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30 Cards in this Set

  • Front
  • Back
What kind of cord insertion is this?
Velamentous Insertion
What is the definition of the third stage of labor?
Time from the birth of the infant to complete expulsion of the placenta
What are the signs of placental separation?
-Bleeding ‘spurt’
-Lengthening of the cord
-Uterus becomes globular, may have contractions that mother is aware of
-Sometimes ‘feeling of rectal pressure’
What are the components of placental examination?
-Fetal side: chorion and amnion - membranes
-Maternal side: cotyledons
-Cord:
*Vessels
*Insertion - central
*Variations
+Battledore
+Velamentous
+Vasa Previa
What are the five leading causes of maternal death in developing countries?
-Unsafe abortions
-Sepsis
-Hypertensive disorders
-Obstructed labor
-Postpartum hemorrhage
ICM/FIGO joint statement (2003)
“more than _____ of all _______ deaths occur within __ hours of delivery, mostly from ________ _______.”
ICM/FIGO joint statement (2003)
“more than half of all maternal deaths occur within 24 hours of delivery, mostly from excessive bleeding”
WHO:
______ _______ ______ accounts for _____ of all postpartum maternal deaths in developing countries.
WHO:
Excessive blood loss accounts for half of all postpartum maternal deaths in developing countries
WHO:
High incidence of ______ _______ during pregnancy contributes to the risk of ____ and maternal death in these settings (developing countries)
WHO:
High incidence of severe anemia during pregnancy contributes to the risk of PPH and maternal death in these settings (developing countries)
What is the optimal time limit for the 3rd stage of labor?
Optimal time period – unclear in the absence of bleeding. Generally accepted time is 30 minutes
What is the definition of postpartum hemorrhage and how is it assessed (in the basic sense) ?
General assessment of PPH is visual and definition is >500cc in the first 24 hours of birth
How reliable is visual assessment of EBL when assessing for postpartum hemorrhage?
It is recognized that EBL is unreliable and predicted to be underestimated by 30-50%
What is expectant management of the 3rd stage of labor also referred to as?
physiological or passive management
Where is expectant management common?
Some Northern European countries, some areas of US and Canada, and in countries with poor resources.
What is expectant management of the 3rd stage of labor?
-Waiting for signs of placental separation
-Contraction of the uterus
-Increase of bleeding
-Lengthening of the cord
-Then delivery is effected by gravity, maternal effort and nipple stimulation.
What are the components of active management of the 3rd stage of labor, and what is the controversy surrounding this 2004 update?
1. Administration of uterotonic agents
2. Cutting/clamping cord soon after birth
3. Controlled cord traction
4. Uterine massage after delivery of the placenta, as appropriate

*Clinical update at 2004 meeting described the ‘components’ as the new standard – however, the ICM/FIGO statement was not intended to be a mandate for universal implementation
What are the 12 factors associated with postpartum hemorrhage in the Coombs et al study?
1. Prolonged 3rd stage 7.56
2. Preeclampsia 5.02
3. Mediolateral epis 4.67
4. Previous PPH 3.55
5. Twins 3.31
6. Arrest of descent 2.91
7. Soft tissue lacs 2.05
8. Augmented labor 1.66
9. Operative VD 1.66
10. Asian ethnicity 1.73
11. Hispanic ethnicity 1.66
12. Midline episiotomy 1.58
Nulliparity 1.45
What are the causes of postpartum hemorrhage, and which one is the primary reason?
1. Uterine atony – primary
2. Vaginal lacerations
3. Retention of placental fragments or membranes
What are techniques to reduce bleeding after delivery?
-Early suckling
-Nipple stimulation
-Prophylactic use of uterotonic medications
When the secondary analysis was done in the Bristol trial, which was more effective: active or physiologic management of the 3rd stage of labor?
Benefit was shown but less strong
Odds ratio 2.4=PPH (active) versus 3.13=PPH (physiologic)
In the Hinchingbrooke trial, active management showed less postpartum hemorrhage, but what were the increased side effects? And did maternal position matter in amount of EBL?
Increase of maternal N&V and neonatal jaundice in active mgmt group
No evidence that upright position affected EBL
What did the Thilaganathan study show of rates of postpartum hemorrhage in the physiologic group vs active management group?
no difference, but physiologic group took more time in minutes
What did the Abu Dhabi trial show regarding pitocin administration after placental delivery vs. before placental delivery?
administration of oxytocin was more effective when given before rather than after placenta was delivered.
What did the Jackson trial show regarding pitocin administration at anterior shoulder vs. after placental delivery?
timing of administration of oxytocin does not reduce the incidence of PPH.
What did the McCormik study show when looking at active management in out of hospital settings especially home births?
Conclusions echo strong support for use of active management, specifically controlled cord traction as uterotonic medications require both injection and proper storage
What did the Zamora study show regarding timing of pitocin adminstration to prevent postpartum hemorrhage?
No difference in mortality
What area is there little research on regarding population and active management of the 3rd stage of labor?
outcomes of expectant management in low income women cared for by CNMs in the United States
What is a general summary statement about most all of the research regarding active management of the third stage of labor?
Efficacy of active management of the third stage of labor
Why is it important to know how to do active management of the 3rd stage of labor, but ALSO physiological as well (in regards to principle)
-Treating birth as normal and promotion of non-interventive approaches embody the midwifery model of care.

-The AMTSL is a technique to add to the skill set of providers, however, the ICM/FIGO group did not intend the AMTSL to be a requirement nor a standard
What should patients be taught during prenatal care about active management of the 3rd stage of labor?
That is may need to be used, when it would, and risk/benefits of it
What is the summarization of use by CNMs regarding active management of the 3rd stage of labor in the US?
-There is no evidence of harm to the practice of physiologic, non-interventive approach with normal women in the US cared for by CNMs

-Finally, oxytocin should be used liberally to prevent excess blood loss in low risk women