CLINICAL AUDIT(2023)

3RD STAGE MANAGEMENT IN LABOR ROOM

 Clinical Audit Team
SERIAL NO NAME DESIGNATION
1 DR SANTOSH MINHAS PROFESSOR & HOD
(OBGYN)
2 DR MONIKA JINDAL PROFESSOR (OBGYN)
3 DR MANISHA BEHAL PROFESSOR (OBGYN)
4 DR ALEEZA PAL ASSISTANT PROFESSOR (OBGYN)
5 DR HARINDER KAUR PG JR 2
6 DR HARLEEN KAUR PG JR 1
 INTRODUCTION OF CLINICAL AUDIT
• A quality improvement process that seeks to improve patient care and
outcome through systematic review of care against explicit criteria and
the implementation of change.
• There are stages that follow the systematic process of establishing best
practices, measuring against criteria, taking action to improve care,
and monitoring to sustain improvement.
• As the process continues, each cycle aspires to a higher level of
quality.
first stage (stage of uterine
contractions and cervical
dilatation)

2nd stage (delivery of the

baby)

3rd stage (delivery of

placenta)
most crucial
STAGES OF LABOR
AMTSL(Active)
3RD STAGE OF LABOR

EXPECTANT(Passive)
 AMTSL(ACTIVE MANAGEMENT OF 3RD

• inj
syntocino
n 10 U
I/M or
I/V-first
choice
• contr
olled
• delayed cord
(IF
UNAVAIL cord tracti
ABLE) clampin on
• tab g- durin
misopros minimu g
STAGE OF LABOR)

tol 600
m at 1 uterin
ug ORAL
• inj minute
e
methergo
metrine contr
or fixed action
drug
combinat
oxytocics

placental
clamping
ion of

delivery
oxytocin

cord
&
ergometr
ine
 AIM AND OBJECTIVE
1.To review the management of 3rd stage ( active or passive)
2.To implement the practice of active management of 3rd stage of labor
as per WHO guidelines.
3.Training of the nursing staff/Junior Residents for AMTSL & its
importance
AIM
To prevent the most dreaded complication of 3rd stage i.e . PPH by
AMTSL .
DATA SOURCE
Data Source and Audit type-
Retrospectively data collected from medical records for the months of
January, February, March, April 2023.
Post audit data from 1st of June, 2023 till 24th September 2023 by
residents prospectively.
SERIAL NO CHECK LIST RESPONSE(TICK APPROPRIATE)
1 CHECK
CLEANINGLIST
AND DRAPING YES/NO

2 POSITION-LITHOTOMY YES/NO
3 MODE OF DELIVERY VAGINAL
4 IV line secured yes/no
5 AMTSL - yes/no
a) OXYTOCICS syntocinon 10 U IM /MESOPROSTOL 600 MCG
PO/METHERGIN 0.2MG IM
b) DELAYED CLAMPING YES (90 SECS/120 SECS/ CESSATION OF CORD
PULSATION)/NO

c) SIGNS OF PLACENTAL SEPERATION OBSERVED YES/NO

d) CONTROLLED CORD TRACTION YES/NO

6 PLACENTA RETAINED/ INCOMPLETE REMOVAL/COMPLETE
REMOVAL
7 ANY 3RD STAGE COMPLICATION RETAINED PLACENTA/INVERSION/PPH

8 DURATION OF 3RD STAGE <10 mins/>10 mins

DATA ANALYSIS( 1st January 2023-30th
April 2023)

retrospectively data available from medical records

 RESULTS
S NO MONTH TOTAL DELIVERIES VAGINAL LSCS
1 JANUARY 168 106 62
2 FEBRUARY 142 96 46
3 MARCH 165 112 53
4 APRIL 154 103 51
TOTAL 629 417(66.30%) 212(33.70%)
SERIAL NO CHECK LIST RESPONSE RESULTS
1 CLEANING AND DRAPING YES/NO 100%(yes)
2 POSITION-LITHOTOMY YES/NO 100%(yes)
3 MODE OF VAGINAL 100 %
DELIVERY(INCLUDING
INSTRUMENTAL)
4 IV line secured yes/no 100 %

5 AMTSL - YES/NO 80 % YES AND 20 % NO

a) oxytocic syntocinon 10 U IM /MESOPROSTOL (SYNTOCINON IN ALL CASES, OTHER
600 MCG PR/METHERGIN 0.2MG IM OXYTOCICS IF NEEDED)
b) DELAYED CLAMPING YES (90 SECS/120 SECS/ CESSATION (DELAYED CORD CLAMPING UPTO 90
OF CORD PULSATION)/NO SECS IN 90 %)
c) CONTROLLED CORD YES/NO 100 %
TRACTION
d) SIGNS OF PLACENTAL YES/NO OBSERVED IN 100 %
SEPERATION OBSERVED
6. PLACENTA RETAINED/ INCOMPLETE COMPLETE REMOVAL IN 96 % ,
REMOVAL/COMPLETE REMOVAL 4 % PATIENTS REQUIRED
ASSISTANCE/No retained palcenta
7 ANY 3RD STAGE RETAINED MILD TO MODERATE PPH WAS
COMPLICATION PLACENTA/INVERSION/PPH OBSERVED IN 4 %
8 DURATION OF 3RD STAGE <10 mins/>10 mins <10 MINS IN 83 %
upto 25 mins in 17 %
 Data Analysis

