THIRD STAGE OF LABOUR-AN UNFORGETTABLE STAGE OF LABOUR.

THIRD STAGE OF LABOUR-AN UNFORGETTABLE STAGE OF LABOUR.
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.

DIFFERENT LEVELS OF MANAGEMENT OF THIRD STAGE OF LABOUR.

IN THE ANTENATAL CLINIC.
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.

IN LABOUR
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.

IMMEDIATELY AFTER THE DELIVERY OF BABY
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

A. PHYSIOLOGICAL (EXPECTANT) 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 OF PHYSIOLOGICAL APPROACH
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.

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

B.ACTIVE APPROACH
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.

THE STEPS OF ACTIVE APPROACH.
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.

BENEFITS OF ACTIVE APPROACH
-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.

IMPORTANT POINTS TO NOTE IN THE USE OF ACTIVE APPROACH
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
contractility.
*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.

COMPLICATIONS OF THIRD STAGE OF LABOUR
-Postpartum Haemorrhage.
-Retained Placenta.
-Uterine Inversion.
-Placenta Accreta and its var