Assignment

Title: Active management of 3rd stage of labour,

management of 3rd stage of labour & delayed cord
clamping

Authors:
Hasne Ara Akther (v16hasak)
Zohra Khatoon (v16hasak)

Teacher/Examiner:
Christina Pedersen,
Kerstin Erlandsson

Credits: 5 cp

Date of Oral Examination seminar: 16-17 June, 2016

Introduction
By the end of 2015 3,03,000 women died in the world due to pregnancy related
complications and childbirth. Every day, approximately 830 women die from preventable causes
and 99% of these deaths occur in developing countries (WHO 2015).
This situation appears to be very poor in Bangladesh. The MMR1 is about 176 death per
100,000 live-births2 due to some common causes including postpartum hemorrhage, eclampsia
and complications of abortion, obstructed labour and postpartum sepsis (Nour, N. M.,2008). The
NMR is 44.09 deaths/1,0002 live-births which are due to improper perinatal management.
Around 15% of all pregnant women develop potentially life-threatening complications. (P.
Sarkar 2009).
Most of maternal and neonatal deaths are preventable. The prevention can be enacted by
proper pre-conception care, Antenatal, Intranatal, Postnatal and Newborn care. Active
management of 3rd stage of labour (AMTSL3) follows a guideline from WHO which can prevent
PPH and led active prevention of maternal death. Accordingly delayed cord clamping, which
prevents neonatal anemia, can reduce NMR.

Background
In Bangladesh there is a high maternal mortality rate, with the major causes due to
postpartum hemorrhage (PPH) (BNC, 2013). Active management of 3rd stage of labour is the
most important part during the labour. Active management of the third stage of labour should be
offered to women since it reduces the incidence of post-partum hemorrhage due to uterine atony
(70%) (Anderson JM, Etches D, 2007). Bangladesh has a high maternal mortality ratio, with 320
deaths per 100,000 births. This means there are about 11,000 to 12,000 women dying from
pregnancy or childbirth complications every year in Bangladesh (BNC, 2013).
Postpartum hemorrhage (PPH), which is a leading cause of maternal mortality. It is responsible
for about a quarter of all maternal deaths. Worldwide, around 127,000 women die every year of
postpartum hemorrhage. 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 minimize 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, AMTSL can reduce the risk of postpartum hemorrhage by
more than 60% (The Open University, 2015).
MMR in Bangladesh substantially decreased from 322 deaths per 100,000 live births in
19982001, to 194 deaths per 100,000 live births in 20072010. The implied average annual rate
of decrease is 56%, slightly faster than the average annual reduction rate required (55%)
(Shehzad Noorani, 2007). Even though direct obstetric causes of death also substantially
decreased between 2001 and 2010 (eclampsia by 50%, hemorrhage by 35%, obstructed labour by
1

Maternal mortality ratio= Number of maternal deaths per 100 000 live births during a specified time period,
usually one year; Neonatal mortality rate = Number of deaths during the first 28 completed days of life per 1 000
live births in a given year or period. (WHO 2016)
2
CIA World Factbook 2015
3
A sequence of clinical actions taken by the skilled birth attendant to facilitate the delivery of the placenta, by
promoting uterine contraction and placental expulsion (Fullerton 2006)

26%, and abortion by 85%), most of these causes of deaths were still important in 2010 S. (El
Arifeen, K. Hill, K. Z. Ahsan, K. Jamil, Q. Nahar, P. Kim, 2014).
Another trend is neonatal mortality, in recent years Bangladesh is one of few developing
countries on track to achieve Millennium Development Goal 4 to reduce child mortality.
Between 2004 and 2007child mortality has fallen from 88 per 1,000 live births to 65 per 1,000
live births. However, despite this encouraging trend, neonatal mortality in Bangladesh is still
high, accounting for more than half of all under-five deaths and more than two thirds of infant
deaths. An estimated 120,000 newborns die every year in Bangladesh. The share of neonatal
deaths to infant mortality has increased over the period 2002-2006, largely because there has
been little progress in preventing neonatal deaths. Poor neonatal health and under-nutrition of
both mothers and children could affect the current success in improving child survival.
Midwives must be highly skilled, competent, and confident in managing PPH. Other
skills for correct management of third stage of labour are also important; these include correct
estimation of blood loss so that appropriate treatment is administered; and careful examination of
the genital tract for trauma and inspection of the placenta, which maybe the cause of excessive
bleeding at the birth. Correct examination of the placenta is a vital midwifery skill especially in
Bangladesh (BNC, 2013).

