Third stage (placenta delivery, post-placental) - Qpercom

Objective
The third stage begins as soon as the child has been born and ends with the birth of the placenta. It can therefore be defined very exactly. The duration is mostly between 10 and 30 minutes.
The post-placental stage lasts up to two hours after the birth of the placenta. It is important that the midwife remains present during these stages to diagnose any potential complications in time.
The objective during the third stage is to carefully estimate the general condition of the newborn infant and to take measures if this is not satisfactory, and at the same time to carefully monitor the condition of the new mother, to ascertain that no postpartum haemorrhage occurs and that the birth of the placenta takes place correctly.

Procedure

During the third stage the following tasks must be performed:

note the time of the birth
drain the nose, mouth and throat of the newborn
determine the Apgar score after 1 and 5 minutes
clamp the baby’s umbilical cord
hand the child to the mother
perform check-ups on mother. Note the fundal height: a fundal position that is too high can be the consequence of an unrecognised multiple pregnancy or of intra-uterine blood loss. Also note the strength of the uterine contractions, vaginal blood loss and any possible tear in the wall of the vagina or perineum
supervise the birth of the placenta.

The neonate immediately after birth
As soon as the infant has been born, it needs to breathe. The lung circulation begins and must not be hindered by mucus and/or blood in the air passages. This moment is crucial for the newborn and the vital functions should therefore be assessed immediately after birth and recorded in the Apgar score. The connection with the mother should be broken by cutting the umbilical cord. Measures must be taken to ensure that the child does not cool down too much.

Clearing the nose, mouth and throat
Immediately after the birth of the head the mouth should be wiped clean and the nose cleared. As the baby starts to breathe, the nose and oral cavity must be cleaned thoroughly to prevent mucus, amniotic fluid and/or meconium being aspirated during the first breaths. This reduces the risk of so-called aspiration pneumonia.

Procedure

Take mucous suction device.
Place the broad mouthpiece in your mouth.
Carefully place a little finger in the child’s mouth or hold the mouth open by exerting external pressure on the cheeks.
With the other hand carefully insert the small suction part past the little finger into the mouth and throat (about 4 cm).
Pull the tube backwards in one movement while sucking through the mouthpiece.
Insert the narrow suction part carefully into one of the child’s nostrils.
Carefully drain the nostril.
Repeat the last two steps in the other nostril.
Catheterise the oesophagus and if necessary drain the stomach.
Do not allow the entire clearing procedure to last longer than about 15 seconds.

Determine the condition using the Apgar score
With the help of the Apgar score five important and easily observed clinical criteria are evaluated:

heart rate
breathing
skin colour
muscle tone
response to stimuli.

Although there are some objections to this method (subjectivity and limited relationship with the later development of the child), it is still generally used due to its simplicity.
For each criterion a score of 0, 1 or 2 points can be given. The total score (minimum 0 and maximum 10) gives an impression of the neonate’s vitality.
The Apgar score is determined 1 minute and 5 minutes after birth. If necessary the score can be repeated after 10 minutes. Interpretation of the total score is as follows:

8-10 points: optimal score
6-7 points: indicates moderate depression of the vital functions
4-6 points: indicates severe depression of the vital functions
1-3 points: indicates very severe depression of the vital functions
0 points: indicates a dead child.

For a score of less than 10 it is recommended that the individual scores are noted in addition to the total score.

Heart rate
A normal newborn has a heart rate of 100 to 120 beats per minute. This can be established with a stethoscope at the apex of the heart or on the umbilical cord by palpating this several centimetres from the attachment to the child.

A heart rate of more than 100 beats per minute: 2 points
A heart rate of less than 100 beats per minute: 1 point
The absence of any observable heart action: 0 points.

Breathing
The strength of the crying provides a good indication of the quality of breathing. A healthy baby continues to cry strongly. The breathing rate will be at least 30 breaths per minute. The breathing rate is established by observing the abdominal breathing or listening to the chest with the help of a stethoscope.

Regular, powerful breathing at a rate of more than 30 breaths per minute, good continuous crying: 2 points.
Weak, slow (less than 30 breaths per minute), irregular breathing, ‘gasping’ for air: 1 point.
The absence of any observable breathing: 0 points.

