UNIT 4

2. MANAGEMENT
OF THIRD STAGE
OF LABOUR

3. •PERIOD FROM BIRTH OF
BABYTILLTHE
DELIVERY OF PLACENTA

4.  THIRD STAGE IS MOST CRUCIAL STAGE OF
LABOR.
 Previously uneventful first and second stage
can become abnormal with in a minute with
disastrous consequences.

5.  Lengthening of cord.
 Gush of bleeding.
 Uterus becomes full OR boggy uterus.

6.  The third stage of labour stage of
labour consist of following phases:
1. PLACENTAL SEPARATION
2. ITS DESCEND TO LOWER
SEGMENT
3. PLACENTAL EXPULSION

7.  At the beginning of the labour, the placental attachment
is roughly corresponds to an area of 20cm in diameter.
 In the first stage of labour, there is no decrease in the
surface area of placental attachment.
 In second stage of labour, there is slight but progressive
decrease in surface area because of retraction.
 There is marked decrease or attain its peak, immediately
following the birth of the baby.
 After the birth of the baby, uterine measures about 20cm
vertically and 10cm antero- posteriorly, shape become
discoid.

8.  There are 2 ways of separation of
placenta:
1. CENTRAL SEPARATION
2. MARGINAL SEPARATION.

9. 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
(retroplacental hematoma), with increasing the
contractions, more and more detachment
occurs facilitated by weight of placenta and
retroplacental blood until whole of the
placenta get detached.

10.  Separation starts at its margins as it is mostly
unsupported with progressive uterine
contractions, more and more areas of the
placenta get separated. Marginal separation is
found more frequently.

11.  After the placenta has separated, it descends into the
lower uterine segment by effective contractions and
retraction of uterus
These are as follows:
1. Sudden trickle or gush of blood.
2. Lengthening of the amount of umbilical cord visible at
the vaginal introitus.
3. Change in the shape of the uterine from a discoid to
globular.
4. Change of the position of the uterus as it rises in the
abdomen, because the bulk of placenta is in the lower
uterine segment or at upper vaginal vault.

12.  After complete separation of the placenta and
descend of the placenta. Thereafter, it is
expelled out by either voluntary contractions
of the abdominal muscles (bearing down
efforts) or by manipulative procedure.

13.  After the placental separation there are so many torn
sinuses which have free circulation of blood from uterine
and ovarian vessels have to be removed.
 The occlusion is effected by complete retraction where by
arterioles, as they pass twistedly through the interlacing
intermediate layer of the myometrium, are literally
clamped. It is the principle mechanism to prevent
bleeding.
 Thrombosis occurs to occlude the torn sinuses, a
phenomenon which is facilitated by hyper- coagulable
state of pregnancy.
 Constriction of the walls of uterus following expulsion of
the placenta also contributes to minimize the blood loss.

14.  Expectant management
 Active Management

15.  In this management, the placental
separation and its descent into the vagina
are allowed to occur spontaneously.
Minimal assistance may be given for the
placental expulsion if it needed.

16.  Constant watch
 To note features of placental separation
 To assess the amount of blood loss
 A hand is placed over the fundus
(a) To recognize the signs of separation
of placenta
(b) To note the state of uterine activity

17.  When the features of placental separation
and its descent into the lower segment are
confirmed, the patient is asked to bear
down simultaneously with the hardening of
the uterus.
 If the patient fails to expel, one can wait
safely up to 10 minutes if there is no
bleeding.
 as the placenta passes through the introits,
it is grasped by the hands and twisted round
and round with gentle traction so that the
membranes are stripped intact.

18.  Placenta is separated within minutes
following the birth of the baby.
 A watchful expectancy can be extended up to
15-20 minutes.
 The patient is expected to expel the placenta
within 20 minutes with the aid of gravity.
 'no touch' or 'hands off' policy

19.  Control Cord Traction
Never apply cord traction
(pull) without applying
counter traction (push) above
the pubic bone with the other
hand.

20. FUNDAL
PRESSURE :
the pressure must be given
only when the uterus becomes
hard.

21. The placenta is placed on a
tray and is washed out in
running tap water to
remove the blood and clots :
 MATERNAL SURFACE
 THE MEMBRANES

22.  THE MARGIN OF THE GAP
INDICATES A MISSING
SUCCENTURIATE LOBE.
 THE CUT END OF THE CORD IS
INSPECTED FOR NUMBER OF
BLOOD VESSELS

24.  Midwife/Nurse should assess
sustained contractions of the
uterus.
 Ideally the fundus should lie on the
mid-plane of the pelvis at or below
the umblicus.

