1. THIRD STAGE OF LABOUR

2. DEFINITION
Third stage is that separation and expulsion of the placenta and membranes and also involves the control of bleeding

3. EVENTS IN THE THIRD STAGE OF LABOUR
Seperation and expulsion of the placenta
Interplay of mechanical and hemostatic factors
TIME
Last between 5 and 15 minutes

4. PHYSIOLOGY OF THIRD STAGE OF LABOUR/CONTROL OF HEMOSTASIS
Separation and descend of the placenta
Mechanical factors
Hemostasis

5. MECHANICAL FACTORS
Seperation of the placenta
Expulsion of the placenta

6. MECHANICAL FACTORS……Contd
PLACENTAL SEPERATION
1.Second stage uterine cavity empties
2.Enabling the retraction process to accelerate
(1 & 2)Placental site has already begun to diminish in size
Placenta becomes compressed
Blood in the intervillous space is forced back into the spongy layer of the decidua

7. MECHANICAL FACTORS…..Contd
Retraction of the oblique uterine muscle fibres exert pressure on the blood vessels so that the blood does not drain back into the maternal circulation
Vessels during this process become tense and congested
With the next contraction the distended veins burst and a small amount of blood seeps between the spongy layer and placental surface
Placenta strip from its attachment
Surface area of placental attachment reduces and begin to detach from the uterine wall

8. MECHANICAL FACTORS…..Contd
Retraction of the oblique uterine muscle fibres exert pressure on the blood vessels so that the blood does not drain back into the maternal circulation
Vessels during this process become tense and congested
With the next contraction the distended veins burst and a small amount of blood seeps between the spongy layer and placental surface
Placenta strip from its attachment
Surface area of placental attachment reduces and begin to detach from the uterine wall

11. MECHANICAL FACTORS……Contd
METHODS OF PLACENTAL SEPERATION
Schultze Method
Matthews Duncan

12. Schultze Method SEPERATION BEGINS CENTRALLY
Retroplacental clot is formed
Aids further seperation by exerting pressure at the midpoint of the placental attachment
Increased weight helps to strip the adherent lateral borders
Increased weight also helps to peel the membrane of the uterine wall
Clot formed becomes enclosed in the membranous bag
Placenta descends with fetal surface first
More complete shearing of both placenta and membrane
Less blood loss
Schultze Method

15. Matthew Duncan Method SEPERATION BEGINS LATERALLY
Detach unevenly at one of its lateral borders
Blood escapes so that seperation is unaided by the formation of a retroplacental clot
Placenta descends, slipping sideways
Maternal surface comes out first
Takes longer time
Associated with ragged, incomplete expulsion of the membranes
Higher fluid blood loss

16. TWO METHODS OF PLACENTAL SEPERATION

17. HAEMOSTASIS RETRACTION OF THE OBLIQUE UTERINE MUSCLE FIBER
PRESENCE OF VIGOROUS UTERINE CONTRACTION
ACTIVATION OF THE COAGULATION AND FIBRINOLYTIC SYSTEM

18. LIVING LIGATURE ACTION OF OBLIQUE UTERINE MUSCLES

19. MANAGEMENT OF THE THIRD STAGE OF LABOUR
Guard the uterus from massaging prior to placental seperation
Do not massage the uterus before placental expulsion except when partial seperation
Do not pull the umbilical cord before placenta separates
Do not try to deliver the placenta prior to its complete seperation unless in the emergency of third stage haemorrhage
Wait for the natural process to occur

20. DELIVERY OF THE PLACENTA AND MEMBRANE
Fundus is palpable below the umbilicus
Fundus feels broad as the placenta is still in the upper segment
SIGNS OF PLACENTAL SEPERATION

21. DELIVERY OF THE PLACENTA AND MEMBRANE……Contd
METHODS OF PLACENTAL DELIVERY
EXPECTANT MANAGEMENT
ASSISTED EXPULSION
Controlled cord traction (modified Brandt – Andrews method)
Expression by fundal pressure

22. EXPECTANT MANAGEMENT
Placental seperation and descent occur spontaneously
Mothers efforts are used to aid expulsion
Minimal assistance is given if mothers effort fails to deliver the placenta
Method can be practiced when mother has not received any anesthesia or oxytocic drugs at the delivery of the anterior shoulder

