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Course: Maternity Nursing

Topic: Nursing Care During Third Stage of Labour

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Module Goals

The learner will be able to:

Define the third stage of labour and management
List the observations needed during the third stage of labour
Examine a placenta after delivery
List the causes of postpartum hemorrhage
Manage a patient with postpartum hemorrhage

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Third Stage of Labour

Starts after the delivery of the infant and ends with the delivery of the placenta and membranes
Usually lasts less than 30 minutes
Uterine contracts: less frequently than stage 2
Uterus becomes smaller
Placenta delivered
Complications: hemorrhage, retained placenta

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The third stage of labour starts immediately after the delivery of the infant and ends with the delivery of the placenta and membranes. It usually lasts less than 30 minutes and mostly happens within 2-5 minutes. However, it fully depends upon the method used for the delivery of the placenta.

During the third stage of labour:

The uterine contraction continues but the frequency of contraction is less than in the second stage of labour
The uterus contracts and becomes smaller
Due to the contraction, the placenta is squeezed out of the upper uterine segment to the lower uterine segment and expels out of the vagina.
The contraction of the uterus muscle compresses the uterine blood vessels and prevents bleeding.

Importance of the third stage of Labour:

The major complication in the third stage of labour is excessive bleeding. Therefore, if it is not appropriately managed, it can lead to postpartum hemorrhage (a common cause of maternal deaths in low and middle income-oriented countries)

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Third Stage of Labour: Management

Two Methods of management:

The active method :

Used by doctor and nurses in secondary and tertiary level hospital
Used in immediate high-risk patients
Use of Oxytocin
Use of controlled cord traction

The Passive Method:

Used by Midwives working in primary clinic or hospital
Used in low-risk patient
Spontaneous delivery of placenta
Maternal effort for the delivery of placenta

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What is the active management of the third stage of labour?

This method is used by the doctor and nurses working in a secondary or tertiary level hospital and an assistant is available at the site of delivery.
This method is generally applied to patients who are at high risk.
After the delivery of the infant, an abdominal examination is done in order to exclude a second twin.
When it is confirmed of no other fetus present inside the uterus, the drug Oxytocin is given.
The uterus starts to contract with the infused dose of oxytocin. When it contracts, controlled cord traction is applied.
For this, Steady tension should be kept on the umbilical cord with one hand and another hand should be placed above symphysis pubis and push the uterus upwards.
Controlled cord traction is also called the Brandt-Andrews method (maneuver).

Uterus contracts and placenta separates from the upper segment of uterus come to the lower uterine segment and expels out of the vagina. If the placental separation does not take place during the uterine contraction (after oxytocin dose). A nurse or midwife has to wait until another contraction occurs, and then the same maneuver has to be repeated

What is the passive method of managing the third stage of labour?

This method is generally used by the midwives (A midwife working on her own has to choose this method) working in a primary healthcare facility and does not have assistant available at the delivery.
It is used in low-risk patients.
Here, she has to wait for the signs of spontaneous placenta separation.
When the sign occurs, the patient is asked to bear down and the placenta delivers with maternal effort.
Oxytocin is only given after the placenta delivers

Note: While following the passive method, if there is no sign of placental separation till 30 minutes after the start of the third stage of labour, then the active method should with the drug oxytocin.

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Drugs Choice at Third Stage of Labour

Two Drug choice :

Oxytocin:

First drug of choice
10 units IM
Not light sensitive, store in refrigerator

Syntometrine:

Used rarely
Injection
Contains 5 units of oxytocin and 0.5 mg of Ergometrine
Light sensitive: store in opaque container in fridge
Contraindicated in HTN and Valve Diseases

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Drugs given during the third stage of labour

There are two drug choices:

Oxytocin (Syntocinon) 10 units is the first drug choice during the third stage of labour. It is given intramuscularly, and it is not light sensitive. However, it has to be stored in the refrigerator.
Syntometrine is given sometimes by intramuscular injection after the delivery of the infant. It Contains 5 units of oxytocin and 0.5 mg of ergometrine maleate and is supplied 1 ml ampoule. This is light sensitive and must be stored in a refrigerator in an opaque container.

