Description of third stage of labor Third stage of labour is defined as the period between birth of the baby to complete expulsion of placenta and membranes. It is the shortest but most dangerous stage of labour since there is for postpartum haemorrhage, uterine inversion and rupture. Physiology of third stage of Labour This involves separation, descent, expulsion and control of haemorrhage. The time the placenta actually separates from the uterine wall varies. Separation may start during final expulsive contraction of the second stage or may remain attached some time.  Third stage of labour lasts between 5 – 15 mins but up to 1 hour is still normal. It comprise of mechanical factors and control of haemorrhage (haemostasis) Mechanical factors Management of the third stage of labour Placenta could be delivered using physiologic and active management of third stage of labour Physiologic management or Expectant management Routine administration of uterotonics is withheld. Signs of separation of cord are observed.  Active management of Third stage of labour The active management of Third stage of labour is discussed in three (3) steps Step 1: Give oxytocin Give oxytocin 10 I.U I.M within one minute of birth of the baby after checking for a second baby Step2: Controlled cord traction to delivery of placenta Step 3: Massaging the uterus and control of bleeding Procedure for Active management of Third stage of labour Advantages of Active management of Third stage of Labour STEP TO STEP IMMEDIATE CARE OF THE NEWBORN Stimulation The baby that is active does not need stimulation. Rough handling of newborn children should be discouraged. If the baby is not breathing. Stimulate the baby after suctioning by gently rubbing the back. Most babies start to breathe very well after stimulation. Handling a baby roughly like beating the back, turning upside down can cause injury to internal organs and brain Assess the Apgar Score at 1 minute and 5 minutes after delivery Apply Olive oil This helps to maintain warmth. Clean off any blood stain on the baby’s skin. Do not remove vernix  caseosa because it also help to keep baby warm and will later be absorbed Weigh the baby, measure height, length and head circumference Complications of third stage of labour  Final Notes

What is the menstrual cycle? Menstruation is a monthly physiological bleeding from the endometrium that lasts from about 4 days from the time of menarche to menopause. The occurrence of monthly menstrual flow is known as menstrual cycle. Physiology of menstruation The uterine changes which relate to menstruation occur in the corpora endometrium, as a result of its stimulation of the ovarian hormones; oestrogen and progesterone. These takes form of: The  Proliferative Phase This begins at the end of menstrual phase and lasts for about 10 days ie until ovulation. During this period, a graffian follicle starts to develop in the ovary. FSH from anterior pituitary stimulates the cells of the graffian follicle to secrete oestrogen which is responsible for the growth of the endometrium from unchanged deeper layer. At the conclusion of these phase, the endometrium consist of three layers:  A basal layer: lies immediately above the myometrium about 1mm in thickness. This layer never alter during the menstrual cycle. It contains all the necessary rudimentary structures for building up new endometrium  A functional layer: which contains tubular glands and is 2.5mm thick. This layer changes constantly according to the hormonal influences of the ovary. A layer of cuboidal: ciliated epithelium Covers the functional layer. It deeps down to line the tubular glands. The Secretory Phase After the proliferative phase, ovulation takes place and corpus luteum is formed. The corpus luteum is under the influence of luteinizing hormone(LH) from anterior pituitary, secretes progesterone. This cause the endometrium which was being growing under the influence of oestrogen to undergo further growth and glands increase in size, become more tertous and secrete more mucus. Blood supply is also increased giving a red corrugated surface. This is in preparation for the fertilized ovum. The Menstrual Phase Should fertilization not take place the ovum dies, the corpus luteum disintegrates. The secretion of oestrogen and progesterone falls. The endometrium shows degenerative changes which is followed by bleeding lasting for 3-4 days. Disorders of Menstrual Cycle

