INTRODUCTION:

Labour is the physiological process by which a viable foetus and the products of
conception i.e. at the end of 28 weeks or more is expelled or is going to be expelled from the
uterus. Delivery means actual birth of the foetus. The World Health Organization (WHO) states
that the process of childbirth is not finished until the baby has safely transferred from placental to
mammary nutrition. They advise that the new born be placed skin-to-skin with the mother,
postponing any routine procedures for at least one to two hours. The WHO suggests that any
initial observations of the infant and the mother can be done while the infant remains close to the
mother, saying that even a brief separation before the baby has had its first feed can disturb the
bonding process.

An overview of the stages of labour:

I. The first stage( stage of dilatation):

It starts from the onset of true labour until the cervix is fully dilated. It is divided into two
phases: 1. The latent phase: - Starts from onset of labour until the cervix reaches 3cm dilatation.
2. The active phase: From 3cm- full cervical dilatation (10cm), here the contractions becomes
more frequent and stronger .

II. The second stage ( stage of expulsion):

It starts from full dilatation of the cervix until the foetus is born. It is also divided into
two phases:1. The passive phase :the time between full dilatation and the onset of involuntary
expulsive contractions. There is no maternal urge to push and the foetal head is still relatively
high in the pelvis. 2. The active phase: there is a maternal urge to push because the foetal head is
low, causing a reflex need to bear down.

III. The third stage :

It starts from the birth of the foetus or foetuses until the placenta and membranes are
delivered and the uterus has retracted firmly to compress the uterine blood sinuses.
The placenta usually delivered within few minutes of the birth of the baby.
 IV. The fourth stage:
It is the stage of early recovery. Begins immediately after expulsion of the placenta and
membranes and lasts for one hour. During which careful observation for the patient, particularly
for signs of postpartum haemorrhage is essential. Routine uterine massage is usually done every
15 minutes during this period.

THIRD STAGE OF LABOUR:

DEFINITION:

The third stage of labour begins after expulsion of the foetus and ends with expulsion of the
placenta and membranes.
DURATION:
Its average duration is not merely 15 minutes in both primigravida and multipara. The duration is
however, reduced to 5 minutes in active management.

EVENTS INVOLVED IN THE THIRD STAGE OF LABOUR:

The third stage of labour comprises the phase of placental separation; its descent to the
lower segment finally its expulsion with the membranes. The events which involved in the
third stage of labour are:
1. Placental separation.
2. Placental Expulsion.

1. PLACENTAL SEPARATION: At the beginning of labour, the placental attachment roughly

corresponds to an area of 20 cm in diameter. There is no appreciable diminution of the
surface area of the placental attachment during first stage. During the second stage, there is
slight but progressive diminution of the following successive retractions, which attains its
peak immediately following the birth of the baby.
After the birth of the baby, the uterus measures about 20 cm vertically and 10 cm
anteroposteriorly, the shape becomes discoid. The wall of the upper segment is much
thickened while the thin and flabby segment is thrown into folds. The cavity is much
reduced to accommodate only the afterbirths.
 Signs of separation of placenta:
a. A small fresh blood loss.
b. Lengthening of the cord.
c. Fundus becoming rounder, smaller and more mobile in the abdomen.

Mechanism of separation:
There are two ways of separation of placenta.
a) Central separation (Schultze)
b) Marginal separation (Mathews-Duncan)

a) Central separation (Schultze): Detachment of the placenta from its uterine attachment
starts at the centre resulting in opening up of few uterine sinuses and accumulation of
blood behind the placenta (retroplacentalhaematoma). With increasing contraction, more
and more detachment occurs
facilitated by weight of the placenta and retroplacental blood until whole of the placenta
gets detached.
b) Marginal separation (Mathews-Duncan): Separation starts at the margin as it is mostly
unsupported. With progressive uterine contraction, more and more areas of the placenta get
separated. Marginal separation is found more frequently.

Separation of the membranes:

The membranes which are attached loosely in the active part are thrown into
multiple folds. Those attached to the lower segment are already separated during its
stretching. The separation is facilitated partly by uterine contraction and mostly by weight
of the placenta as it descends down from the active part. The membranes so separated
carry with them remnants of decidua vera giving the outer surface of the chorion its
characteristic roughness.