Contraindication of Syntometrine:

Syntometrine contains 0.5 mg of ergometrine and, therefore it is contraindicated for the patient with

Hypertension: Ergometrine causes vasospasm and can result in a severe increase in blood pressure.
Patient with Heart Valve Disease: The tonic contraction resulting from the ergometrine action pushes a large volume of blood into the patient’s circulatory system. It might result in heart failure with pulmonary edema.

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Signs of Placental Separation

Uterine contraction
Rise of fundus of uterus during placental descend
Umbilical cord lengthens
Vaginal Bleeding
Separation confirmed by suprapubic pressure

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Active Management of the Third Stage of Labour

In expectant/passive (physiological) management,

Uterotonic drugs are not given prophylactically
The cord may or may not be clamped early, and the placenta is delivered by maternal effort

Active management of the third stage of labour consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony

Administration of uterotonic agents after the delivery of the baby
Expulsion of placenta with controlled traction of the cord
Uterine fundal massage after expulsion of the placenta

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Advantages and Disadvantages of Active Method

Advantages

Less blood loss
Less possibility of additional oxytocin

Disadvantages

The patient should not be left alone
Risk of retained placenta
Risk of inversion of uterus

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Active vs Passive (Physiologic/Expectant) 3rd Stage of Labour Management

Active

Uterotonic drugs are given before delivery of the placenta
The cord is usually cut 2–3 minutes after birth
Placenta is delivered by controlled cord traction (CCT)

Less blood loss

Needed in excessive bleeding of if placenta does not separate spontaneously

Passive

Uterotonic drugs are not given prophylactically
The cord may or may not be clamped early
Placenta is delivered by maternal effort

No assistant needed

Less chance of retained placenta

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Recordings During and After the Third Stage of Labour

During:

Duration of third stage
Amount of blood loss
Medication given
The condition of perineum

Immediately after delivery of placenta:

Contraction of uterus
Excessive Vaginal Bleeding
Note of suturing of episiotomy (if any)
The completeness of the placenta and any abnormalities

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What recordings must always be made during and after the third stage of labour?

Recordings made about the third stage of labour:

Duration of the third stage.
The amount of blood lost.
Medication is given.
The condition of the perineum and the presence of any tears.

Recordings made immediately after the delivery of the placenta:

Whether the uterus is well contracted or not.
Any excessive vaginal bleeding.
A short note on the suturing of an episiotomy or perineal tear.
The patient’s pulse rate, blood pressure, and temperature.
The completeness of the placenta and membranes, and any placental abnormality.

Recordings made during the first hour after the delivery of the placenta:

During this time ( also called the fourth stage of labour), the proper contraction of the uterus and presence of excessive bleeding is recorded (if any). This hour is very crucial as it has a higher chance of postpartum hemorrhage.

In case the patient is normal then vitals and bleeding should be assessed every 15 minutes for an hour.

If the third stage of labour was not normal, the observations must be repeated every 15 minutes, until the patient’s condition is normal. Thereafter, Assessments should be repeated every 15 minutes for an hour. If normal after one hour, the assessment must be repeated every 30 minutes for the 2nd hour. If normal continue with observations every 4 hours.

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Holding & Breastfeeding a Newborn:

Kangaroo care

If the infant has no any breathing difficulty

Note: Please refer to slide deck “Breastfeeding”

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Placenta Examination After the Birth

Assess for completeness: inspect for missing parts
Abnormalities: cloudy membranes, clots, odor
Size: 1/6 of infant weight
Umbilical Cord: inspect for two arteries and one vein
Infracts and calcification: Pale areas on maternal surface

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Examination of the placenta after birth

Completeness: a nurse or midwife should assess the completeness of both the placenta and the membrane.

The placenta should be held up by the umbilical cord (so that membranes hang down). Membranes must be carefully examined for completeness.
The membranes should have a bright, shiny, and transparent appearance. In the case of the placenta, it is held in both hands and the maternal surface is examined for the missing part or cotyledon (it is easily noticed). The number of cotyledons ranges from 15-20.

