Here I Bring Active Management of Third Stage of Labour Lecture Notes in Hindi For Nursing Students.
The third stage of labor commences with the completed delivery of the fetus and ends with the completed delivery of the placenta and its attached membranes. The clinician immediately recognizes that from a practical perspective, the risk of complications continues for some period after delivery of the placenta. For this reason, many authorities have advocated a so-called fourth stage of labor, which begins with the delivery of the placenta and lasts for an arbitrary period afterward. The most commonly chosen duration is 1 hour; however, periods as long as 4 hours have been suggested. The length of the third stage itself is usually 5-15 minutes. The absolute time limit for delivery of the placenta, without evidence of significant bleeding, remains unclear. Periods ranging from 30-60 minutes have been suggested.
The third and fourth stages of labor are usually uneventful, although significant complications can occur in this period. The most common is postpartum hemorrhage (PPH). While maternal mortality rates have declined dramatically in the developed world, PPH remains a leading cause of maternal mortality.
Several complications encountered in the third stage of labor may lead to maternal morbidity. PPH may cause anemia or lead to poor iron reserves, ultimately contributing to anemia. Anemia may cause weakness and fatigue. Hospitalization may be prolonged, and the establishment of breastfeeding may be affected. A blood transfusion may ameliorate the anemia and shorten the hospital stay, but it carries risks of transfusion reaction and infection. Access to safe blood is not universal, and PPH can sometimes strain the resources of the best blood bank. Severe PPH, retained placenta, and uterine inversion may require emergency anesthetic services. Any exploration or instrumentation of the uterus increases the risk of sepsis.
Signs of placental separation
Traditionally, 4 signs of placental separation are taught. [6, 1]
The most reliable sign is the lengthening of the umbilical cord as the placenta separates and is pushed into the lower uterine segment by progressive uterine retraction. Placing a clamp on the cord near the perineum makes it easier to appreciate this lengthening. Never place traction on the cord without countertraction on the uterus above the symphysis; otherwise, one may mistake cord lengthening due to impending prolapse or inversion for that of uncomplicated placental separation.
The uterus takes on a more globular shape and becomes firmer. This occurs as the placenta descends into the lower segment and the body of the uterus continues to retract. This change may be clinically difficult to appreciate.
The uterus rises in the abdomen. The descent of the placenta into the lower segment, and finally into the vagina, displaces the uterus upward.
A gush of blood occurs. The retroplacental clot is able to escape as the placenta descends to the lower uterine segment. The retroplacental clot usually forms centrally and escapes following complete separation; however, if the blood can find a path to escape, it may do so before complete separation and thus is not a reliable indicator of complete separation. This occurrence is sometimes associated with increased bleeding and a prolonged third stage, with the delivery of the leading edge of the placenta and maternal surface first (Matthews Duncan method), rather than the cord insertion and fetal surface, which is more common (Schultze method).
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