Undergraduate course lectuers in Obstetrics&Gynecology,Faculty of medicine ,Zagazig UNIVERSIRY ,Prepared by DR MANAL BEHERY

2. Defintion:
Defintion
3rd stage of labor: commences with
the delivery of the fetus and ends with
delivery of the placenta and its
attached membranes.
Duration:
- normally 5 to15 minutes.
- 30 minutes have been suggested if
there is no evidence of significant
bleeding.

3. Cause of placental separation
 After 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.

4. primary and secondary
mechanism for placental
separation

5.  Primary mechanism is the reduction in
surface area of placental site as the uterus
shrinks

6.  Secondary mechanism is the formation
of haematoma due to venous occlusion
and vascular rupture in the placental bed
caused by uterine contractions

7. Placental Site during
Separation

8. Methods of Placental
Separation

9. Schultze 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)

10. Duncan Method
 separation starts at the
lower 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.

11. Signs 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 ).

12. Assess the uterus
1-To exclude an undiagnosed
twin
2-To determine a baseline
fundal height
3-to detect the signs of placenta
separation
4- to detect an atonic uterus.

13. Control 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)

14. Management of the Third
Stage of Labour

15. Physiologic or Active

16. Active vs physiologic
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

17. Physiological Active
Placental By gravity and By controlled cord
delivery maternal effort traction with counter
traction on funds
Uterotonic after placenta delivery With birth of anterior
Shoulder
Uterus Assessment of size Assessment of size
and tone and tone
Cord Clamping Variable Early

18. Physiological Management
 Passive or expectant management
 No prophylactic
oxytocics
 Cord clamped after
delivery of placenta
 No Controlled Cord Traction (CCT)

19. Physiological Management
 Upright/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

20. Active Management
 Reduceslength 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 cut
 Placenta delivered by
 Controlled Cord Traction

21. Guarding the Uterus

22. Controlled cord traction

23. Placental delivery

24. Delivering the Membranes

25. Controlled Cord Traction
CHECKS 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?

26. Which is better active or physiologic
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.

27. Manual removal of retained
placenta

28. After Care: Before leaving to check
placenta and membranes
 Check the uterus is well contracted
 Check that PV loss is minimal
 Inspect perineum, vulva and vagina in good light
(? Repair)
 Babyshould be pink (respirations; heart rate)
warm, fed, cord clamp secure

29. check placenta and
membranes
for completeness
and normality

30. Abnormal placenta (accessory
lobe)
Succentriate
lobe

31. Effects of labor on the
mother

32.  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.

33. 3rd Stage
Blood loss from
 Placental site = 200-300 C.C due to
placental separation.
 Lacerations or episiotomy = about
100 - 200 C.C

34. Effects of labor on the
Fetus

35. Moulding
 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

36. Types & Degrees
 a. Physiological:
 "beneficial“ decreases
 the size of head &
 facilitates its passage
 through the birth canal.
 1. First degree:
 2. Second degree

37. Pathological : may lead to
intracranial 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

38. Caput Succedaneum:

39. Types
 A: Natural
 Cervical:
 with cervical dystocia.
 Pelvic:
 with obstructed labour
 usually formed in prolonged labour
 after rupture of membranes.

40. Cehalnematoma

41. Cehalhematoma(subperiosteal
hemorrhage

42. Thank You