Third stage of labor

Third stage of labor: commences with
the delivery of the fetus and ends
with delivery of the placenta and its
attached membranes.

 normally 5 to15 minutes.
 30 minutes have been suggested if there
is no evidence of significant bleeding.
 The risk of complications continues for
some period after delivery of the
placenta.

Placental separation
Separation of membranes
Placental separation
Mechanism of control of bleeding

 Central separation (Schultze):
Detachment of placenta from its uterine
attachment starts at the centre resulting in opening
up of few uterine sinuses and accumulation of
blood behind the placenta (retro placental
hematoma). With increasing contraction, more and
more detachment occurs facilitated by weight of
the placenta and retro placental blood until whole
of the placenta gets detached.

The separation is facilitated partly by uterine
contractions and mostly by weight of the
placenta as it descends down from the active
part

Separated placenta is expelled out by
either voluntary contraction of abdominal
muscles (bearing down efforts) or by
manipulative procedure.

1. The uterus becomes globular and as a rule, firmer
2. There is often a sudden gush of blood
3. The uterus rises in the abdomen because the
placenta, having separated, passes down into the
lower uterine segment and vagina. Here, its bulk
pushes the uterus upward
4. The umbilical cord protrudes farther out of the
vagina, indicating that the placenta has descended.

 PAINS: experiences no pain, intermittent discomfort in the
lower abdomen disappears, corresponding with uterine
contractions.
 BEFORE SEPARATION
Per abdomen – uterus become globular firm and
ballottable. The fundus height is slightly raised as the separated
placenta comes down in the lower segment and the contracted
uterus rest on the top of it. There may be slight bulging in the
supra pubic region due to distension of the lower segment by
the separated placenta.

EXPULSION OF PLACENTA AND
MEMBRANES
The expulsion is achieved
either by voluntary bearing down effort or
more commonly aided by manipulative
procedures. The “after birth” is soon followed
by slight to moderate bleeding amounting to
100-250ml.
MATERNAL SIGNS
There may be chills and occasional
shivering. Slight transient hypotension is not
unusual.

After placental separation, innumerable torn sinuses
which have free circulation of blood from uterine
and ovarian vessels have to be obliterated. The
occlusion is effected by complete retraction
where by the arterioles, as they pass tortuously
through the interlacing intermediate layer of the
myometrium, are literally clamped. It is the
principal mechanism to prevent bleeding;
however, thrombosis occurs to occlude the torn
sinuses, a phenomenon which is facilitated by
hypercoagulable state of pregnancy. Apposition
of the walls of the uterus following expulsion of
the placenta, (myotamponade) also contributes to
minimize blood loss.

To promote natural separation of the
placenta and membranes and their
complete expulsion
To arrest haemorrhage
To secure good and permanent contraction
and retraction of the uterus

Expectant management
Active management

Advantages are
 To minimize blood loss in third stage
approximately to 1/5th
 To shorten the duration of third stage to half
 disadvantage is slight incidence of retained
placenta and consequent increased incidence of
manual removal. Of course accidental
administration during delivery of the first baby in
undiagnosed twins produces grave danger to the
unborn second baby caused by asphyxia due to
tetanic contraction of the uterus, thus, it is
imperative to limit its use in twins only during the
delivery of the second baby.

Inj. Ergometrine 0.25 mg or methergin
0.2mg is given intravenously following the
birth of anterior shoulder.

 The palmar surface of the fingers of the left
hand is placed approximately at the junction
of upper and lower uterine segment. The
body of the uterus is pushed upwards and
backwards, towards the umbilicus while by
the right hand steady tension is given in
downward and backward direction holding the
clamp until the placenta comes outsides the
introitus. It is thus more a uterine elevation
which facilitates expulsion of the placenta.
The procedure is to be adopted only when the
uterus is hard and contracted.

The fundus is pushed downwards and
backwards after placing four fingers
behind the fundus and the thumb in front
using the uterus as a sort of piston. The
pressure must be given only when the
uterus become hard. If it is not, then make
it hard by gentle rubbing. The pressure is
to be withdrawn as soon as the placenta
passes through the introitus.

Steps-1: the operation is done under
general anaesthesia. The patient is placed
in lithotomy position. With all aseptic
measures the bladder is catheterized.

Steps-II: one hand is introduced into the
uterus after smearing with the antiseptic
solution in cone shaped manner following
the cord, which is made taut by the other
hand. While introducing the hand, the labia
are separated by the fingers of the other
hand. The fingers of the uterine hand
should locate the margin of the placenta.

counter pressure on the uterine fundus is
applied by the other hand placed over the
abdomen. The abdominal hand should
steady the fundus and guide the
movements of the fingers inside the
uterine cavity till the placenta is completely
separated

Steps-IV: as soon as the placenta margin
in reached, the fingers are insinuated
between the placenta and the uterine wall
with the back of the hand in contact with
the uterine wall. The placenta is gradually
separated with a side ways slicing
movements of the fingers, until whole of
the placenta is separated.

