
*computed tomography.
*magnetic resonance imaging.

The prognosis of postpartum haemorrhage depends on:
-cause of bleeding.
-duration of PPH.
-amount of blood loss
-co-morbid conditions.
-effectiveness of treatment


There are African fruits,roots, seeds, barks, and leaves that are very useful to human health but most times we take them without knowning their health value. Some of them will be discussed in this page.

A.Name: Bitter Kola
Botanical Name : Garcinia Kola
Other Names : Igbo – Aku ilu.
Ordinary Uses : i. As antidote for ingested poison.
ii.Treatment of abdominal colicky pain.
iii.Treatment of hepatitis.
iv.Treatment of chest cold and cough.
Clinical Uses : i. Drug detoxification.
ii.Bronchodilation (for asthma)
iii.Liver disorders.
iv.Male virility.
v.Blood sugar regulation.
vi.Lipid disorders.
vii.Infectious diseases.
viii.Boosting of immune system.
ix.Weight reduction.

B.Name : Garlic.
Botanical Name :Allium Sativum.
Other Names : Igbo – Ayuu.
Yoruba : Ayu.
Actions : It is :-bacteriostatic
Uses : Treatment of :
i. fever.
iv. asthma
v.nervous disorders.
vi. hypertension.
vii.ulcers and skin diseases.

C. Botanical Name : Anthiocieista djalonensis.
Other Names : Igbo :Okpokolo.
Yoruba : Sapo.
Hausa : Kwari.
Uses : i.As diuretic.
ii. As purgative.
iii. Poison antidote ( in Ivory Coast ).
iv. As emmenagogue (stimulates menstruation).
vi.Treatment of :-oedema
-elephantiasis of the scrotum.

Other Uses : Treatment of : - chest pain
The hot water extract of the root is used in Nigeria for women with
-irregular painful menstruation.

D.Name : African pepper (guinea pepper).
Botanical Name : Xylopia aethiopica.
Other Names : Igbo : uda
Edo – unien.
Ibibio/ Efik – Atta.
Yoruba –Eeru
Uses : of the stem ,bark, fruits, seeds, and roots.Treatment of :
i. stomach ache.
ii. dysentery.
iii. bronchitis
iv. cancer
v. ulcers
vi fever and debility
viii. postpartum management
ix. enhances fertility.
x. vermifuge.

E.Botanical Name : Cajanus cajan.
Other Names : Igbo : fio fio
Edo : olele.
Gwari : shingwazo
Hausa : Aduwa.
Igala : agadagbulu.
Tiv : alev.
Yoruba : otili.
Leaf extract is used as :-anti-sickling agent and treatment of :
-urinary infections.
-yellow fever.

F.Name :Brimstone tree.
Botanical Name : Morinda Lucida.
Other Names : Igbo :eze-ogu /njisi.
Yoruba : oruwo /erewo.
Hausa : marga.
Uses : Treatment of :
-typhoid fever.
-dressing of wounds to prevent infections.
-boost low sperm count.

G.Name : African Nutmeg.
Botanical Name : Pycanthus angolensis.
Other Names : Igbo : egwnoma
Yoruba : akomu
Hausa : akujaadi
Uses : -wound healing.
-stomach ulcer.
-helibacter pylori.

H.Name : Aloe vera .
Uses : -curing soft tissue cancer.
-restrains the development of cancer tumour.
-raises levels of tumour necrosis.
-stimulates immune system response.
-enhances healthy tissue.

I.Name : Grape seed extract.
Uses : damages cancer cells’ DNA ( via increased reactive oxygen species and stops the pathway that allow repair as seen by the decreased of the DNA repair molecules Brca1, Rad51, and DNA repair foci.

J.Name : Tomatoes.
Tomatoes contains a chemical component called lycopene which is a natural anti-oxidant that :
-prevents prostrate cancer in elderly men.
-prevents breast cancer in women.
-reduce the occurence of other forms of cancer.

K.Name : Sausage tree.
Botanical Name : Kigelia african / pinnata.
Has antibacterial activity, has cytotoxic effects against cancer cell lines.
Uses : Treatment of skin cancer.

L.Name : Citrus.
Contains limonoids which
-fights cancer of the mouth, skin, lungs, breast, stomach, and colon.
-inhibits development of cancer cells.
-reduces cholesterol.