2. EXPULSION OF PLACENTA: After complete separation of the placenta, it is forced down

into the flabby lower uterine segment or upper part of the vagina by effective contraction
and retraction of the uterus. Thereafter, it is expelled out by either voluntary contraction of
abdominal muscles (bearing down efforts) or by manual procedure.
 COURSE OF THIRD STAGE OF LABOUR:

Third stage includes separation, descent and expulsion of the placenta with its membranes.
1. Pain: For a short time, the patient experiences no pain. However, intermittent discomfort
in the lower abdomen reappears, corresponding with the uterine contractions.
2. Before separation:
 Per abdomen — Uterus becomes discoid in shape, firm in feel and non-
ballottableFundal height reaches slightly below the umbilicus
 Per vagina: There may be slight trickling of blood. Length of the umbilical cord as
visible from outside remain static.
3. After separation: It takes about 5 minutes in conventional management for the
placenta to separate.
 Per abdomen — Uterus becomes globular, firm and ballottable. The
fundal height is slightly raised as the separated placenta comes down in
the lower segment and the contracted uterus rests on top of it. There may
be slight bulging in the suprapubic region due to distension of the lower
segment by the separated placenta.
 Per vagina — There may be slight gush of vaginal bleeding. Permanent
lengthening of the cord is established. This can be elicited by pushing
down the fundus when a length of cord comes outside the vulva which
remains permanent, even after the pressure is released. Alternatively, on
suprapubic pressure upwards by fingers, there is no indrawing of the
cord and the same lies unchanged outside the vulva.

4. Expulsion of placenta and membranes: The expulsion is achieved either by

voluntary bearing down efforts or more commonly aided by manipulative
procedure. The "after-birth" delivery is soon followed by slight to moderate
bleeding amounting to 100-250 ml.
5. Maternal signs : There may be chills and occasional shivering. Slight transient
hypotension is not unusual.

MANAGEMENT OF THIRD STAGE OF LABOUR:

Third stage is the most crucial stage of labour. Previously uneventful first and second
stage can become abnormal within a minute with disastrous consequences.
 The principles underlying the management of third stage are to ensure strict vigilance
and to follow the minagement guidelines strictly. In practice so as to prevent the
complications, the important one being postpartum haemorrhage.

STEPS OF MANAGEMENT :
Two methods of management are currently in practice:
1. Expectant management
2. Active management (preffered)

1. EXPECTANT MANAGEMENT:
In this method of management, the placental separation and its descend into the
vagina are allowed to occur spontaneously. Mother's efforts are used to aid the expulsion.
Minimal assistance is given if the mother's efforts fail to expedite the expulsion. This
method can be practiced when the mother has not received any anesthesia, or an oxytocic
drug has not been administered at the delivery of the anterior shoulder.

Steps of the Method:

o A hand is placed over the fundus to feel the signs of placental separation, the state of
uterine activity i.e. Contraction and relaxation, and any collection of blood in the
uterine cavity. The placenta generally separates within minutes and 15 to 20 minutes
may be allowed for the separation to occur.
o When the features of placental separation and its descend into the lower segment
are confirmed, the client is asked to bear down simultaneously with the hardening
of the uterus. With a good uterine contraction. mother's bearing down effort will
usually bring about expulsion of the placenta. The tendency to massage the uterus
must be avoided. If the placenta fails to expel, one can wait for up to ten minutes if
there is no bleeding. With another contraction and bearing down by the mother, it is
likely to be expelled.
o 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. If the membranes threaten to tear, they are to be
held by an artery forceps and gentle traction applied to deliver the rest of the
membranes. Gentleness and patience are important in delivering the membranes
completely.

 Assissted Expulsion:
A. Controlled Cord Traction (Modified Brandt-Andrews Method):
If CCT is to be used, there are several checks to be made before proceeding:
 o That a uterotonic drug has been administered

o That it has been given time to act

o That the uterus is well contracted

o That counter-traction is applied

o That signs of placental separation and descent are present.

The left hand is placed above the level of the symphysis pubis with the palmar
surface facing towards the umbilicus to exert pressure in an upward direction The body
of the uterus is displaced upwards and towards the umbilicus while with the right
hand,steady tension is given in a downward and backward direction following the line
of birth canal (curve ofCarus), by holding on the clamp placed on the cord at the vulva.
It is important to apply steady traction by pulling the cord firmly and maintaining .
Force and jerky movements must be avoided

B. Expression by Fundal Pressure :

This is done by placing four fingers of the hand behind the fundus and the thumb
in front of the uterus to use as a piston. The uterus is made to contract by gentle rubbing.
When the uterus becomes hard, it is pushed downward and backwards. The pressure is to
be withdrawn as soon as the placenta passes through the introitus. This method is
preferred in eases where the baby is premature or macceratcd, at the cord in such cases
tends to have reduced tensile strength.

FUNDAL HEIGHT DURING THIRD STAGE:

At the beginning of the third stage, the fundus is palpable below the umbilicus. It finds
broad as the placenta is still in the upper segment An the placenta separates and fails
into the lower uterine segment, there a small fresh blood loss, the cord lengthen, and
the fundus becomes rounder, smaller and more mobile as it rises in the abdomen to the
level of the umbilicus or just above the umbilicus. At the end of third stage following
the expulsion of the placenta, the fundus is about 4cm below the umbilicus.

