Premonitory Stage of Labour

Definition of Premonitory stage of labour A short time previous to the commencement of labour where certain symptoms manifest themselves, which are looked upon as indications of the approaching event is termed as the premonitory stage of labour. Signs & Symptoms of Premonitory stage of labour o o o o o o o o o o o A feeling of activity and lightness on the part of the patient A diminution of the abdominal protuberance An increased vaginal secretion Frequently a sympathetic irritability of the bladder, and sometimes of the rectum also. Lightening: the mother would feel the descent of the fetus and changes the abdominal contour. Bra ton hicks contraction: painless irregular contractions Bloody show !udden rush of energy: due to change in levels of estrogen and progesterone "ncreased backache and sacroiliac pressure #ipening of cervi : soft $as butter% feeling of the cervi #upture of the membrane: &bag of water'

First Stage of Labour

(he first stage of labour is a stage of dilatation of the cervical os. "t begins with the onset of true labour contractions to full dilatation of the cervi . )uration of first stage is an average of *+ hours for nullipara and ,.- hours for multipara. (he first stage is clinically manifested by progressive uterine contraction, progressive taking up of the cervi and ultimate rupture of membranes. Phases of First stage of Labour Latent Phase (he latent or preparatory phase begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. .ontractions during this phase are mild and short, lasting /0 to 10 seconds.

.ervical effacement occurs, and the cervi dilatates from 0 to + cm. (he phase lasts appro imately 2 hours in a nullipara and 1.- hours in a multipara.

Active Phase )uring the active phase of labor, cervical dilatation occurs more rapidly, increasing from 1 to , cm. .ontractions grow stronger, lasting 10 to 20 seconds, and occur appro imately every + to - minutes.

(his phase lasts appro imately + hours in a nullipara and / hours in a multipara. !how $increased vaginal secretions% and perhaps spontaneous rupture of the membranes may occur during this time. (his phase can be a difficult time for a woman because contractions grow so strong, last longer, and begin to cause true discomfort. "t can be a frightening time as she reali3es labor is truly progressing and her life is about to change forever.

Transition Phase )uring the transition phase, contractions reach their peak of intensity, occurring every / to + minutes with a duration of 20 to 40 seconds and causing ma imum dilatation of 5 to *0 cm. "f the membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation $*0 cm%.

"f it has not previously occurred, show occurs as the last of the mucus plug from the cervi is released. By the end of this phase, both full dilatation $*0 cm% and complete cervical effacement have occurred.

Factors affecting First Stage of Labour 1. Uterine factors Fundal dominance: 6terine contraction strart from the fundus of the uterus and moves downward. .ontractions of the fundus are strong and intense and last for a longer time in the fundus. Pollarity: "t is used to describe the neuromuscular harmony between upper uterine segment and the lower uterine segment. .ontractions of the uterus takes place at the upper pole and there is slight contractions and dilatation of the cervi taking place at the lower pole.

Contraction and retraction: As the contractions begin it will not rela completely which is called as retraction. (his retraction will favour in further contractions and e pulsion of the fetus. Formation of upper and lo er uterine segment: (he uterus forms a thick upper layer and thin lower muscular layer. (he upper longitudinal muscles pull on the lower circular muscles situated in the lower uterine segment which will aid in the descent of the presenting part. !etraction ring: (his is a ridge formed between the upper and the lower uterine segment. "ts also called as Bandl7s #ing. Cer"ical effacement: "t is the thinning out of the cervi which is accomplished in the first stage of labour. "t is e pressed in terms of percentage. *008 effaced means that the cervi is fully effaced. "n

primi effacement preceeds the dilatation of the cervi . "n multigravidae, both occur simultaneously.

Cer"ical dilatation: "t is a process of enlargement of the e ternal os which is a tightly closed operture to an opening large enough to permit the passage of the fetal head. (his is e pressed in centimeters and ranges from 09*0cm. Presence of sho : As the cervi dilates, operculum is discharged out with light blood stains called as :!how7. (his is due to the ruptured capillaries of the deciduas, where the chorion detaches due to dilatation of the cervi .

