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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 anteriorShoulder
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 given Why?
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.
CehalhematomaCehalhematoma
Cephalhematoma(subperiosteaCephalhematoma(subperiostealhemorrhagelhemorrhage
Thank You
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