Third stage of labour

Signs of placental separation

• Ballotable uterus,
• gush of blood,
• lengthening of the umbilical cord,
• anterior-cephalad movement of the uterine fundus,
• Uterus becomes firmer and globular after the placenta detaches.
• Supra pubic bulge

06/17/2023 B.K, MD, MPH, MFM 2

 Events in third stage of labor
• Phase of placental separation and expulsion
Two types of placental separation
1. Central separation (Schultze): Retroplacental clot
 Blood loss is less
 No gush of blood before placenta delivery
 Fetal side comes fisrt
2. Marginal separation (Mathews-Duncan): separation starts at the
margin
 Blood loss is more
 Maternal side comes first
- Found frequently.
 Mechanism of placental separation:
•  Myometrial thickening after delivery of the infant leads to
• substantial reduction in uterine surface area, resulting in
• shearing forces at the placental attachment site and placental separation.

• This process generally begins at the lower pole of the placental margin
and progresses along adjacent sites of placental attachment. A "wave of
separation" spreads upwards so that the uppermost part of the
placenta detaches last

06/17/2023 B.K, MD, MPH, MFM 5

Cont…

•  Placental expulsion follows separation as a result of a

combination of events
1. spontaneous uterine contractions,
2. downward pressure from the developing retroplacental
hematoma,
3. an increase in maternal intraabdominal pressure
06/17/2023 B.K, MD, MPH, MFM 6
Duration of the third stage of labor
• The duration of the third stage of labor is important because
the prevalence of postpartum hemorrhage increases as the
duration lengthens 

• Gestational age is the major factor influencing the length of

the third stage: preterm deliveries are associated with a
longer third stage of labor than term deliveries

• Prolonged when greater than 30 min!

06/17/2023 B.K, MD, MPH, MFM 7
 Complications of third stage
• The major complications of the third stage of labor are:

• Hemorrhage
• Retained placenta
• Uterine inversion

06/17/2023 B.K, MD, MPH, MFM 8

Management
Two types

1. Physiological/ expectant
• by waiting for signs and symptoms of separation and with little
assistance.

2. Active:
use of uterotonics, controlled cord traction and uterine massage.
• the preferred approach to management of the third stage of labor.
Cont…
• care to avoid avulsion of the cord.

• Examination of placenta, membranes & cord

• Count the number of vessels in the cord.

BLOOD LOSS
• Average blood loss after vaginal delivery is 500-600ml.

06/17/2023 B.K, MD, MPH, MFM 10

Shortening the third stage
Types of placental delivery
1.Brandt-Andrews maneuver => an abdominal hand secures the uterine
fundus to prevent uterine inversion while the other hand exerts
sustained downward traction on the umbilical cord.

2. Crede’s maneuver => the cord is fixed with the lower hand while the
uterine fundus is secured and sustained upward traction is applied using
the abdominal hand.
 Examination of genitalia- The cervix, vagina, and
perineum
• The major risk factors for third and fourth degree perineal lacerations are
 nulliparity,
 operative delivery,
 episiotomy, and
 delivery of a large for gestational age infant

• Repair of lacerations 

• Transfer of the parturient

• Discarding and disinfecting the equipment's.

 Care of newborn:
- APGAR score at the 1st & 5th minutes

- Drying

- Avoid heat loss & covering with cotton clothes

- Label, anthropometric measurements

- Initiate breast feeding or other options

- Tetracycline (TTC) eye ointment & Vit. K administration

- If needed, neonatal resuscitation

 Partograph

• Early detection of abnormal labor and prevention of prolonged labour

► ↓maternal and perinatal morbidity and mortality

Intro…

• The partograph is the graphic recording of the progress of labour and

the salient condition of the mother and the fetus .

• It serves as an “early warning system” and assists in early decision to

transfer, augmentation and termination of labor.
 Components of the partograph

Part I : Fetal condition ( at the top )

Part II : Progress of labor ( at the middle )

Part III : Maternal condition ( at the bottom )

Advantages of partograph
• Prevention of prolonged labor

• Avoids unnecessary use of augmentation

• Hand over of patients

- More precise and fluent

- At a glance appreciation of preceding hours of labor

cont…
• Considerable educational value

- All interrelated variables of labor can be

seen on a single paper

• Low cost, feasible

• Improved out come of labor

Alert line
• The alert line drawn from 3 cm dilatation represents the
rate of dilatation of 1cm/hour
• Moving to the right of the alert line means referral to
hospital for extra vigilance
Action line
• The action line is drawn 4 hour to the right of the alert line
and parallel to it.
• This is the critical line at which specific management
decisions must be made at the hospital.
Number of contraction in ten minutes and duration of
each contraction in seconds

• Less than 20 seconds: 

• Between 20 and 40 seconds:

• More than 40 seconds:

Normal progress of labor in
partograph
 A. Active phase remains on or left of the alert line

• Do not augment with oxytocin if latent and active phases go normally

• Do not intervene unless complications develop
• Artificial rupture of membranes (ARM)
• No ARM in latent phase
• ARM at any time in active phase
B. Between alert and action lines

• In health center, the women must be transferred to a hospital with

facilities for cesarean section, unless the cervix is almost fully dilated
• Observe labor progress for short period before transfer
• Continue routine observations
• ARM may be performed if membranes are still intact
 C. At or beyond action line
• Conduct full medical assessment
• Consider intravenous infusion/bladder catheterization/analgesia
• Options
- Deliver by cesarean section if there is fetal distress or obstructed
labor
- Augment with oxytocin by intravenous infusion if there are no con-
traindications