#. $echanical factors Formation of fore aters: As the chorion detaches, a loosened sac of amniotic fluid bulges downwards into dilating internal os. "n case of complete fle ion where the presenting part gets completely fi ed, fluid cuts into two compartments. ;ne compartment with fetus and some fluid called :hind waters7 and another compartment with fluid in front of the presenting part called :forewaters7. Forewaters when ruptured releases prostaglandins causing uterine contractions. !upture of membranes: "t occurs at the end of the first stage of labour. "t can sometimes rupture before the dilation of the cervi .

%eneral fluid pressure: <hen the bag of membranes is not ruptured, the pressure of uterine contraction is on the fluid also and is equali3ed over the uterus and fetal body parts. Fetal a&is pressure: At each uterine contraction, the uterus rears forwards and the force of fundal contraction is transmitted to the upper pole of the fetus, down the long a is of the fetus and is applied by the presenting part of the cervi and is called fetal a is pressure.

$anagement of First Stage of Labour (he ob=ective is to have a watchful e pectancy and to monitor the progress of labour and to prevent complications.

'nitial assessment > ;nset of contraction > Frequency > )uration > ?embrane > Liquor > @resent and previous obstetric history > )rug history Clinical e&amination > @allor > Aaundice > Bydration > @ulseC B@C temperatureC respiratory rate > .hestC .D! > ;edema Per abdomen e&amination > 6terine contraction > Frequency and duration in *0 mi > Fundal height > LieC presentation > FB!C minute to be noted every *- minutes in the first stage Per "agina e&amination > )ischarge show > @resence or absence of membrane > !tation of head > Effacement > )ilatation > Any bony part > .aputC moulding 'n"estigations > Baemoglobin count > AB;, #B typing

> #outine 6rine *. /. +. 1. -. 2. ,. 5. $anagement (ake a brief history and assessment Encourage the woman to have a warm bath or vulval toileting. Five a soap and water enema. <hen membranes are intact, allow the woman to walk, sit or lie down in lateral position according to her convenience. "f membranes are ruptured bed rest must be advised. Analgesics may be given as per doctor7 s prescription Encourage the woman to take fluid diet soup, fruit =uice, salt lemon =uice or plain water. Food and oral fluids to be withheld, when the woman is in active labour. Encourage the woman to empty her bladder herself frequently. ?onitor the progress of the labour by recording a partograph. (he following are recorded in partograph. ?aternal vital signs .ervical dilation

!tation of fetal head .ervical effacement @resence or absence of membranes Fetal heart rate, $Gormal FB# is **0 H *-0 per minute%. )rugs given

4. <atch for maternal and fetal well9being ?onitor pulse, blood pressure and temperature every second hourly and FB# every hour ?onitor urine output

;bserve the tongue to assess the hydration status.

*0. @sychological preparation of the mother and her family is equally important as her ambitions play a great role in managing labour pain and discomfort. **. @C D e amination to be done four times: *. At the onset of labour /. For progress of labour9dilatation of cervi

+. )escent of head following rupture of membrane in early labour to e clude cord prolapse 1. )iagnosis of second stage9full dilatation of cervi Diagnosis of poor progress of labour @rolonged bradycardia and meconium stained liquor @ossibility of foetal distress

@rolonged latent phase when more than eight hours in primigrvida and more than si hours in multigravida @rolonged latent phase may be due to fault in power, passage or passenger @assage is small due to contracted pelvis @assenger, hydrocephalous, brow Iocciput not feltJ Large baby, shoulder presentation

!ole of nurse in caring of the oman in the first stage of labour: Admitting client to birthing area after determining that client is in labor )etermining if clientKs membranes have ruptured

Encouraging family participation as appropriate with the labor process @erforming Leopold maneuver and vaginal e ams as appropriate ?onitoring maternal vital signs and fetal heart rate and patterns, reporting any deviations or abnormalities Applying electronic fetal monitor as appropriate Assessing pain level, instituting positioning, breathing, rela ation, and other methods for pain controlL administering analgesics as ordered @roviding ice chips, wet washcloth, or hard candy Encouraging voiding at least every / hours Assisting with anesthetic administration

