Physiology and Management of Normal Third Stage of Labour

PHYSIOLOGY AND MANAGEMENT OF NORMAL THIRD STAGE OF LABOUR

K. BHASKAR RAo, M.D., Resident Medical Officer, Govt. Raja Sir Ramaswamy Mudaliar's Lying-in Hospital, and Asst. Professor of Midwifery, Stanley Medical College, Madras.

For the past two centuries inches x 7 inches to 4 inches x 4 clinicians have thought over the inches without causing separation, mechanism of separation and ex- and maintained that the contraction pulsion of the placenta, because, till of the uterus, superimposed on this a clear understanding of this stage retraction, was the factor which of labour is reached, its management brought about placental separation. cannot be perfected. According to According to Eastman, placenta is Macafee, haemorrhage in the third torn off at the level of spongy layer stage of labour causes more deaths of the decidua "just as from the than any other obstetric complication. p e r f o r a t i o n s between postage In the Lying-in Hospital, Madras, · stamps." Shaw considers that the 18j~ of the maternal deaths in 1951 glands lie deeper still and take no were due to this complication. Apart part in the mechanism of separation. from the mortality, excessive blood The plane of cleavage occurs below loss during the third stage predis- the layer of Nitabusch in a layer of poses to increased puerperal mor- loose cells which are spread over the bidity. whole placenta and decidua vera. The physiology of the third stage Freeland observed that the peri covers two phases-separation of the phery of the placenta is the most placenta and its expulsion. It was adherent portion and separation formerly supposed that separation is begins elsewhere. This has been caused by the formation of a retro- confirmed by Brandt radiologically. placental haematoma. But we know The membranes remain in situ till the now, that the reverse is correct-that placental separation is complete and haematoma is the result and not the are then gradually peeled off from the cause of separation. In 1889, uterine wall partly by contraction and Barbour estimated that the retraction of the uterine wall and placental site after the delivery could partly by traction exerted by the shrink to about half its size from Jl separated placenta. The placenta, ''Based on a paper presented at the monthly meeting of The Obstetric and Gynae ---cological Society of South India, Madras on 26th July 1952.

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thus separated, slides down into the surface first. No blood is noticed till lower uterine segment or vagina aud placenta is extruded, as any bleeding is rarely expelled outside, withovt from placental site pours into the any external aid, in the dorsal inverted sac and is enclosed by position. The body of the uterus nc,w membranes. This method is likely to well contracted lies perched on top occur if the placenta is situated evP.n of the lower segment where the partially on the fundal wall, or in placenta is now situated. large placenta, high or sym metrical insertion of the cord, Signs of separation are (i) there is and when the membranes a trickle of blood from the vagina separate almost simultaneously when the placenta separates com with the placenta. (ii) Ma pletely. It is not always the case. thews Duncan's method:-Where In 12 out of 50 cases studied by me the placenta is delivered ed~ewise, no initial bleeding was noticed. (!.i) maternal surface first. Membranes Persistently globular contracted take longer time to separate and the uterus (Calkin's Sign). (iii) The upper end of placenta is held in the fundus of the uterus rises higher to upper segment resulting in more loss the level of the umbilicus or a little of blood. Forceful expression of above it and is dextroverted as placenta before it is completely in the well.-Noticed in only 3 cases (pro lower segment will change Schultze's bably I did not wait sufficiently long). type into that of Mathews Duncan's. (iv) Distension of the lower uterine segment by placenta as shown by - ~ Incidence of the Two Types of slight suprapubic bulge. If the Placental Delivery placenta lies in the vagina-this sign is negative. ( v) If fundus of the uterus is lifted up and the placenta No. of M. is separated, cord remains stationary cases Schultze's Duncan's outside. (\!i) The length of cord lying outside the vulva increases. Of Tucker 2700 64.8 % 35.2 % these probably the early signs (seen Freeland 2600 82.5 7r 17.5 ~lc in 4-7 minutes) are slig1ht initial Pastore 1870 71.1 7r 28.9 % bleeding and Calkin's sign. Others Ours 50 56.0 ;~c 44.0 /o ~ are not signs of separation but those of placental descent (seen later-14 to 17 minutes). Mathews Duncan's method is al ways associated with more loss of Once it is separated, it is ex blood than Schultze's type of deli pelled-rarely by itself or .by aid of very. gravity, but often by increased intra abdominal tension or external manual aid. There -are two methods of Schultze's M. Duncan's placental expulsion. (i) Schultze's Burton-Brown 180 ml. 360 ml. method:-The placenta is expelled Our series 92 ml. 205 ml. like an inverted umbrella-foetal

