Mrs Siame

DEFINITION
 This is a stage of separation and expulsion of the
placenta and membranes and control of
bleeding, it commences with complete expulsion
of the baby and ends with delivery of the
placenta and membranes.
DURATION
➢ In both Primigravida and multigravida it should
last 10 – 15 minutes not more than one hour.
➢ With Active management it should last 5 minutes.
1. PLACENTAL SEPERATION
2. DESCENT
3. EXPULSION
4. CONTROL OF BLEEDING
1. PLACENTAL SEPERATION
➢ Placental separation begins after the
expulsion of the baby.
➢ After expulsion of the baby from the uterus,
the surface area of the uterine cavity is
greatly reduced and the uterine muscles
contract and retract.
➢ This will cause the portion of the placenta
which is unable to contract with uterine
muscles to become detached from the uterine
wall at its implantation site.
PLACENTAL SEPERATION
➢ The placenta being implanted in the basal layer
of the decidua shears off uniformly from the
uterine wall like a postage stamp from another
hence the name postage stamp layer (Layer of
Nitabuch).
➢ When a portion of the placenta becomes
detached from the uterine wall blood vessels
which supply the maternal side of the placenta
are ruptured.
➢ There is an outflow of blood between the decidua
and the maternal surface of the placenta.
PLACENTAL SEPERATION
➢ The extra vasation of blood causes further
detachment of the placenta from the uterine
wall about 500-800ml/minute flow through
the placental bed.
➢ The uterine muscles will continue to contract
and retract which will complete the placental
detachment from the uterine wall.
PLACENTAL SEPERATION
➢ There are two methods of placental
separation and the description is based on
the way the placenta will emerge from the
uterus.
➢ Shultz (shiny) method
➢ Mathew Duncan (dirty method)
TYPES OF PLACENTAL SEPERATION
SHULTZ METHOD
➢ This type of placental separation occur when the placenta
is implanted on the upper part of the uterine body.
➢ The Center of the placenta separates from the uterine wall
first.
➢ The blood (retro-placental clot) collects in the Center of
the placenta and causes the placenta to invert (turn) as it
descends in the uterus and birth canal.
➢ In this way the shiny fetal surface emerges on the vaginal
orifice first with blood clot contained within the
membranes and very little blood is spelt.
➢ The membranes are usually intact except for the hole
through which the baby passed through called fenestrum.
TYPES OF PLACENTAL SEPERATION
MATHEW DUNCAIN
➢ This type of separation may occur when the placenta
is implanted in the side walls of the uterine body.
➢ The lower edge of the placenta separates from the
uterine wall first causing bleeding which dislodges
the membranes below.
➢ The placental separation continues upwards and
when it is complete, the lower edge slips through the
cervical os and emerges on the vaginal orifice first.
➢ There is often a gush of blood followed by the
maternal surface of the placenta and the torn rugged
membranes.
2. DESCENT
➢ During this stage, the placenta will fall into
the lower uterine segment by force of gravity.
3. EXPULSION
➢ Due to contraction and retraction of the
uterus the placenta is pushed into the vagina
and is expelled from the birth canal.
4. CONTROL OF BLEEDING
➢ During control of bleeding, three things
occur:
I. Constricting effect of the contracting muscle
fibres on the blood vessels (living ligatures).
II. There is surface apposition of the inner
uterine wall on the placental site.
III. The normal coagulation process of blood
occurs.
➢ The average amount of blood loss in normal
3rd stage of labour is 150-250ml.
Anticipatory signs
➢ A small gush of blood may trickle from the
vaginal orifice.
➢ Lengthening of the umbilical cord.
➢ The woman may want to bear dawn because
of contractions.
➢ The fundus of the uterus rises into the
abdomen to the level of the umbilicus.
➢ The uterus becomes hard and round
➢ There is no retraction of the umbilical cord
when pressure is applied just above the
symphysis pubis.
➢ The placenta may be visible at the vaginal
orifice.
AIMS
 To prevent infection
 To minimize bleeding
 To deliver the placenta as soon as possible
 The midwifes skill should be aimed at
reducing complications of
haemorhage,infection,retained placenta and
shock which may increase maternal morbidity
and mortality.
 There are two methods of managing 3rd stage
of labour.
1.PHYSIOLOGICAL METHOD (EXPECTANT)
 This involves non use of oxytocics,nipple
stimulation may be used in form of allowing
the baby to suckle or rubbing the nipples
between the thumb and index finger.
 It involves delivery of the placenta by gravity
and maternal effort.
PHYSIOLOGICAL METHOD (EXPECTANT)
 The midwife waits for signs of placental
separation such as:
 A small gush of blood may trickle from the
vaginal orifice.
 There will be elongation of the cord, it will be
seen lengthening.
 The woman will have the urge to bear down
Conclusive signs
 The fundus of the uterus rises in the
abdomen to the level of the umbilicus.
 The uterus becomes round and hard.
 The placenta may be visible at the vaginal
orifice.
 The placenta and membranes should be
delivered by asking the mother to push.
PHYSIOLOGICAL METHOD
Advantages
 No drug administration/stock required.