23. EXPECTANT MANAGEMENT STEPS OF THE PLACENTAL DELIVERY
A hand is placed over the fundus to feel for the signs of placental seperation
When the features of placental seperation and its descend into the lower segment are confirmed, the client asked to bear down simultaneously with the hardening of the uterus
As soon as the placenta passes through the introitus, it is grasped by both hands and twisted round and round or slightly up and down with gentle traction applied as the membranes are stripped off intact
If the membranes are threatened to tear, they are to be held by an artery forceps and gentle traction is applied to deliver the rest of the membranes

25. STEPS OF THE PLACENTAL DELIVERY
A hand is placed over the fundus to feel for the signs of placental seperation
When the features of placental seperation and its descend into the lower segment are confirmed, the client asked to bear down simultaneously with the hardening of the uterus
As soon as the placenta passes through the introitus, it is grasped by both hands and twisted round and round or slightly up and down with gentle traction applied as the membranes are stripped off intact
If the membranes are threatened to tear, they are to be held by an artery forceps and gentle traction is applied to deliver the rest of the membranes

26. ASSISTED EXPULSION
CONTROLLED CORD TRACTION (MODIFIED BRANDT – ANDREWS METHOD)
Several checks to be made before proceeding
An oxytocic drug has been administered
It has been given time to act
The uterus is well contracted
Counter traction is applied
The signs of placental seperation and descend are present

27. ASSISTED EXPULSION……Contd
METHODS OF CONTROLLED CORD TRACTION (MODIFIED BRANDT – ANDREWS METHOD)
The left hand is placed above the level of the symphysis pubis
Palmar surface facing toward the umbilicus to exert pressure in an upward direction
Body of the uterus is displaced upward towards the umbilicus with left hand
With the right hand a steady tension is given in a downward and backward direction following the line of birth canal by holding on the clamp placed on the cord at the vulva
It is important to apply a steady traction by pulling the cord firmly
There should be a pause before another contraction is palpated and further attempt is made

28. Controlled cord traction

29. ASSISTED EXPULSION……Contd
COMPLICATIONS OF CONTROLLED CORD TRACTION (MODIFIED BRANDT – ANDREWS METHOD)
Inversion of the uterus
Partial seperation of the placenta
Haemorrhage
Detachment of cord

30. ASSISTED EXPULSION……Contd
ADVANTAGES OF CONTROLLED CORD TRACTION (MODIFIED BRANDT – ANDREWS METHOD)
Reduced blood loss
Reduction in third stage of labour

31. ASSISTED EXPULSION EXPRESSION BY FUNDAL PRESSURE
Place four fingers of the hand behind the fundus and the thumb in front of the fundus to use as a piston
The uterus is made to contract by gentle rubbing
When the uterus is hard it is pushed downwards and backwards
The pressure is to be withdrawn as soon as the placenta passess through the introitus

32. USE OF OXYTOCIC AGENT TIME OF ADMINISTRATION
At the crowning of the baby’s head
At the delivery of the anterior shoulder
At the end of second stage of labour
Following the delivery of the placenta
PROPHYLACTIC USE
Prevention of post partum haemorrhage
Active management of third stage of labour
THERAPEUTIC USE
Ergometrine 0.5mg IM
Methergin 0.2mg IM

33. FUNDAL HEIGHT DURING THIRD STAGE
At the beginning fundus palpable below the umbilicus, feels broad as the placenta still in the upper segment
As the placenta separates, becomes rounder, smaller and more mobile as it rises in the abdomen to the level of umbilicus or just above the level of umbilicus
At the end of third stage fundus is about 4cm below the umbilicus

34. COMPLETION OF THE THIRD STAGE
Ensure that uterus is well contracted
Fresh blood loss is minimal
Inspection of the perineum and the lower vagina
Suture the episiotomy or any slight laceration
Change all the soiled linen
Cleanse the perineum
Application of sterile pad
Examination of the placenta membrane

37. ASSESSMENT OF THE PLACENTA
Infractions that are recent(bright red) or old(gray patches)
Localised calcification(flattened white plaques)
Lobes
Blood vessels
Insertion of the cord
Umbilical vessels
Cord length
Weight of the placenta

38. IMMEDIATE CARE OF BABY Well being and security
Cord clamp need to be checked
Warmth
Full neonatal assessment
Baby kept close to the mother
Breast feeding

39. IMMEDIATE CARE OF MOTHER
Cleansing the body
Mouth wash
Empty her bladder
Vital signs
Bleeding checked every 15 minutes