A birth attendant applying active management of third stage of labour (AMTSL) is the key to reducing the risk of the complications set out in the Box below. The term 'active management' indicates that you are not waiting for spontaneous placental delivery. Rather, you will intervene in a carefully programmed sequential manner, as follows:
Immediately after the birth of the baby, check for the presence of a second baby by palpating the uterus through the mother's abdomen. When you feel certain that the uterus does not contain a second baby, and you can feel that it has reduced in size to no larger than at 24 weeks of gestation, go to step 2. The reason for checking so carefully is because the drug you will administer to the mother in step 2 will make the uterus contract so powerfully that it will damage a baby that remains inside it. If you find that there is a twin, give the the uterotonic drug after the birth of the second baby.
The commonly used uterotonic drugs in obstetric practice are:
These drugs help the uterus to continue contracting strongly and rhythmically after the baby is born: they facilitate placental delivery and help to prevent excessive bleeding from a relaxed (atonic) uterus. Although there are three possible drugs, for deliveries in low-resource settings, such as homes in rural areas, on many occasions misoprostol may be the only one of these drugs that you will be able to use. Oxytocin is the drug recommended by the World Health Organization (WHO), but it may not be practical for the following reason:
Oxytocin and ergometrine always have to be kept refrigerated at 2–8°C, so they are not suitable for a home delivery unless the household has a refrigerator, or you have a mobile icebox. They also have to be protected from exposure to light.
In less than one minute after the delivery of the baby, and after clamping and cutting the umbilical cord, give the mother one of the following:
OR (if you carry this in an icebox)
OR
When the uterus is well contracted it will feel very hard. This should occur between 2–7 minutes after the administration of the drug, depending on which one is given.
Note that ergometrine is not recommended for use by some rural health facilities.
Misoprostol is less effective than oxytocin and has more side-effects. However, in many rural situations you will have no other option but to use it because of the need to store oxytocin in a refrigerator or icebox. It will be important therefore to advise the mother that while it will be effective in preventing bleeding, she may also experience some side-effects. This applies whichever uterotonic drug you are giving, but especially in the case of misoprostol, which causes side-effects in a significant proportion of women. They are:
What is the great advantage that misoprotol has compared to the other uterotonic drugs?
It comes in tablet form, so injection equipment (syringes, needles) are not required, and it does not need to be stored in a refrigerator so it can be used where there is no way of keeping drugs very cold.
Oxytocin is the recommended uterotonic drug in all situations where it is feasible to use it, because it is more effective than the other drugs and has fewer side-effects. Oxytocin is a naturally occurring hormone in the woman's body, which is involved in the onset and progression of uterine contractions during labour. Manufactured oxytocin is given after the delivery to ensure that the uterus goes on contracting rhythmically, like natural uterine contractions. However, it does not have a sustained action (the effect subsides quite quickly) and it must be stored in a refrigerator and protected from light.
Ergometrine is less widely used because it is such a strong uterotonic drug that it may hasten the closure of the cervix before the delivery of the placenta. It takes longer to act than oxytocin (6–7 minutes when given intramuscularly) and it causes marked spasm of the uterus by a series of rapid sustained contractions, which are unlike the natural uterine contractions. However, it is long-lasting, with an effect over approximately 2–4 hours.
Ergometrine may not be approved for use in your health facility. It must never be given to a woman with pre-eclampsia, eclampsia or high blood pressure, because it causes the blood vessels to constrict, forcing her blood pressure even higher.
When the uterus is well contracted it will feel very hard. This should occur 2–3 minutes after the administration of one of the uterotonic drugs. Then controlled cord traction with counter pressure is used to help to expel the placenta (see Figure and Box below).
To avoid inversion of the uterus (turning inside out and coming out of the vagina), controlled cord traction should NEVER be applied without counter-pressure to the abdomen.
The following actions complete the rest of the delivery of the placenta.
As the placenta is delivered, it should be caught in both hands at the vulva to prevent the membranes tearing and some being left behind. Hold the placenta in two hands and gently turn it until the membranes are twisted (see Figure below). Slowly pull to complete the delivery of the placenta.
Delivery of the placenta marks the end of the third stage of labour. At this time the uterus should be hard, round and movable when you palpate the abdomen. You should be able to feel it midway between the mother's umbilicus (belly button) and her pubic bone. There should be no bleeding from the vagina. The bladder should be empty.
Right after the placenta is delivered, rubbing the uterus is a good way to contract it and stop the bleeding. Many women need their uterus rubbed to help it to contract.
You must look carefully at the placenta to be sure that none of it is missing.
From your knowledge of the anatomy of the placenta, which is the 'maternal' surface — the top side where the umbilical cord emerges, or the underside (bottom) of the pelvis?
The maternal surface of the placenta is the underside, opposite to the side where the umbilical cord emerges.
If a portion of the maternal surface (bottom of the placenta, see Figure below) is missing, or there are torn membranes with blood vessels, suspect that retained placenta fragments remain in the uterus and refer the mother quickly.
Can you explain why?
She is more at risk of postpartum haemorrhage if a piece of the placenta is retained in the uterus.
The irregular rounded shapes on the underside of the placenta are called lobes (some textbooks call them cotyledons). By contrast the top of the placenta (the side that was facing the baby) is smooth and shiny. The cord attaches on this side, and then spreads out into many deep-blue blood vessels that look like tree roots (Figure below).
The cut end of the cord has two arteries and one vein.
It is dangerous for the mother if any parts of the placenta or membranes are left behind in the uterus.
To complete the management of the third stage of labour, do the following:
Why is it important to complete the six steps of AMTSL in a particular order and what is that order?
Keeping to the exact order of actions is important, because the evidence on which AMTSL is based shows that if it is correctly applied (including in the right order) it can reduce the risk of PPH by 60%. Refer back to Box 6.2 if you can't remember the order of the six steps.