Lesson plan

on
THIRD STAGE OF LABOuR & ITS MANAGEMENT

SUBMITTED BY:
VARSHA SHARMA
TUTOR
HOLY FAMILY COLLEGE OF NURSING
 GENERAL INFORMATION

Name : Varsha Sharma

Subject : Obstetrics & Gynecology Nursing

Topic : Third stage of labor & its management.

Group : GNM 3rd year students

Date :

Duration : 45 minutes

Methods of teaching : Lecture cum discussion

Place : GNM 3rd year classroom

Language : English

Previous knowledge of group: Group has some knowledge about the third stage of labor & its management.
General Objective:

After the completion of class students will be able to gain in depth knowledge about third stage of labor & its management..

Specific Objectives:

After the completion of class students will be able to,

 Define labor, normal labor and abnormal labor.

 Define 3rd stage of labor
 List down the clinical course of 3rd stage of labor
 Explain events in 3rd stage of labor
 Describe the mechanism of control of bleeding
 Explain the management of 3rd stage of labor
 Enlist the complications of 3rd stage of labor
 Discuss the nursing management
TIME SPECIFIC TEACHING LEARNING EVALUATION
OBJECTIVE CONTENT ACTIVITY/A.V AIDS
INTRODUCTION
2 Min The physiological transition
from being a pregnant
woman to becoming a
mother means an enormous
change for each woman
both physically and
psychologically.
2min To define labor, DEFINITION Teacher has defined labor Define Normal
normal labor and LABOUR: with the help of ppt. labor?
abnormal labor.  The series of events that take place in the genital
organs in an effort to expel the viable product of
conception out of the womb through the vagina into
the outer world is called labor.

NORMAL LABOUR (EUTOCIA):

 Occurs at term and is spontaneous onset with the fetus
presenting by the vertex.
Labor is called normal if it full fills the following
criteria:
 spontaneous in onset and at term,
 with vertex presentation,
 without undue prolongation,
 natural termination with minimal aids,
 without having any complication affecting the health
of mother.

ABNORMAL LABOUR (DYSTOCIA):

Any deviation from the normal definition of normal labor is
called abnormal labor. Thus, a labor in a case with
presentation other than vertex or having complications, even
 with vertex presentation affecting the course of labor or
modifying the nature of termination or adversely affecting the
maternal and/or fetal prognosis is called an abnormal labor.
2Min To define 3rd Third Stage of Labor Teacher has defined the 3rd Define third
stage of labor Definition: stage of labor with the help stage of labor?
 It begins after expulsion of fetus and ends with expulsion of PPT.
of placenta and membranes (after births).
 Its average duration is about 15minutes in both
primigravida and multiparae.
The duration is however reduced to 5minutes in active
management.
10 Min To list down LABOUR Teacher has listed down the What is the
clinical course of It includes separation, descent and expulsion of placenta with clinical course of the 3rd clinical course of
third stage of its membranes. stage of labour with the third stage of
labor. help of PPT. labour?
PAIN:
 For a short time, the patient experiences no pain.
 However, intermittent discomfort in the lower
abdomen reappears, corresponding to the uterine
contractions.
BEFORE SEPARATION:
Per abdomen:
 Uterus become discoid in shape, firm in feel and non
ballotable.
 Fundal height reaches slightly below the umbilicus.

CLINICAL COURSE OF THIRD STAGE OF

Per vagina:
 There may be slight trickling of blood.
 Length of the umbilical cord as visible from outside,
remains static.
AFTER SEPARATION:
It takes about 5 minutes in conventional management for the
 placenta to separate.
Per abdomen:
 Uterus becomes globular, firm and ballotable.
 Fundal height is slightly raised as the separated
placenta comes down in the lower segment.
 Slight bulging in the suprapubic region due to
distension of lower segment by the separated placenta.
Per vagina:
 Slight gush of vaginal bleeding.
 Permanent lengthening of cord is established.
EXPULSION OF PLACENTA AND MEMBRANES:
 The expulsion is achieved 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 100-250ml.
MATERNAL SIGNS:
 There may be chills and occasional shivering.
 Slight transient hypotension is not unusual.
5Min To list down EVENTS IN THIRD STAGE OF LABOUR Teacher has listed down the What are the
events in third It comprises the phase of placental separation, its descent to events in third stage of events take place
stage of labour. the lower segment and finally its expulsion with the labour with the help of in third stage of
membranes. PPT. labour?
It includes:
 PLACENTA SEPARATION
 EXPULSION OF THE PLACENTA

1.PLACENTA SEPARATION:
MECHANISM:
 Marked retraction reduces effectively the surface area
at the placental site to about its half.
But the placenta is inelastic, it can not keep pace with such an
extent of diminution resulting in its buckling.
  A shearing force instituted between the placenta and
the placental site which brings about its ultimate
separation.
 The plane of separation runs through deep spongy
layer of decidua basalis so that the variable thickness
of decidua covers the maternal surface of the
separated placenta.