Colour
The colour of the neonate it is a good measure of the oxygen supply during the passage through the birth canal. Optimally, there is a pink baby. This is rarely the case. The hands and feet usually retain a blue discoloration for some time. This is the consequence of blood stasis due to the obstruction of venous return caused by the flexed position of the hands and feet during delivery.
A distinction is made between blue and white asphyxia. In the case of white asphyxia the baby has too little circulating volume. Oxygen administration with the intention of improving the oxygenation has little effect, because the baby has insufficient resources to transport the oxygen. The prognosis is therefore worse than in the case of blue asphyxia.
Blue asphyxia occurs due to the insufficient saturation of the haemoglobin present. After oxygen administration the child will usually gain colour quite quickly if there are no other factors hindering oxygen uptake. The prognosis is therefore better.

Entirely pink: 2 points.
Pink torso and head and peripheral cyanosis: 1 point.
A completely blue (cyanotic) or very pale baby: 0 points.

Muscle tone
A healthy newborn will hold their limbs in flexion and adduction. The examiner will therefore feel resistance upon passive extension of the limbs.
When crying, the child will wave its arms and legs around. If there is reduced muscle tone it will be easier to extend the newborn’s limbs, after which they will slowly return to flexion or not at all. A completely flaccid baby lies still with the extremities in extension and abduction. No resistance is observable. The child does not move when crying.

Good muscle tone: 2 points.
Moderate, reduced muscle tone: 1 point.
Complete hypotonia, flaccid child: 0 points.

Response to stimuli
The child can be stimulated in various ways. In a healthy child, stroking or tapping the sole of the foot causes a retractile movement of the leg concerned. The insertion of a mucous suction device into the mouth, throat or nostril causes a grimace or makes the child cry.

Retraction, grimace, crying: 2 points
Moderate response: 1 point
No response at all: 0 points.

Tying the umbilical cord
If the child is in a good condition, the tying of the umbilical cord can be deferred by a few minutes. Once the child has cried several times sufficient blood will have been drawn into the circulation. If the child is born in a poor condition and therefore has a poor Apgar score, its umbilical cord should be tied as quickly as possible so that it can receive further proper treatment on the changing table or other suitable surface.
When tying the umbilical cord before the child has cried, stroke the umbilical cord empty several times in the direction of the child, so that the child receives extra blood from the placenta to ensure that the pulmonary circulation has sufficient blood once breathing starts.

Procedure

Holding the Kocher clamp in your hand, clamp the umbilical cord at about 5 cm from the abdominal skin of the newborn.
Stroke the umbilical cord along about 2-3 cm in the direction of the placenta to empty it.
Place a second Kocher clamp nearer to the placenta 2-3 cm away from the first.
Place a plastic umbilical cord clamp on the umbilical cord 2-3 cm away from the newborn’s abdominal skin (between the abdominal skin and the first Kocher clamp).
Hold the umbilical cord between the two Kocher clamps in the fold of the hand and cut through it.
The first Kocher clamp can then be removed; the second remains attached to the placental part of the umbilical cord.
In the case of rhesus incompatibility:
Detach the Kocher clamp from the umbilical cord.
Hold the bleeding end of the umbilical cord above a lab vial.
Allow about 10 ml of blood to pass out of the umbilical cord into the vial.

Handing the child to the mother
It is important that the mother sees the child herself and holds it as soon as possible after the birth. After the birth, the child is wet and slippery (vernix). As the child can thrash about, it is important to hold the child safely when transporting it.

Procedure

Hold the ankles of the baby in one hand in a fork grip [Figure 33a].

Figure 33a

Place the thumb and index finger of the other hand dorsally around the baby’s neck and if necessary hook the little finger under the child’s armpit [Figure 33b].

Figure 33b

Hand the child to the mother [Figure 33c].

Figure 33c

Dry the child and cover it with a dry flannel or other cloth.

The mother immediately after birth
The initial focus of attention after birth is the newborn child. However, as soon as it has been established that the child is in a reasonable condition, it is important to pay attention to the mother. There is always a risk of postnatal complications, and these must be identified as early as possible.

