THIRD STAGE OF LABOUR

Ruth Maithya
3rd Stage of labour
 Period from birth of the baby to complete
expulsion of the placenta and the membranes
 Involves separation, descent of the placenta & its
membranes & the control of bleeding from the
placental site
 Separation and expulsion of placenta is by both
mechanical and hemostatic factors
 3rd stage lasts 5-15 min (but normal up to 30
minutes)
 Separation of the placenta
Schultze’s mechanism(80%)
 The central area of the placenta separates first and placenta

is delivered like an inverted umbrella so the foetal surface

appears first followed by the membranes containing small
retro placental clot.
 There is less blood loss and less liability for retention of

fragments.
Duncan’s mechanism (20%)
 The lower edge of the placenta separates first and placenta

is delivered side ways.

 There is more liability of bleeding and retained fragments.
 Control of bleeding
3 factors promote control of bleeding:
 Retraction of the oblique muscle fiber in upper

segment.
 The thick muscles exert pressure on torn muscles acting as
natural ligatures
 Vigorous uterine contraction following separation
brigs the uterine walls into apposition
 Exerting pressure on placental site
 Achievement of hemostasis-activation of coagulation
and fibrinolytic system at the placental site
 Placental site is rapidly covered by a fibrin mesh
 Muscle fibers of the uterus
5
 Placental attachment to uterus showing maternal
blood vessels
6

Life Saving Skills Manual

for Midwives, Draft, 4th
Edition
 Placental separation from the
uterus
7

Empty
uterus

Life Saving Skills Manual for

Midwives, Draft, 4th Edition
Active Management of the 3rd stage of
labour (AMTSL)
Active management of third stage of labour
(AMTSL)

 AMTSL a preventive strategy for PPH

 Consists of interventions or actions by the skilled
birth provider in order to prevent PPH
Steps in the AMTSL
AMSTL steps
1. Palpate abdomen to rule out presence of another
baby
2. Give oxytocin 10 IU IM ( uterotonic drug) within
1 minute of childbirth.
 Promotes contraction of the uterus to expel the
placenta
 Oxytocinon IM 10 IU

12
AMTSL
3.Within 2-3 minutes clamp and cut the cord
 Delayed cutting improves baby’s iron stores
AMSTL steps
4.Await for a strong contraction
5. Deliver the placenta by controlled cord traction
(CCT) while applying counter traction above pubic
bone
Counter traction prevents uterine inversion
 If placenta does not descend, stop traction and await

next contraction
CCT with counter traction
 AMTSL Steps
16

 Massage the uterus

through the abdomen
after delivery of the
placenta to expel any
clots
Repeat every 15
minutes for 1 hour to
ascertain the uterus is
well contracted
 Examine the placenta & the membranes
17

 Examine the placenta and the membranes for completeness

 This ensures no tissue has been retained
 Hold the placenta by the cord and let the membranes hang
 Spread a hand inside the membranes to aid in inspection
 Piece membranes together to ensure there is no gap
 Lay the placenta on a flat surface
 Peel the amnion from the chorion up to to the cord and
view the chorion
 Remove any clots on maternal surface
Examine the placenta & the membranes

 Replace any broken fragments of the cotyledons to

ensure the placenta is complete
 Lobes of a complete placenta fit neatly
 The edges form a complete circle
 Blood vessels should not radiate beyond the edges
 Is so it may indicate a separate lobe (succenturiate
lobe)
 Estimate blood loss
 Soaked in linen, swabs, clots & measurable fluid
Examine the placenta & the membranes
20

 Inspect the lower

vagina and perineum
for lacerations
-Expel clots
 Repair any tears
 Monitor the woman closely after
21
delivery of the placenta
 During the first two hours after the delivery of the
placenta, monitor the woman at least every 15 minutes
(more often if needed) during the first hour after birth:
 Palpate the uterus to check for firmness
 Massage the uterus until firm
 Check for excessive vaginal bleeding
 Ask the woman to call for help if bleeding increases or her
uterus gets soft.
 If excessive bleeding is detected, take action to evaluate and
treat PPH immediately
 Monitor the newborn closely
22

 Check the baby at the same time you check the

mother every 15 minutes during the first two
hours after childbirth:
 Check the baby’s breathing.
 Check the baby’s color.
 Check warmth by feeling the baby’s feet.
 Check the cord for bleeding.
 Take immediate action if a problem is detected.
AMTSL

Egometrine Intramuscular injection:

 Acts within 6 to 7 minutes.

 Effect lasts 2 to 4 hours

 Affected by exposure to heat

Fourth Stage of Labor
 Fourth stage of labour
From delivery of placenta until 2 hours later
25

Mother:
• Initiate breastfeeding if not done

• Examine the placenta then dispose it in a correct, safe and

culturally appropriate manner

• Keep mother and baby warm

• Give mother a hot drink and encourage her to pass urine frequently

• Encourage to continue massaging uterus

• Ensure no excessive blood loss

• Observe mother closely during the 4th stage and advise her report

any problems
 Fourth stage (2)
26
Newborn:
 Observe the breathing rhythm (character) and heart beat (at apex)
 Ensure baby is warm and fed
 Ensure the cord is dry and not bleeding
 Wipe eyes and apply antimicrobial within one hour (1%
tetracycline eye ointment)
 Continue applying skin to skin contact with the mother
 Encourage mother to breastfeed where applicable
 Carry out first physical examination of the baby and take the
weight