 WAYS OF SEPARATION OF PLACENTA:

It includes:
 Central separation (schultze):
 Marginal separation (Mathew- Duncan)

i.Central separation
Detachment of placenta from its uterine attachment starts at
the centre resulting in opening up of few uterine sinuses and
accumulation of blood behind the placenta (retroplacental
hematoma).
 The separation is facilitated partly by uterine
contraction and mostly by weight of the placenta as it
descends down from the active part.

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.
 Therefore, it is expelled out by either voluntary
contraction of abdominal muscles (bearing down
efforts) or by manual procedure.
 With increasing contraction, more and more
detachment occurs facilitated by weight of placenta
and retroplacental blood until whole of the placenta
 gets detached.

ii)
Marginal separation:
 Separation starts at the margin as it is mostly
unsupported.
 With the progressive uterine contraction, more and
more area of placenta get separated
 It is found more frequently.

5Min To describe the MECHANISM OF CONTROL OF BLEEDING Teacher has described the Explain the
mechanism of  After placental separation, innumerable torn sinuses mechanism of control of mechanism of
control of which have free circulation of blood from uterine and bleeding with the help of control of
bleeding. ovarian vessels have to be obliterated. PPT. bleeding?
 The occlusion is effected by complete retraction
where by the arterioles, as they pass tortuously
through the interlacing intermediate layer of the
myometrium, are literally clamped.
 It (living ligature) is the principal mechanism of
haemostasis, however the thrombosis occurs to
 occlude the torn sinuses, a phenomenon which is
facilitated by hyper-coagulable state of pregnancy.
 Apposition of the walls of the uterus following
expulsion of the placenta (myotemponade) also
contributes to minimize the blood loss.
5Min To explain the MANAGEMENT OF THIRD STAGE OF LABOUR Student teacher has Explain about
management of explained the management management of
3rd stage of  It is the most crucial stage of labour. of 3rd stage of labour with third stage of
labour.  The principles underlying the management of third the help of PPT. labour?
stage are to ensure strict vigilance and to follow the
management guidelines strictly in practice so as to
prevent the complications, the important one being is
post partum haemorrhage.

STEPS OF MANAGEMENT:
2 Methods are currently in practice, these are:
1. Expectant management
2. Active management

Scheme of management of 3rd stage of labour

EXPECTANT ACTIVE
Management Management

NURSING MANAGEMENT
It includes:
 Prevention of complications
 Treatment

Prevention of complications:
During pregnancy:
a. Detection and correction of anaemia.
b. Hospital delivery with ready cross-matched blood for high
risk patients as:
1. Antepartumhaemorrhage.
2. Previous postpartum haemorrhage.
3. Polyhydramnios and multiple pregnancy.
4. Grand multipara

During labour:

a. Proper use of analgesia and anaesthesia.

b. Avoid prolonged labour by proper oxytocin which should
be extended to the end of the 3rd stage if used.
c. Avoid lacerations by:
 Proper management of the 2nd stage.
 Follow the instructions for instrumental delivery.
d. Routine examination of the placenta and membranes for
completeness.

Postpartum:

 Exploration of the birth canal after difficult or

instrumental delivery as well as precipitate labour.
 Careful observation in the fourth stage of labour (1-2
hours postpartum)

Treatment
1. Restoration of blood volume:
Urgent cross-matched blood transfusion with the other
antishock measures is given.
Colloids and/or crystalloids therapy can be started till
availability of the blood.
2. Arrest of bleeding:
Placental site bleeding:
 a) Before delivery of the placenta:
The placenta should be delivered by;
 Ergometrine and massage with gentle cord
traction if failed,
 Brandt -Andrews maneuver if failed
 Do Crédé’s method if failed
 Do,Manual separation of the placenta

b) After delivery of the placenta:

The following steps are done in succession if each previous
one fails to arrest bleeding.

1. Inspection of the placenta and membranes: any

missed part should be removed manually under
anaesthesia.

2. Massage of the uterus and use ecbolics as:

Oxytocin drip: 10-20 units in 500 ml glucose 5% or
normal saline.
Ergometrine (Methergin): 1-2 ampoules (0.25-0.50
mg) IV or IM.
Syntometrine 0.5 mg IV if available.
Prostaglandins (PGs): 0.25 mg methyl PG F2a IM
(Prostin methyl ester) or
20 mg PG E2 (Prostin E2) rectal suppositories every
4-6 hours.

