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Labor Initiation: Getting It Going
Introduction to Stages of Labor
Stage 1 of Labor & Birth: Contractions, Dilation & Effacement of the Cervix
Stage 2 of Labor & Birth: Pushing The Baby Out
Stage 4 of Labor & Birth: Immediately Postpartum
STAGE 3 LABOR
After a brief time (usually 15 to 45 minutes after the birth of the baby), mild contractions begin again. As the uterus contracts, the placenta (afterbirth) separates from the uterine wall and is expelled during this phase. Initiating breast-feeding at birth releases the hormone oxytocin, which stimulates the contractions of the uterus.
When giving birth at home, your midwife will usually try to get your baby on your breast as quickly as possible to stimulate uterine contractions and aid in the expelling of the uterus and clamping down of the uterine muscle afterward to prevent excessive bleeding (hemorrhage). A safe delivery of the placenta with minimal blood loss is the goal of the midwife. The delivery of the placenta should only be attempted when the placenta if fully separated to avoid uterine inversion (uterus turning inside out) or pulling off a section of the placenta from the wall of the uterus leaving the remainder attached, thus creating an open bleeding area in the uterine wall.
Expelling the placenta.
Uterine involution (the gradual return to normal size) begins. Placental expulsion may be accompanied by a sudden gush of blood. If the uterus doesn't contract and remain firm, hemorrhaging may occur.
DELIVERY OF THE PLACENTA
After birth of baby, the cord stops pulsating and is cut, severing the baby from the mother. The midwife follows the cord and grasps it at the vaginal opening, taking up any cord slack, pulling it straight out the vaginal opening.
A large ring forceps is clamped onto the cord at the entrance to the vagina and let it hang down by its own weight.
Placenta Delivery: Placental Separation, Uterine Configuration. Checking for placental separation and release along with uterine tone and contraction by placing a hand on the uterus. Do not massage the uterus. Allow it to contract on its own. When the uterus contracts, it will form a hard globular ball which rises slightly under your hand. Tell the mother to let you know when she begins to have contractions again.
Placenta Delivery: Noting whether there is a gush of blood and/or lengthening of the cord may not always be readily apparent. Keep track of time since the birth to when separation occurs. At home, this may take longer (usually 15 to 45 minutes) than the hospital (5 to 20 minutes) because many homebirth midwives do not give medications to stimulate contractions like they do in a hospital setting. Checking placental separation and release from the uterus by placing a hand on the uterus and using the other hand for cord traction. Uterine firmness is noted.
Cord traction is applied, using the ring forceps to obtain a firm hold (the cord is very slippery), taunt traction is done, pulling gently but firmly away from the vagina. The mother should be having contractions at this point. There is usually a little gush of blood as the placenta begins to pull away from the uterine wall. Placenta separation may be apparent by the increasing cord length between the forceps and the vaginal opening.
Placenta Delivery: Controlled cord traction. Have the mother begin pushing with her contractions. If there is a gush of blood and lengthening of the cord, have the mother push whether or not there is a contraction.
Placenta Delivery: Using one hand to apply suprapubic pressure against the fundus of the uterus with your cupped hand, and your thumb placed just above the pubic bone to keep the uterus from entering the pelvis and causing spurious cord lengthening or other false evidence of separation, or even inverting the uterus. Provide some steady cord traction to not whether there is a sense of "give" as the placenta moves into the vagina and the cord lengthens, or conversely, does not progress, in which case cease your maneuvers and wait. If you are uncertain whether the placenta has actually separated, you may follow the cord with your hand in the vagina, up to the cervix, to determine if the placenta is trapped in the cervical os, or whether the cord disappears into the uterus.
NOTE: In the absence of heavy bleeding, there is no hurry to deliver the placenta. It is normal and safe, if there is no bleeding, to wait up to an hour, checking for separation periodically. The placenta has been known to stay attached to the uterine wall for days after a delivery. If this occurs because there is acreta, this is the safe state until the problem can be evaluated more completely.
