Lesson plan

on
THIRD STAGE OF LABOR & 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 labour & 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

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 OBJECTIVE CONTENT LEARNING V. ATION
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INTRODUCTION
The physiological
transition from
being a pregnant
woman to
becoming a
mother means an
enormous change
for each woman
both physically
and
psychologically .

DEFINITION
1) 2min To define labour, LABOUR: Student teacher PP
normal labour  The series of events that take place in the genital has defined
T
and abnormal organs in an effort to expel the viable product of labour with the
labour. conception out of the womb through the vagina into help of ppt.
the outer world is called labour.

NORMAL LABOUR (EUTOCIA):

 Occurs at term and is spontaneous onset with the
fetus presenting by the vertex.
 Labour is called normal if it full fills the following

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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 labour is
called abnormal labour. Thus, a labour in a case with
presentation other than vertex or having complications,
even with vertex presentation affecting the course of labour
or modifying the nature of termination or adversely affecting
the maternal and/or fetal prognosis is called an abnormal
labour.

Third Stage of Labour

2) 2min. To define 3rd Definition: Student teacher PP
stage of labour.  It begins after expulsion of fetus and ends with expulsion has defined the T
of placenta and membranes (after births). 3rd stage of
 Its average duration is about 15minutes in both labour with the
primigravida and multiparae. help of PPT.
 The duration is however reduced to 5minutes in active
management.
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3) 3min. To list down CLINICAL COURSE OF THIRD STAGE OF Student teacher Ppt Enlist
clinical course LABOUR has listed down the
of third stage It includes separation, descent and expulsion of the clinical course
clinic
of labour. placenta with its membranes. of the 3rd stage
of labour with the al
help of PPT. cours
PAIN:
 For a short time, the patient experiences no e of
pain. 3rd
 However, intermittent discomfort in the lower stage
abdomen reappears, corresponding to the of
uterine contractions. labou
BEFORE SEPARATION:
r.
Per abdomen:
 Uterus become discoid in shape, firm in feel
and non ballotable.
 Fundal height reaches slightly below the
umbilicus.
Per vagina:
 There may be slight trckeling 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 become globular, firm and ballotable.

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 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.

EVENTS IN THIRD STAGE OF LABOUR

4) 5min. To explain It comprises the phase of placental separation, its
Student teacher Expla
events in 3rd has explained the Ppt in
descent to the lower segment and finally its expulsion
stage of events in 3rd the
with the membranes.
labour. stage of labour
It includes:
with the help of
even
1. PLACENTA SEPARATION ts in
PPT.
2. EXPULSION OF THE PLACENTA
3rd
stage
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1.PLACENTA SEPARATION: Of
MECHANISM: labou
 Marked retraction reduces effectively the r.
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:
i. Central separation (schultze):
ii. 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).
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 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.

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SEPARATION OF MEMBRANES:
 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.

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6. 5min. To describe MECHANISM OF CONTROL OF BLEEDING Student teacher Ppt Descr
the  After placental separation, innumerable torn has described the ibe
mechanism of sinuses which have free circulation of blood mechanism of
the
control of from uterine and ovarian vessels have to be control of
bleeding. bleeding with the mech
obliterated.
 The occlusion is effected by complete help of PPT. anis
retraction where by the arterioles, as they pass m of
tortuously through the interlacing intermediate contr
layer of the myometrium, are literally clamped. ol of
 It (living ligature) is the principal mechanism of bleed
haemostasis, however the thrombosis occurs to ing.
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.