Findings of field visit

We have visited a district hospital near our institution in Munshiganj with the permission
of authority. It is a district general hospital stands at the middle of sadar upajilla, Munshiganj.
There are 8 sub-centers, 6 community clinics, 5 private clinics and one maternal and child health
care center working together with the collaboration of general hospital. Highly qualified doctors,
nurses and other supporting staffs are working together in a familiar environment in this hospital.
It provides all necessary services for emergency cases like emergency obstetric care (EmOC) e.g.
prolonged and obstructed labour, PPH, Pre-eclampsia , eclampsia, retained placenta and newborn
care.
There are different units of maternal and child health care, such as- ANC, Labour (INC)
PNC and neonatal care unit. There is always a heavy work load that prevents the stuffs to
provide standardized care for every patient. More than 200 patients get care every day related to
mother and child care issues who are not equally served due to skill and manpower gaps. Each
unit needs an expert working group in every shift but only 1 or 2 nurses were found on duty each
shift. There are 2-3 intern midwives/nurses per ward per shift accompanying the duty nurses for
clinical practice. The interns are supervised by clinical supervisors and nursing instructors of the
institution. Due the proximity of nursing institution near the hospital, students have great
opportunity for clinical practices and academic attachments.
In labor word there are qualified nurses to conduct delivery along with some interns. We
have learnt that, all are aware about the active management of the 3rd stage of labor which they
follow in practice. Though the stuffs are aware about the benefits of delayed cord clamping, in
practice they dont always follow due to time constrain and work load. Otherwise, when a patient
is delivered out of the hospital like in the community level or home, most of the cases were
found to be handled by unskilled professionals resulting PPH, Perineal/Cervical tear, retained
placenta etc. complexities. Those patients hence at critical situation got admitted quickly at the
hospital. Most cases result with better cure and treatment with hurdles. Some cases end up by
compromising the health or life of mother or child.

SWOT Analysis
Internal Factors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Strengths
Skilled nurse-midwives
Skilled Gynecologists
Ambulance service
Functional referral system
Blood transfusion
Operation theatre
Proper instruments
Well furnished
Functional communication & cooperation
among health workers
Monthly service quality meetings

1.
2.
3.
4.
5.
6.
7.
8.
9.

Weaknesses
Lack of Human resources & Heavy workload
No separate neonatal ward
No separate eclampsia ward
Poor referral system for rural area
Delayed decision making by patients family
members
Lack of feedback
Community level skill is low
Appraisal and Promotion of health worker is
absent
Not enough power supply

External Factors
Opportunities
1. Good infrastructure to reach hospital
2. Optimum location of the hospital
3. Skill development trainings from national and
international bodies
4. Donor fund for service improvement
5. Monthly supervision from top authority
6. Support and appraisal from local govt.
authority
1. 7. Well-equipped diagnostic centers available
at common location

Threats
1. Various superstitions about pregnancy and
neonatal care among patients
2. Pro-poor Economic condition of the patients
3. Medicine and essential equipment supply
sometimes delayed
4. Presence of threats to the health workers by
political leaders
5. Lack of acknowledgement for good treatment

Discussion
MMR in Bangladesh is substantially decreasing every year but the rate is not sufficient.
Also the neonatal mortality rate is decreasing gradually. Active management of 3rd stage labor
and delayed chord clamping can bring the success faster before any compromising situations.
In our field study, several cases of complications during deliveries were found of which
major cases are referred from community and home based deliveries. Most of those cases are
resolved by quality services given by nurse midwives of the hospital. But the number of nurse
midwives to serve the growing number of patients is not adequate. For that reason most of the
cases couldnt be handled with optimum care. The SWOT of the facility is discussed as follows:
Strengths: Competent nurse midwives are appointed in this facility. Experienced
gynecologists are also handling the critical situations. For emergency transportation of mother
and baby, functioning ambulance service is also present for referral purposes. Doctors assess the
patient condition immediately and refer to tertiary facilities for appropriate treatment. For most
cases possible operations are done at in-house operation theatre which is functional and well
equipped with proper instruments, blood transfusion facilities etc. There is excellent teamwork
and environment of communication, cooperation and collaboration among the healthcare

providers both in and out of the facility. Monthly quality service meetings are held regular basis
for the monitoring and improvement of healthcare services of the facility.
Weaknesses: Health care provider per patient ratio is low in number in the facility. So
there is always heavy workload on the stuffs. Separate neonatal & eclampsia ward is not present,
which is hampering the intensive care of the patients. Referral system to and from patients
household is not functioning. Therefore it is almost impossible for patients from remote villages
to reach the facility timely. Three types of delays are hampering the treatment of the patient. The
delay in patients relative decision making for timely referral, delay in transporting the patient
and delay in starting the treatment. Follow-up system is not applicable in this healthcare setting.
Healthcare is not improving because of inactive appraisal and promotion system. The community
level health workers are not trained adequately to give care related to mother and child health.
Especially deliveries for rural women couldnt be done at hospitals due to communication and
know-how barriers.
Opportunities: The hospital is located at the center of the Munshiganj municipal,
communication is good, and so the patients can reach the hospital easily. There is some Govt.
and non-Govt. authority present here, such as social welfare, foreign donor projects etc. to
provide financial and technical support for the poor patients as well as strengthening the hospital
facility. Sometimes in-service trainings are provided from the Govt. and Foreign organizations to
improve the knowledge and skills of the healthcare providers. Monthly supervision is done from
top authority to ensure transparent service. Sometimes acknowledgements and appraisals are
given by the local authority and community for better service. It is easy to the take decision for
treatment of critical patient as some rare investigations can be done at diagnostic centers which
are near to the hospital.
Threats: Superstitions on pregnancy and neonatal care among patients and their elderly
relatives is still a common threat to AMTSL. It is an un-denying fact that the patients pro-poor
Economic condition sometimes hamper to get better pregnancy care. Health facility utilization is
much greater among the richer households, who are definitely more able and willing to pay for
services from the increasingly widespread private health facilities. Due to some delays in
medicine and essential equipment supply the treatment also hampers. Health workers sometimes
have to face threats by local political leaders and ignored or underestimated by them. Good
treatment isnt always acknowledged instead blames are rewarded from the patients.