Conversely, if you do not make an accurate diagnosis of separation and separation has indeed occurred, then the uterus may be silently filling with blood. This is another reason for keeping your abdominal hand over the uterus at all times until the delivery of the placenta is imminent at the introitus.Placenta Delivery:Use maternal efforts to deliver the placenta, assisted by the following maneuvers, as needed, when you believe the separation has occurred. Maintain your abdominal hand over the uterus, using your flattened fingers just above the pubic bone to aid the placenta as it exits the cervical os into the vagina. Instead of pressure with flattened fingers, the Brandt Andrews maneuver may also be used, but this is more uncomfortable for the mother. Place your fingers around the ring forceps at the point where the cord is attached, and apply steady cord traction with a downward motion. The Upward Placental Lift: then upward along the curve of Carus as the placenta traverses the vagina to the introitus. When the placenta is visible at the introitus, lift it partially through with the hand holding the ring forceps.
Placenta Delivery: Remove your other hand from the abdomen and let the placenta fall into your hands. At this point, drop the cord and ring forceps. Encompass the placenta using both hands to support it during delivery, making sure the membranes do not tear.
Placenta Delivery: Using an Up-Down-Rotation method to bring it through the os.
Placenta Delivery: Once the placenta is delivered, continue to rotate it and the membranes to form a thicker cord of membranes help the membranes release intact without tearing or shredding.
Placenta Delivery: Grasping the membranes with the ring forceps to help in delivery and to aid in making a thicker cord of membranes.
Placenta Delivery of the Membranes: Rotating the ring forceps to "tease" the membranes loose from the uterine lining without shredding them by a slight up and down movement. NOTE: Slow controlled delivery is necessary to avoid tearing of the cord or membranes.
Placenta Delivery Cleanup: Once the placenta is out, massage the belly once or twice above the uterus to get the uterus to contract and form a grapefruit size firm ball under your hand. Wipe out the blood from the introitus (vaginal opening) after the delivery of the placenta to determine if you have additional bleeding.
VIDEOS: BIRTH OF THE NORMAL PLACENTA
Utah Medical School Video: Placental Separation
VIDEOS: BIRTH OF THE PROBLEM PLACENTA
PLACENTAL EXAMINATION
while keeping an eye on the vaginal opening for bleeding, conduct a complete inspection of the fetal and maternal surfaces of the placenta. This quick examination is conducted to be sure the entire placenta is out. Examinations of both the maternal and the fetal side of the placenta are done and note any abnormalities. This should take no more than 15 seconds and is a critical step before using medications or other remedies to manage a heavy bleed or hemorrhage, if there is a problem.
Examining the placenta to make sure it's intact.
Examining the placenta.
PLACENTA EXAMINATION
PLACENTA EXAM:
Placenta, Fetal Side
PLACENTA EXAM:
Placenta, Maternal Side
PLACENTA EXAM:
Placenta MembranesPlacenta Exam: Start with the fetal surface since that is the most common presentation of the placenta at birth (shiny schultz). Fetal Surface - note general size and shape and look for any variations or for any abnormalities, such as a circumvallate placenta (an opaque ring on the fetal surface formed by a doubling back of the chorion and amnion membranes), extra placental lobes, vessels running off the edge of the placenta (which could mean that a placental lobe may still be in the uterus).
Placenta Exam: Note the cord insertion location. A normal placenta should have the cord firmly attached into the center or near the center of the placenta (concentric). Other variations include eccentric (away from the center of the placenta), or more rarely a Battledore placenta (the cord at the edge of the placenta). Occasionally seen is a velamentous insertion of the cord in which the umbilical vessels run through the membranes from the cord to the placenta, without the protection of the gelatinous portion of the cord, which ends several centimeters above where the vessels insert into the placenta.
