DEFINITION

Third stage is that separation and

expulsion of the placenta and membranes

and also involves the control of bleeding

 EVENTS IN THE THIRD STAGE OF LABOUR

Seperation and expulsion of the placenta

Interplay of mechanical and hemostatic factors

TIME

Last between 5 and 15 minutes

PHYSIOLOGY OF THIRD STAGE OF
LABOUR/CONTROL OF HEMOSTASIS

Separation and descend of the placenta

Mechanical factors

Hemostasis
MECHANICAL FACTORS

Seperation of the placenta

Expulsion of the placenta

MECHANICAL FACTORSContd
PLACENTAL SEPERATION
1.Second stage uterine cavity empties

2.Enabling the retraction process to accelerate

(1 & 2)Placental site has already begun to diminish in size

Placenta becomes compressed

Blood in the intervillous space is forced back into the spongy

layer of the decidua
MECHANICAL FACTORS..Contd
Retraction of the oblique uterine muscle fibres exert
pressure on the blood vessels so that the blood does not
drain back into the maternal circulation
Vessels during this process become tense and congested

With the next contraction the distended veins burst and a

small amount of blood seeps between the spongy layer and
placental surface

Placenta strip from its attachment

Surface area of placental attachment reduces and begin to

detach from the uterine wall
MECHANICAL FACTORS..Contd
Retraction of the oblique uterine muscle fibres exert
pressure on the blood vessels so that the blood does not
drain back into the maternal circulation
Vessels during this process become tense and congested

With the next contraction the distended veins burst and a

small amount of blood seeps between the spongy layer and
placental surface

Placenta strip from its attachment

Surface area of placental attachment reduces and begin to

detach from the uterine wall
MECHANICAL FACTORSContd

METHODS OF PLACENTAL SEPERATION

Schultze Method

Matthews Duncan
SEPERATION BEGINS CENTRALLY
Retroplacental clot is formed
Aids further seperation by exerting pressure at the midpoint of
the placental attachment
Increased weight helps to strip the adherent lateral borders
Increased weight also helps to peel the membrane of the
uterine wall
Clot formed becomes enclosed in the membranous bag
Placenta descends with fetal surface first
More complete shearing of both placenta and membrane
Less blood loss
SEPERATION BEGINS LATERALLY
Detach unevenly at one of its lateral borders
Blood escapes so that seperation is unaided by the formation
of a retroplacental clot
Placenta descends, slipping sideways
Maternal surface comes out first
Takes longer time
Associated with ragged, incomplete expulsion of the
membranes
Higher fluid blood loss
TWO METHODS OF PLACENTAL SEPERATION
HAEMOSTASIS
RETRACTION OF THE OBLIQUE UTERINE
MUSCLE FIBER

PRESENCE OF VIGOROUS UTERINE

CONTRACTION

ACTIVATION OF THE COAGULATION AND

FIBRINOLYTIC SYSTEM
LIVING LIGATURE ACTION OF
OBLIQUE UTERINE MUSCLES
MANAGEMENT OF THE THIRD STAGE OF
LABOUR
Guard the uterus from massaging prior to placental
seperation
Do not massage the uterus before placental expulsion
except when partial seperation
Do not pull the umbilical cord before placenta separates

Do not try to deliver the placenta prior to its complete

seperation unless in the emergency of third stage
haemorrhage
Wait for the natural process to occur
DELIVERY OF THE PLACENTA AND
MEMBRANE
Fundus is palpable below the umbilicus
Fundus feels broad as the placenta is still in the upper
segment
SIGNS OF PLACENTAL SEPERATION
DELIVERY OF THE PLACENTA AND
MEMBRANEContd
METHODS OF PLACENTAL DELIVERY
1. EXPECTANT MANAGEMENT
2. ASSISTED EXPULSION
Controlled cord traction (modified Brandt Andrews
method)
Expression by fundal pressure
EXPECTANT MANAGEMENT