Bimanual compression of the uterus: Under general

anaesthesia, the uterus is firmly compressed for 5-30 minutes
between the closed fist of the right hand in the anterior
vaginal fornix and the left hand abdominally behind the body
of the uterus.
 The compression is maintained until the uterus is
 firmly contracted. During this period, blood
transfusion, oxytocin and ergometrine are given.

International midwives Guidelines

GUIDELINES
In a physiological or expectant third stage of Labour,
immediately following the birth and while awaiting delivery
of the placenta the midwife:
 Hands the baby to the mother to hold,
 encouraging skin to skin contact; both are kept warm,
dry and covered
 Encourages the woman to adopt a position
comfortable for her but preferably upright to aid
observation of blood loss and descent of the placenta
 Observes both the mother’s and baby’s vital signs and
well-being
 Encourages breastfeeding when the baby is ready to
feed Observes for excessive vaginal blood loss
Umbilical cord management
The cord is left alone until either:
 It has stopped pulsating or until the placenta has been
delivered at which point the cord is then clamped or
tied and cut
 If the baby requires resuscitation there are some
indications that it may be beneficial to leave the cord
intact during resuscitative efforts.
Controlled cord traction is contraindicated in the absence
of uterotonic drugs or prior to signs of separation of the
placenta as this can cause partial placental separation, a
ruptured cord, excessive bleeding, and/or uterine
inversion.

Immediately following the birth of the placenta The

midwife:
 Observes and estimates blood loss
 Palpates the uterine fundus to confirm that the uterus
is well contracted (the uterus will be found in the area
around the naval and should feel firm to the touch)
 Examines the placenta for completeness
 Continues to observe mother’s and baby’s vital signs
and well-being

The first two hours after the birth of the placenta The
midwife:
 Observes and estimates blood loss
 Teaches the woman how to check her blood loss and
the firmness of her own uterus
 Palpates for a contracted uterus on a regular basis
 Encourages mother/baby attachment by skin to skin
and breastfeeding
 Maintains a warm, calm environment for mother and
baby

Jhpiego :- PPH:Causes and

other prevention strategies
Causes
 Retained placenta
 Retained placental fragments
 Episiotomy and lacerations
 Uterine rupture
Prevention Strategies
 Partograph
 Avoid unnecessary episiotomy
 Inspection of placenta
 Inspection for lacerations
 Postpartum monitoring for minimum of 6 hours
To enlist the COMPLICATIONS OF 3RD STAGE OF LABOUR Student teacher has enlisted
complications of the complications of 3rd
3rd stage of Complications of the Third Stage of Labour Include: stage of labour with the
labour.  Postpartum haemorrhage. help of PPT.
 Retained placenta.
 Inversion of the uterus.
 Obstetric shock (collapse).
 Sepsis
 Anemia
 Failure of lactation
 Acute renal failure
SUMMARY
Today we have discussed
about the normal and
abnormal labour, 3rd stage
of labour, its definition,
clinical course, events
mechanism of control of
bleeding, management and
complications of 3rd stage
of labour, Jhpiego
guidelines.
CONCLUSION
It is the most crucial stage
of labour. The management
of third stage needs strict
vigilance and to follow the
management guidelines
strictly in practice so as to
prevent the complications,
the important one being is
post partum haemorrhage.
 BIBLIOGRAPHY

1) Dutta, D.C. Textbook of obstetrics. Edition 6th 2004. Reprint 2009, Kolkata: New central book agency (P) Ltd, 2006. Page
no.(114-124).
2) Fraser , Diane M. , Cooper, Margaret. Myles Textbook For Midwives. Edition 14th 2003, China : Elsevier Publications (P) Ltd,
2007. Page no. (435-444).
3) Basvanthappa, B.T. Textbook Of Midwifery & Reproductive Health Nursing . Edition 1st 2006, N.Delhi: Jaypee Brothrers
Medical Publishers (P) ltd, 2006. page no.(297-304).
4) http://obgnursing.blogspot.in/2012/07/third-stage-of-labour.html
5) http://obgnursing.blogspot.in/2012/07/process-of-labour.html
6) http://www.ncbi.nlm.nih.gov/pubmed/26083416
7) http://www.internationalmidwives.org/assets/uploads/documents/Links/GL2011_001%20Guideline%20for%20attendance%20
at%20a%20physiological%20(expectant)%203rd%20stage%20of%20labour.pdf