 The mother does not require a skilled
attendant.
 There are no side effects expected.
Disadvantages
 It delays delivery of the placenta predisposing
the woman to post partum hemorrhage.
2. ACTIVE MANAGEMENT OF THIRD STAGE OF
LABOUR
 This involves the administration of oxytocic's
and delivery of the placenta and membranes
by Controlled Cord Traction (CCT).
 This method is mandatory under the ministry
of health in order to prevent postpartum
hemorrhage.
ACTIVE MANAGEMENT OF THIRD STAGE OF
LABOUR
STEPS
 Palpation of the abdomen to rule out second
twin.
 Administration of oxytocin 10iu
intramuscularly to help in placental
separation.
 The midwife places the left hand on the
abdomen to feel for a contraction.
ACTIVE MANAGEMENT OF THIRD STAGE OF
LABOUR
STEPS
 The midwife pushes the uterus backwards to
prevent uterine inversion/prolapse.
 Use of controlled cord traction (CCT) with the
right hand, hold the umbilical cord on a
forceps with palm facing upwards and apply
steady tension.
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR
STEPS
 Wait for a contraction and with the right hand, gently
pull on the cord in an upward downward movement,
with the left hand apply counter traction on the
uterus to prevent uterine inversion.
 When the placenta appears on the vulva, grasp it in
both hands and rope the membranes (turn) to ensure
delivery of the membranes and prevent retained
products of conception.
 After delivery of the placenta, quick uterine massage
is done to ensure uterus is firm and well contracted.
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR
STEPS
 Quick inspection of the maternal side of the placenta
is done to ensure that there are no retained lobes or
pieces.
 Quick inspection of the genitalia from the cervix out
wards to inspect for tears and lacerations and control
of bleeding through repair of tears and lacerations.
 Estimation of blood loss should be done and
documented ,blood loss of above 500ml is abnormal
the woman should be checked for lacerations and
tears and managed as postpartum hemorrhage.
 The bladder should be emptied to help contraction of
the uterus.
Environment
 Keep the woman in labor ward for the next
one hour for close observation.
 The mother should be observed in labor ward
for one hour with the baby, both can be
transferred to postnatal ward after one hour
when both the mothers and baby's condition
is satisfactory.
HYGIENE
 After inspection and repair of tears, clean the
patients vulva to prevent infection and put a
sterile pad.
 Change the patients soiled linen to provide
comfort.
Observations
 Observations should be done immediately after
delivery of the placenta and membranes such as
Temperature,pulse,respirations and blood
pressure recorded and continuous monitoring
should follow at 15 minutes interval for the next
one hour.
 Lochia/Bleeding should be observed every 15
minutes for one hour to rule out PPH.
 The uterus should be massaged and monitored
for contraction at 15 minutes interval for one
hour.
BLADDER CARE
 Encourage the mother to frequently empty the
bladder to aid in uterine contraction and prevent
postpartum hemorrhage.
INFORMATION EDUCATION AND COMMUNICATION
 Give the mother advice on importance of latching
the baby to the breast within half an hour in
order for the baby to benefit from colostrum.
 She should be encouraged to empty the bladder
frequently to aid in uterine contraction to
prevent postpartum hemorrhage.
 The mother should be advised to report any
excessive bleeding, failure of the baby to breath.
 Vitamin A 200,000IU orally should be given so as
the baby can benefit through the breast.
DOCUMENTATION
 Documentation of delivery notes should be done
which should include type of delivery i.e. SVD,C/S
,time of delivery,sex, either mature or premature,
Apgar score at 1,5 and 10 minutes, the birth
weight length, head circumference and condition
of the baby at birth as well as blood loss, state of
the uterus either firm and well contracted or not.
Type of lochia and how much.
 Abnormalities on the baby if any.
 Post partum hemorrhage due to uterine atony
(full blader),trauma to the cervix,vagina and
perineum (Faulty episiotomy repair).
 Uterine inversion due to lack of skill.
 Prolonged third stage due to placental
abnormalities.
 Retained placenta due to placenta
pacreta,acreta and increta.
 Obstetric shock due to severe bleeding.
 00/00/23 at 14:00 SVD live mature female infant
Apgar score 9/10:1,9/10:5,9/10:10 minutes,
Birthweight 3.5kg, length 48cm, Head circumference
36cm, passed both urine and meconium at birth.
Mother uterus palpated to rule out second twin, and
oxytocin 10IU i.m stat was given to aid in placental
separation. Placenta and membranes delivered by
Controlled Cord Traction (CCT) appeared complete
and healthy. Bladder emptied, uterus massaged, firm
and well contracted, blood loss plus/minus 150ml.
Episiotomy performed and sutured in layers or
perineum intact. Lochia rubra moderate flow. Post-
delivery readings mother Temperature 36 degrees
Celsius, Pulse 80 beats/min Respirations 20
Breaths/min, Blood Pressure 120/88mmHg.
 Baby Temperature 36,Apical beat
136,Respirations 36,head to toe examination
no congenital abnormalities detected,
learning to grasp the mothers nipples well.
 General condition of both mother and baby
satisfactory.
 Reported by Student Midwife………………..