Placental seperation and descent occur spontaneously

Mothers efforts are used to aid expulsion

Minimal assistance is given if mothers effort fails to deliver

the placenta

Method can be practiced when mother has not received any

anesthesia or oxytocic drugs at the delivery of the anterior

shoulder
EXPECTANT MANAGEMENT
STEPS OF THE PLACENTAL DELIVERY
1. A hand is placed over the fundus to feel for the signs of
placental seperation
2. When the features of placental seperation and its descend
into the lower segment are confirmed, the client asked to
bear down simultaneously with the hardening of the
uterus
3. 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 applied as the
membranes are stripped off intact
4. If the membranes are threatened to tear, they are to be
held by an artery forceps and gentle traction is applied to
deliver the rest of the membranes
STEPS OF THE PLACENTAL DELIVERY
1. A hand is placed over the fundus to feel for the signs of
placental seperation
2. When the features of placental seperation and its descend
into the lower segment are confirmed, the client asked to
bear down simultaneously with the hardening of the
uterus
3. 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 applied as the
membranes are stripped off intact
4. If the membranes are threatened to tear, they are to be
held by an artery forceps and gentle traction is applied to
deliver the rest of the membranes
ASSISTED EXPULSION
CONTROLLED CORD TRACTION (MODIFIED BRANDT
ANDREWS METHOD)

Several checks to be made before proceeding

1. An oxytocic drug has been administered

2. It has been given time to act

3. The uterus is well contracted

4. Counter traction is applied

5. The signs of placental seperation and descend are present

ASSISTED EXPULSIONContd
METHODS OF CONTROLLED CORD TRACTION (MODIFIED
BRANDT ANDREWS METHOD)
1. The left hand is placed above the level of the symphysis pubis
2. Palmar surface facing toward the umbilicus to exert pressure in an
upward direction
3. Body of the uterus is displaced upward towards the umbilicus with
left hand
4. With the right hand a steady tension is given in a downward and
backward direction following the line of birth canal by holding on
the clamp placed on the cord at the vulva
5. It is important to apply a steady traction by pulling the cord firmly
6. There should be a pause before another contraction is palpated and
further attempt is made
Controlled cord traction
ASSISTED EXPULSIONContd
COMPLICATIONS OF CONTROLLED CORD TRACTION
(MODIFIED BRANDT ANDREWS METHOD)

1. Inversion of the uterus

2. Partial seperation of the placenta

3. Haemorrhage

4. Detachment of cord
ASSISTED EXPULSIONContd
ADVANTAGES OF CONTROLLED CORD TRACTION
(MODIFIED BRANDT ANDREWS METHOD)

1. Reduced blood loss

2. Reduction in third stage of labour

ASSISTED EXPULSION

EXPRESSION BY FUNDAL PRESSURE

1. Place four fingers of the hand behind the fundus and the thumb in

front of the fundus to use as a piston

2. The uterus is made to contract by gentle rubbing

3. When the uterus is hard it is pushed downwards and backwards

4. The pressure is to be withdrawn as soon as the placenta passess

through the introitus

USE OF OXYTOCIC AGENT
TIME OF ADMINISTRATION
At the crowning of the babys head
At the delivery of the anterior shoulder
At the end of second stage of labour
Following the delivery of the placenta
PROPHYLACTIC USE
Prevention of post partum haemorrhage
Active management of third stage of labour
THERAPEUTIC USE
Ergometrine 0.5mg IM
Methergin 0.2mg IM
FUNDAL HEIGHT DURING THIRD STAGE
At the beginning fundus palpable below the umbilicus,

feels broad as the placenta still in the upper segment

As the placenta separates, becomes rounder, smaller and

more mobile as it rises in the abdomen to the level of

umbilicus or just above the level of umbilicus

At the end of third stage fundus is about 4cm below the

umbilicus
COMPLETION OF THE THIRD STAGE
Ensure that uterus is well contracted

Fresh blood loss is minimal

Inspection of the perineum and the lower vagina

Suture the episiotomy or any slight laceration

Change all the soiled linen

Cleanse the perineum

Application of sterile pad

Examination of the placenta membrane

ASSESSMENT OF THE PLACENTA
Infractions that are recent(bright red) or old(gray patches)

Localised calcification(flattened white plaques)

Lobes

Blood vessels

Insertion of the cord

Umbilical vessels

Cord length

Weight of the placenta

IMMEDIATE CARE OF BABY
Well being and security

Cord clamp need to be checked

Warmth

Full neonatal assessment

Baby kept close to the mother

Breast feeding
IMMEDIATE CARE OF MOTHER
Cleansing the body

Mouth wash

Empty her bladder

Vital signs

Bleeding checked every 15 minutes