THIRD STAGE OF LABOR

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DR MANAL BEHERY Assistant Professor Zagazig
University 2013
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• Defintion
• 3rd stage of labor commences with the
  delivery of the fetus and ends with delivery of
  the placenta and its attached membranes.
• Duration
• - normally 5 to15 minutes.
• - 30 minutes have been suggested if there is no
  evidence of significant bleeding.

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Cause of placental separation

• After delivery of the fetus,
• the uterus retracts and the
• placental bed diminished.
• As the placenta is inelastic
• and does not diminish in
• size it separates.

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Uterine Retraction and Placental Separation
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Placental Site during Separation
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Placental Site during Separation
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Separation and Descent of Placenta

• Non-elastic placenta has detached from the
  shrinking uterine wall
• Primary mechanism is the reduction in surface
  area of placental site as the uterus shrinks
• Secondary mechanism is the formation of haematoma
  due to venous occlusion and vascular rupture in
  the placental bed caused by uterine contractions

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Methods of Placental Separation
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Schultze Method

• Placenta separates in the centre and folds in on
  itself(80), as it descends into the lower part
  of uterus
• Fetal surface appears at vulva
• with membranes trailing behind
• Minimal visible blood loss as
• retroplacental clot contained within membranes
  (inverted sac)

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Duncan Method

• separation starts at the
• lower edge of placenta
• (20) lateral border separates.
• maternal surface appears first at vulva
• Usually accompanied by more bleeding from
  placental site due to slower separation and no
  retro placental clot.

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Signs of Separation and Descent

• lengthening of the
• umbilical cord outside.
• The uterus becomes
• firm and globular (Descent).
• The uterus rises in the
• abdomen.
• A gush of blood(separation ).
• 2

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Assess the uterus

• 1-To exclude an undiagnosed
• twin
• 2-To determine a baseline
• fundal height
• 3-to detect the signs of placenta separation
• 4- to detect an atonic uterus.

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Control of Bleeding

• 1. Normal blood flow through placenta site is
  500-800 ml/minute (10-15 of cardiac output)
• 2.Strong contraction/retraction of uterus
  constrict blood vessles by interlacing muscle
  fibres in myometrium (living ligature)
• 3. Pressure exerted on placental site by walls
  of contracted uterus
• 4. Blood clotting mechanism (sinuses and torn
  vessels)

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Management of the Third Stage of Labour
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Physiologic or Active
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Active vs physiologic management

• Active management includes a prophylactic
  oxytocic drug,early clamping and cutting of cord
  and controlled cord traction
• Physiological management involves no prophylactic
  oxytocic drugs, no cord clamping until after
  placental delivery and no cord traction

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Physiological Active
Placental delivery By gravity and maternal effort By controlled cord traction with counter traction on funds
Uterotonic after placenta delivery With birth of anterior Shoulder
Uterus Assessment of size and tone Assessment of size and tone
Cord Clamping Variable Early
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Active Management

• reduces length of 3rd stage and incidence of PPH
  (blood loss and need for transfusion)

• Oxytocic given after birth of
• shoulder (check for a twin/
• no shoulder dystocia)
• Cord clamped and cut
• Placenta delivered by
• Controlled Cord Traction

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Guarding the Uterus
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Controlled cord traction
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Placental delivery
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Delivering the Membranes
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Controlled Cord TractionCHECKS FIRST!

• Check that an oxytocic (uterotonic) has been
  given Why?
• Check that the uterus is well contracted Why?
• Check that countertraction is applied (Brandt-
  Andrews manoeuvre) Why?
• Check for signs of separation descent Why?
• Check that cord traction is released before
  countertraction is stopped Why?

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Physiological Management1

• Passive or expectant management
• Allows placenta to separate and
• descend without interference
• No prophylactic oxytocics
• Cord clamped after delivery of placenta
• No Controlled Cord Traction (CCT)

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Physiological Management2

• Upright/kneeling/squatting position best- easy
  to observe blood loss
• Hands off just check uterus contracted and
  observe PV loss
• waits and watches for signs of separation and
  descent
• Mother expels placenta when she feels contraction
  and placenta in vagina

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Which is better active or physiologic management ?

• Active management is superior to physiological in
  terms of blood loss
• Physiological management is only appropriate for
  women with low risk of PPH and who have normal
  physiological labour
• If physiological management is attempted but
  intervention is subsequently required ( the
  placenta is retained after one hour) active
  management should be considered.

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Manual removal of retained placenta
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After Care Before leaving to check placenta and
membranes

• Check the uterus is well contracted
• Check that PV loss is minimal
• Inspect perineum, vulva and vagina in good light
  (? Repair)
• Baby should be pink (respirations heart rate)
  warm, fed, cord clamp secure

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check placenta and membranes

• for completeness
• and normality

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Abnormal placenta (accessory lobe)

• Succentriate
• lobe

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Effects of labor on the mother
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• 1 st stage anxiety mild tachycardia.
• 2 nd stage
• Pulse up to 100 b.p.m.
• Temp mild increase (37.5 - 37.7).
• B.P. systolic increased during pains.
• Conjunctiva edematous congested.
• Birth canal minor lacerations in the cervix or
  perineum especially in PG.

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3rd Stage

• Blood loss from
• ? Placental site 200-300 C.C due to placental
  separation.
• ? Lacerations or episiotomy about 100 - 200 C.C
  

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Effects of labor on the Fetus
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Moulding

• Overlap of the flat bones
• of the vault of the skull
• due to compression of
• the head during labour
• leading to alteration in
• its shape

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Types Degrees

• a. Physiological
• "beneficial decreases
• the size of head
• facilitates its passage
• through the birth canal.
• 1. First degree
• 2. Second degree

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Pathological may lead to intracranial hemorrhage

• 3 rd degree
• Overriding of one parietal
• bone over the other with
• Contractions but it is not
• Reducible inbetween.
• 4 th degree overriding of the 2 parietal bones
  over each others both override the occipital

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Caput Succedaneum
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Types

• A Natural
• Cervical
• with cervical dystocia.
• Pelvic
• with obstructed labour
• usually formed in prolonged labour
• after rupture of membranes.

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Cehalnematoma
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Cehalhematoma(subperiostealhemorrhage
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• Thank You