THIRD STAGE

of LABOR
Post-Graduate Interns
Faustino, Jenelle C.
Fong, Henrick C.
Tabangcura, Marvin Steve T.
 Third stage of labor
- starts from fetal delivery and ends with delivery
of placenta and fetal membranes
- as neonate is born, uterus spontaneously
contracts
- Majority of cases occur in the following order
1. Separation of the placenta
2. Descent of the placenta
3. Expulsion of the placenta
Signs of Placental Separation
1. Calkin’s sign- uterus from discoid
becomes globular
2. Gush of blood from the vagina
3. Lengthening of the cord- most reliable
4. Uterus rises in the abdomen as the
placenta descends
Mechanisms of Placental Delivery

1. Schultz- central separation of placenta

from decidua
2. Duncan- peripheral separation of placenta
Why do active management?

Reduces the risk of postpartum hemorrhage by more than 60%

Postpartum hemorrhage - leading cause of maternal mortality

 Active
Management of
the
3rd Stage of Labor
 Administration of Uterotonic
drug within 1 min of delivery of
baby

Delivery of Placenta by
Controlled Cord Traction (CCT)

Uterine Massage
 Oxytocin
● Uterine stimulant, vasopressive and Complications:
antidiuretic
● Activates G-protein-coupled receptors ● Cardiovascular effects (transient fall in BP
that trigger increases in intracellular and abrupt increase in cardiac output)
calcium levels which results in uterine ● Water intoxication
contraction
● Increases prostaglandin production,
which further stimulates uterine
contraction
● Given as 20 units (20 mL) of Oxytocin per
liter of infusate IV or 10 units IM
Alternatives:
Methylergonovine
● Produces vasoconstriction to increase strength, duration and frequency
of uterine contraction -> impedes uterine blood flow
● Methergine
● Given as 0.2 mg IM or IV slowly

Precautions & Contraindications:

● Hypertension, pre-eclampsia, heart disease

Alternatives:
Prostaglandins
● Carboprost - prostagladin analogue of PGF2a
● Binds to prostaglandin E2 receptor, causing myometrial contractions
● Used in obstetrical emergency such as uterine atony with hemorrhage
● Given as 250 ug IM

Precautions & Contraindications:

● Asthma
 Delivery of Placenta by
Controlled Cord Traction (CCT)
1. One hand hold to cord
2. Other hand suprapubic for counter-traction
3. Wait for uterus to contract
4. As uterus contracts, as evidenced by uterus becoming
hard and lengthening of the cord, gently pull
downwards the cord
5. If placenta does not descend, wait for next contraction
Signs of Placental Separation
1. Calkin’s sign- uterus from discoid
becomes globular
2. Gush of blood from the vagina
3. Lengthening of the cord- most reliable
4. Uterus rises in the abdomen as the
placenta descends
 Delivery of Placenta by
Controlled Cord Traction (CCT)

6. Twist placenta while delivering so that

membranes won’t tear off

7. Examine the placenta and membranes for

complete removal
 Uterine Massage

● Massage the uterine fundus until well contracted

● Repeat massage every 15 min for 2 hours
● Ensure that the uterus does not become flabby
 Complications of
the
3rd Stage of Labor
 POSTPARTUM
HEMORRHAGE
SHOCK

RETAINED PLACENTA

PULMONARY / AF EMBOLISM

UTERINE INVERSION
 POSTPARTUM
HEMORRHAGE
- Most common complication
- Blood loss in excess of 500ml (1L in CS) following birth of the baby
- Managed through uterine massage and the use of uterotonics
- AMTSL has clearly been shown to reduce the frequency of this
complication and therefore most likely has a positive impact on
maternal mortality and long-term morbidities such as anemia
POSTPARTUM
HEMORRHAGE
 Management of PPH secondary to Atonic
Uterus
● Administration of uterotonic agents (Oxytocin,
Methylergonovine, Prostaglandin analogues)
● Bimanual compression of uterus
● Balloon Tamponade
● B-Lynch Suture or Multiple Square sutures
● Uterine Devascularization
● Hysterectomy
 RETAINED PLACENTA
- Retention of placenta in utero >30 minutes
- 10% of PPH cases, occurs in 0.5-3% of all deliveries
- Clinical assessment of whether significant bleeding is occurring
- Ensuring that the bladder is empty may speed up the delivery of
the placenta and at least aid in the assessment and control of the
uterus.
- Retained or partially detached placenta interferes with uterine
contraction and retraction and leads to significant bleeding
Management of Retained Placenta
Manual removal of placenta under GA
○ Catheterize, prophylactic antibiotic
○ Hold umbilical cord with a clamp. Pull the
cord gently until it is parallel to the floor
○ Insert the other hand (with long gloves) into
the vagina up into the uterus
○ Let go of the cord and move the other hand
to the abdomen to do counter-traction
○ Insinuate fingers between the placenta and
uterine wall until it is detached
○ Remove placenta by traction of cord
 UTERINE INVERSION

- Rare but life-threatening

- Uterus is turned inside out partially or completely (1st - 3rd
degree)
- 1 in 20,000 deliveries
- Risk is increased in abnormalities of placentation such as placeta
accreta and is more likely with fundal cord inversions and any
condition that predisposes patients to atony and cord prolapse
 Management of Uterine Inversion
● Manual Correction
○ Wearing high-level sterile
gloves, grasp the inverted uterus
and push it through the cervix in
the direction of the umbilicus to
its normal anatomic position,
using the other hand to stabilize
the uterus
● O’ Sullivan’s Hydrostatic
Method
○ Tube passed into the posterior
fornix
○ Assistant close vulva around
operator’s wrist
○ Warm saline run until pressure
gradually restores position of
uterus
 PULMONARY / AF EMBOLISM

- Hypercoagulable state
- AF embolism: grave but uncommon complication of labor and immediate
postpartum period
- Infusion of amniotic fluid or fetal tissue into maternal circulation through
a tear in the placental membranes or rupture of uterine veins
- Inflammatory reaction and activate clotting in the mother’s lungs and
blood vessels
- Cardiorespiratory collapse, massive bleeding (coagulopathy)
Management of Pulmonary / AF Embolism

● Anticoagulants
○ Unfractionated heparin
○ Warfarin
○ Low molecular weight heparin (LMWH) - Enoxaparin
● Thrombolytic Therapy
○ Streptokinase
○ Urokinase
○ Recombinant Tissue Plasminogen activator (rTPA)
Thank you