MANAGEMENT OF 3RD STAGE

 Principles:- To ensure strict vigilance

Follow management guidelines strictly

Two methods are in practice

(i) Expected Management

(ii) Active Management

(1) Expected Management:- It has two parts

Placental separation

Its descent in to vagina

General

Continuous observation

If delivered in features of placental separation & amount of blood loss

Place hands over fundus

To note signs of separation & amount of blood loss

Place hands over fundus

To note signs of separation of placenta

To defect cupping of fundus

Note:- In this stage wait for spontaneous expulsion of placenta other wise assisted expulsion is done

Expulsion of placenta:-

When features of placental separation & decent in to lower segment are confirmed pt is asked to bear down with hardening of Uterus.

Increase  intra abdominal pressure causes expulsion of placenta

As soon as placenta is passed through introit us it is grasped by hands & twisted sound & round so that membranes are stripped intact.

If spontaneous expulsion is failed then following-

Assisted Expulsion

(i) Fundal pressure:-

Place four finger behind fundus & thumb in front 

Push fundus backwards & down wards

With draw the pressure as soon as placenta passes through introit us

Inspect vulva, Vagina & Perineum

(ii) Controlled cord traction:-

Place finger of left hand at the symphysis & from right hand steady tension is given

(Up ward & back ward towards the umbilicus)

Right hand steady tension is given in down ward & back ward dissection until placenta comes out side 

After expulsion of placenta & membranes, Inspection is done

Examine the Pt. for any vaginal bleeding

Genital area is cleaned with cotton swab

A sterile pad is placed over the valve.

(iii) Manual Removal of placenta under G.A:-

One hand is introduced in to the uterus is cone shaped

Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen.

As soon as the placental margin is reached the finger are insinuated between the placenta & the uterine wall.

The placenta is separated by slicing movement of the fingers

Separated placenta is extracted by traction of the card by the other hand.

2. Active Management:-

Principle:- To excite powerful uterine contraction

Advantages:- Minimize blood loss

Shorted the duration of 3rd stage

Disadvantages:- Increased incidence of retained placenta

Procedure:- 

Inj.- ergometrine 0.25 mg

Methargin 0.2 mp IV after delivery of ant. Shoal

Followed by delivery of body & placenta

If placenta is not delivered it should be delivered by controlled card traction.

If 1st attempt fails repeat it after 2-3 mints

If still fails than manual removal is to be done

IV stage management:-

Observe vital, behavior of uterus & any abnormal vaginal bleeding for 1 hrs.

If general condition is good pulse is normal uterus is contracted & no abnormal vaginal bleeding is present

Sent the patient to ward.