25.  Fundus of uterus is palpated
by placing the side of one
hand on top of,
 Slightly cupped above the
fundus,
 While the other hand is
placed suprapubically with
the exertion of slight
pressure.

26.  Massage the uterus if it is
found boggy on palpation,
until it contracts and
becomes firm.
 Avoid Over stimulation as it
leads to muscle fatigue with
subsequent relaxation of
uterus and possible
hemorrhage

27.  Should be inspected for injuries
 To be repaired, if any injury or laceration
because it may lead to pph.
 Vulva & adjoining part are cleaned with
cotton swabs soaked in antiseptic solution.

28. NURSING
MANAGEMENT

29.  Prompt separation and expulsion of the
placenta
 To ensure strict vigilance
 To follow the management guidelines
striclty in practice
 To prevent the complications
“ POSTPARTUM HAEMORRHAGE”

30. Placenta separation is indicated by the following
signs :
 A firmly contracting fundus.
 The uterus changing from a discoid to globular
ovoid shape as the placenta moves into the
lower uterine segment

31.  A sudden gushing of dark blood from the
introitus
 Apparent lengthening of the umbilical cord as
the placenta gets closer to the introitus
 The finding of a vaginal fullness on vaginal or
rectal examination or of fetal at the introitus.

32.  Cardiac output increases
 Pulse rate slows

33.  To assist the women in the delivery of the
placenta, the nurse or primary health care
provider has the woman push when signs of
separation have occurred.
 The placenta should be expelled by maternal
effort during a uterine contraction, plus
minimum, controlled traction on the umbilical
cord may be used to facilitate delivery of the
placenta and amniotic membranes

34.  When the third stage is complete and
episiotomy is sutured, the vulval area
should be cleansed with warm sterile water
or normal saline.
 Apply a sterile perineal pad.
 Remove any drapes and /or place dry linen
under the woman’s buttocks.
 Reposition the birthing table or bed.

35.  Lower the mother’s legs simultaneously from the
stirrups if she is in a lithotomy position.
 Assist the woman onto her bed while transferring
from the birthing area to the recovery area.
 Provide the woman with a clean gown and cover
with a warmed blanket.
 Raise the side rails of the bed during transfer.

36. NURSING
DIAGNOSIS

37.  RISK FOR FLUIDVOLUME DEFICIT RELATED
TO :
a. Blood loss occurring following placental
separation and expulsion
a. Inadequate contraction of the uterus

38.  Monitor fluid loss ( i.e. blood, urine,
perspiration) and vital signs ; inspect skin turgor
and mucus membranes for dryness to evaluate
hydration status
 Administer oral/parenteral fluids per physican /
nurse – midwife orders to maintain hydration.

39.  Monitor the fundus for firmness after
placental separation to ensure adequate
contraction & prevent further blood loss.
 Administer medications per physician / nurse
– midwife orders to aid contraction of the
uterus.

40.  Lack of preparation for sensations that occur
during third stage of labor

41.  Explain to women and labor partner what is
expected in the third stage of labor to enlist
cooperation.
 Have woman maintain her position to facilitate
delivery of the placenta
 Ask mother if she wishes to dispose of the
placenta in any specific manner to comply with
certain cultural customs.

42.  Energy expenditure associated with
childbirth and the bearing down efforts of the
second stage

43.  Educate mother & partner about the need for rest and
help them to plan strategies;
for e.g. restricting visitors, increasing the role of
support systems performing functions associated with
daily routines.
 As it allow specific times for rest & sleep to ensure that
women can restore depleted energy level in
preparation for caring for a new infant.
 Monitor the woman’s fatigue level and the amount of
rest received to ensure restoration of energy.

44.  Stage of observation for at least 1 hr after
expulsion of the after births

45. Check vital signs
of mother & baby
Bleeding per
vagina.
Breast Feeding.

46. Comfortable
position.
Observation for
urine output
Comfort of mother
and newborn.

47.  Encouragement to couples : discuss
anxiety & expectations of each
others.
 Transition to parenthood : parent –
child relationships
 Role of fathers : lack of attention
 Role of family