Integrated Maternal and Newborn Care Basic Skills Course ...

Reference Manual
Managing the Third Stage When the Birth Attendant Is Alone and the Baby Needs
Resuscitation
There is a potential “conflict of interest” in caring for the mother and baby when the baby needs
resuscitation. How the provider cares for each one will depend upon several factors: if the birth
attendant is alone or has an assistant and what type of resuscitative efforts are required for the
baby.
If the birth attendant is alone and the baby is not breathing or is gasping at birth, the birth
attendant will manage the third stage of labor as follows: If the baby begins breathing after
stimulation, active management of the third stage of labor will most likely be possible. Place the
baby in such a position that you can observe him/her during implementation of AMTSL:
1. Administer a uterotonic drug within one minute after the baby is born (oxytocin is the
uterotonic of choice) and a second twin has been ruled out.
2. Apply controlled cord traction with simultaneous countertraction to the uterus.
3. Perform uterine massage immediately after delivery of the placenta.
If the baby requires resuscitation with bag and mask, there are two possible scenarios:
Scenario 1: The provider is alone but is able to administer a uterotonic drug within one
minute after birth of the baby:
1. Administer a uterotonic drug within one minute after the baby is born (oxytocin 10 IU
IM or misoprostol 600 mcg by mouth) and a second twin has been ruled out.
2. Deliver the placenta either by maternal effort or with assistance of the provider.
3. Perform uterine massage immediately after delivery of the placenta.
Scenario 2: The provider is alone and is not able to administer a uterotonic drug within
one minute after birth of the baby:
1. Perform physiologic management of the third stage of labor.
2. Perform uterine massage immediate after delivery of the placenta.
Managing the Third Stage When the Woman Is Infected with HIV
The practice of AMTSL is the same for all women regardless of their HIV status. However,
women who are HIV-infected may choose not to breastfeed, so providers need to respect and
support the woman’s choice for infant feeding. In addition, providers need to ensure that
national guidelines for PMTCT are implemented for the woman and newborn in addition to
routine care during labor, childbirth, and in the immediate postpartum.
Recommendations for Selecting a Uterotonic Drug to Prevent PPH
In the context of active management of the third stage of labor, if all injectable uterotonic drugs
are available:
• Skilled attendants should offer oxytocin to all women for prevention of PPH in preference
to ergometrine/methylergometrine. This recommendation places a high value on
avoiding adverse effects of ergometrine and assumes similar benefit for oxytocin and
ergometrine for preventing PPH.
• Skilled attendants should offer oxytocin for prevention of PPH in preference to oral
misoprostol (600 mcg). This recommendation places a high value on the relative benefits
of oxytocin in preventing blood loss compared to misoprostol, as well as the increased
adverse effects of misoprostol compared to oxytocin.
Integrated maternal and newborn care
Basic skills course
75