What is an abnormal pelvis? Abnormal pelvis is a pelvis with disruption in its structure or function.  It is the main cause of prolonged or obstructed labour that necessitates cesarean delivery.  There are different types of abnormal pelvis which are classified under two main groups. Congenital abnormalities of the pelvis Justo Minor: This is like gynaecoid in shape but all the diameters of the brim cavity and outlet are proportionately reduced, it is seen in women of small status. The shoe size is less than 4. Effects of Justo Minor pelvis  on labour  Naegele’s pelvis: Here the sacrum has only one wing or alae. This can occur in a woman who has limping gait for many years Roborth pelvis: The sacrum has no wings or alae at all and so it is contracted in all directions High Assimilation: In this type of pelvis, the last lumbar vertebra is fused to the upper part of the sacrum producing a large promontory with a subsequence reduction of anterior posterior diameter of the brim, because of this the head may fail to engage Achondroplastic pelvis: Failure of the growth of both the long bones leading to dwarfism. This condition also affects the shape and inclination of the pelvis Contracted pelvis: This is the type of pelvis in which the one or more essential diameter like anteroposterior position (AP), transverse, or oblique diameter of the brim, cavity and outlet of the brim is reduced by 1 cm or more. Acquired abnormalities of the pelvis Rachitic Pelvis: the pelvis is deformed due to ricket in early childhood. Ricket is due to lack of vitamin  D, causing non-absorption of calcium and phosphorus. The incidence of this type of pelvis is now reduced due to infant welfare facilities and health care. Osteomalacia Pelvis: Deformity here is due to deficiency of minerals, vitamin A and D in diet. This makes the bones to be soft on the side walls of the pelvis canal, squashed together until the brim becomes a mere slit shape. Spondylolytic  Pelvis: This is a condition where the lower lumbar vertebra slight forward to over hanged the sacral promontory thus markedly reduced the anterior posterior diameter of inlet Fractured Pelvis: Badly healed fracture of the pelvis reduces the diameter of the brim, cavity and outlet. Kyphotic Pelvis: This is when there is curvature of the vertebrae the shape of the pelvis(hunch back). The shape and inclination of the pelvis are always affected because the diameters are all reduced and squashed Effects of abnormal pelvis on labour If the degree of contraction is sereve elective C/S is carried out. But where there is  minor or moderate contraction of the pelvis, trials of labour may be carried out, as fortunately these women often have small babies (law of compensation is observed). Conclusion Normal(gynaecoid) pelvis is ideal for pregnancy and parturition.   However, abnormal pelvis does not favour vaginal delivery and is usually associated with operative delivery.  We encourage that all women during pregnancy receives adequate nutrition and take their prescribed routine drugs(vitamins and minerals) to ensure that the baby in-utero obtains good supply of nutrients from maternal bloodstream.  Again, all girl children should be placed on balaced diets, encouraged to engage in moderate and regular exercises and prevent them from engaging in anything capable of causing trauma or injury.

The essential functions of umbilical cord cannot be over emphasized. Therefore, any  abnormal umbilical cord  predisposes to rupture, mechanical failure, entanglement, disruption of labour, uterine malfunction, and premature labor.  What are abnormalities of umbilical cord?  Cord abnormalities are silent and invisible but can be diagnosed prenatally with meticulous ultrasound scan. Sometimes, may not be diagnosed until in labour/delivery. The followings are abnormalities with their accompanying risks: False knots:  This is also known as Pseudoknots, resulting from merely a varicosity or redundancy of an umbilical blood vessel (usually the vein) within the cord substance and cannot be physically released in an intact cord. This cord anomaly has no clinical significance. Nuchal Cords:   Dr. J. Selwyn Crawford of the British Medical Research Council in 1962 was first  to define this  as the condition in which the umbilical cord is wound at least once around the neck of the fetus.  Simply, whenever a fetus’s umbilical cord crosses itself 360 degrees  around the neck, it’s called a nuchal cord. This increases the risk for entanglement, fetal distress and neonatal depression, and possibly prolonged labour or even fetal death. Thin or ‘lean” knot:  This is called Thin-cord syndrome which is characterised by reduced or completely absent Whartonʼs jelly.Whartonʼs jelly surrounding the three umbilical vessels offers a flexible protective layer against vessel compression, kinking and other mechanical forces, and hence, assuring the fetal blood supply and removal of metabolic waste products. With deficient or absent Wharton’s  jelly, the umbilical cord is drastically exposed to dangers.  