What Is Labor and Its Stages?
Childbirth (labor and delivery) is the end of pregnancy when one or more infants leave the mother's body through vaginal delivery or a cesarean section. The experience of labor is distinct for each and every woman. Sometimes it only lasts a few hours. Other times, labor puts a mother's physical and emotional endurance to the test.
There are three stages of labor,
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First Stage - The cervix (neck of the womb) dilates by 10 cm during the first stage.
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Second Stage - The baby descends via the vagina and is born during the second stage.
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Third Stage - The placenta (afterbirth) is delivered during the third stage.
The placenta and its connected membranes are delivered toward the end of the third stage of labor. However, the doctor realizes right away that difficulties are still possible after placenta delivery from a practical standpoint. Due to this, many authorities have supported what is known as the "fourth stage of labor," which starts with the placenta delivery and continues for an unspecified amount of time after. Although intervals as long as 4 hours have been proposed, the most common time is 1 hour.
Why Does the Third Stage of Labor Need to Be Managed?
The period from the time the baby is fully delivered until the placenta is fully delivered is referred to as the third stage of labor. The uterine contractility and the length of placental separation have an impact on the length of the third stage and associated problems. The third stage usually lasts less than 30 minutes in both multiparous and nulliparous women.
The third and fourth stages of labor are typically uneventful, but serious problems might arise during this time. The most frequent is postpartum hemorrhage (PPH). Although maternal mortality rates have significantly decreased in developed nations, PPH continues to be a major factor in maternal death.
Substantial evidence supports the routine administration of uterotonic drugs to reduce postpartum hemorrhage (PPH) by 40%. In addition, these drugs enhance uterine contractions naturally during the third stage of labor.
What Are the Risks and Complications in the Third Stage of Labor?
In the third stage of labor, complications are a possibility for every woman who gives birth.
These complications include,
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Uterine Inversion - The birthing process can result in uterine inversion, which could be fatal. After the baby is delivered, the placenta typically separates from the uterus and leaves the vagina about 30 minutes later. During uterine inversion, the placenta is still connected and pulls the uterus inside.
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Postpartum Hemorrhage (PPH) - PPH is the most typical third-stage labor complication. It has been amply demonstrated that active management of the third stage lowers the occurrence of this complication, which most likely has a good effect on maternal mortality and longer-term morbidities, including anemia.
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Retained Placenta - When the placenta is not delivered within 30 minutes of the baby's delivery, it is said to have been retained. Since it can result in major illness or life-threatening blood loss, it is a serious issue.
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Conditions Manifested During First Stage of Labor (Placenta Accreta) - When the placenta inserts itself too deeply into the uterine wall during pregnancy, a dangerous condition known as placenta accreta develops. After birthing, the placenta typically separates from the uterine wall. When a placenta accreta develops, some or all of the placenta is still connected. This may result in significant blood loss after delivery.
How Is the Third Stage of Labor Managed?
The third stage of labor can be managed in one of two ways,
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Passive or Expectant or Physiological Management of the Third Stage of Labor - The placenta is delivered spontaneously during the third stage of labor under expectant management. Doctors watch for symptoms of placental separation after the baby is delivered. When placental separation symptoms arise, the patient is instructed to press down, and the placenta is only naturally delivered through maternal effort. An oxytocic medication is only administered after the placenta has been delivered.
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Active Management of the Third Stage of Labor - The third stage of labor is actively managed with prophylactic uterotonic therapy, early cord clamping, and carefully timed cord traction to deliver the placenta.
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Prophylactic Uterotonic Therapy - It is a straightforward and well-researched strategy to provide uterotonics during the third stage of labor, which can greatly reduce the risk of postpartum hemorrhage.
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Delivery of Placenta With Controlled Cord Traction - After the woman's uterus has contracted after giving birth to her child and it is felt that the placenta has separated from the uterine wall, controlled cord traction (CCT) is used to pull on the umbilical cord while counter-pressure is applied to her uterus beneath her pubic bone until the placenta delivers.
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Uterine Fundal Massage After Placental Expulsion - Uterine fundal massage induces uterine contractions by promoting endogenous prostaglandin secretion after placental evacuation. This strategy was mentioned as optional for the active management of the third stage.
What Are the Various Uterotonic Agents Used in Active Management?
Various uterotonic agents used in active management of the third stage of labor are as follows,
1. Oxytocin - The drug of choice and the most widely used substance is Oxytocin. The amplitude and frequency of contractions are increased by Oxytocin, which only affects the smooth muscles of the uterus. After the baby's front shoulder has been delivered or the placenta has been expelled, Oxytocin may be administered. Typically, it is administered intramuscularly (IM) at a dose of 10 IU. Additionally, it can be administered intravenously (IV), which is frequently favored during cesarean operations (CS). Recently, a new Oxytocin pill is unveiled that can be successfully administered sublingually. Both modes of administration have the same effect on Oxytocin.
2. Ergometrine (Methergine) - Ergot alkaloids have a variety of physiological effects. They are non-selective 5-hydroxytryptamine-1 agonists with an affinity for dopamine and noradrenaline receptors. After being administered orally, ergot alkaloids are quickly and fully absorbed. After an intramuscular (IM) injection, both typically take effect within 1 minute to 5 minutes. Ergometrine leads to continuous contraction of the uterus. There is insufficient evidence about its use as a sole agent. It is administered as a dose of 0.2 mg IM. Patients with hypertension must refrain from using it.
3. Syntometrine - This has 0.5 mg of Ergometrine and 5 IU of Oxytocin. The uterine reaction starts sooner after IM injection than after Ergometrine alone, and the effect lasts many hours. Although a review revealed it to be more effective than Oxytocin, its use is limited due to the adverse effect profile (hypertension, nausea, and vomiting).
4. Misoprostol - This is a synthetic derivative of prostaglandin E1. It is a cheap medicine that may be easily kept. It is safe to use in patients with asthma and does not raise blood pressure. Flushing is the most common adverse effect of this drug. Misoprostol has been used as a preventative measure in numerous trials and has been demonstrated to reduce the quantity of blood loss. However, it is not as effective as Oxytocin. Misoprostol, which comes in three different dosage forms—rectally, sublingually, and orally—can be utilized as the first-line medication in nations with extremely low socioeconomic levels and a high prevalence of home deliveries.
5. Tranexamic Acid (TA)- It can travel via the placenta and reach a nursing child. It must be avoided in persons with renal insufficiency since it is eliminated through the urine. It can be administered parenterally, topically, or orally. It is often a medicine that is well tolerated. Rarely, it could result in hypotension, nausea, vomiting, and dizziness.
What Are the Drawbacks of Active Management of the Third Stage of Labor?
Adverse effects of uterotonic substances include,
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Ergot alkaloids cause hypertension, nausea, and vomiting.
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Placental retention risk.
Hazards to newborns from early cord clamping include,
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Anemia due to a lack of iron.
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Intraventricular bleeding.
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Hypertension.
Conclusion:
Everyone involved enjoys the time right after the baby is delivered, but the mother could face severe risks at this time. The period following the baby's birth and the placenta's complete ejection is referred to as the third stage of labor. As a result of the placenta being separated, there is some blood loss following the delivery. Both high-income and low-income nations experience a high maternal mortality rate due to postpartum hemorrhage (PPH). The term "active management of the third stage of labor" refers to the procedures of administering a drug to the mother (often by injection to aid in womb contraction), clamping the placental chord, and pulling on the cord while exerting counter-pressure to aid in placenta delivery (controlled cord traction or CCT). It could make the woman feel uncomfortable and sabotage her desire for a natural birth.
