Guideline on Active Third Stage of Labor
The Ethiopian society of obstetrician and gynecologists wishes to thank the following persons and institutions for their technical and logistic support:
Ashebir Getachew, MD, obstetrician & gynecologist,
Biruk Tafesse, MD, obstetrician & gynecologist,
Mulu Muleta, MD, MPH, obstetrician & gynecologist,
Solomon Kumbi, MD, obstetrician & gynecologist,
Kasahun Kiros, MD, obstetrician & gynecologist,
Cristina Ruden, R.N., M.P.H.,
Tesfanesh Belay, MD
MOH: family health department
Office personnel’s of ESOG: - Tsion, Anteneh and Tsige
ANC antenatal care
AMTSL active management of the third stage of labor
DHS demographic health survey
FIGO International federation of obstetricians & gynecologists
EMOH Ethiopian Ministry Of Health
INTRAH Intra Health International Incorporated
ENMWA Ethiopian Nurse Mid Wife’s Association
USAID United States Agency for International Development
WHO World Health Organization
PPH postpartum hemorrhage
PPPH prevention of postpartum hemorrhage
Reduce Postpartum Hemorrhage (PPH) in Ethiopia and Focus on the Active Management of the 3rd Stage of Labor
The maternal health picture in Ethiopia is currently an alarming situation. The maternal mortality ratio in Ethiopia for the period of 1994-2000 is 871 deaths per 100,000 live births  and although statistics vary, it is estimated that 25,000 women and girls die each year from pregnancy-related complications. Additionally, the number of mothers who deliver at a health facility by a skilled attendant is less than 5%. Consequently, complications, which arise, cannot be properly managed and if a woman does deliver at a health facility and hemorrhages after delivery, only 18% of clients in rural areas have access to Postpartum hemorrhage (PPH) services and only 49% in urban areas  PPH accounts for greater than 25 percent of these maternal deaths.
Starting in March 2003, the Ethiopian Society Of Obstetrician & Gynecologists in collaboration with the Ministry Of Health through the Family Health Department, the Ethiopian Nurse Midwives Association and PRIME II/IntraHealth International have worked to improve maternal outcomes by bridging the gap between midwifery providers' current practices and evidence-based interventions for the prevention and management of PPH. Low-cost practices by skilled birth attendants to prevent and manage PPH improved maternal survival focusing on the active management of the third stage of labor (AMTSL) an intervention proven to effectively prevent PPH. As a result of this initiative, current practices in early postpartum have been replaced by redefining active management of the third stage of labor in selected sites in Ethiopia, Clinically, this consists of administration of a uterotonic (preferably oxytocin) immediately following the birth of the baby, application of a controlled cord traction maneuver, massage of the uterine fundus after placental expulsion, and close surveillance of the mother (and baby) thereafter for at least 2 hours. Results have yielded an increased number of skilled attendants practicing AMTSL; improved provider performance in the counseling and client-provider interaction, educating pregnant women and other key community members about the importance of and need for birth plans, complication readiness plans and having a skilled attendant at birth.
In order to sustain these newly introduced practices, revised national service policies, standards and protocols are needed to promote and support the practice of active management of the 3rd stage of labor in order to equip providers and pre-service teachers and trainers the documentation and verification needed to ensure AMTSL, as redefined by the World Health Organization, is translated to practice.
Cristina Ruden, R.N., M.P.H. Country Director, IntraHealth Ethiopia
The death of mothers and their children has been getting better emphasis since the 1989 safe mother hood summit in Nairobi. These were further strengthened by the Cairo conference and then the devising of the millennium development goal that aspires a decrease in the maternal mortality ratio by 50 % by the year 2015. We are only a decade far from the designated time but we still didn’t record a noteworthy reduction in maternal mortality.
Pregnancy and labor are still continued to be associated with enormous health risks particularly in developing countries. Forty percent of all pregnant women experience some degree of pregnancy related health problems in the course of their gestation. In nearly 15 % of the cases the complications are severe enough to threaten their life 3.
Annually 515,000 mothers die from complication of pregnancy and childbirth 4. It is a tragic fact that nearly ninety nine percent of these deaths occur in developing countries. In most of these countries more women tend to receive antenatal care (ANC) than delivery care. Unfortunately many of pregnancy and labor related complications can not be predicted early and significant proportion of mothers die with in 24 hours delivery; indicating the significance of appropriate care in delivery and postpartum.
Ethiopia has one of the highest maternal mortality in the world. Our maternal mortality ratio, 871 per 100,000 live births 1, is staggeringly high. Given a 3% annual birth rate about 20,000 – 25,000 mothers die every year 5 The country is among those 8 countries where nearly 50 % the world’s maternal death occurs.
Sever bleeding or hemorrhage, is the single most important cause of maternal death worldwide accounting for about 25% of maternal mortality. About14 million mothers bleed severely linked with their pregnancy and 128,000 bleed to death; survivors often suffer from severe anemia and continued ill health 6. In nearly 2/3 of these cases there is no identifiable risk factor.