Thick knot: Umbilical cord is naturally designed in a way to regulate blood flow. Therefore, the thickness of the cords can disrupt circulation. Single umbilical artery (SUA):  This tends to cause disturbance in the fetal blood flow leading to fetal distress and stillbirth. SUA occurs in two forms: a helical form and a straight form.  The absent left or right umbilical artery is linked with increased risk of fetal abnormalities. SUA is found  to be common in twins and diabetic pregnancies, and also with long cords and small placentas. Single umbilical artery may indicate  kidney abnormalities.  Abnormal insertions of the cords: These may occur as:  True Knots:   True knots is a rare cord anomaly occurring in 0.5% of all pregnancies. True knot is the abnormal twisting of the cord leading to disturbances in blood flow and it may be single, double, or triple. True knots are associated with hematomas.  Fetuses with true umbilical knots are at high increased risk of fetal hypoxemia and intrauterine death due to constriction of blood vessels.  Probably, true knots develop early in pregnancy when intrauterine space is available for excessive fetal movement As the fetus grows, a true knot may tighten or tightening may occur at delivery when the umbilical cord undergoes traction. The constriction or hematoma development may lead to fetal hypoxia, neurologic impairment or fetal demise. Etiologically, true knots are linked with conditions(risk factors) that allow for increased fetal movement including multigravidae, long cord length, male fetuses,small fetuses, monoamniotic twins and increased amniotic fluid(polyhydramnios). Cord torsion:  Torsion is an anomaly of umbilical cord where twists are  superimposed on the cord itself like an overly twisted telephone cord. Note that torsion is not a natural state of the umbilical cord and hence,torsioned cords must never be likening to naturally helical, coiled, or spiraled cords. Knots and nuchal cords do not usually accompany torsion, but they can be observed with torsion.   The  harmful effect of torsion on the fetus ranges from heart failure to stillbirth owing to disrupted blood flow.  Absent umbilical cords:  This is a rare cord anomaly. If the umbilical cord does not develop, the fetus can develop but can be malformed. The fetus is directly attached to the placenta at the abdomen and usually develops defects. Fetuses without cords have been born by C-section. Without an umbilical cord, life is usually not possible. Short cord (<40):  A short cord has found to be associated with increased risk for fetal malformations, umbilical vein and arteries to tears, which can lead to hematomas (vessel rupture of the cord, fetal distress and death, stillbirth risk especially with  relatively short cords which can be more heightened in the presence of other factors like toxemia,  maternal labor and delivery complications, including retained placenta, uterine inversion(inside out and a medical emergency) can occur from traction on a short cord, placental abruption and  prolonged  labour due to  poor fetal descent seen in short cord accruing operative vaginal delivery (forcep, vacuum extractions or even cesarean section).  Short cords and cigarette smoking tend to result in small babies, called IUGR  (intrauterine growth retarded).  Moreover, restricted  fetal movements and when they occur,  may predispose the cord vessels to compression/constriction, thrombosis, hemorrhage, or hematoma formation.  Relatively short cords interfere with the mechanics of labor and delivery while exhibiting changes in fetal heart rate patterns.  Short cord is  believed  to be associated with placental trisomy 16. Long cord (>60):  Excessive lengthy cords are found to be associated with cord entanglements around the neck and body, cord prolapse (slip out of the womb), emergency deliveries and fetal thrombotic vasculopathy in the placenta, fetal death and increased risk of neurological complications. Long cords can enter  the fetal mouth acting as ”pacifier” or the fetus handles the cord like a toy.  This may result in cord blockage  during the sucking and handling thereby affecting the fetus. Risk factors associated with long umbilical cords: Naturally, male cords tend to be longer than female cords, and term vertex fetuses may have longer lengths than term breech fetuses (with the duration of presentation unknown).  Multigravida cord length may be longer than primigravida cord length (the first pregnancy having a shorter length than the third, this may imply more room for movement-tension or more blood supply/hormone production/fetal and maternal weight gain).  Multifetal pregnancies may have fetuses with discordant lengths and shorter lengths than singletons.   Patent urachus: This results in fistulous or abnormal connection of the bladder with umbilicus.  Variable umbilical cord-vessel number: These are rare though reports had shown presence of