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7) 5min. To explain the MANAGEMENT OF THIRD STAGE OF Student teacher PPT Explai
management has explained the n the
of 3rd stage of LABOUR management of mana
labour. 3rd stage of geme
 It is the most crucial stage of labour. labour with the nt of
 The principles underlying the management of help of PPT. 3rd
third stage are to ensure strict vigilance and to stage
follow the management guidelines strictly in of
practice so as to prevent the complications, the labour
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

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7) 2min. To enlist the COMPLICATIONS OF 3RD STAGE OF Student teacher PPT Enlist
complications has enlisted the the
of 3rd stage of LABOUR complications of compl
labour. 3rd stage of icatio
Complications of the Third Stage of Labour Include: labour with the ns of
 Postpartum haemorrhage. help of PPT. 3rd
 Retained placenta. stage
 Inversion of the uterus. of
 Obstetric shock (collapse). labour
 Sepsis .
 Anemia
 Failure of lactation
 Acute renal failure

NURSING MANAGEMENT Student teacher PPT

8) 6min. To explain the Explai
It includes: has explained the
nursing n the
 Prevention of complications nursing
management nursin
 Treatment management of
of 3rd stage of g
3rd stage of
labour. mana
labour with the
Prevention of complications: geme
help of PPT.
During pregnancy: nt of
a. Detection and correction of anaemia. 3rd
b. Hospital delivery with ready cross-matched blood stage
for high risk patients as: of
1. Antepartumhaemorrhage. labour
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.

3. Bimanual compression of the uterus: Under

general anaesthesia, the uterus is firmly

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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.

9) 2min. To discuss the International midwives Guidelines Student teacher PPT Discus
international GUIDELINES has discussed the s the
midwife In a physiological or expectant third stage of Labour, international intern
guidelines. immediately following the birth and while awaiting midwife ationa
delivery of the placenta the midwife: guidelines. l
 Hands the baby to the mother to hold, midwi
 encouraging skin to skin contact; both are kept fe
warm, dry and covered guidel
 Encourages the woman to adopt a position ines.
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 Student teacher list
10) 2min. To list down
Causes has list down the down
the Jhpiego
 Retained placenta Jhpiego the
guidelines.
 Retained placental fragments guidelines. Jhpieg
 Episiotomy and lacerations o
 Uterine rupture guidel
Prevention Strategies ines.
 Partograph
 Avoid unnecessary episiotomy
 Inspection of placenta
 Inspection for lacerations
 Postpartum monitoring for minimum of 6 hours

SUMMARY
Today we have discussed about the normal and
9) 1min To summarize
abnormal labour, 3rd stage of labour, its definition,
the topic.
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
10) 1min. To conclude
management guidelines strictly in practice so as to
the topic.
prevent the complications, the important one being is
post partum haemorrhage.
 RESEARCH EVIDENCE
Optimising psychophysiology in third stage of labour:
theory applied to practice.
Hastie C, Fahy KM.
Author information
Abstract
BACKGROUND:
Active management of the third stage of labour is
routine in delivery suites. New South Wales (NSW)
Health has a policy which prescribes active
management because medically designed randomised
controlled trials have claimed a reduced blood loss in
third stage with active, compared with 'physiological',
management. In home and birth centre settings
however, physiological third stage is common as
women who access these settings prefer to labour
without medical intervention and midwives who work
in these settings adopt a holistic approach to working
with women. The holistic approach is
psychophysiological as the midwife engages with and
supports integration of the woman's spirit, mind and
body in her childbearing process.
PURPOSE:
To present midwifery theory that describes, explains
and predicts how women and midwives work together
to enable selected women to safely experience an
optimal psychophysiological third stage of labour.
METHOD:
Key terms are defined. The literature relevant to
psychophysiology and management of the third stage
 of labour is reviewed. An expanded understanding of
risk factors for postpartum haemorrhage is presented
and justified. A theoretical framework of Midwifery
Guardianship is presented and discussed and applied
to third stage care.
CONCLUSIONS:
A psychophysiological third stage is quite different
from what has been defined as 'physiological
management' in the medically designed randomised
trials comparing active versus physiological care. The
conditions for deciding if a particular woman, in a
particular context with a particular midwife is a good
candidate for a psychophysiological third stage are
presented and discussed. Only if all these conditions
are met it is safe to proceed with a psychophysiological
third stage. Research about the effectiveness of
midwifery care in a psychophysiological third stage of
labour urgently needs to be conducted.

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
%20at%20a%20physiological%20(expectant)%203rd%20stage%20of%20labour.pdf