Checklist for Conducting

(III stage of labor), AMTSL

3 Continues active management of third stage of labour

(AMTSL):

• B. Controlled cord traction (CCT): (attempts only when the

uterus is contracted)
 Assures the woman that delivering the placenta will not
hurt, because it is much smaller and softer than the baby
 Clamps the maternal end of the umbilical cord close to
the perineum with an artery clamp

 Holds the clamped end with one hand and places the
other hand just above the symphysis pubis, for counter
traction on the uterus to prevent inversion
 Holds the cord with the help of the clamp and waits for a
contraction
 Only during contractions, gently pulls the cord
downwards and then downwards and forwards to
deliver the placenta
 With the other hand, pushes the uterus upwards by
applying counter traction. (If the placenta does not
descend within 30-40 seconds of CCT, does not continue
to pull on the cord. Waits for about 5 more minutes for
 the uterus to contract strongly, then repeats CCT with
counter traction)
 As the placenta appears at the vaginal introitus, holds it
with both hands and twists it clock wise to deliver it
complete and prevents tearing of the membranes
 Gently keeps twisting the placenta with membranes so
that they get twisted in to a rope and are expelled and
slip out of the introitus intact and complete
 Places the placenta in a tray
• C. Uterine massage:
 Places the cupped palm on the uterine fundus and feels
for the state of contraction
 If the uterus is soft and not-contracted, massages the
uterine fundus in a circular motion with the cupped
palm until the uterus is well contracted. A well
contracted uterus feels like a cricket ball or the forehead
 When the uterus is well contracted, places her fingers
behind the fundus and pushes down in one swift action
to expel clots
 Estimates and records the amount of blood loss
approximately
 Encourages the attendant to help the woman to breast
feed
• Examination of the lower vagina and perineum.
 Ensures that adequate light is falling on the perineum
 With gloved hands, gently separates the labia and
inspects the perineum and vagina for bleeding,
laceration/tears
 If lacerations/tears are present, manages them as per
the protocols (will be dealt with in detail during PPH)
 Cleans the vulva and perineum gently with warm water
or an antiseptic solution and dries with a clean soft
cloth
 Places a pad or clean, sun-dried cloth on the woman’s
perineum
 Removes soiled linen to make the woman comfortable
and shifts her up to lie comfortably on the delivery table
• Examination of the placenta, membranes and the umbilical
cord:
• Maternal surface of the placenta:
 Holds the placenta in the palms of the hands, keeping
the palms flat. Makes sure the maternal surface is facing
up
 Checks if all the lobules are present and fit together
 After the maternal side has been rinsed carefully with
water, it should shine because of the decidual covering
 If any of the lobes is missing or the lobules do not fit
together, suspects that some placental fragments may
have been left behind in the uterus
• Foetal surface:
 Holds the umbilical cord in one hand and lets the
placenta and membranes hang down like an inverted
umbrella
 Looks for holes which may indicate that a part of the
lobe has been left behind in the uterus
 Looks for the point of insertion of the cord, the point
where it is inserted into the membranes and from where
it travels to the placenta
• Membranes :
 Puts one hand inside the membranes to open them and
see for any holes or irregular edges other than the one
from where the membranes ruptured and the baby
came out
 Places the membranes together and makes sure that
they are complete
• Umbilical cord:
 Inspects the umbilical cord for two arteries and one vein.
If only one artery is found, looks for congenital
malformations in the baby
• Decontamination and disposal of waste:
 Disposes the placenta in the yellow coloured
contaminated waste bin after removing the artery clamp
 Places the instruments used in 0.5% chlorine solution for
10 minutes for decontamination
 Decontaminates or disposes of the syringes and needles
  Immerses both the gloved hands in 0.5% chlorine
solution
o Removes the gloves by turning them inside out
o For disposing of the gloves, places them in a leak
proof container or red plastic bin
o If the surgical gloves are to be re-used, submerges
them in 0.5% chlorine solution for 10 minutes to
decontaminate them
• Washes hands thoroughly with soap and water and air dries
• Completes the records of the woman
* Prepare for newborn resuscitation (NBR) if required:
Immediately after birth-
• Prepare for newborn resuscitation (NBR) if required:
Immediately after birth-
• If the baby is not crying or not breathing, irrespective if
the meconium is present or not, quickly applies suction
to the mouth and then the nose to clear the airways
while the baby is on the mother’s abdomen and quickly
dries the baby with the warm towel
• Assesses the baby’s breathing:
• If the baby starts breathing well and the chest is rising
regularly, between 30–60 times a minute, provides
routine care
• If the baby is still not breathing or is gasping, calls for
help. Clamps the cord immediately, even before 1
minute and asks the co-provider to take the baby to the
radiant warmer at the NBCC in the LR for further suction
and resuscitation with bag and mask while she manages
the third stage of labour
• The steps of resuscitation (as described in the checklist
for NBR) need to be carried out immediately
Immediate care of mother after delivery (within 2 hours
of delivery- in or near the labour room):
• Checks the uterus and vaginal bleeding at least every 15
minutes for the first 2 hours, massaging as and when
necessary to keep it hard. Makes sure the uterus does not
become soft (relaxed) after massage is discontinued.
Ensures, the mother is comfortable and her vitals are
normal.
• Ensures the baby is breathing normally. Checks weight of
the baby and gives injection Vitamin K intramuscular, 1 mg
to > 1000 gms baby and 0.5 gm to the baby weighing < 1000
gms in the anterolateral thigh to prevent haemorrhagic
disease of the newborn.
• If both mother and baby are normal shift them together to
the postpartum ward.