417 patients delivered vaginally ,out of which

9(2.17%) had instrument Aided vaginal delivery .
All patients(100%) were properly cleaned and draped
in lithotomy position.
100 % patients had IV cannula secured, 80% of
patients received complete AMTSL and 20 % were
managed expectantly or received delayed oxytocic.
Delayed cord clamping was recorded in 90 % , as 10 % of the neonates
needed resuscitation due to various reasons.
All placental deliveries were by CCT after placenta got separated.
4% of the cases required exploration due to PPH .
Duration of 3rd stage was <10 mins in 83 % of patients and was upto
25 mins in 17 % of cases.
 RCA (Root Cause Analysis)
• Newly recruited staff / newly joined Junior residents were not aware
about the importance of AMTSL.
 CORRECTIVE MEASURES
TAKEN(CAPA)
Benchmark to be achieved was complete AMTSL in 100 % as it reduces the
duration of 3rd stage and PPH.

1.Staff and Junior residents were trained about the significance of active
management of third stage of labour.
2. Training about how to manage the third stage actively was also provided in
skill lab on mennequins to junior residents and staff seperately.
DATA ANALYSIS( 1st June 2023- 24th SEPTEMBER 2023)

• Prospective data collection

 RESULTS
S NO MONTH TOTAL DELIVERIES VAGINAL LSCS
1 JUNE 174 128 46
2 JULY 167 119 48
3 AUGUST 146 79 67
4 SEPTEMBER (24TH) 118 78 40
5 TOTAL 605 404(66.78%) 201(33.22%)
 CHECK LIST
SERIAL NO CHECK LIST RESPONSE
1 CLEANING AND DRAPING YES/NO 100% yes
2 POSITION-LITHOTOMY YES/NO 100% yes
3 MODE OF VAGINAL 100% yes
DELIVERY(INCLUDING
INSTRUMENTAL)
4 IV line secured yes/no 100% yes
5 AMTSL - YES/NO 100 %
a) oxytocic syntocinon 10 U IM /MESOPROSTOL SYNTOCINON IN ALL CASES, OTHER
600 MCG PR/METHERGIN 0.2MG IM OXYTOCICS IF NEEDED
b) DELAYED CLAMPING YES (90 SECS/120 SECS/ CESSATION 95 % cases at 90 sec
OF CORD PULSATION)/NO 5 % had early clamping
c) CONTROLLED CORD YES/NO 100 %
TRACTION
6 SIGNS OF PLACENTAL YES/NO 100 %
SEPERATION OBSERVED
7 PLACENTA RETAINED/ INCOMPLETE 99.75%(COMPLETE)
REMOVAL/COMPLETE REMOVAL
 RESULTS
8 ANY 3RD STAGE RETAINED MILD PPH (0.25 %)
COMPLICATION PLACENTA/INVERSION/PPH
9 DURATION OF 3RD STAGE <10 MINUTES/>10 MINUTES <10 MINUTES IN 100 %
 RE-AUDIT
• OUT OF TOTAL 605 BIRTHS , 404 ( 66.78%) DELIVERED
VAGINALLY AND ALL PATIENTS RECEIVED AMTSL AND HAD
IMPROVED MATERNAL OUTCOME IN TERMS OF PPH and
SHORTENING OF THIRD STAGE
 CONCLUSION
Severe pph may lead to maternal morbidity as well as mortality in unlucky ones, so just by
giving oxytocics within one minute of anterior shoulder delivery we can save maternal health
and life .

Each year about 14 million women experience PPH resulting in about 70,000 maternal deaths
globally
delayed cord clamping is beneficial for the new born in terms of

• improved transitional circulation

• better RBC volume
• increased iron stores
• lesser NEC, IVH and need for blood transfusion
 RECOMMENDATIONS
1. AUDIT TEAM RECOMMENDS THAT 3RD STAGE MUST BE
MANAGED ACTIVELY TO REDUCE THE CHANCES OF DREADED
COMPLICATION
OF PPH.
2. STAFF and JUNIOR RESIDENTS MUST BE TRAINED ABOUT
AMTSL METHOD & ITS IMPORTANCE AS THEY ARE FIRST
CONTACT HEALTH CARE PROVIDERS FOR VAGINAL DELIVERY
3. AMTSL PROTOCOL FOR ALL PATIENTS MUST BE ENSURED .

A STITCH IN TIME SAVES NINE

 REFERENCES
1.Updated WHO PPH recommendations-PPH Community of Practice Annual
Meeting .July 21–23, 2020
Mariana Widmer
Maternal and Perinatal Health Research, SRH, WHO
2. WHO Labour Care Guide: User’s Manual pp 30

• The use of an effective uterotonic for the prevention of PPH

during the third stage of labour is recommended for all births.