Checking the mother immediately after birth
The quantity of vaginal blood loss must be assessed as well as fundal height and the strength of the uterine contraction, since the latter is the most important factor in stopping blood loss from the uterus and releasing the placenta.
If the fundal height increases, it can be a sign of retroplacental haemorrhage. In this case it is important that the placenta is born quickly. If the fundal height does not increase and the uterus remains well contracted, the immediate birth of the placenta is not so urgent.
During a normal parturition blood loss mostly remains limited to less than 500 ml. In the Netherlands a postpartum haemorrhage is said to occur if the blood loss is greater than 1 litre. The international WHO definition states a limit of 500 ml or more blood loss postpartum. In unfavourable circumstances, such as a low hemoglobine (Hb), measures to limit the blood loss are taken earlier, e.g. by administering substances that stimulate uterine contraction (e.g. oxytocin 2 IU intravenous or 5 IE intramuscular). Ergotalkaloids (methylergometrine) are contraindicated as long as the placenta has not been born.

Procedure

Place a bedpan under the woman’s buttocks so that it collects the vaginal blood loss.
Place the ulnar border of the hand on the mother’s abdomen and palpate for the fundus.
Determine the fundal height (normally the height of the navel).
Determine the state of contraction of the uterus; this should be well contracted. If necessary gently massage the uterus.
Regularly inspect the contents of the bedpan and estimate the blood loss. In the case of doubt, measure the quantity of blood.
Inspect the perineum, the anal sphincter, the labia and the vulva for ruptures.
Measure the woman’s pulse rate and blood pressure.
Cover up the woman, ensure that she is relaxed and stay with her.
If necessary administer 1000 IU anti-D gamma globulin intramuscularly.

Checking the child immediately after birth
Tasks to be performed:

perform the neonatal examination
put the baby to the mother’s breast if desired
determine the Apgar score
take the temperature
note the umbilical cord stump (bleeding)
note micturition and defecation
administer 1 mg vitamin K orally.

Birth of the placenta
The third stage ends with the birth of the placenta. After the birth of the child the uterus contracts powerfully around the greatly reduced contents. The fundus rises to the height of the navel. Due to the contractions the uterine wall becomes firmer and can be palpated externally. The placenta, which is usually located in the fundus, becomes compressed by the shrinking uterus and therefore becomes thicker. The uterine wall shortens as a result of which the area of placental attachment becomes smaller. This leads to the vessels that proceed from the myometrium to the placenta becoming torn. A haematoma develops as a result of which the placenta is separated further from the site of attachment. Due to the postpartum contractions, the placenta and membranes become increasingly detached from the uterus. Usually the placenta is completely detached within several minutes of a child being born. As the membranes are often still attached to the uterine wall, the placenta is only driven slowly to the lowest uterine segment.

Küstner’s manoeuvre
About 15 minutes after the birth of a child it is usual to assess whether the placenta is in the lower uterine segment and detached. This is done with the help of Küstner’s manoeuvre.

Procedure

With one hand take hold of the Kocher clamp on the umbilical cord.
Exert moderate traction on the umbilical cord side such that this becomes tensed.
Place the ulnar border of the other hand transversely across the mother’s abdomen, just above the pubic symphysis.
From this position above the pubic symphysis, exert downward pressure on the abdominal wall and consequently on the tensed umbilical cord [Figure 34].

Figure 34

If the placenta is still in the uterine cavity (detached or fixed) the umbilical cord will be pulled inwards slightly (negative Küstner sign).
If the Küstner sign is negative, it can be repeated after about 10 minutes.
If the placenta lies in the lowest uterine segment or in the vagina, the umbilical cord will protrude outwards slightly (positive Küstner sign).

Supervision of the birth of the placenta
When it has been established that the placenta is detached using the above approach, the modified Bär manoeuvre follows. The aim of this is to support the abdominal wall during the expulsion of the placenta. Due to the increased space in the abdomen following the birth of the child, an effective abdominal push is no longer possible. In the majority of cases the placenta is born quickly with the aid of the modified Bär manoeuvre and this is referred to as passive management of the third stage of labour.