Abnormalities:

Abnormalities like a cloudy membrane, foul smell suggests the Chorioamnionitis (bacterial infection of the chorion, amnion, and amniotic fluid )
Similarly, blood clots that are seen attached to the maternal surface suggest placenta abruption.

Size: During an examination, the size of the placenta is also measured. Usually, the placenta is expected to increase with the gestational age and weighs about 1/6 of the weight of the infant (450-650 gm.) at term.

A heavy, edematous placenta is suggestive of congenital syphilis.
A heavy, pale placenta is suggestive of Rhesus hemolytic disease.
Maternal diabetes may cause the placenta heavier than the expected weight but with normal appearance.
A lighter placenta suggests intrauterine growth restriction.

Umbilical cord: Umbilical cord should be assessed for the two arteries and a vein. And it should be seen on the cut surface of the cord. If only one umbilical artery is present, the infant must be carefully examined for other congenital abnormalities.

Also, infarcts are assessed on the surface of the placenta. It is seen as the pale areas on the maternal surface. However, calcification on the maternal surface is normal.

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Third Stage Of Labour: Complications

Prolonged third stage:

No placental delivery after 30 minutes

Management:

An IV with 20 units of oxytocin over 4 hours
Used cord traction after uterus contracts

Note: Retained Placenta is a Medical Emergency

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What would the nurse do?

A patient with normal first and second stages of labour has been delivered by a midwife working alone at a peripheral clinic. After the presence of a twin baby is ruled out, the passive method is used to manage the third stage of labour. After 30 minutes, there has been no sign of placental separation. A diagnosis of retained placenta is made; the patient is referred to the nearest hospital for a manual removal of the placenta.

What is wrong with the diagnosis?

What should have been done in this case?

What complication is more likely to develop and how to manage it?

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What is wrong with the diagnosis?

The diagnosis of the retained placenta can be made only if the placenta is not delivered after the active method of managing the third stage is used. The correct diagnosis of it is a prolonged third stage of labour.

What should have been done in this case?

The placenta should have been delivered by the active method of managing the third stage of labour, i.e. by giving oxytocin 10 units intramuscular and using controlled cord traction.

What complication is more likely to develop and how to manage it?

Postpartum hemorrhage due to an atonic uterus is more likely to develop.

It can be managed with a rapid intravenous fluid with a side infusion of 20 units of Oxytocin in 100mls of Basol or normal saline. A nurse should carefully observe to make sure that the uterus is well contracted. Vitals especially pulse and blood pressure has to be monitored every 15 minutes until the patient is transferred to Operation theater or level 2 or 3 hospital.

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Retained Placenta

The placenta fails to separate spontaneously in the third stage with or without active management

Risk Factors:

Multiparity
Previous History of Retained Placenta
Induced labour
Previous Injury or scar of the uterus
Preterm Delivery

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Retained Placenta

Pathophysiology:

Atonic Uterus
Full Bladder
Abnormal Adherence or invasion of the placenta in the uterine wall

Placenta Accreta
Placenta Increta
Placenta Percreta

Constriction ring-reforming cervix

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Glossary:

Atonic: Having no tone

Pathophysiology of Retained Placenta:

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Atonic Uterus: Inadequate contraction of the uterus leads to placenta retention as there will be no mechanical force to squeeze the placenta out of the uterine wall.
Full Bladder: Full bladder obstructs the power of the uterine contraction and results in the inadequate contractile expulsion of the placenta,
Abnormal Adherence or invasion of the placenta in the uterine wall: Sometimes placenta grows, attaches abnormally, and invades the uterine wall.

Placenta Accreta – The placenta attaches itself too deeply and too firmly into the uterus.
Placenta Increta – The placenta attaches itself even more deeply into the muscle wall of the uterus.
Placenta Percreta – The placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder.

Constriction ring-reforming cervix: A separated placenta may be trapped or incarcerated due to closure of the cervix before delivery of the placenta

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Retained Placenta: Management

Obstetric has to be informed
Continue IV infusion Oxytocin
Monitor blood loss
The patient needs close monitoring and go to the OT for manual removal
The patient should be kept NPO
Vaginal examination for palpable placental before shifting the patient to OT

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Management of a retained placenta

After the delivery of the infant and before the diagnosis of retained placenta, active management is recommended to facilitate spontaneous placental separation, including oxytocin, controlled cord traction, and uterine massage.

