Third Stage of Labor

The third stage of labor begins with the delivery of the baby. Appropriate equipment for resuscitation should be available. Maternal pushing with contractions will cause the fetal head to bulge the perineal tissues with increasing pressure to distend the opening of the vaginal canal and allow the fetal head to deliver. It is only when the head is stretching these tissues should the decision for episiotomy be made. The fetal head delivers with extension, after which the practitioner suctions the fetal mouth, pharynx, and nose. If meconium is present, wall suction to a DeLee trap is used for suctioning, and the fetus is not stimulated to breathe before a laryngoscope is used to assess the presence of meconium below the cords. After delivery of the fetal head and suctioning is complete, the neck of the fetus is explored for nuchal cords, which are preferably reduced if possible. If too tight to reduce, the cord must be clamped, then cut. The anterior shoulder of the fetus is then delivered with gentle downward traction, but predominantly with maternal expulsive forces to avoid excessive pulling on the fetal neck, which can be associated with brachial plexus injury. Hyperflexion of the legs at the hip joint will allow the anterior shoulder to deliver more easily. After delivery of the anterior shoulder, the posterior shoulder is delivered usually quite easily with gentle upward traction. Excessive maternal efforts at this point can cause perineal lacerations. Thus the mother is instructed to push hard for the delivery of the anterior shoulder and gently for the posterior shoulder. Once the shoulders are delivered the remainder of the body escapes easily. The baby can then be placed on the mother's abdomen where warm towels await. The timing of clamping of the cord is controversial. As long as the baby is kept on the maternal abdomen, excessive blood shifts through an unclamped cord will usually not occur. The cord can then be clamped. Cord blood is obtained, as well as cord pH if desired.

The placenta should then be allowed to separate spontaneously. During this time, inspection of the vaginal canal and cervix for tears can be started, but adequate inspection for lacerations should be done after delivery of the placenta. Signs of placental separation include lengthening of the cord, gush of blood, and change in contour of the uterine fundus. Separation of the placenta from the maternal decidua is most likely from shearing forces as the now-smaller uterus contracts. After separation, uterine contractions decrease the size of the implantation site to arrest bleeding from this area. Maternal expulsive forces may be required to deliver the placenta along with gentle traction on the cord. Uterine massage and immediate breastfeeding will aid in maintaining a contractile state of the uterus and decrease uterine atony. In some cases, oxytocin may be required to maintain uterine contractility. After separation of the placenta, the episiotomy (if cut) and any lacerations should be repaired.

New Mothers Guide to Breast Feeding

New Mothers Guide to Breast Feeding

For many years, scientists have been playing out the ingredients that make breast milk the perfect food for babies. They've discovered to day over 200 close compounds to fight infection, help the immune system mature, aid in digestion, and support brain growth - nature made properties that science simply cannot copy. The important long term benefits of breast feeding include reduced risk of asthma, allergies, obesity, and some forms of childhood cancer. The more that scientists continue to learn, the better breast milk looks.

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