Placenta Exam of the Membranes: Turning the placenta over to the maternal surface, pull the membranes up gently to identify the location of the hole which resulted from the rupture of the membranes. Checking for tears in the membranes with a hole near the center of the membranes indicates a placenta attached to the upper portion of the uterus. A hole near the edge of a placenta indicates a low lying placenta (one attached in the lower uterine segment closer to the cervical os. Ideally there should only be one tear - the one the baby came out of.
Placenta Exam: Checking membrane for both layers - The Amnion and the Chorion.
Placenta Exam: Placental Cord Vessels - There should be three in a normal umbilical cord (2 arteries and 1 vein).
Placenta Exam: Maternal Surface Inspection. After noting whether or not there were tears in the membranes or blood vessels passing through them, pull the membranes completely back to expose the maternal surface of the placenta. Look for and note the cotyledons which make up a normally thick, red surface and ensure that there is not any missing pieces or sections that may still be in the uterus. Note any blood clots, calcified infarctions (white, thickened areas), or a pale overall color. These signs indicate an aging placenta, or one that has not had a healthy maternal/fetal transfer unit. Run your finger around the edge areas of the placenta to determine whether there are any vessels or succinturiate lobes in the membranes. NOTE: any retained uterine fragments may cause severe bleeding problems (hemorrhage) since the uterus is not able to effectively contract down to close off open uterine vessels found in the former placental site. This can be life threatening, which is why it is important to do a proper placental examination. The mother may be given oxytocin, methergine, or other medications if needed. These medications are not usually required in a normal third stage of labor with minimal bleeding.
Placenta Exam: Maternal Side Inspection of Cotyledons, looking for missing pieces, broken vessels and missing extra placental lobes.PLACENTAL VARIATIONS Placenta Exam: Checking for meconium, maternal side of the placenta. Meconium is the blackish-greenish tar-like feces found in the newborn. Sometimes during labor, the baby becomes stressed and may lose oxygen. When this happens, it causes the anal sphincter to relax and the baby releases the meconium into the amniotic fluid, staining the fluid, the placenta and the baby. If the baby happens to breathe this meconium into the lungs at the time of birth, it can make the baby very sick and cause severe breathing difficulties and neonatal lung infections.
Placenta Exam: Meconium staining on placental lobes, fetal side. If meconium is found in the amniotic fluid during the birth, the midwife must make sure she thoroughly cleans out the baby's mouth and throat using suctioning, preferably before the baby takes his or her first breath. This may be done as soon as the head emerges from the vagina and before the body is born. A baby with meconium staining should be professionally examined for meconium aspiration and possibly treated by a health care provider.
Placenta Exam: Succinturiate Lobes, Maternal Side.
Placenta Exam: Battledore Cord Insertion.
Placenta Exam: Placental Circumvallate, Partial and Complete.
Placenta Exam: Placental Abruption With Large Blood Clots.
Placenta Exam: Placental Infarction, Calcified Areas of The Placenta.
PLACENTAL EXAMINATION VIDEOS
The mother is examined after the placenta has been expelled for tears in the vagina or cervix. If an episiotomy has been done, it is repaired at this time (with or without local anesthesia).
Continuing assessments are made on both the mother and infant. Both are cleaned up and made warm and comfortable. Breast-feeding, if not initiated before the expulsion of the placenta, is now usually encouraged. This helps the uterus to remain firm and contracted preventing excess blood loss.
Breast-feeding the infant.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or a family member has questions or concerns about labor and delivery.
Labor Initiation: Getting It Going
Introduction to Stages of Labor
Stage 1 of Labor & Birth: Contractions, Dilation & Effacement of the Cervix
Stage 2 of Labor & Birth: Pushing The Baby Out
Stage 4 of Labor & Birth: Immediately Postpartum
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Some photos obtained from "Attending Ob/Gyn Patients" Nursing Photobook by Nursing Books, Intermed Communications, Inc. and Utah Medical School Library and Tutorials
