In the final study session of this Module, you will learn about postpartum haemorrhage (PPH), which is a leading cause of maternal mortality, responsible for about a quarter of all maternal deaths. Worldwide, around 127,000 women every year die of postpartum haemorrhage. The majority of these fatal cases of excessive bleeding occur in the first 24 hours after delivery of the baby, as a result of complications arising during the third stage of labour. To minimise the risks of PPH in this critical stage of labour, a set of procedures have been developed that all birth attendants should follow, called active management of third stage of labour (AMTSL). Correctly applied, AMSTL can reduce the risk of postpartum haemorrhage by more than 60%.
In this study session, you will learn what is meant by AMTSL and the procedures you will conduct during each of its six steps. This knowledge will help you to identify the complications that may arise during the third stage of labour and manage them more effectively.
When you have studied this session, you should be able to:
6.1 Define and use correctly all of the key words printed in bold. (SAQ 6.1)
6.2 Explain the natural physiological process of placental delivery. (SAQ 6.1)
6.3 Describe the six steps of active management of third stage of labour (AMTSL). (SAQ 6.2)
6.4 Summarise the regimens for each of the uterotonic drugs used in AMTSL. (SAQs 6.2 and 6.3)
6.5 Explain how you would examine the placenta and membranes for completeness. (SAQ 6.3)
6.6 Describe the warning signs for complications that may arise during the third stage of labour. (SAQ 6.4)
The third stage of labour begins with the birth of the baby and ends with the delivery of the placenta and fetal membranes. Normally, it should last less than 30 minutes.
In a complication-free labour, the third stage is when natural physiological processes spontaneously deliver the placenta and fetal membranes. For this to happen unproblematically, the cervix must remain open and there needs to be good uterine contraction. In the majority of cases, the processes occur in the following order:
This expulsion marks the end of the third stage of labour. Thereafter, the muscles of the uterus continue to contract powerfully and thus compress the torn blood vessels. This, (together with blood clotting) quickly reduces and stops the postpartum bleeding.
Study Session 11 of this Module will tell you in detail about postpartum haemorrhage and atonic uterus; the other terms in Box 6.1 are covered in this study session.
Women who give birth unattended by a skilled healthcare provider (like you) are more likely to experience complications at all stages of labour, including the third stage. These complications are listed in Box 6.1 below. They can arise even in a delivery where the placenta was implanted in a good position in the top two-thirds of the uterus, labour was not prolonged and the birth was normal. In such cases, while a normal and spontaneous delivery of the placenta during the third stage might be expected, complications can still arise unpredictably. You should always be prepared for the unexpected emergency.
All these complications are much more likely to occur if the third stage is not properly managed, using the AMTSL approach.
The placenta remains inside the uterus for longer than 30 minutes after delivery of the baby, usually due to one or more of the following:
Excessive bleeding (PPH)
PPH is the loss of more than 500 ml of blood following delivery of the baby. Most bleeding comes from where the placenta was attached to the uterus, and is bright or dark blood and usually thick. PPH occurs when the uterus fails to contract well, usually due to:
The uterus is pulled ‘inside out’ as the baby or the placenta is delivered, and partly emerges through the vagina.
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 Box 6.1. 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 of Ethiopia, 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:
Health Posts are supplied with a refrigerator and mobile icebox for transport of vaccines to outreach events, as described in the Immunization Module.
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)
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 rural Health Extension Practitioners.
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.
It is not planned to use ergometrine in the rural Health Extension Service. 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 6.2 and Box 6.3).
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 6.3). 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 (Figure 6.4).
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 (Antenatal Care Module, Study Session 5), 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 6.5) 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 6.6).
It is dangerous for the mother if any parts of the placenta or membranes are left behind in the uterus.
The anatomical terms in this section were all explained and illustrated in Study Session 3 of the Antenatal Care Module, Part 1 (see Figure 3.2). 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.
You will learn the definition of excessive bleeding and the actions to take if the woman has postpartum haemorrhage (PPH) in Study Session 11 of this Module; it also describes the interventions you can take during and after the third stage of labour to reduce the risk of PPH. The main points are summarised briefly here.
Remember not to exceed 1,000 µg of misoprostol (5 tablets). If the woman has already taken 600 µg (3 tablets) after the birth of the baby, and she needs a second dose because of excessive bleeding, it should be no more than 400 µg (2 tablets) via the rectum. This way, the woman will have fewer side-effects. If she did not take 600 µg of oral misoprostol after the birth of the baby and has signs of excessive bleeding, give her 1,000 µg of misoprostol via the rectum in one dose.
Do not give additional misoprostol if oxytocin was the drug used originally.
If excessive bleeding occurs, the mother should be taken to the health facility immediately. You will learn what to do on the journey in Study Session 11.
If the bleeding does not stop quickly after the second dose of misoprostol, then refer the woman to the nearest health facility urgently. Sometimes, bleeding comes from a torn vagina, a torn cervix, or a torn uterus. Usually this bleeding comes in a constant, slow trickle. The blood is usually bright red and thin. Actions to take while waiting for transport:
Retained placenta is when the placenta remains in the uterus beyond 30 minutes after the birth of the baby. If this happens:
In Study Session 6 you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Alemitu is a Health Extension Practitioner (HEP) in a village Health Post. She has just delivered a baby at her Health Post and the mother is in the third stage of labour, and has begun breastfeeding. Alemitu has been trained to use AMTSL. What, in detail, are the six steps that she must follow in order to do this?
Six steps to follow:
1 Check: is there a second baby?
2 Give a uterotonic drug to help the uterus contract:
3 Deliver the placenta by controlled cord traction with counter-pressure (see Box 6.3 for details of how to do this).
4 Massage the uterus.
5 Examine the placenta and fetal membranes to check nothing is missing (i.e. check the maternal surface and the lobules, put your hand inside the membranes to make sure they are complete, and check that the position of the cord is normal).
6 Examine the women’s vagina and external genitalia for signs of tears and active bleeding.
Imagine that you have managed the third stage of labour for a woman in your community by correctly using AMTSL, but she has developed continuous bleeding.
What are the warning signs for the complications that may arise during the third stage of labour?
Warning signs of potential complications during the third stage of labour are: