THIRD

STAGE
OF
LABOR
INTRODUCTION:

Midwives should be competent in both

active management and physiological management.
Active management involves giving a prophylactic
uterotonic, cord clamping and controlled cord traction.
Physiological management involves no administration
of a prophylactic uterotonic, no clamping and cutting
the cord until the placenta is delivered and promoting
the use of gravity to assist delivery of the placenta in a
timely manner with maternal effort.
DEFINITION:
The third stage of labour lasts from the
birth of the baby until the placenta is expelled. It is
known as the placental stage of labour.

DURATION:
Normally 5 to15 minutes.

30 minutes have been suggested if there is no

evidence of significant bleeding.
 PHYSIOLOGICAL PROCESSES OF PLACENTAL
SEPERATION AND EXPULSION:

Placental separation.
Descend of the placenta.

Expulsion of the placenta.

A. PLACENTAL SEPARATION:

At the beginning of the labor, the placental

attachment roughly corresponds to an area of 20
cm in diameter.
There is no appreciable diminution of the surface
area of the placental attachment during first stage.
During the second stage, there is slight but
progressive diminution of the area following
successive retractions, which attains its peak
immediately following the birth of the baby.
 After the birth of the baby, the uterus measures
about 20 cm vertically and 10 cm antero-
posteriorly, the shape becomes discoid.
The wall of the upper segment is much thickened
while the thin and flabby lower segment is thrown
into folds.
The cavity is much reduced to accommodate only
the after births.
MECHANISM OF SEPARATION:

A shearing force is instituted between the placenta

and the placental site which brings about its
ultimate separation.
The plane of separation runs through deep spongy
layer of deciduas basalis so that a variable
thickness of deciduas covers the maternal surface of
the separated placenta.
There are two ways of separation of placenta:
i. Central separation (Schultze):
ii. Marginal separation (Mathews-Duncan):
 I. Schultze Method:

Placenta separates in the centre and folds in on

itself as it descends into the lower part of
uterus (80%).
Fetal surface appears at vulva

with membranes trailing behind

Minimal visible blood loss as

retroplacental clot contained within membranes

(inverted sac)
II. Duncan Method:
separation starts at the
lower edge of placenta
lateral border
separates (20%).

maternal surface appears first at vulva

Usually accompanied by more bleeding from
placental site due to slower separation and no
retro placental clot.
B. DESCEND OF THE PLACENTA

Sudden trickle or gush of blood.

Lengthening of the umbilical cord.

Change in the shape of the uterus,

globular.
Change in the position of the uterus.
C. EXPULSION OF PLACENTA:

After complete separation of the placenta, it is

forced down into the flabby lower uterine segment
or upper part of the vagina by effective contraction
and retraction of the uterus.

Thereafter, it is expelled out by either voluntary

contraction of abdominal muscles or by manual
procedure.
 HEMOSTASIS:

Retraction of the oblique uterine muscle

fibres .
vigorous uterine contraction following
placental separation.
transitory activation of the coagulation and
fibrinolytic systems.
Control of Bleeding

Normal blood flow through placenta site is 500-800

ml/minute (10-15% of cardiac output)
Strong contraction/retraction of uterus constrict blood
vessles by interlacing muscle fibres in myometrium
(living ligature)
Pressure exerted on placental site by walls of
contracted uterus
Blood clotting mechanism (sinuses and torn vessels)
CLINICAL
COURSE
PAIN:
For a short time, the patient experiences no pain.
However, intermittent discomfort in the lower
abdomen reappears, corresponding with the uterine
contraction.

MATERNAL SIGNS:
Chills and occasional shivering

Slight transient hypotension is not unusual.

Before Separation:

Per abdomen:
Uterus become discoid in shape, firm
in feel and ballottable.
Fundal height reaches slightly below the
umbilicus.
Per vaginam:
There may be slight trickling of blood.
Length of the umbilical cord as visible
from outside remains static.
 After Separation:

Per abdomen:
Uterus become globular, firm and

ballottable.
fundal height is slightly raised.

supra pubic bulging

Per vaginum:
Slight gush of vagina bleeding.

Permanent lengthening of the cord.

MANAGEMENT
 Third stage is the most crucial stage of labor.
Previously uneventful first and second stage can
become abnormal within a minute with disastrous
consequences.

PRINCIPLES:
To ensure strict vigilance

To prevent the complications.

 Guard the uterus to keep yourself and anyone
else from massaging it prior to placental
separation.

Do not massage the uterus before placental

separation, except when partial separation
has occurred by natural processes and
excessive bleeding evident.
 Do not pull on the umbilical cord before the
placenta separates or ever with an uncontracted
uterus.

Do not try to deliver the placenta prior to its

complete separation unless in the emergency of
third stage haemorrhage.

