MANAGEMENT OF 3RD STAGE OF LABOUR

1. R. Liangkiuwiliu
Assistant Professor

3.  Giving birth can be a vulnerable and painful
experience and every mother and her
companion deserve and have right to be
treated with dignity, kindness and respect.
 Fear of being mistreated might give the
reason for a woman not to seek skill care that
she needed in future.
 As health care professional it is your duty to
make labouring woman feel safe and
comfortable all time.

4.  Remember to communicate with respect and
listen to the questions and preferences and
explain medical procedure and what to aspect in
simple and clear language.
 Always respect her privacy
 Ask for permission before you do any
examination or procedure
 Always woman to have companion of her choice
during the labour and her stay in facility.
 Do not leave a labouring woman alone if you
have to leave make sure that someone stays with
her.

6.  Initial assessment:
 Pulse rate, BP, RR
 Look for pallor, jaundice, pedal oedema,
 Record height, weight
 Auscultate chest and CVS
 do breast examination
 Inspect abdominal scar or over distension,
measure fundal height and go for abdominal
examination
 Palpate for fetal presentation, lie, position,
engagement, descent of presenting part,
amount of AF, number of fetuses.

7.  Fell for uterine contraction and note down frequency,
duration, intensity
 Observe how woman is coping with labour
 Listen to FRS for 1 minute soon after the contraction
 If FRS is between 120 – 160 bpm, it means the fetus is
tolerating labour well
 If contraction present perform PV
 Take verbal consent and maintain privacy and explain
procedure woman to determine cervical dilatation,
effacement, confirm fetal presentation, position of fetal
head in relation to maternal pelvis.

9.  The latent first stage is not in active labour
which is characterized by painful, weak
uterine contraction associated with cervical
effacement and cervical dilatation less than
4cm.
 Progression may be slowed and may take
many hours.
 In every 1 hours monitor
 FHR (120-160bpm)
 Contraction: frequency, intensity, duration.

10.  Difficulty breathing
 Shock
 Per vaginal bleeding
 Convulsions
 Unconsciousness
 Raise in temperature
 Pulse and blood pressure

11.  Cervical dilatation
 Frequent vaginal examination increases the risk
of infection
 If after 8hrs there is no increase of intensity,
frequency or duration of contraction, the
membranes are no rupture and no progress in
cervical dilatation.
 Then ask woman to relax, advice her come or
send for you again when the pain or discomfort
increases or there is vaginal leaking or bleeding
and or membrane rupture.

12.  Consult the woman and companion about the
sign of active labour and danger signs and
welcome them back at any time.
 Some woman may need admission before
active labour starts and you must provide
them care and support in latent phase.
 Reassure and encourage her to be ambulatory
and take oral fluids.

17.  Woman is in active phase when she has
regular uterine contractions and with increase
intensity and duration.
 Cervix dilated at least 4cm
 If these two criteria is not achieve she is not
in active phase.
 Active phase usually does last more than 12
hrs and if woman gives birth for the first time
or more than 10 hrs in subsequent labour.

18.  If you wrongly diagnosed active labour too
early, you will increase the risk of
unnessacery and potentially harmful
intervention.
 Labour induction is not advice in routine
practices
 Never try to shorten labour with oxytocin or
rupturing of membrane if woman and fetus
are doing well
 The cervix continue dilating and labour is
within normal limits

19.  When the woman is in active labour, begins
labour care:
 Explain what to aspect and inform her
periodically and respectfully
 Monitor labour using the partogragh
 Document findings and note the time
 Good documentation helps timely decision
making and clinical outcome will be
improved
 What is not written in record is legally
considered to not have been done

20.  Every 30 minutes monitor: during active
phase
 Pulse rate
 Contraction: duration, intensity and
frequency
 Listen to FHR immediately after contraction
 Condition of membrane and vulva
 Colour of amniotic fluid at vulva

21.  Following need to be monitor every 4 hrs;
 PV for CD, decent of head or presenting
part
 Maternal temperature, PR, BP,
 Assess the woman stage of mind, mood and
behaviour
 Document your findings and provide care
accordingly

57. By the end of the session student will be able to
explain:
 second stage of labour
Mechanism of labour
describe the signs of imminent delivery
describe the evidence-based care of a woman
during the second stage of labour
Explain the steps for conducting normal
vaginal delivery

58.  Second stage of labour is the period of time
from full dilatation to birth of the baby.
 During which the woman has an involuntary
urge to push, as a result of expulsive
contractions and descent of the presenting
part of the foetus.
 Duration of second stage of labour varies
 Primi-gravidas: about hours
 Multigravidas:1/2 hours

59.  The mechanism of labour is the positional
movements that the foetus undergoes to
accommodate itself and moves down in the
maternal pelvis.

