Clinical Management of the Third Stage of Labor: Techniques and Best Practices

• Start early, and get ready when delivering the baby's head. Around this time, request staff to load the oxytocin. As soon as the baby is delivered (both shoulders), the staff will give the oxytocin injections (10 units IM as per the Government of India recommendations). 
• Sometimes there is a loop of cord, nuchal cord, so as not to panic. Often, the loops are loose enough and can be taken out of the baby's neck. 
• The concern here is that as the baby is pulled out, the loops may get tightened and compressed, interfering with the baby's crying or breathing.
• Just take out the loops slowly, be it single loops or multiple loops. Only if it's too tight, interfering with the delivery of the baby, or there are issues uncoiling the loop; in such cases, clamping and cutting are considered. However, cutting and clamping must be avoided as much as possible. One of the reasons is that clamping this way interferes with the circulation. Furthermore, if there is a problem like shoulder dystocia were to happen, the delivery would be prolonged, and the oxygenation of the fetus would be broken.
• Once the baby has been delivered and an oxytocin injection has been administered, examine the fundus immediately.
  • The position of the fundus is noted after delivery. The fundus will be just at the level of the umbilical. 
  • Note for uterine contractions, like if they are atonic or not.
  • Exclude 2nd baby. It is important as many patients may present with no medical records. Antenatal clinical examination is going to help you to know if it is a single-term pregnancy or if it is a multiple pregnancy. 
  • Also, if there is a second baby yet to be delivered, then uterotonics should not be given. 
  • Note signs of placental separation. 

Process Of Delayed Cord Clamping

• Avoid rushing into cord clamping until there is an indication of an early cord clapping.
• Where to keep the baby. 
• Position of the baby and effect of gravity. The umbilical vein brings blood to the baby, and the umbilical artery takes blood from the fetal or newborn side. 
• If the baby is at a higher level, the amount of placental transfusion is decreased. 
• If the baby is at a higher level, the amount of placental transfusion is increased. The speed of transfusion is increased. It is well documented. Without oxytocin, the effect of gravity is the most evident. A distance of 20 cm above or below the placenta or the level of the introitus. 
• While there is an increase in the speed of placental transfusion, the new amount of the placenta may not change much. Moreso, when oxytocin is given as a part of active management, 3rd Stage of Labor.
• With the term vaginal delivery, a woman given oxytocin within minutes of birth, placing the baby on the mother's abdomen, or best, did not affect the volume or total volume of placental transfusion. 
• Early essential care of the newborn is initiated.
• Secretions cleared if copious or appear to be obstructing airways.
• Meconium present and baby vigorous at birth—delayed cord clamping can continue. 

Also read: Understanding and Managing Right Occiput Posterior (ROP) Position in Labor

Controlled Cord Traction

• To be done with uterine contractions
• Counteraction helps prevent uterine inversion. 
• The backward and forward pull is applied on the umbilical cord, and another hand is placed around the public symphysis, somewhere on the junction of the lower segment and the upper segment. Simultaneous traction and countertraction are used together with uterine contraction. 
• It also helps to feel the uterine contractions and avoid tugging of the umbilical cord. At the same time, tugging at the umbilical cord when the uterus is relaxed. When the umbilical cord is tugged, uterine inversion can take place. 
• While tugging the cord, it may seem like coming down, but it is just the apparent lengthening of the cord, where the placenta is not separated. This is a tricky citation and must be focused upon.  Place hands properly, be cautious, and wait for the contractions. 
• When they begin the controlled contractions is another question. It is important to decide whether to begin with placental separation or before the signs of placental separation.
• The latest Nice guidelines in intrapartum care suggest starting with controlled cord tractions after the signs of placental separation. 
• This is a safer practice because the uterotonic is given 10 units of iron oxytocin after the delivery of the baby, allowing time for delayed cord clamping. So, by the time the placenta is delivered, the uterotone must have taken effect, contractions must have started, and the placenta is expected to separate. 
• Sometimes the signs of placental separation may not be that obvious. In such cases, it is better to initiate controlled cord tractions with uterine contractions. 
• Clinically, the uterotonic is given, delayed cord traction is applied, there is no rush, there is no third-stage bleeding, and there is no indication of early necessary interventions. Also, intermittent tone assessment is carried out, and once the contraction begins, controlled cord traction is done. 
• Sometimes, there could be an apparent lengthening of the umbilical cord because of the fetoplacental hematoma  (central method), which may result in blood collection. The placenta is just at the central os. This is the point where one is aware that controlled cord traction can be started. 
• Important points are that it should be done with contractions. Controlled contractions can be started as soon as the rhythmic contractions have set in. NICE recommends that it should be done after the signs of placenta separation. 
• The process requires training; therefore, it should be done with skilled birth attendants around. 
• The contractions also help to detect and prevent uterine inversion, as with the countertractions, the fundus is pushed upwards and backward. 

Also read: Preconception Counseling: Optimizing Health for a Successful Pregnancy

After The Delivery Of The Placenta

• After the delivery of the placenta, there is no need for routine exploration of the uterus. It is not recommended. 
• More important is to examine the placenta and membranes for completeness and abnormalities. If there is suspicion, the uterus can be explored. Retained placental bits and bits of membranes may impact uterine contractility. Many times, this is the clinical clue. The uterus may not be contracting as desirable with intermittent bits of relaxation. It is not the hard uterus; then, in such cases, there is a possibility of bits of the membrane, etc. 
• Also, look for the presence of abnormalities. Examine both the maternal and fetal sides of the placenta. Document every detail regarding the possible abnormalities.
• Examining the maternal surface of the placenta, check for missing load, check for retroplacental clot, and document. 
• Examination of the placenta is crucial as, in some cases, it may be sent to histopathological examinations. 
• Examine the lower genital tract for lacerations. If there is any tear, it needs repairing. Any excessive bleeding may need complete cervical exploration.
• Close observations of the vitals, such as the pulse rate and blood pressure, every 15 minutes are necessary. One should not miss out on any signs of tachycardia suggesting an excessive amount of bleeding.
• Continue the assessment for ongoing bleeding. 
• Similarly, continue the intermittent uterine tone assessment. It is crucial in the fourth stage, the 1-hour period of observation after the placental delivery. 
• For instance, if there is a patient with tachycardia, it may suggest excessive bleeding. Further request staff to check for visible external bleeding. 
• When the patient is supine in bed, the blood is collected inside the uterus. Here, the P/A should be able to detect if there is uterus atonicity. So there may not be visible bleeding. Here, the P/A examination can be employed to see if the uterus is relaxed.. Furthermore, the fundal is elevated because of the uterus; with blood clots and massaging, it may result in bleeding and clots trickling out.  
• Importantly, the full bladder interferes with the contractility of the uterus. Emptying the bladder brings the uterus back to its level. 

Also read: Physiology Of Lactation : Prolactin Hormone

Hope you found this blog helpful for your OBS-GYN preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs, video lectures, QBank, Mock Tests and more!

Download PrepLadder's best app for neet pg preparation for Android 

Download PrepLadder's best app for neet pg preparation for Ios