Recommendations
1. Better work environment for stuffs should be ensured and relevant skills should be
utilized by proper job placement
2. Ambulance service must be improved in number and quality, and transport service to and
from patients household should inaugurated
3. Referral system is more monetary focused rather than service focused, so the mindset
should be changed
4. Follow-up and feedback system should be started to provide better care
5. Damaged equipment should be replaced and equipment operators must me trained
properly
6. In-service training on maternal and child health should be provided for stuffs and interns

7. Well-designed clinical practice curriculum should be adopted for intern nurse midwives
8. More healthcare providers should be recruited
9. Separate neonatal and eclampsia ward must be established
10. Mass people and healthcare providers must be aware about danger signs, three risky
delays and pregnancy related superstitions etc.
11. Active appraisal and promotion system should be initiated for motivated workforce
12. Community level skill training should be arranged for perinatal management at remote
13. More development funds should be allocated for infrastructural improvement and new
service development.

Referances
Anderson JM, Etches D (2007). "Prevention and management of postpartum hemorrhage".
American Family Physician 75 (6): 87582. PMID 17390600
BNC, UNFPA, WHO (2013), Diploma in midwifery, Lesson plan, Volume-2, Semester-3
Fullerton, J. T., Frick, K. D., Fogarty, L. A., Fishel, J. D., & Vivio, D. M. (2006). Active
Management of Third Stage of Labour Saves Facility Costs in Guatemala and Zambia.
Journal of Health, Population, and Nutrition, 24(4), 540551.
Nour, N. M. (2008). An Introduction to Maternal Mortality. Reviews in Obstetrics and
Gynecology, 1(2), 7781.
P. Sarkar & K.M. M. Rahman (2009), Situation of Maternal Health Care Services in Bangladesh,
Volume 4, Issue 5, Page 499-504
Shehzad Noorani (2007), UNICEF, Maternal Health in Bangladesh,
S. El Arifeen, K. Hill, K. Z. Ahsan, K. Jamil, Q. Nahar, P. Kim (2014), Maternal mortality in
Bangladesh: a Countdown to 2015: country case study
The Open University (2015), Labour and Delivery Care Module: 6. Active Management of the
Third Stage of Labour, http://www.open.edu/openlearnworks/mod/oucontent/view.php?
id=274&printable=1, retrieved on 5/21/2016 11:18 PM
WHO, UNFPA UNICEF, WORLD BANK (2015), Managing complications pregnancy & child
birth
WHO, Maternal Mortality Factsheet (Nov 2015),
http://www.who.int/mediacentre/factsheets/fs348/en/, retrieved on 6/10/2016 10:52:13
AM
World Factbook (2015), CIA, https://www.cia.gov/library/publications/the-worldfactbook/geos/bg.html, retrieved on 5/21/2016 11:05:52 PM

Annex I
Standard of practice for AMTSL Step by step procedure

Step 1: administer uterotonic within 1

minute of delivery of the baby

Step 2: controlled cord traction

Step 3: massage the uterus

Prepare Oxytocics (Oxytocin, Ergometine

or Misoprostol) during second stage of
labor

Wait until pulsation of cord stops

Immediately massage fundus of uterus until

it contracts

Deliver baby

Re-clamp cord close to the perineum

Rule out presence of additional babies

Confirm the uterus is contracted

Give uterotonic
Choice 1 -- Oxytocin (20IU)
Choice 2 -- Ergometrine (0.2 mg) if no
heart disease or elevated blood
pressure
Choice 3 Misoprostol (600g), if
other uterotonics are contraindicated or
unavailable
Put baby to breast (if mother plans to
breastfeed)

Clamp and cut the cord

Keep slight tension on cord close to the

perineum
With a contraction, stabilize uterus using
counterpressure by pushing uterus upwards
& backwards from just above the pubic
symphysis (pubic bone), while gently
pulling downwards on the cord; encourage
mother to push
TAKE NOTE: If placenta does not descend
during 30 40 seconds of controlled cord
traction, STOP TRACTION
Gently hold cord and await next
contraction. Repeat controlled cord traction
As placenta delivers, hold in two hands and
gently turn so membranes are twisted on
themselves until they slowly deliver

If membranes tear, gently examine cervix,

remove any pieces of membrane missing
Ensure none of the placenta is missing, if
retained placental fragments are suspected,
take appropriate action
Palpate for contracted uterus every 15
minutes, keep bladder empty, Repeat
uterine massage if uterus is soft during first
2 hours
Teach mother and family to massage the
uterus