Assisting with amniotomy with assessment of fetal heart rate, fetal positioning, and fetal cord after amniotomy .leansing perineum and assisting with pad changes regularly ?onitoring progress including vaginal discharge, cervical dilation and effacement, position, and fetal descent @erforming vaginal e aminations as necessary Assisting coach and supporting client and partner @reparing supplies and equipment for delivery Gotifying primary health care provider at appropriate time to scrub for attending delivery Derifying maternal and fetal heart rate response to uterine contractions during intrapartal care "nstructing client and partner about reasons for electronic monitoring Applying tocotransducer snugly after determining fetal position via Leopold maneuver @alpating to determine contraction intensity #eassuring client about normal fetal heart rates Ad=usting monitor to achieve and maintain clear tracing "nterpreting rhythm strips when at least a *09minute tracing has been obtained

Second Stage of Labour !econd stage of labour is the stage of fetal e pulsion. "t begins with full dilation of cervical os and ends with the birth of the baby. !econd stage lasts for / hours for nullipara and /09+0 minutes in multipara. Changes ta(ing place during the second stage of the labour: *. (he second stage is clinically manifested by increased frequency and intensity of uterine contractions every /9+ minutes lasting for 20940minutes. /. (he long a is of the fetus is parallel to the long a is of the pelvis. +. @elvic floor muscles e ert some pressure over the fetus as it descends down. 1. (he mother e erts pressure with her abdominal muscles at the peak of inspiration with glottis closed called as &bearing down' efforts with pursed lips, distension of neck veins, rapid pulse rate, increased respiratory rateand increased perspiration which result in e pulsion of the fetus -. (he mother may show features of e haustion. )*uipments for conduction of deli"ery

!terile gloves !terile drapes !terile leggings !terile towels !terile sponges !teel Basin .ord clamp !uture cutting !cissors Allies (issue Forceps Episiotomy !cissors !uture material Bulb !yringe #ubber .atheter Geedle holder !pot light Signs of Deli"ery )istension of perineum which becomes tense and glistening Dulval opening looks like a slit through which scalp hairs are visible

Fetal head will not reside back even after the cessation of uterine contraction called :.rowning7. Anal sphincter gets stretched with visibility of anterior rectal wall.

$anagement of the Second Stage of Labour (he second stage of labor, as noted previously, is characteri3ed by complete cervical dilationL descent of the fetal verte L and in patients without anesthesia, a sensation of pelvic pressure and the urge to bear down. "nternal e amination should confirm complete dilation, as well as the fetal position and station, prior to the commencement of maternal pushing efforts.

<omen should be encouraged to continue to labor in the position that is most comfortable for them and those results in the most effective pushing efforts. ;bstetric lacerations are minimi3ed by keeping the babyKs head well fle ed until the occiput passes beyond the subpubic arch. As the head appears beneath the symphysis, the perineum is supported by direct pressure over the coccygeal region. As the head delivers, it often will rotate to a transverse position, at which time gentle downward traction combined with maternal pushing effort will achieve delivery of the anterior shoulder. )elivery of the posterior shoulder is conducted by upward traction after which the rest of the baby is delivered. (he baby can be placed immediately on the maternal abdomen or handed directly to the neonatal care providers depending on the clinical situation or according to maternal preference. <hile delayed clamping of the cord is associated with higher newborn hematocrit levels.

+he role of nurse in caring the oman in the second stage of labour Gotifying the delivery team !etting up trays for delivery

@roviding a warm environment for the newborn .hecking for the working condition of the neonatal resusucitation @reparation of delivery room (o assist in the natural e pulsion of the fetus slowly and steadily. (o prevent perineal in=ures. (o assist labour under aseptic precautions Digilant monitoring of maternal vital sign and fetal heart rate.