AFTER DELEVERY OF THE PLACENTA:

o Continuing evaluation is essential at the completion of third stage.

o The midwife must ensure that the uterus is well contracted and fresh blood loss is
minimal.
o Careful inspection of the perineum and lower vagina under good light is important.
o Slight lacerations are usually repaired immediately.
o If repair of a more extensive wound, such as an episiotomy or a second degree tear,
is necessary, the mother should be made comfortable by changing soiled bed linen
while preparations are made for suturing.
o The vulva and perineum are gently cleansedusing antiseptic solution, softly dried
and a clean and placed in position.
o The mother's blood pressure, pulse and temperature should be taken and recorded at
least once.
o Once the mother is comfortable, examination of the placenta and membrane is the
next priority.

Examination of Placenta and Membranes:

a. This should be performed as soon as after delivery as possible, so that if there is
doubt about their completeness, further action could be taken before the mother
leaves the labor room or the midwife leaves the home in ease of home delivery.
b. A thorough inspection must be carried out in order to make sure that no part of the
placenta or membraneshas been retained.
c. The membranes often become torn during delivery and may be ragged and hence,
care must be taken to piece them together to have an overall picture of their
completeness. This is easier to see if the placenta is held by the cord, allowing the
membranes to hang.
d. The placenta should then be laid out on a flat surface and both placental surfaces
examined carefully.
e. The amnion should be peel from the chorion right upto the umbilical cord, which
allow the choroid to be fully viewed.

Assessment of the placenta:

Any cloth from the maternal surface must be removed and kept for measuring.
Brokessements of cotelydons must be carefully replaced before an accurate assessment is made.
 Infarction that are recent or old: These areas on the placental surface indicates
deprivation of blood supply. Recent infarction appears bright red and old infarction
as grey patches.
 Localized calcifications: These are seen as flattened white plaques that feel gritty
(as small hard particles of sand) to the touch.
  Lobes: The lobes of complete placenta fit neatly together without any gaps, the
edges forming a uniform circle.
 Blood vessels: They should not radiate beyond the placental edge. If they do, it
denotes a succenturiate lobe.
 Insertion of the cord (on the fetal surface): Normal insertion is central. Lateral
insertion is abnormal.
 Umbilical vessels: Two umbilical arteries and one vein should be present. The
absent of one artery may be associated with congenital abnormality, particularly
renal agenesis.
 Cord length: Average length is 50cm.
 Weight of the placenta: Approximately one sixth of the baby’s weight.

2. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR:

The underlying principle in active management is to excite powerful uterine contractions

within one minute of delivery of the baby (WHO) by giving parenteral oxytocic This
facilitates not only early separation of the placenta but also produces effective uterine
contractions following its separation.

The advantages are:

 To minimise blood loss in third stage approximately to 1 /5th.

 To shorten the duration of third stage to half.
The only disadvantage is slight increased incidence of retained placenta (1-2%) and
consequent increased incidence of manual removal.

Procedures:

 Inj. oxytocin 10 units IM (preferred) or methergin 0.2 mg EM is given within one

minute of delivery of the baby (WHO).
 The placenta is expected to be delivered soon following delivery of the baby. If
the placenta is not delivered thereafter, it should be delivered forthwith by
controlled cord traction (Brandt- Andrews) technique after clamping the cord
while the uterus still remains contracted.
 If the first attempt fails, another attempt is made after 2-3 minutes failing which
another attempt is made at 10 minutes.
 If this still fails, manual removal is to be done.
  Oxytocic may be given with crowning of the head, with delivery of the anterior
shoulder of the baby or after the delivery of the placenta.

IMMEDIATE CARE TO MOTHER AND BABY :

The mother and baby should remain in the midwife's care for at least an hour after
delivery. In some hospitals, the baby may be in a nursery unit and cared for by another
nurse. Both need careful observation and specific care during this period.
1. The mother should receive cleansing body wash, mouthwash and perineal care.
2. She should be encouraged to empty her bladder and a bedpan offered.
3. Blood pressure, pulse, uterine contraction and bleeding should be checked every
15 minutes
4. The baby's general well-being and security of the cord clamp needs to be checked.
5. As the baby will quickly chill afterbirth, it is important to thoroughly dry and wrap
the baby in a clean, dry towel or blanket.
6. A full neonatal examination is done at an early stage and the baby is kept in warm
crib, or cuddled close to the mother.
7. Mothers intending to breastfeed may be encouraged to put their babies to the breast
during early contact. Babies are usually and their sucking reflex strong at this time.
For the mother, early breastfeeding causes a reflex release of oxytocin from the
posterior lobe of the pituitary gland that stimulate uterus to contract.