Evidences, however, proved beyond the shadow of doubts that PPH can easily be prevented by universal application of the active management of the third stage of labor (AMTSL). This approach has been accepted by the WHO 7and international federation of obstetricians & gynecologists (FIGO) and has also been in practice for quite some time around the world.
To assess the adoptability of the practice of universal AMTSL to our situation, the Ethiopian society of obstetricians and gynecologists (ESOG) in collaboration with Intra Health International (INTRAH) implemented a pilot project in 24 sites in the country; including the capital Addis. The results were encouraging and explicitly showed that the practice can be replicated.
The practice of managing the third stage of labor actively was virtually non-existent at the beginning the pilot period. It was, however practiced in more than 90% of all the deliveries at the end of the project. Moreover, rapid transfer of knowledge and skill among providers was exhibited indicating the simplicity of the package. Many care providers expressed their satisfaction on the improved quality of care they are giving, reduced number of complication and referrals; and reduced time spent in managing the third stage of labor. Nevertheless, there were also some problems like shortage and lack of proper storage facilities for oxytocic drugs 8.
Based on the available evidences elsewhere and our achievements, the Ethiopian Ministry Of Health (EMOH) and ESOG developed this guideline in order to help all labor and delivery care providers familiarize them selves with all elements of the active management of the third stage of labor and provide evidence based care. Moreover ESOG has strong belief and conviction that the publishing of this document, disseminating it widely and in the processes of adopting the practice nation wide some of the problems noted during implementation of the pilot project will gradually be solved.
This guideline is intended to be used by skilled attendants at delivery; however, it can equally be useful for all delivery care providers. The manual is composed of sections that familiarize the user with the major components of the active management of the third stage of labor, management of potential third stage complications and precautionary measures in storing and handling of oxytocic drugs.
The guideline was developed through a series of processes in which experts from ESOG and the ministry of health actively participated. Moreover, through workshops it was tried to enrich the guideline by accommodating the suggestions and comments of the wider reproductive health community.
It should, however, be remembered that this manual doesn’t replace standard textbooks. It only contains guides, in one most important aspect of handling PPH. Thus, the user is advised to refer to standard texts especially concerning the detailed management of PPH and related complications when needed.
Steps of active management of labor
Most cases of PPH occur during the third stage of labour. The third stage of labor is the period of time from the birth of the child until the placenta is delivered. During this time, the muscles of the uterus contract and the placenta begins to separate from the uterine wall. The amount of blood lost depends on how quickly this occurs. The third stage typically lasts between 5 and 15 minutes. After 30 minutes, the third stage of labour is considered prolonged, indicating a potential problem. If the uterus is atonic and does not contract normally, the blood vessels at the placental site do not adequately constrict, and severe bleeding results.
A series of procedures, conducted during the third stage and collectively called Active management consists of interventions designed to speed the delivery of the placenta by increasing uterine contractions and prevent PPH by averting uterine atony.
The components are:
(1) Giving uterotonic (uterus-contracting) drug within one minute of birth of the newborn.
(2) Clamping and cutting the umbilical cord soon after birth.
(3) Applying controlled cord tension (also referred to as controlled cord traction) to the umbilical cord while applying simultaneous counter-pressure to the uterus through the abdomen; and
(4) Immediately massaging the funds of the uterus through the woman’s abdomen until the uterus is contracted.
• Within 1 minute of delivery of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units IM.
• Oxytocin is preferred because it is effective 2 to 3 minutes after injection, has minimal side effects and can be used in all women. If oxytocin is not available, give ergometrine 0.2 mg IM.
Controlled Cord Traction
• Clamp the cord close to the perineum using sponge forceps. Hold the clamped cord and the end of forceps with one hand.
• Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying counter traction during controlled cord traction. This helps prevent inversion of the uterus.
• Keep slight tension on the cord and await a strong uterine contraction (2–3 minutes).
• When the uterus becomes rounded or the cord lengthens, very gently pull downward on the cord to deliver the placenta. Do not wait for a gush of blood before applying traction on the cord. Continue to apply counter traction to the uterus with the other hand.
• If the placenta does not descend during 30–40 seconds of controlled cord traction, do not continue to pull on the cord:
→ Gently hold the cord and wait until the uterus is contracted again.
→ With the next contraction, repeat controlled cord traction with counter traction.
• As the placenta delivers, the thin membranes can tear off. Hold the placenta in two hands and gently turn it until the membranes are twisted.
• Slowly pull to complete the delivery.
• If the membranes tear, gently examine the upper vagina and cervix wearing sterile or high-level disinfected gloves and use a sponge forceps to remove any pieces of membrane that are present.
• Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placental fragments and manage accordingly (page 14).
• If uterine inversion occurs, reposition the uterus (page 15).
• If the cord is pulled off, manual removal of the placenta may be necessary (page 11).
• Immediately massage the funds of the uterus through the woman’s abdomen until the uterus is contracted.
• Repeat uterine massage every 15 minutes for the first 2 hours.
• Ensure that the uterus does not become relaxed (soft) after you stop uterine massage.
Examination for tears
• Examine the woman carefully and repair any tears to the cervix or vagina, repair episiotomies.