Encouraging spontaneous bearing9down efforts for second stage Evaluating pushing efforts and length of time in second stage

+hird stage of labour $echanism of placental seperation !eparation of the placenta is brought about by contraction and separation retraction retraction of the myometrium which thicken the uterine wall and reduces the si3e of the placental area. As the placental area becomes smaller, the placenta begins to tear off the uterine wall because, unlike the uterus, it is

not elastic and cannot contract and retract. At the area of separation a clot forms. (his clot, known as a retroplacental clot, collects between the decidua and the placenta and further promotes separation. !ubsequent uterine contractions completely detach the placenta from the uterine wall and it descends into the lower uterine segment and then into the vagina from where it is e pelled. (here are two methods of separation of the placenta which have been described by !chult3e and ?atthews )uncan. (hese methods are not under the control of the birth attendant. (he Schult,e method is said to be the more common. (he placenta detaches from a central point and slips down into the vagina through the hole in the amniotic sacL the fetal surface appears at the vulva, with the membranes trailing behind like an inverted umbrella as they are peeled off the uterine wall. (he maternal surface of the placenta is not seen, and any blood clot is inside the inverted sac. "n the $atthe s Duncan method, the placenta slides down sideways and comes through the vulva with the lateral border first, like a button through a buttonhole. (he maternal surface is seen, and the blood escapes as it is not inside the sac. "t is more likely that parts of the membranes will be left behind with the ?atthews )uncan method, as they may not be peeled off as completely as in the !chult3e method. (he ?atthews )uncan method may be associated with a placenta lying lower in the uterus. (he process of separation takes longer and blood loss is greater $because there are fewer oblique fibres in the lower segment%. Signs of placental separation *. (he fundus feels hard and globular, and rises abdominally to the level of the umbilicus. /. (he cord lengthens at the vulva. +. A trickle of blood appears when the placenta separates. Control of bleeding

About -00H500 ml of blood flow through the placental site each minute. "f there was no mechanism after delivery to control the bleeding, this is how quickly the woman would lose blood. !he would bleed to death in a matter of minutes. (he contraction and retraction of the uterine muscle that bring about separation of the placenta also compress the blood vessels strongly and thus control the bleeding. (his is possible because of the presence of oblique muscle fibres in the upper uterine segment. Later, blood clots also form in the torn blood vessels at the placental site, and these too will stop the blood flow. A full bladder or anything left behind in the uterus after delivery such as placental tissue, membranes or blood clots, interfere with the ability of the uterus to contract and will cause the woman to bleed e cessively. )&amination of the Placenta and membranes Appearance of the (he placenta is a round, flat mass. (he maternal surface is placenta at term bluishHreddish and made up of lobules which are composed of chorionic villi. "t is through these villi that the interchange of substances between the fetal and maternal blood takes place. (his interchange occurs without mi ing of fetal and maternal blood under normal circumstances. (he fetal surface is smooth, white and shiny branches of the umbilical vein and arteries can be seen running across the surface to the insertion of the umbilical cord. (he fetal surface is covered with the amnion which is continued beyond its outer edge to form the membraneous sac that, together with the chorion, contains the fetus and amniotic fluid. (he umbilical cord e tends from the fetal umbilicus to the fetal surface of the placenta. "t usually measures appro imately -2 cm in length. "t carries three vessels, two arteries containing deo ygenated fetal blood going to the placenta, and one vein containing o ygenated blood going back to the fetus. (he cord is usually inserted in the centre of the fetal surface of the placenta. ;ccasionally the cord is inserted into the membranes of the fetal sac some distance from the edge of the placenta. "n these cases the umbilical blood vessels run through the membranes between placenta and cord $velamentous insertion%. (his form of insertion is more dangerous because, when membranes of the fetal sac rupture or when an amniotomy is done, the blood vessels may be damaged and bleeding occurs.

