DefintionDefintion: 3rd stage of labor: commences with

the delivery of the fetus and ends with delivery of the placenta and its attached membranes.

Duration:Duration:- normally 5 to15 minutes. - 30 minutes have been suggested if

there is no evidence of significant bleeding.

Cause of placental separationCause of placental separationAfter delivery of the fetus,

the uterus retracts and the

placental bed diminished. As the placenta is inelastic

and does not diminish in

size it separates.

primary and secondary primary and secondary mechanism for placental mechanism for placental

separation separation

Primary mechanism is the reduction in surface area of placental site as the uterus shrinks

Secondary mechanism is the formation of haematoma due to venous occlusion and vascular rupture in the placental bed caused by uterine contractions

Placental Site during Placental Site during SeparationSeparation

Methods of Placental Methods of Placental SeparationSeparation

Schultze MethodSchultze Method

Placenta separates in the centre and folds in on itself as it descends into the lower part of uterus (80%).

Fetal surface appears at vulva

with membranes trailing behind Minimal visible blood loss as retroplacental clot contained within

membranes (inverted sac)

Duncan Method Duncan Method

separation starts at thelower edge of placenta lateral border separates (20%).

maternal surface appears first at vulva Usually accompanied by more bleeding

from placental site due to slower separation and no retro placental clot.

Signs of Separation and DescentSigns of Separation and Descent

lengthening of the umbilical cord outside.The uterus becomes firm and globular (Descent). The uterus rises in the abdomen. A gush of blood(separation ).

2

Assess the uterusAssess the uterus

1-To exclude an undiagnosed twin2-To determine a baseline fundal height3-to detect the signs of placenta

separation 4- to detect an atonic uterus.

Control of BleedingControl of Bleeding 1. Normal blood flow through placenta site is

500-800 ml/minute (10-15% of cardiac output)

2.Strong contraction/retraction of uterus constrict blood vessles by interlacing muscle fibres in myometrium (“living ligature”)

3. Pressure exerted on placental site by walls of contracted uterus

4. Blood clotting mechanism (sinuses and torn vessels)

Management of the Third Management of the Third Stage of Labour Stage of Labour

Physiologic or Active Physiologic or Active

Active vs physiologic Active vs physiologic management management

Active management includes a prophylactic oxytocic drug,early clamping and cutting of cord and controlled cord traction

Physiological management involves no prophylactic oxytocic drugs, no cord clamping until after placental delivery and no cord traction

Physiological Active

Placental delivery

By gravity and maternal effort

By controlled cord traction with counter traction on funds

Uterotonic after placenta delivery With birth of anterior

Shoulder

Uterus Assessment of size and tone

Assessment of size and tone

Cord Clamping Variable Early

Physiological ManagementPhysiological Management

Passive or expectant managementNo prophylactic oxytocics

Cord clamped afterdelivery of placenta

No Controlled Cord Traction (CCT)

Physiological ManagementPhysiological ManagementUpright/kneeling/squatting position best-

easy to observe blood loss

Hands off just check uterus contracted and observe PV loss

waits and watches for signs of separation and descent

Mother expels placenta when she feels contraction and placenta in vagina

Active ManagementActive ManagementReduces length of 3rd stage and incidence of

PPH (blood loss and need for transfusion)

Oxytocic given after birth of

Shoulder (check for a twin/

no shoulder dystocia)

Cord clamped and cutPlacenta delivered by Controlled Cord Traction

Guarding the UterusGuarding the Uterus

Controlled cord tractionControlled cord traction

Placental delivery Placental delivery

Delivering the MembranesDelivering the Membranes

Controlled Cord TractionControlled Cord TractionCHECKS FIRSTCHECKS FIRST!!

Check that an oxytocic (uterotonic) has been givenWhy?

Check that the uterus is well contracted Why?Check that countertraction is applied (Brandt-

Andrews manoeuvre) Why?

Check for signs of separation & descent Why?

Check that cord traction is released before countertraction is stopped Why?

Which is better active or physiologic Which is better active or physiologic management ?management ?

Active management is superior to physiological in terms of blood loss

Physiological management is only appropriate for women with low risk of PPH and who have normal physiological labour

If physiological management is attempted but intervention is subsequently required ( the placenta is retained after one hour) active management should be considered.

Manual removal of retained Manual removal of retained placentaplacenta

After CareAfter Care: Before leaving to check : Before leaving to check placenta and membranesplacenta and membranes

Check the uterus is well contracted

Check that PV loss is minimalInspect perineum, vulva and vagina in good light

(? Repair)

Baby should be pink (respirations; heart rate) warm, fed, cord clamp secure

check placenta and check placenta and membranesmembranes

for completeness

and normality

Abnormal placenta (accessory Abnormal placenta (accessory lobe)lobe)

Succentriate

lobe

Effects of labor on the Effects of labor on the mother mother

1 st stage: anxiety & mild tachycardia.

2 nd stage Pulse: up to 100 b.p.m. Temp: mild increase (37.5 - 37.7). B.P. systolic increased during pains. Conjunctiva; edematous & congested. Birth canal: minor lacerations in the

cervix or perineum especially in PG.

33rdrd Stage Stage

Blood loss from Placental site = 200-300 C.C due to

placental separation. Lacerations or episiotomy = about

100 - 200 C.C

Effects of labor on the Effects of labor on the FetusFetus

MouldingMoulding

Overlap of the flat bones of the vault of the skull

due to compression of

the head during labour

leading to alteration in

its shape

Types & DegreesTypes & Degrees

a. Physiological: "beneficial“ decreases the size of head & facilitates its passage through the birth canal. 1. First degree:2. Second degree

Pathological : may lead to Pathological : may lead to intracranial hemorrhageintracranial hemorrhage

3 rd degree:

Overriding of one parietal

bone over the other with

Contractions but it is not

Reducible inbetween. 4 th degree: overriding of the 2 parietal

bones over each others & both override the occipital

Caput Succedaneum:Caput Succedaneum:

Types Types

A: Natural Cervical: with cervical dystocia. Pelvic: with obstructed labour usually formed in prolonged labour after rupture of membranes.

CehalnematomaCehalnematoma

Cehalhematoma(subperiostealCehalhematoma(subperiostealhemorrhagehemorrhage

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