Details:

Management Details If the placenta is undelivered after 30 minutes consider:

Emptying bladder
Breastfeeding or nipple stimulation
Change of position – encourage an upright position

If the above method does not work but bleeding continues, Immediately:

Inform Obstetric Registrar/ Clinical Charge Midwife about the problem.
Insert large bore IV (16g) (patient needs high-density fluids or blood products)
Send group and hold urgently, ring and inform blood bank of urgency, request blood to be available for theatre within 30 minutes
send Full blood count
Continue Oxytocin infusion 20 units in a liter of NS at the rate of 250 mls per hour
Measure and accurately record blood loss
Prepare and complete appropriate documentation for theatre
While waiting for transfer, the patient has to be continuously checked for uterine contraction and vaginal bleeding. Blood pressure and pulse must be measured every 15 minutes.
Keep patient NPO
Transfer the patient to the theatre for manual removal of the placenta under general anesthesia.

Finally, a Vaginal examination should be repeated in order to check the placenta. If any segment or parts of the placenta is palpable in the vagina or lower segment of the uterus. A big as a possible portion is grabbed and the placenta is delivered.

Complications of Manual Removal of a Retained Placenta:

Perforation of uterus
Retained products
Infection

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Manual Removal of Retained Placenta: Complication

Perforation of Uterus
Retained products
Infection
Uterine Inversion
Shock
Puerperal Sepsis
Hysterectomy

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Complications of Manual Removal of a Retained Placenta:

Perforation of the uterus
Retained products: Sometimes a portion of placental tissue may remain in the uterus even while manual removal of placenta. It may lead to abnormal bleeding days after the delivery. Breastfeeding, manual removal, some medications are used in treating it. The term retained products of conception (RPOC) refers to placental and/or fetal tissue that remains in the uterus after a spontaneous pregnancy loss (miscarriage), planned pregnancy termination, or preterm/term delivery.
Infection: Due to the risk of endometritis, routine antibiotics are generally administered just before or shortly after manual removal of the placenta
Uterine inversion: Can be acute or chronic. Inversion can cause acute hemorrhage and shock. It can result from pulling of the cord while the uterus is still relaxing. If this occurs, it has to reposition without an attempt to remove the placenta.
Hypovolemic Shock: Excessive hemorrhage can lead to the hypovolemic shock
Puerperal Sepsis: due to the invasion of the sterile environment of the uterus, it might sometimes result in puerperal sepsis. It is the infection of the genital tract during the onset of labour and rupture of the membrane.
Hysterectomy: Sometimes, in cases of extensive placenta Accreta, Increta or Percreta, a hysterectomy might be the only solution.

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Third Stage Of Labour: Complications

Postpartum Hemorrhage:

Loss of more than 500 ml of blood within the first 24 hours after a vaginal delivery of the infant
Medical emergency and needs immediate attention

Note: Management depends on the delivery of placenta

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What would the nurse do?

A patient with normal first and second stages of labour is being managed for the third stage of labour (active method). Patient has no hypertension or heart valve disease. Syntometrine is given intramuscularly by the attending nurse, and the patient is under observation for the placental separation.

Was it wise to give syntometrine? Is there any step left to do before administration?

Is 3^rd stage being correctly managed by the active method?

How soon does the drug begin to contract the uterus?

What should have been done as soon as uterus contracted?

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Was it wise to give syntometrine? Is there any step left to do before administration?

Before administering syntometrine the presence of a second baby must have been ruled out.

Is the third stage of labour being correctly managed by the active method?

No. The placenta must be delivered when the uterus contracts. If the active method of managing the third stage is used, it is incorrect to wait for signs of placental separation. Instead, controlled cord traction should be used.

How soon after giving the Syntometrine does the uterus contract?

Syntometrine includes oxytocin which causes uterine contractions 2 to 3 minutes after intramuscular administration.

What should have been done as soon as the uterus contracted?