COMPLICATIONS OF THIRD STAGE OF LABOUR:

A number of complications of the third stage of labour may involve a general surgeon, especially
where experienced obstetric help is unavailable:
1. Postpartum haemorrhage : PPH is define as excessive bleeding from the genital tract at any
time following the baby’s birth to sixth weeks after delivery. It is of two types:
o Primary postpartum haemorrhage: If bleeding occurs within first 24 hours after birth of
the baby.
o Secondary postpartum haemorrhage: If bleeding occur after 24 hours following childbirth
and it continues till sixth weeks.
2. Retained placenta: If the placenta is not being able to delivered and remain inside the uterine
cavity.
Manual Removal of the Placenta:
  One hand is inserted through the vagina and into the uterine cavity.
 Insert the side of your hand in between the placenta and the uterus. You may need to
push through the placental membranes to accomplish this.
 Using the side of your hand, sweep the placenta off the uterus.
 After most of the placenta has been swept off the uterus, curl your fingers around the
bulk of the placenta and exert gentle downward and outward traction. You may need
to release the placenta and then re-grab it.
 Then pull the placenta through the cervix. Most placentas can be easily and
uneventfully removed in this way. A few prove to be problems.

3. Perineal and vulval trauma:These are common during the delivery of the fetal head, but
serious injury can usually be avoided by an appropriately timed episiotomy. Labial
and clitoral lacerations usually heal without treatment, but should be sutured if they
are deep or bleed persistently.

4. Acute uterine inversion: Uterine inversion may occur spontaneously, but is usually
the result of mismanagement of the third stage of labour. Spontaneous inversion is
extremely rare, but may be caused by a sustained rise in intra-abdominal pressure,
such as vomiting, when the placenta is adherent at the fundus of an atonic uterus.
Fundal pressure or sustained traction on the umbilical cord with an adherent fundal
placenta and atonic uterus is, however, a much more common cause of uterine
inversion.

NURSING MANAGEMENT:

Nursing assessment:
1. Determine that normal third stage progress is occurring.
o Rhythmic contractions until the placenta is born.
o Birth of placenta occurs 5 to 30 minutes after birth of the baby.

o Signs of placental separation is seen.

o Following birth of placenta, the uterine fundus remains firm and is located two
finger breadths below the umbilicus.
o The mother may experience chills or shivering.

2. Assess maternal blood pressure following birth of the baby.

3. Assess status of the uterus: Contractions will continue until birth of the placenta.
4. Assess the newborn's Apgar score and complete newborn assessment.
5. Examine placenta to document that all cotyledons and membranes are present.
Nursing diagnosis:
1. Acute pain related to tissue trauma and birth process, intensified by fatigue.
2. Impaired tissue integrity related to placental separation.
3. Deficit fluid volume related to excessive blood loss.
4. Impaired skin integrity related to tissue trauma.
5. Risk for injury related to potential haemorrhage.
6.
Nursing interventions:
1. Administer analgesics as indicated.
2. Assure that epidural catheter has been removed.
3. Assist the woman in finding comfortable positions.
4. Assist the woman with a partial bath and perineal care, and change linens and pads
as necessary.
5. Allow for privacy and rest periods between postpartum checks.
6. Provide warm blankets, and reassure the woman that tremors are common during this
period.
7. Delivery of the placenta typically occurs within the m it 5 to 10 minutes, but preterm
gestations may persist past: 30 minutes. Once signs of placental separation are noted, the
woman is asked to bear down gently to assist the delivery of the placenta. Observe for the
signs of placental separation.
8. Evaluate the placenta for size, shape, implantation site of cord, and intact cotyledons.
Umbilical cord should be inspected for true knots, clots, length, and number of vessels.
Abnormalities in the placenta, cord, or both should be confirmed by an additional practitioner
and documented on the labor record. Occasionally, the primary practitioner may want the
placenta sent to pathology for evaluation.
9. Maintain intravenous fluids as indicated.
10. Ensure accurate measurement of intake and output maintained throughout labor and
delivery.
CONCLUSION
The period following delivery of the baby is a time of relief and joy for all involved.
However this period holds great potential danger for the mother. Complications of the third
stage, especially PPH, account for much maternal mortality and morbidity. Compelling
evidence suggests that active management of the third stage results in a decrease in
complications and morbidity. The practice of prophylactic oxytocin administration with
delivery of the baby and CCT with countertraction when the uterus is well contracted is
strongly advocated. Care givers must be prepared to diagnose and manage the complications
that arise in the third stage in a timely and systematic manner.

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