Modified Bär manoeuvre

Procedure

The woman should lie in the supine position with both legs flexed.
If the uterus is not contracted, stimulate its contraction by gently massaging the fundus.
Support the abdominal muscles by placing the palms of the hands slightly under the navel transverse to the direction of the rectus abdominis muscle.
Take the end of the umbilical cord where the Kocher clamp is located in the other hand and exert carefully traction on the umbilical cord [Figure 35].

Figure 35

Have the woman push during a contraction of the uterus.
Allow the placenta and the membranes to be slowly born.

If the membranes do not follow:

Take the placenta in both hands.
Rotate the placenta several times by 360°. This rotation will cause the membranes to shear from the uterus wall.

If there has been considerable blood loss before the placenta is born, it may be advisable to speed up the birth of the placenta.
This is discussed later in the section entitled Special skills during childbirth.
If the placenta has still not been born one hour after the birth of the child, there is little chance that this will still happen spontaneously and the patient must be referred to hospital, even in the case of little blood loss.

Inspection of the placenta
Once the placenta has been born the following examination should be performed:

Inspect the maternal side of the placenta and note:
- completeness
- lobes
- haematomas
- open vessels on the edge of the placenta (secondary placenta).
Inspect the foetal side of the placenta and note:
- position where umbilical cord is inserted
- inspect the membranes and note the completeness
- the location of membrane rupture
- blood vessels.
Inspect the umbilical cord and note the number of vessels (2 arteries, 1 vein)
- knots (true and false)
- quantity of Wharton jelly; length.
If parents are interested, show them how the child, surrounded by the membranes, was positioned in the uterus.
Determine the quantity of blood lost in millilitres or grams.

Inspection of the vulva, vagina, perineum and anal sphincter
If an episiotomy was not performed, then the vulva, vagina wall, perineum and anal sphincter will have been placed under considerable pressure. During the delivery of the head, in particular, these structures will have been stretched as a result of which tearing could have taken place. Even if an episiotomy was performed during parturition, tears in the vagina, vulva or perineum could still have occurred in addition to the episiotomy wound.

Diagnosing labial tears

Procedure

Ensure good lighting.
If necessary dab the labia clean.
Inspect the labia major and minor (especially on the inside) carefully and when doing this note tears.

Diagnosing vaginal wall tears

Procedure

Ensure good lighting.
Dab the vaginal wall clean as well as possible.
Insert a gynaecological tampon (gauze with a string attached) as high as possible into the vagina and allow the string to hang out of the vagina.
Spread out the vagina wall as far as possible and inspect it for small tears.

Diagnose first, second and third degree tears
It is important to establish the severity of the tear.
Severity of tear is defined as follows.

First-degree tear. The most superficial and most frequently occurring type. Only the skin and/or epithelium of the vagina wall are lacerated. The underlying tissue is still intact. In general, this tear does not need to be sutured.
Second-degree tear. Besides the skin and/or the vaginal wall, the subcutaneous connective and/or muscle tissue is torn. The muscle fibres of the anal sphincter are, however, still intact. This type of tear should always be sutured. This can mostly be done immediately postpartum by a GP, physician or midwife.
Third-degree (total) tear. This is the most severe and least frequently occurring form. Besides the skin, vaginal wall and subcutaneous connective and muscle tissue, the muscle tissue of the anal sphincter is either partially or completely torn. Sometimes the rectal mucous membrane has also been torn. Such a tear should be sutured by a specialist.

Procedure

Ensure good lighting.
Spread the labia as well as possible.
Clean the area to be inspected as well as possible by patting it dry.
In the case of doubt between a second- and third-degree tear, perform a digital rectal examination whilst at the same time inspecting the tear:
- insert the right gloved middle finger into the woman’s rectum
- push the sphincter upwards
- use another finger to palpate whether the sphincter is intact
If there is any doubt, assume that there is a third-degree tear and refer the patient to the hospital.

Suturing second-degree tears
The technique for suturing second-degree tears depends on the depth of the tear. If the tear is superficial, then a few skin sutures are sufficient. If the tear is deeper, then the suturing must be performed in layers, as is the case for an episiotomy. An infiltration anaesthetic must then be given as well.