The umbilical cord should have been steadily pulled with one hand while the other hand was pushing upwards on the uterus, i.e. controlled cord traction. Placental separation and then placental delivery occurs with the uterine contraction.

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Management of Hemorrhage : Placenta Not Delivered

If Active Method:

Rapid IV infusion with side infusion of 20 units of Oxytocin
Controlled cord traction to deliver placenta with uterine contraction
Massage the fundus for the proper contraction of the uterus after placental delivery

If passive method:

Rapid IV infusion 20 unit of Oxytocin
Placental delivery by controlled cord traction
Attempt to deliver suggests retained placenta

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Management of a postpartum hemorrhage if the placenta has not been delivered?

Both of the methods have the same steps to follow:

Active Method:

If an active method is used, a rapid IV infusion with the side infusion of 20 units of Oxytocin in 1000 mls of normal saline has to be given over 4 hours (in order to ensure the proper uterus contraction)

Controlled Cord traction should be used to deliver the placenta.

Fundus has to be rubbed well in order to ensure the uterus contraction immediately after the delivery of the placenta.

Passive Method:

If the passive method is used, a rapid IV infusion with the side infusion of 20 units of Oxytocin in 1000 mls of normal saline has to be given over 4 hours (in order to ensure the proper uterus contraction)

Controlled Cord traction should be used to deliver the placenta.

Remember: If the attempt to deliver the placenta fails, the patient has a retained placenta and should be managed correctly.

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Management of Hemorrhage: Placenta Not Delivered

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Management of Postpartum Hemorrhage: Placenta Delivered

Dangerous Complication

Call for help
Massage the uterus
Rapid IV with side infusion of 20 units of Oxytocin
Check for perineal and vaginal tears
Empty the bladder
Rule out the reason for hemorrhage and manage it

Remember: The main causes of hemorrhage is atonic uterus and trauma.

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Management of a patient with a postpartum hemorrhage, when the placenta has already been delivered.

This is a dangerous complication and needs immediate attention and management

Step 1: Call for help: It is impossible to manage postpartum hemorrhage alone so one should call for help. Oxytocins, cannulation, infusion sets, IV fluids have to be made ready by one person where the other person will be controlling bleeding.

Step 2: In order to contract the uterus, it has to be rubbed or massaged. This will help in controlling bleeding.

Step 3: A rapid intravenous infusion should be started with a side infusion of 20 units of oxytocin in 1000mls of normal saline over 4 hours. Massage should be continued during this process.

Step 4: Check for perineal and vaginal tears as it may be another culprit of hemorrhage.

Step 5: A full bladder may interfere with the uterine contraction and leads to bleeding. Therefore, the patient’s bladder must be emptied.

After these steps have been done, the cause of hemorrhage has to be ruled out.

Nursing care includes:

Monitoring vital signs, amount of bleeding, and level of consciousness
Provide explanation, instruction, and reassurance to the patient
Call for assistance to help manage mother and infant
Documentation
Provide oxygen if necessary and order blood work if indicated
Allow infant to breastfeed ( stimulates oxytocin production and helps uterus to contract.

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Placenta Delivered

Management of Postpartum Hemorrhage:

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Cause of Postpartum Hemorrhage: Atonic Uterus

An atonic uterus: No tone in uterus to contract

Traumas, tears (lacerations): perineal tears, cervical tears, trauma due to instruments

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Atonic Uterus

Uterus feels soft and spongy
Bleeding (dark red clots) is intermittent
Escaping of clots while rubbing or massaging

Common Causes:

Blood clots
Full bladder
Retained placental fragments
Prolonged labour
Abruptio placentae

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Atonic Uterus: Uterus loses its tone and ability to contract leading to hemorrhage.
Clinical signs indicate that the bleeding is caused by an atonic uterus
The uterus feels soft and spongy. But tend to become atonic after rubbing or oxytocin infusion.
The bleeding consists of dark red clots and is intermittent
A large amount of dark red clots escapes from the vagina if the uterus is rubbed and becomes contracted.
Possible causes of an atonic uterus?
A uterus full of blood clots.
A full bladder.
Retained placental cotyledons (fragments).
Factors during the pregnancy, which resulted in an abnormally large uterus:

A large infant.
Multiple pregnancies.
Polyhydramnios.

