Third stage of labour

Events in third stage of labor

• Phase of placental separation and expulsion
• Two types of placental separation
1. Central separation (Schultze): Retroplacental clot
2. Marginal separation (Mathews-Duncan): separation starts at the
margin
- Found frequently.
 Mechanism of placental separation:
•  Myometrial thickening after delivery of the infant
leads to substantial reduction in uterine surface area,
resulting in shearing forces at the placental
attachment site and placental separation.
• This process generally begins at the lower pole of the
placental margin and progresses along adjacent sites
of placental attachment. A "wave of separation"
spreads upwards so that the uppermost part of the
placenta detaches last

06/17/2023 B.K, MD, MPH, MFM 3

Mechanism of placental separation
•  Placental expulsion follows separation as a result of a combination of
events including spontaneous uterine contractions, downward
pressure from the developing retroplacental hematoma, and an
increase in maternal intraabdominal pressure

06/17/2023 B.K, MD, MPH, MFM 4

Signs of placental separation
• a gush of blood, lengthening of the umbilical cord, and anterior-
cephalad movement of the uterine fundus, which becomes firmer and
globular after the placenta detaches.

06/17/2023 B.K, MD, MPH, MFM 5

duration of the third stage of labor
• The duration of the third stage of labor is important because the
prevalence of postpartum hemorrhage increases as the duration
lengthens 
• Gestational age is the major factor influencing the length of the third
stage: preterm deliveries are associated with a longer third stage of
labor than term deliveries
• Prolonged when greater than 30 min

06/17/2023 B.K, MD, MPH, MFM 6

Complications of third stage
• The major complications of the third stage of labor
are:
• Hemorrhage
• Retained placenta
• Uterine inversion

06/17/2023 B.K, MD, MPH, MFM 7

Management- cont’d
Third stage management: Two types
1. Physiological/ expectant: by waiting for signs and
symptoms of separation and with little assistance.
2. Active: includes cord clamping & cutting, use of
uterotonics, controlled cord traction and uterine
massage.
• the preferred approach to management of the third stage
of labor.
• Shorten the third stage, reduce the incidence of PPH, the
quantity of blood loss, and the use of blood transfusion
Management- cont’d
Types of placental delivery
1. Brandt-Andrews maneuver (an abdominal hand
secures the uterine fundus to prevent uterine
inversion while the other hand exerts sustained
downward traction on the umbilical cord)
• Preferred
2. Crede’s maneuver (the cord is fixed with the lower
hand while the uterine fundus is secured and sustained
upward traction is applied using the abdominal hand).
3. Pastuer technique
Management- cont’d  
Placental delivery
• care should be taken to avoid avulsion of the cord.
• Examination of placenta, membranes & cord
• The fetal side is assessed for any evidence of vessels
coursing to the edge of the placenta and into the
membranes, suggestive of a succenturiate placental
lobe.
• Count the number of vessels in the cord.
 

06/17/2023 B.K, MD, MPH, MFM 10

Management- cont’d
BLOOD LOSS
• Average blood loss after vaginal delivery is 500-600ml

06/17/2023 B.K, MD, MPH, MFM 11

Management- cont’d
• Examination of genitalia- The cervix, vagina, and perineum
• The major risk factors for third and fourth degree perineal lacerations are nulliparity,
operative delivery, episiotomy, and delivery of a large for gestational age infant
• Repair of lacerations 
• Transfer of the parturient
• Discarding and disinfecting the equipment's.
Management- cont’d
Care of newborn:
- APGAR score at the 1st & 5th minutes
- Drying
- Avoid heat loss & covering with cotton clothes
- Label, anthropometric measurements
- Initiate breast feeding or other options
- Tetracycline (TTC) eye ointment & Vit. K
administration
- If needed, neonatal resuscitation
Partograph
INTRODUCTION
• Early detection of abnormal labor and prevention of prolonged labour

► ↓maternal and perinatal morbidity and mortality

• The partograph was developed to this endeavor
Introduction
• The partograph is the graphic recording of the progress of labour and
the salient condition of the mother and the fetus .
• It serves as an “early warning system” and assists in early decision to
transfer, augmentation and termination of labor.
The WHO partograph-cont’d
Components
- Patient information
- Fetal condition
- Progress of labor
- Maternal condition
Advantages of partograph
• Prevention of prolonged labor
• Avoids unnecessary use of augmentation
• Hand over of patients
- More precise and fluent
- At a glance appreciation of preceding
hours of labor
Advantages of partograph (Ctd.)
• Pictorial display of events of labor
- Clarifies recordings
- Avoids lengthy written notes
- Facilitates recognition of any omissions
- Saves time → Companionship
• Considerable educational value
- All interrelated variables of labor can be
seen on a single paper
• Low cost, feasible
• Improved out come of labor →↑Credibility of formal
health sector
Advantages of partograph
• Prevention of prolonged labor
• Avoids unnecessary use of augmentation
• Hand over of patients
- More precise and fluent
- At a glance appreciation of preceding
hours of labor
Advantages of partograph (Ctd.)
• Pictorial display of events of labor
- Clarifies recordings
- Avoids lengthy written notes
- Facilitates recognition of any omissions
- Saves time → Companionship
• Considerable educational value
- All interrelated variables of labor can be
seen on a single paper
• Low cost, feasible
• Improved out come of labor →↑Credibility of formal
health sector
 Components of the partograph
• Part I : Fetal condition ( at the top )

• Part II : Progress of labor ( at the middle )

• Part III : Maternal condition ( at the bottom )

Alert line
• The alert line drawn from 3 cm dilatation represents the rate
of dilatation of 1cm/hour
• Moving to the right of the alert line means referral to
hospital for extra vigilance
Action line
• The action line is drawn 4 hour to the right of the alert line
and parallel to it.
• This is the critical line at which specific management
decisions must be made at the hospital.
Number of contraction in ten minutes and duration of
each contraction in seconds

• Less than 20 seconds: 

• Between 20 and 40 seconds:

• More than 40 seconds:

Normal progress of labor in
partograph
 A. Active phase remains on or left of the alert
line
• Do not augment with oxytocin if latent and active phases go normally
• Do not intervene unless complications develop
• Artificial rupture of membranes (ARM)
• No ARM in latent phase
• ARM at any time in active phase
B. Between alert and action lines

• In health center, the women must be transferred to a hospital with

facilities for cesarean section, unless the cervix is almost fully dilated
• Observe labor progress for short period before transfer
• Continue routine observations
• ARM may be performed if membranes are still intact
 C. At or beyond action line
• Conduct full medical assessment
• Consider intravenous infusion/bladder catheterization/analgesia
• Options
- Deliver by cesarean section if there is fetal distress or obstructed
labor
- Augment with oxytocin by intravenous infusion if there are no
contraindications