Bold the placenta in the palms of the hands $palms should be kept flat%L all the lobules on the maternal side should be present and they should fit together. (here should be no irregularities on the margins. "f the maternal side is carefully rinsed with water and held to the light, a shiny layer should be seen $the decidua%. "f it is not intact, it may indicate that some fragments of placenta are left behind. ;n the fetal side, the membranes should appear complete. Bold the umbilical cord in one hand and let the placenta hang down: check that the membranes are complete, there should be one hole H where the baby came through $if placenta e pelled by ?atthews )uncan method, the membrane may be torn in more than one place%. "t also gives you the opportunity to look for free9ending vessels on the membranes which may indicate the presence of an e tra lobe of placenta $placenta succenturiata or bipartita% which is left behind in the uterus. $-.-%)$).+ /F +0) +0'!D S+-%) /F L-1/U! (he third stage of labour is the most dangerous time, because of the risk of bleeding which can be life9threatening. (he active management of the third stage must be carried out correctly, otherwise serious complications may occur such as haemorrhage andCor inversion of the uterus. -cti"e management: *. An o ytocic drug $such as o ytocin *0 "6 "? or ergometrine 0./ mg "?% is given after delivery of the baby and immediately after the midwife has palpated the uterus to check that there is not a multiple pregnancy. /. (he cord is clamped and cut, immediately after the drug is given. +. <hen the uterus is well contracted it will feel very hard. (his should occur /H+ minutes after the administration of o ytocin. (hen controlled cord traction is used the lateral surface of one hand is placed firmly over the lower segment of the contracted uterus and counter traction is applied while the cord is gently pulled with the other hand until the placenta and membranes are delivered. !teady, sustained cord traction is applied following the curve of the birth canalL this means that at first traction is in a downward direction, then hori3ontally and finally, when the placenta is visible in the vagina, in an upward direction. "f controlled cord traction fails on the first attempt after a minute or two, the midwife should stop traction and wait for the uterus to

contract again before a second attempt. Apply .ontrolled cord traction 9 to avoid inversion of the uterus, controlled cord traction should never be applied without counter9traction 1. 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. Physiological management: Go o ytocics are used before delivery of the placenta. !igns of placental separation are awaited. )elivery of the placenta is by gravity and maternal effort. (he cord is clamped after delivery of the placenta $or sometimes when the pulsations have ceased%, unless there is a need to clamp and cut the cord for neonatal reasons.m (his method should only be used in situations when no o ytocic drugs are available. ;nce signs of placental separation are visible, check that the uterus is well contracted and, if it is, ask the woman to bear down to push the placenta out. .atch the placenta in both hands as it emerges from the vagina. " f the placenta fails to deliver, check that the bladder is empty and, if not, ask the woman to pass urine, then try again to deliver the placenta with the ne t uterine contraction. Choice of o&ytocic drugs ; ytocics cause the uterus to contract. (hey speed up the delivery of the placenta and lessen the blood loss. (he choices are: A. ; ytocin. B. !yntometrine. .. Ergometrine. -./&ytocin ; ytocin is a pituitary $posterior lobe% e tract which can be prepared synthetically: causes contraction of smooth muscle and therefore has apowerful action on the uterine muscle acts within /M minutes when given intramuscularly.

Advantages of oxytocin: "t has a rapid action and does not cause side effects in most cases. "t is also more stable in hot climates. Disadvantages of oxytocin: "t does not have a sustained action. 1. Syntometrine !yntometrine is a combined preparation, ergometrine and o ytocin which is given by intramuscular in=ection. Advantages of syntometrine: "t has the combined effect of the rapid action of o ytocin and the sustained action of ergometrine. Disadvantages of syntometrine: (here is a greater risk of producing temporary hypertension and vomiting. C. )rgometrine Ergometrine is a preparation of ergot which: may be given orally, intramuscularly or intravenously. Bowever, oral preparation has been found to be ineffecti"e for acti"e management of the third stage 9 and should not be used for this purpose takes 2H, minutes to take effect when given intramuscularly, and 1seconds when given intravenously

causes marked spasm of the uterus by a series of rapid contractions has an effect lasting appro imately /H1 hours.