A prolonged first stage of labour.
The intravenous infusion of oxytocin during the first stage of labour to augment uterine contractions.
General anesthesia: Paralyze the smooth muscles
Abruptio placentae: forms clots and concealed hematoma. Concealed hematoma increases the intrauterine pressure.

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Bleeding Due to Atonic Uterus: Management

Rub or massage of the uterus
Empty the bladder
IV Oxytocin 20 Units in 1000mls of NS
If no retention of placenta or parts, it needs doctors supervision
Rapid IV infusion and prepare for the transfusion
Manual Compression of uterus
Oxygen
IM ergometrine
Uterine Balloon (further management)
May need sub or total hysterectomy

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Management of postpartum hemorrhage if the clinical signs indicate bleeding from an atonic uterus

Massage up the uterus
Empty the patient’s bladder and start a fast intravenous infusion of 20 units oxytocin in 1000 ml Basol or normal saline.
If the placenta is complete (no retained placenta or placental parts) and the uterus remains poorly contracted, a doctor must be called urgently to examine the patient. In case a doctor is not available, the patient has to be referred to a tertiary hospital. While waiting for the doctor, or arranging a transfer, the following management must be followed:

Start a second, rapidly running IV. A blood transfusion may be required so it is wise to send some blood samples for urgent cross-matching.
The uterus must be manually compressed between a hand over the uterus abdominally and the other hand, palm upwards, in the anterior fornix of the vagina. This should control the bleeding until a doctor arrives or reaches a level 2 or 3 hospital.
Allow the patient to lie on her back and start oxygen via face mask.
One ampule of Ergometrine is given by intramuscular injection (If not available place 3 misoprostol tablets each 200 µg sublingually or to swallow.

Further management includes the use of a uterine balloon to tamponade the uterus to control bleeding.

NOTE: Patient may need a sub or total hysterectomy

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What Would the Nurse Do?

You are a nurse managing the third stage of labour in a level 2 hospital. After the delivery of the baby and placenta, you noticed that membranes or placenta are not complete, but the patient is not bleeding.

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Incomplete membranes usually do not cause any complications. But an incomplete placenta with one or more cotyledons missing can cause a postpartum hemorrhage due to an atonic uterus.

Management:

A nurse has to call for help
The nurse should start an IV infusion and side infusion of 20 Units of Oxytocin in 1000mls of Balsol or Normal saline. (In order to make the uterus contract)
The doctor has to be informed immediately and arrangements have to be made to transfer her to the OT to evacuate the uterus.
While processing the transfer, a blood sample has to be sent for urgent cross-match. The patient might need a blood transfusion.
Keep the patient NPO, as a general anesthetic may be necessary.
An evacuation of the uterus under spinal or general anesthesia is required if placental cotyledons are retained in the uterus.

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Reducing the Risk of PPH

Assess the risk factors like: multiple pregnancy, polyhydramnios
Start Intravenous infusion during the active phase of the first stage of labour
Give 20 Units of Oxytocin in 100mls of NS as soon as the placenta delivers
Ensure the contraction of the uterus during the first 2 hours of delivery of the placenta
Ensure the bladder is emptied

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Postpartum Hemorrhage: Tear Trauma or Laceration

Clinical Signs:

Uterus remains contracted
Red blood trickles continuously from the uterus

Management:

Place patient in lithotomy Position
Examination of tear for bleeding from an episiotomy in perineum area
Repair tear
If no tears are found outside, cervical tear or ruptured uterus may be present

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Clinical signs that indicate bleeding from a tear

The uterus is well contracted.
A continuous trickle of bright red blood comes from the uterus despite a well-contracted uterus.
Bleeding from a tear causes a continuous trickle of bright red blood in spite of a well-contracted uterus.