Wait for the natural process to occur and do not

interfere.
 STEPS OF MANAGEMENT:

1. Expectant management

2. Active management
 1. EXPECTANT MANGEMENT

A hand is placed over the fundus to feel the signs of

placental separation.
the client asked to bear down simultaneously with
the hardening of the uterus.
If the placenta fails to expel, one can wait for upto
10 minutes.
As soon as the placenta passes through the introitus,
it is grasped by both hands and twisted round and
round or slightly up and down with gentle traction .
A. CONTROLLED CORD TRACTION:

The palmar surface of the fingers of the left hand is

placed (above the symphysis pubis) approximately at
the junction of upper and lower uterine segment.
The body of the uterus is pushed upwards and
backwards toward the umbilicus while by the right hand
steady tension is given in downward and backward
direction holding the clamp until the placenta comes
outside the introitus.
It is thus more an uterine elevation which facilitates
expulsion of the Placenta.
The placenta is to be adopted only when the uterus is
hard and contracted.
 Controlled cord traction [ modified Brandt-Andrews
method]:
 B. FUNDAL PRESSURE:

This is done by placing four fingers of the hand behind

the fundus and thumb in front of the uterus to use as a
piston.
The uterus is made to contract by gentle rubbing. When

the uterus becomes hard, it is pushed downwards and

backwards.
The pressure should be withdrawn as soon as the

placenta passes through the introitus.

If the baby is macerated or premature, this method is

preferable to cord traction as the tensile strength of the

cord is much reduced in both the instances.
 USE OF OXYTOCIC AGENTS:

The sterile gloved hand should be introduced and the

placenta is to be grasped and extracted.
The uterus is massaged to make it hard, which
facilitates expulsion of retained clots if any.
Injection of Oxytocin (5-10 units) IV slowly
Methergin 0.2 mg is given intramuscularly.
Oxytocin is more stable and has lesser side effects
compared to ergometrine (nausea, vomiting, rise of
BP).
Fundal Height During Third Stage:

At the end of the third

stage following the expulsion of the
placenta, the fundus is about 4cm
below the umbilicus.
 Completion Of Third Stage:

Continuing evaluation
ensure that the uterus is well contracted
Slight lacerations are usually repaired
immediately
The vulva and perineum are gently cleansed
mothers blood pressure, pulse and temperature
should be taken
Once the mother is comfortable the placenta and
membranes is the next priority
 Examination of placenta and membrane:

The placenta is placed on a

tray and is washed out in
running tap water to remove
the blood and clots.
The maternal surface is first
completeness and anomalies.
The maternal is covered with
grayish deciduas (spongy
layer of the deciduas
basalis).
 Normally the cotyledons are placed in close
approximation and any gap indicates a missing
cotyledon.
The membranes chorion and amnion are to be
examined carefully for completeness and
presence of abnormal vessels indicative of
succenturiate lobe.
The amnion is shiny but the chorion is shaggy.
The cut end of the cord is inspected for number of
blood vessels.
 Normally, there are two umbilical arteries and one
umbilical vein.
An oval gap in the chorion with torn ends of blood
vessels running up to the margin of the gap indicates a
missing succenturiate lobe.
Vulva, vagina and perineum are inspected carefully for
injuries and to be repaired, if any.
The episiotomy wound is now sutured.
The vulva and adjoining part are cleaned with cotton
swabs soaked in antiseptic solution.
A sterile pad is placed over the vulva.
2. ACTIVE MANAGEMENT:

PRINCIPLES:

Enhance separation of placenta

Safe and complete delivery of placenta

Minimize bleeding
COMPONENTS:
Use of oxytocics

Delivery of placenta by controlled cord

traction
Massage of uterus after placental delivery

Examination of birth canal and afterbirth

Repair of tears/episiotomy
 ACTIVE MANAGEMENT

Inj. Oxytocin 10 units IM or inj. Methaergin 0.2

mg IM to the mother within 1 min after delivery
of the baby.
Clamp divide and ligate the cord.

To deliver the placenta by controlled cord

traction soon after the delivery of the baby

availing first uterine contraction.
If it will be fails then, repeat after 2-3 minutes.
 If it still fails then wait for 10 minutes and repeat
the procedure then it fails.
Manual removal of the placenta is to be done.
Oxytocic may be given with crowning of the head ,
with delivery of the anterior shoulder of the baby
pr after the delivery of the placenta.
Inj. Oxytocin 5-10 units slowly IV/IM or Methergin
0.2 mg IM.
To examine the placenta and membranes.
To inspect the vulva, vagina and perineum.
COMPLICATIONS OF THE THIRD
STAGE:

Post partum haemorrhage.

Hematoma formation.

Retained placenta

Inversion of uterus.

shock
Thank you