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Radiological Evidence. Over 30 Method of Study. Only 50 normal years ago, Warnekros and Weibel vaginal deliveries were studied. independently demonstrated by in . After the head was born, the delivery jection of radio-opaque substances of the child was performed slowly. into umbilical vein (after the delivery At the completion of the delivery of of the child) that (i) placental sepa the baby the stopwatch was started. ration occurs within 3 to 5 minutes, An Aluminium "bed-bath" (broader, often with first or second post flatter and more comfortable than a partum contraction, (ii) and that the bedpan) with 3 ounces of 3 y~ Sodium Duncan and . Schultze's methods Citrate solution was kept below the develop only in the vagina as the buttocks, soon after the liquor amnii placenta emerges out from vaginal which follows the child was drained outlet. Brandt injected Sodium off. The time of placental separation Iodide solution into umbilical cord in was noted and later when it was ex 30 . cases and showed that placental pelled completely the stop-watch was separation is complete in 3 minutes. ticked off to mark the duration of the More · recently, Burton-Brown third stage. The placenta and ~ he injected 20-45 ml. of 50-75% blood was collected in the bed-bath pyelosil into umbilical vein in 13 which was removed at this stage. cases, and after a radiographic study After cleaning the placenta of the concluded that placental separation blood and clots, it was examined is completed by 4t minutes. and weighed. The few clots in the

Duration of Third Stage

Text book teaching. Radiological Methods.

Johnstone-Few minutes to an hour. W'Kros- 3 to 5 minutes. Average 20 minutes. M. Kerr-15-30 minutes. B randt- 3 m inutes. Average 20 minutes. Shaw- 20 minutes. B-Brown--H minutes. Mudaliar-- ~- 1 hour--Primi. Clinical lVIethods: 15-30 minutes-Multis. Calkins- 4 minutes. Sometimes a few minutes. Our series-3 minutes 2!1 seconds.

Normal blood loss in the placental receptacle were manually broken stage:-With expulsion of placenta, into very fine bits and the volume of uterus contracts and retracts; and in citrated blood was measured with a addition small thrombi close the graduated jar. The initial volume of maternal sinuses; but with the placenta, there is some blood lost; and citrate solution used was deducted it has been estimated by different from this reading and the volume of workers . blood lost was obtained.

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Duration of Third Stage and Blood Loss in 50 Normal Deliveries. Duration of Third Stage. Blood Loss. No. of cases No. of cases Less 1.han 3 minutes 20 Within 30 ml. 4 5 47 , 60 ml. 12 " " " , 6 49 100 ml. 20 " " " 12 50 150 ml. 34 " " " " ; , 200 ml. 40 300 ml. 48 " Average duration: 3 minutes and 25 Over 300 ml. (390 ml.) 2 seconds. Average blood loss:-141 ml. --- - ··-- Atonic Postpartum Haemorrhage occurred in 4 cases, after the placental expul sion, needing ergometrine parenterally. Average Blood Loss in Third Stage After the delivery, a hand is kept on of Labour the fundus of the uterus, awaiting No. of cases Average loss signs of separation or bleeding. Easlman 348 245 ml. Browne is very outspoken when he Calkins 800 179 ml. remarks, "The well trained student or doctor should be able to control Pastore 2394 230 ml. J Ours 50 141 ml. himself as well as the fundus. If he cannot do so he should change his Bleeding is greater when there is profession." In the absence of bleed an episiotomy or perineal tear (Dieck ing do not massage a lax uterus. mann estimates it as 250 ml.) large Once the placenta has separated it child, twins, or delivery under ether can be expelled. Before that, anaesthesia. After placental expul bladder should be empty and the sion, there is slow oozing of blood uterus contracted. The placenta is an average of 73 ml. for the first now expressed. The usual method hour-it is negligible in volume after followed is Crede's method. It wards-52 ml. for 24 hours excluding does not mean grasping the funcius the first hour ( Dieckmann) . The of uterus and squeezing it forcibly chances of relaxation of the uterus "like squeezing an orange till the and postpartum haemorrhage occur pipe squeaked" but is a more gentle ring are therefore greatest during procedure. Shaw, after g1vmg this first post-placental hour and Crede's original description of the Greenberg suggests labelling it as procedure, emphasises that Crede fourth stage of labour so that patients meant only a gentle massage to sti be looked after very carefully during mulate uterine contraction and then this period. .a gentle and outward pressure to Management starts from the end expel a placenta which is already o£ the second stage. Slow delivery separated. When it presents at the of the foetus is an important proce vaginal orifice, it is grasped by hand dure in reducing the blood lof;S . and slowly rotated. Slight traction