Advantages of ergometrine: "t is the cheapest of the o ytocic drugs and it has a sustained action. Disadvantages of ergometrine: Beadache, nausea and vomiting, and hypertension. Ergometrine is therefore definitely contraindicated and should ne"er be given to women with raised blood pressure andCor cardiac disease. Ergometrine stored at room temperature or e posed to light, may lose a lot of its potency. !ecommendations for practice

*. (he use of o ytocin is recommended. <here this is not available, syntometrine or ergometrine should be used. /. @reparations containing ergometrine should not be used for women with raised blood pressure or cardiac disease. +. "t is recommended that o ytocics should be stored in a refrigerator at /H 5N. and away from light. +iming of administration of o&ytocic drugs A. <ith the crowning of the head. B. <ith the birth of the anterior shoulder. .. After the delivery of the baby when it is confirmed that there is not a second twin. (here is not a great deal of research available on this sub=ect. Bowever, because of the danger of intrauterine asphy ia of an undiagnosed second twin, it makes sense to wait until delivery of the baby and confirmation that there is not a second twin before giving an o ytocic drug. !ecommendations for practice *. Five o ytocic drugs after delivery of the baby, when it has been confirmed by abdominal palpation that there is no second twin. /. Allow time for the o ytocic drug to act and ensure that the uterus is well contracted before applying controlled cord traction. +. !uckling of the baby at the breast stimulates the natural production of o ytocin. ; ytocin helps the uterus to contract.

Fourth stage of Labour

(he delivery of the placenta does not mark the end of risk for bleedingL on the contrary, the uterus may have a tendency to rela slightly following placental delivery, and this is the point at which problems most commonly begin. (he prophylactic use of a uterotonic helps ensure that the uterus continues to contract and retract, but the obstetrician must remain vigilant. Gearly every clinician can recount an episode of being briefly distracted at this point only to have his or her attention abruptly reclaimed by a cascade of blood. Following delivery of the placenta, palpate the abdomen to assess and monitor uterine tone and si3e. At this point, uterine massage is reasonable, especially if concern e ists regarding uterine tone. 6terine massage can be uncomfortableL therefore, e plain the rationale to the patient. "f intravenous access is in place, a continuous infusion of o ytocin for a period following delivery is reasonable. "f ongoing concerns e ist regarding uterine tone, then start an o ytocin infusion or administer a longer9acting agent. Encourage early breastfeeding to promote endogenous o ytocin release. ;nce good, sustained uterine tone has been established, the presence of any bleeding from the lower genital tract can be assessed. "f bleeding is minimal, assess the placenta for completeness. $First, manage any significant lower genital tract bleeding.% Assessment of the placenta before repair of an episiotomy or any lacerations is advised in order to avoid disrupting these repairs if uterine e ploration or instrumentation is necessary. E amine the fetal side for any evidence of vessels coursing to the edge of the placenta and into the membranes. !uch vessels suggest the presence of a succenturiate placental lobe. "f the vessels are torn and the lobe is not present, it is quite likely retained and may subsequently lead to bleeding or infection. "f this is the case, turn the placenta over and lay it on a flat surface to e amine the maternal side, with special attention to any defect suggestive of a missing, retained cotyledon. Gote other abnormalities of the placenta, and consider whether pathological e amination is warranted. .ultures of the placenta seem to be of little value in the diagnosis or management of fetal or uterine infection.

(he lower genital tract is e amined using adequate lighting and appropriate positioning and analgesia. Any episiotomy or lacerations are repaired. )uring this time, note any ongoing blood loss from the upper vagina, and, if present, reassess uterine tone and si3e. .losely observe the patient for blood loss over the ne t hour, with skilled assessment of uterine tone and si3e at least every *- minutes. (he duration of close observation and the presence andCor length of any uterotonic administration depends on the risk factors present and the clinical course. Complications Postpartum hemorrhage (he most common complication of the third stage of labor is @@B. Active management of the third stage has clearly been shown to reduce the frequency of this complication and therefore most likely has a positive impact on maternal mortality and longer9term morbidities such as anemia. !etained placenta #etained placenta is defined in various ways. (he most common definition is retention of the placenta in utero for more than +0 minutes. (his is an arbitrary definition, and management is greatly influenced by the clinical assessment of whether significant bleeding is occurring. (his bleeding may be visible or may manifest only by the increasing si3e of the uterus. "n the absence of any evidence of placental detachment, consider the diagnosis of complete placenta accreta or a variant. (his condition may be present with bleeding if only a portion of the placenta is abnormally implanted. Ensuring that the bladder is empty may speed the delivery of the placenta and at least aid in the assessment and control of the uterus. "deally, women should have an empty bladder at the time of delivery. (his usually occurs naturally because of pressure from the presenting part and maternal e pulsive effort. Encouraging the woman to attempt to void late in the second stage or following delivery is not unreasonable, although this may be difficult. Emptying the bladder is mandatory before any attempt at assisted vaginal delivery.