Correct management if the clinical signs indicate that the bleeding is from a tear

The patient should be placed in the lithotomy position for examination:

The perineum should be examined first for a tear and bleeding from an episiotomy.
If any tear present, it should be repaired immediately.
Second, examine the vagina for tear with the index finger of each hand to hold the vagina open. If a tear is found, it should be sutured.
In case there are no tears found in the vagina and perineal areas but bleeding is continued, a cervical tear or even a ruptured uterus may be present. Therefore, a doctor must be called to examine the patient or she should be transferred to a hospital so that these conditions can be excluded.

Note: If the episiotomy is not been stitched, it should be repaired (to stop bleeding).

If the episiotomy has already been repaired and bleeding continues, the stitches must be removed and the bleeding vessels must be identified and tied off (it should be resutured).

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Who Are at Risk of Cervical Tear?

Patients bearing down and deliver an infant before the cervical is fully dilated
Rapid labour when the cervix dilates very quickly
Delivery with the use of instruments

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An Inverted Uterus & Management

Signs of inverted Uterus

Unable to palpate uterus on abdominal examination
Uterus lies in the vagina or may even hang out of the vagina

Management:

Initiate two rapid -running IV infusions to prevent shock
Replace Uterus
Transfer patient to level 2 0r level 3 hospital

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What Would the Nurse Do?

A primigravida patient who did not cooperate well during the first stage of labour delivers soon after a vaginal examination. At the examination, the cervix was found to be 7 cm dilated and paper-thin. When observations were made an hour after delivery of the placenta, the patient was found lying in a pool of fresh blood. Her uterus was well contracted and her bladder was empty.

What would be the next step of a nurse?

What is the most likely cause of bleeding

Why is this patient at high risk of cervical tears?

How would a nurse manage this situation?

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Examination of perineum and suturing performed by a skilled practitioner and according to national and professional scope of practice regulations

What would be the next step of a nurse?

A rapid intravenous infusion should be started with a side infusion of 20 units oxytocin in 1000 ml Balsol or normal saline, and a nurse has to ensure that uterus is contracting.

What is the most likely cause of bleeding

A tear. Fresh blood with no clots are from tears or trauma

Why is this patient at high risk of a cervical tear?

Because the infant was delivered through an incompletely dilated cervix.

How would a nurse manage this situation?

The patient must be placed in the lithotomy position and be examined for a vaginal or perineal tear. Any tear must be sutured. If she does not find any tears in the vagina and perineal areas, it is more likely to be in the cervix.

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Red Flags

Retained placenta: Medical emergency
Bleeding more than 500 ml after childbirth- Postpartum hemorrhage
Weak uterine contraction: Atonic uterus
Third stage lasting more than 30 minutes
Heavy vaginal bleeding with a contracted uterus (indicates cervical or vaginal laceration)

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Cultural Considerations

A Muslim female will likely not want to with the male doctor or male nurse for vaginal examination
Ethiopian woman seclude themself for 40 days after the childbirth as they are considered dedicate after child birth
Some Somali woman refuse c-sections as they believe that a c-section will kill the baby in early age
Vaginal bleeding is considered impure in many south Asian countries, so woman after childbirth are not touched by the male members of the family until the bleeding goes away
Jehovah’s witness (mother) might not accept blood transfusion even during profused postpartum hemorrhage

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References:

Auckland District Health Board (2015). National Women’s Health Clinical Guideline / Recommended Best Practice: RETAINED PLACENTA MANAGEMENT. Retrieved on 4^th of October 2020 from https://nationalwomenshealth.adhb.govt.nz/assets/Womens-health/Documents/Policies-and-guidelines/Retained-Placenta-Management.pdf

BetterCare Learning programs (n.d). Maternal care: Third stage of Labour (CH 11). Retrieved on 2^nd of October 2020 from https://bettercare.co.za/learn/maternal-care/text/11.html#11-the-third-stage-of-labour

GLOWM (n.d). The safer motherhood Knowledge Transfer Program: The Active Management of Third Stage of Labour. Retrieved on 2nd of October 2020 from https://www.glowm.com/pdf/AMTSL_Wallchart_Single_FINAL.pdf

Perlman, N. C., & Carusi, D. A. (2019). Retained placenta after vaginal delivery: Risk factors and management. International journal of women's health. Vol. 11. Pp 527–534. https://doi.org/10.2147/IJWH.S218933

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