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and rotation helps in the complete 0.2 mg. has been given intravenously removal along with the membranes soon after the birth of the anterior which are formed into a "rope". It "shoulder (Davis and Boynton) or is then carefully examined. posterior shoulder (Dieckmann) or 0.5 mg. intramuscularly as soon as the The Place of Cord T-raction in the head gets crowned (Daley); or after Third Stage of Labour.-Munro Kerr the delivery of the head (Flevv). advises it for postgraduates only, Dieckmann feels that 0.2 mg. is too when the placenta has separated and uterus is contracted. Shaw mentions small a dose and prefers 0.4 mg. in travenously after the. posterior it as a part of the procedure during shoulder, and recommends slow deli expulsion of the placenta. It is given very of the foetus. Lister prefers as a prominent place in the Brandt- Andrew technique of placental ex- high a dose as 1.0 mg. of Ergometrine pulsion. Recently Picton has claimed intravenously and has treated 1500 cases with this dosage without any that it is a procedure of choice in side effects. Pitocin has been used obese patients (where great pressure is needed) or in cases where the by Dieckmann in 1 unit doses (along placenta has descended into the with 9 ml. of normal saline) intravenously and he found it more effica· vagina. But in every case placenta ci·ous in producing uterine con must have been separated and uterus contracted before this is tractions but preferred ergometrine attempted. to it for its prolonged effect. Lister If placenta has not separated in confirming this showed that the - -Crede's method should be tried. incidence. of delayed haemorrhage ( 15-30 minutes after delivery) was Manual removal of the placenta 18.9% in the oxytocic group when even in the absence of any bleeding may be done after half an hour. If compared with 0.6 % in the ergomet- bleeding is present at any time rine group. The placenta separates normally when intravenous oxytocics earlier, manual removal of the are given. In other words separation placenta is immediately done. is not hastened, but the expulsion is The Place of Oxytocics in the Third quickened owing to the good con Stage of Labour. During the past tractions of the uterus-reducing the decade numerous papers have ap- third stage of labour and minimising peared on this subject. Ergometrine the bloqd loss. Duration of Third Stage and Blood Loss with Oxytocics in Third Stage of Labour. ------' Authors. No. of cases Duration of Third Stage. Blood loss. Davis. 1020 Within 3 minutes in 72 %. Under 100 ml. in 81 %. Dieckmann. 900 Within 3 minutes in 92 %. Under 100 ml. in 95 %. Lister. 1500 Under 2 minutes in 75 %. Under 150 ml. in 94 <;i: .

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With oxytocics before placental emphasised. By proper management separation, hour glass contraction is of this terminal stage of labour so a theoretical risk. many valuable lives can be saved.

Incidence of Manual Removal of Summary. The physiology of Placenta. normal third stage of labour has been discussed. 50 cases of normal vagir..al Control. Ergometrine Group. route deliveries were studied in Daley 490-5 510 cases--6 (Little oqer third stage of labour. The average 1 %). duration of third stage was 3 minutes Davis 1 in 127 (Less than 1 % ) . 25 seconds; and the average blood Flew 500 cases-Nil. loss was 120 mi. The management f of the placental stage is described Lister 1.6 %. and the place of oxytocics in this l stage has been considered briefly. Methyl ergonovine tartrate (M-et-h.ergin)-a semisynthetic ergot References: alkaloid acts as quickly as ergo metrine but has been claimed by Gill 1. Barbour-Quoted by Burton- to be 1.5 times stronger and 1.3 times I Brown. longer in duration than ergometrine. 2. Brandt-Quoted by Eastman. Another advantage is that it is less likely to raise the blood pressure of 3. Browne, F . J.-Postgraduate the patient than ergometrine (For Obstetrics & Gynaecology, London, man and Sullivan). Sandin and 195, 1950. Hardy reported that when Mether 4. Burton-Brown, J . R. C.-J. Obstet. gin was followed by a calcium salt Gynaec. Br. Emp., 56, 847, 1949. (Neo-calglucon) intravenously in the 5. Daley D.-J. Obstet. Gynaec. Br. third stage of labour, the average ~ blood loss was reduced to 35.6 ml. Empr., 58, 388, 1951. when with methergin alone it was 6. Davis & Boynton-Quoted by l 84.2 ml. Dieckmann. So there are obvious advantages in 7. Dieckmann W. J. et al-Amer. J. using oxytocics in the third stage of Obstet. Gynaec., 54, 415, 1947. labour. But in our hospital for various reasons we do not use it as 8. Eastman N.J., William's Obstetrics, a routine measure but as a prophy lOth Edn., New York, 349, 1950. lactic in a selected type of patients. 9. Forman J . B., & Sullivan R. L. (i) All deliveries under anaesthesia; Amer. J. Obstet. Gynaec., 63, 640, (ii) twins; (iii) hydramnois; (iv) 1952. multiparae-beyond 7th; and (v) after prolonged labour. 10. Greenberg E. M.-Amer. J . Obstet. Gynaec., 52, 746, 1946. Importance of the study of the normal third stage cannot be over 11. Johnstone R.W. & Kellar R. J .,-

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Text book of Midwifery 14th Edn., 16. Picton F. C. R.-J. Obstet. Gynaec. London, 151, 1949. Br. Emp., 58, 764, 1951. 12. Lister U. M.-J. Obstet. Gynaec. . 17. Sandin H. V. & Hardy J.A. Br. Emp., 57, 210, 1950. Amer. J. Obstet. Gynaec., 61, 1087, 1952. 13. Macafee C. H. G.,-Physiology of Third stage (Modern Trends in 18. Shaw, William Fletcher, Sir, Obstetrics & Gynaecology-Bowes J. Obstet. Gynaec. Br. Emp., 55, K.) London, 324, 1950. 502, 1948. 14. Mudaliar A. A. L.,-Clinical Obs 19. Shaw W.,-Text Book of Mid tetrics, Madras, 612, 1951. wifery, London, 88, 1947. 15. Munro Kerr J . M., & Mair J. C., 20. Warnekros & Weibel,-Quoted by Operative Obstetrics, London, 53, Curtis-Obstetrics & . Gynaecology, 1949. London, 791, 1937.