?anual removal of the placenta is warranted if significant bleeding occurs. (he retained or partially detached placenta interferes with uterine contraction and retraction and leads to bleeding. @erform manual removal with a level of analgesia that matches the clinical urgency of the situation. (he cessation of an o ytocin infusion or the administration of uterine rela ants to promote uterine e ploration and manual removal is of questionable value and may lead to increased bleeding. 6ltrasound may be useful in select cases. <hen possible, an elbow9length glove is worn and attention is paid to asepsis. (he perineum and vagina must be prepared. (he vaginal hand may be immersed in povidone9iodine solution $@roviodine% to facilitate easier entry. (he hand is passed into the vagina through the cervi and into the lower segment following the umbilical cord. .are is taken to minimi3e the profile of the hand as it enters, keeping the thumb and fingers together in the shape of a cone to avoid damage. .ontrol of the uterine fundus with the nonvaginal hand is essential. "f the placenta is encountered in the lower segment, it is removed. "f the placenta is not encountered, the placental edge is sought. ;nce found, the fingers gently develop the space between the placenta and uterus and shear off the placenta. (he placenta is pushed to the palmar aspect of the hand and wristL when it is entirely separated, the hand is withdrawn. Ensure that an o ytocin infusion is running rapidly as the hand is withdrawn in order to encourage strong uterine contraction, and then perform uterine massage. .are must be taken to tease out the membranes. ;nce uterine contraction is established, e amine the placenta and membranes to determine whether further e ploration or curettage is necessary. (he administration of antibiotics following manual removal is sometimes advocated. Bow to gain e perience with potentially lifesaving procedures such as manual removal poses a dilemma. (he days of regional anesthesia being an indication for manual removal are hopefully past, and this opportunity no longer e ists. ?anual removal at cesarean delivery allows the clinician to gain the most critical skills needed for this procedure. Uterine in"ersion

(his condition is very rare. (he risk of uterine inversion is increased in abnormalities of placentation, such as accreta, and is more likely with fundal cord insertions and any condition that predisposes patients to uterine atony and prolapse. .ord traction should never occur without countertraction or in the absence of uterine contraction. Leave the placenta attached, and focus management on maternal resuscitation and rapid return of the uterus to the abdominal cavity. (he fingers are formed into a single cone9shaped unit and placed at the most dependent portion of the protruding mass, which represents the inverted uterine fundus. Fentle upward pressure is e erted in the a is of the birth canal with the fingers and thumb together to minimi3e the risk of uterine perforation. (he action has been likened to that of placing the fingers at the toe of an inside9out sock and pushing to make the sock right9side out. Following uterine replacement, vigorous massage and uterotonic administration should undertaken. ?anual removal of the placenta may be performed when the motherKs vital signs are stable unless concern e ists regarding abnormal placentation. 6terine rela ants, such as nitroglycerin, may be helpful. Placenta accreta @lacenta accreta and its variants are not complications of third9stage management but are most commonly recogni3ed during the third stage. (hese life9threatening abnormalities of placentation may occur spontaneouslyL however, they are much more common in situations in which the placenta has implanted over a previously scarred uterus. (he routine use and improving capabilities of ultrasound may suggest this diagnosis in the antepartum period, and the diagnosis should be considered in high9risk situations. (he possibility of placenta accreta mandates that preparations for the management of severe @@B are in place and, if suggested based on ultrasound findings, that e pertise is available to deal with the complications of placenta percreta.