What are the cardinal signs of placental separation?
3 cardinal signs:
- lengthening of cord
- change in uterine position
- these two signs are due to separation of placenta and descent into lower uterine segment. cored lengthens and uterus moves anteriorily as a response to the weight of the placenta in the lower uterine segment.
- Sudden trickle or small gush of blood
What is the midwife’s role following placental delivery with a stable mom?
-need to monitor vital signs and bleeding
be aware of risk factors for PPH and s & s retained placenta
manage bleeding from lacerations, uterine atony, skin to skin with newborn (early suckling)
Why do some clinician’s advocate for active management of the third stage?
decrease risk of PP bleeding
- decreases other complications
- shortens length of third stage and helps prevent risk of primary PPH
- involves administration of prophylactic uterotonic
- cutting clamping of cord shortly after birth
- controlled traction once placenta has been assessed and separating from wall of uterus
What positions facilitate placental delivery?
sitting, squatting
- gravity helps detachment and expulsion
When should you massage the uterus after second stage of labor?
if uterus is not firm ○ brisk bleeding
- uterine massage after delivery of placenta as is appropriate
When is cord traction indicated?
in active management ○ only if uterus is contracted ○ and placenta is absolutely separated
- Can be used once known placental separation
- NEVER pull on cord if uterus is uncontracted
- if placenta and membranes are adhering to the wall of the uterus, inversion of the uterus is potenital danger
- Use abdominal hand to ensure uterus is contracted - brace body of uterus with surface of hand above symphysis
When does an inverted uterus occur?
- cord traction without placental detachment
- rarely spontaneous
What maneuvers would minimize this?
- guard uterus
- shock is main S&S (fundus may be in vaginal vault)
What is the recommended action for delivery of trailing membranes?
- tease them out (up and down motion without pulling) with ring forceps
- twist them by turning placenta over and over to strengthen
- Support placenta to decrease tension on membranes
- Can tune placenta over and over in hands
- twisting membranes, making the stronger
- while exerting tension in order to release after coming membranes
- Do no need uterine exploration for trailing membranes
- Retention of membranes is not a cause of hemorrhage - will be expelled with lochia
What is the recommended action for partial placental separation?
- leave it and wait for 30 min if no bleeding
- leave hand on uterus to make sure there is not a big retroplacental bleed
- if bleeding, give pit, massage, them manual removal as last resort
What is active management of the third stage?
- pit with anterior shoulder or 1 min of birth
- controlled cord traction with uterine guarding after placental detachment
- uterine massage - after placental delivery
- Why is it advocated?
- to decrease PP bleeding and PPH