Steps-V: when the placenta is completely
separated, it is extracted by traction of the
cord by the other hand. The uterine hand is
still inside the uterus for exploration of the
cavity to be sure that nothing is left behind.

Steps-VI: intravenous ergometrine 0.25mg
is given and the uterine hand is gradually
removed while massaging the uterus by
the external hand to make it hard. After the
completion of manual removal, inspection
of the cervico-vaginal canal is to be made
to exclude any injury.

Steps-VII: the placenta and membranes
are to be inspected for completeness and
be sure that the uterus remains hard and
contracted.

Hour glass contraction –leading to difficulty
in introducing the hand
Morbid adherent placenta – which may
cause difficulty in getting to cleavage of
placental separation.

 The maternal surface is first inspected for
incompleteness and anomalies. The maternal
surface is covered with grayish decidua
(spongy layer of the deciduas basalis).
Normally the cotyledons are placed in close
approximation and any gap indicates a
missing cotedyldon.
 The membrane chorion, amnions are to be
examined carefully for completeness and
presence of abnormal vessels indicative of
succenturiate lobe.

 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.
The absence of a cotyledon or evidence of a
missing succenturiate lobe or evidence of
significant missing membranes demands
exploration of the uterus urgently.

 hemostasis
Anatomical restoration

Vaginal and submucosa - continuous
suture

 In the third or fourth degree of perineal
lacerations, in which the anal sphincters
and the anterior rectal wall are torn, it is
first necessary to isolate the torn ends of
the sphincter after which the tear in the
anterior rectal wall is closed with fine
interrupted catgut sutures tied within the
lumen of the bowel. The end of the rectal
sphincter are reapproximated with
interrupted catgut sutures. Then the
laceration in the more superficial structures

Haemorrhage
Shock
Injury to uterus
Infection
Inversion
Subinvolution
Thrombophlebitis
Embolism

 Risk for deficient fluid volume related to :
- Blood loss occurring after placental
separation and expulsion.
- Inadequate contraction of the uterus.
 Anxiety related to :
-Lack of knowledge regarding separation
and expulsion of the placenta.
-Occurrence of perineal trauma and the
need for repair.
 Fatigue related to :
-energy expenditure associated with
childbirth and the bearing-down efforts of the
second stage.

BLOOD PRESSURE
 Measure blood pressure every 15 mts.
PULSE
 Assess rate and regularity. Measure
every 15 mts for first hour.
TEMPERATURE
 Determine the temperature at the
beginoing of the recovery period and after
the first hour of recovery period and after
the first hour of recovery.

 Just below the umbilicus, cup the hand and press firmly in to the abdomen. At the
same time, stabilize the uterus at the symphisis with opposite hand.
 If the fundus is firm, with uterus in midline, measure its position relative to women’s
umbilicus. Lay finger flat on abdomen under the umbilicu; measure howmany finger
breadths or centimeters fit between the umbilicus, the value is plus(+) if the fundus is
above the umbilicus and if below it is valued as (-).
 The fundus is not firm, massage it gently to contract
 Expel clots while keeping handsplaced. With upper hand , firmly apply pressure
downward toward vagina, observe the perineumfor amount and size expelled clots.

 Assess the distention by noting the location and
firmness of the uterine fundus and by observing and
palpating the bladder. A distended bladder is seen as
suprapubic rounded bulge that is dull to percussion
and fluctuates similar to a water filled balloon. When
the bladder is distended, the uterus is usually boggy in
consistency, well above the umbilicus, and to the
woman’s right side.
 Assist the woman to void spontaneously. Measure the
amount of urine voided.
 Catheterize if the bladder is distented and woman is
unable to void spontaneously.
 Reassess after voiding or catheterization to make sure
the bladder is not palpable and the fundus is firm and
in the midline.

LOCHIA
 Observe lochia on perineal pads and on linen
under mothers buttocks. Determine the
amount and colour ; note the size and
number of clots; note any odour.
 Observe the perineum for source of bleeding
(e.g, episiotomy, lacerations)
PERINEUM
 Ask or assist the woman to turn on her side
and flex the upper leg on the hip.
 Lift the upper buttocks
 Observe the perineum 9in good lighting
 Assess episiotomy or laceration repair for
intactness, heamatoma, edema, bruising, red
ness and drainage.
 Assess the presence of hemorrhoids.

Acute Pain related to physiological
response to Labour
Deficient fluid volume related to uterine
atony after child birth.
Deficient Knowledge related to information
about birth process
Ineffective coping related to labour and
delivery
Anxiety related to hospitalization and birth
process.

Third stage of labor

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Third stage of labor