Management of third stage complications
1- MANUAL REMOVAL OF PLACENTA
→ Pethidine 1 mg/kg IV and Valium 5-10mg IV
→ Ketamine 2mg/kg IV slowly over 2 minutes
→ Ampicillin 2 g IV
FIGURE 1: Introducing one hand into the vagina along cord
FIGURE 2: Supporting the fundus while detaching the placenta
FIGURE 3: Withdrawing the hand from the uterus
2. RETAINED PLACENTAL FRAGMENTS
When a portion of the placenta—one or more lobes—is retained, it prevents the uterus from contracting effectively.
• Feel inside the uterus for placental fragments. Manual exploration of the uterus is similar to the technique described for removal of the retained placenta.
• Remove placental fragments by hand, ovum forceps or large curette.
Note: Very adherent tissue may be placenta accreta. Efforts to extract fragments that do not separate easily may result in heavy bleeding or uterine perforation.
• If bleeding continues in spite of a contracted uterus, assess clotting status using a bedside clotting test (Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy).
3. INVERTED UTERUS
The uterus is said to be inverted if it turns inside out during delivery of the placenta. Repositioning the uterus should be performed immediately. With the passage of time the constricting ring around the inverted uterus becomes more rigid and the uterus more engorged with blood.
→ Follow general care principles (appendix 1) and start an IV infusion.
→ Give analgesics and prophylacticantibiotics as described above.
→ Thoroughly cleanse the inverted uterus using antiseptic solution.
→ Apply compression to the inverted uterus with a moist, warm sterile towel until ready for the procedure.
→ Wearing sterile or high-level disinfected gloves, grasp the uterus and push it through the cervix towards the umbilicus to its normal position, using the other hand to support the uterus (Fig 4, P-15). If the placenta is still attached, perform manual removal after correction.
It is important that the part of the uterus that came out last (the part closest to the cervix) goes in first.
FIGURE 4: Manual replacement of the inverted uterus
→ If correction is not successful, try manual repositioning under general anesthesia using halothane. Halothane is recommended because it relaxes the uterus.
→ If correction is still not successful, combined abdominal-vaginal correction under general anesthesia is required.
Do not give oxytocic drugs until the inversion is corrected.
→ Once the inversion is corrected, infuse oxytocin 20 units in 1000 mL IV fluids (normal saline or Ringer’s lactate) at 10 drops per minute
→ If hemorrhage is marked, increase the infusion rate to 60 drops per minute.
→ If the uterus does not contract after oxytocin, give ergometrine 0.2 mg IV.
Storage and transportation of oxytocic drugs
Parenteral ergometrine, oxytocin and methyl ergometrine are the most commonly used drugs to prevent and treat PPH. However, occasional ineffectiveness of oxytocic drugs particularly ergometrine has been reported by obstetricians and others working in developing countries.
Although most reference books note that parenteral ergometrine should be stored at a temperature not exceeding 80 C and be protected from light, these requirements are neither followed nor better guidelines exist. This however stimulated different researchers to examine on the stability of oxytocic drugs in the tropics.
According to these studies, the stability of different injectable oxytocic drugs (ergometrine, methyl ergometrine, and oxytocin) at various temperatures and in various light conditions showed a gradual loss of the active ingredient over time, the decline being faster at higher temperatures.
When ergometrine and oxytocin were compared ergometrine and methyl ergometrine were both very unstable when exposed to light, with an average loss of 21% and 27%, respectively, of the active ingredient in one month (range 14-61%) and over 90% after one year.
oxytocin however was found to be more stable than either ergometrine or methyl ergometrine mainly because oxytocin lacks the adverse effects of exposure to light and is probably more stable when kept in the dark with or without refrigeration. The data on oxytocin generally suggest that the average quality at the level of the end use is acceptable.
Short exposure (2-4 weeks) to temperatures of 40-50°C in the dark was found to have no serious effect on any of the drugs.
→ In stores, dispensaries and labor wards ampoules of ergometrine, methyl ergometrine and oxytocin should be kept under refrigeration, and should only be taken from their box when actually used.
→ Temporary storage outside the refrigerator at a maximum of 300 C and protected from light is acceptable, in case refrigerated storage is not available for a particular period not exceeding 3 months.
→ For most products short periods of un-refrigerated transport are acceptable (not exceeding one month at 300 C or two weeks at 400 C). However careful supplier selection and International transport by air, not sea is strongly advised.
→ In general, it is safe to try to use the injections within one year of manufacture, irrespective of the official expiry date
→ The practice of keeping a few ampoules ready on a tray in the labor wards should be discouraged, especially for ergometrine and methyl ergometrine ampoules since they are light sensitive
→ Any ampoule with a color of the content different from water implies that more than 10% of the ingredients have been degraded, and that the ampoule should not be used.
→ In view of better stability in tropical climates, similar costs, and comparative efficacy, parenteral oxytocin, rather than parenteral ergometrine, is the drug of choice where active management of the third stage of labor is practiced.
Appendix 1 General care principles
(A) Infection prevention
The recommended infection prevention practices are based on the following principles:
(b) BASIC PRINCIPLES FOR PROCEDURES
FIGURE 5: The lithotomy position
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