60.  Descent takes place throughout labour
 Whichever part leads and first meets the
resistance of the pelvic floor will rotate until
it comes under the symphysis pubis
 Whatever emerges from the pelvis will pivot
around the pubic bone.

62. 1. Descent:
 Descent occurs
throughout the labour
 Contraction and retraction
of uterine muscles exert
pressure on foetus
allowing it to descend.
 As foetus head engages
and descends it assumes
an occipito transverse
position
 In primigravida dsecends
starts in last weeks of
pregnancy.
 In multigravida, descend
and engagement occur
once labour begins.

63. 2. Flexion:
 With increased pressure
on the foetal axis,
increased flexion occurs
Foetal head flexes and
fetal chin is touching
fetal chest
 Engaging diameter
from sub-occipito-
frontal 10 cm, changes
to sub-occipito-
bregmatic which is 9.5
cm
 Occiput becomes the
leading part

64. 3. Internal rotation of
the head:
 During contractions,
occiput moves forward,
touches the pelvic floor,
rotates 1/8th of a circle
forward until it comes
under the symphysis
pubis
 This rotation causes a
slight twist in the neck
 Flexion is maintained
and suboccipito
bregmatic diameter, 9.5
cm distends the vaginal
orifice

65. 4.Crowning:
 The occiput slips
beneath the subpubic
arch and crowning
occurs
 Head no longer
recedes back
between contractions
 Widest transverse
diameter(biparietal)
is born

66. 5. Extension of the
head:
 Foetus head extends
pivoting on the sub
occipital region
around the pubic
bone
 Occiput escapes
under symphysis
pubis, the sinciput,
face and chin sweep
the perineum and the
head is born by
extension

67. 6. Restitution:
 With birth of head,
twist in the neck of
foetus is corrected by
slight untwisting
movement of head
 Occiput moves 1/8 of
circles towards the
side from which it
started
 With this movement,
shoulders lie in left
oblique diameter of
pelvis

68. 7. Internal rotation of the
shoulders and external
rotation of head:
 Internal rotation of
shoulders: Anterior shoulder
reaches and touches pelvic
floor first, rotates 1/8th of
circle forward and comes
under symphysis pubis (from
right to left)
 External rotation of head:
Simultaneously there is
external rotation of head by
1/8th of circle on the same
side of restitution and the
occiput lies laterally

69. 8. Lateral flexion:
 Anterior shoulder
escapes under
symphysis pubis, the
posterior shoulder
sweeps the
perineum and rest of
the body is born by
lateral flexion

70. Summary for second stage of labour:
 Mechanism of labour are the positional
movements that foetus undergoes to
accommodate itself to the maternal pelvis.
Main movements of foetus in an occipito-
anterior position are; descend, flexion, internal
rotation of head followed by extension of head,
restitution then delivery of anterior shoulder
followed by delivery of posterior shoulder and
delivery of the body by lateral flexion.

71. 1. vulva gaping
2. Thinned-out and bulging perineum
3. Anal pouting
4. Baby’s head is visible at the vulva
(crowning)

72.  Always be prepared for birth when a woman
enters the second stage of labour
 Check the delivery tray and items for newborn
care and resuscitation including bag and mask.
 Follow strict aseptic procedure: 6C’S
 Clean hands
 Clean surface
 Clean blade
 Clean cord tie
 Clean cord stamp
 Clean perineum

73.  A woman in the 2nd stage of labour need more
support and close monitoring
 Check the uterine contractions every ½ hourly
 Plot findings on partogragh
 Monitor FHR every 5minutes after each
contraction.
 Encourage the woman on her efforts

74.  Be vigilant for any emergency signs
 Shock
 Difficulty in breathing
 Vaginal bleeding
 Convulsions
 Unconsciousness
 Sudden cessation of pains
Immediate action and helps should be taken
if these signs appear in woman.

75.  The woman should be encouraged to empty
her bladder
 If it is full and unable to empty on her own,
catheterize and empty the bladder
 Women should be encouraged or allowed to
be mobile during labour
 Allow her to take a position which she finds
comfortable and easy to push
 Provide massage or application of warm
packs
 Bearing down: encourage woman to take a
deep breathe during a contraction and push
down

76.  Alternative birthing positions:
 Standing
 On hands and knees
 Squatting
 Half sitting
 Lying on her side

77.  Avoid the following harmful practices during
delivery:
 Do not apply fundal pressure
 No routine episiotomies
 Manipulate and stretch the perineum
 Manipulate baby’s head
 Do not suction routinely. Wipe baby’s face with
clean cloth if meconium present.

78.  Delivery of the head by placing one hand
gently on the fetal head as it advances with
the contraction
 Support the perineum with the pad
 Encourage woman to bear down only during
contractions.
 When the head is delivered, feel gently
around baby’s neck for the presence of
umbilical cord( if there is a loose cord slip it
over the baby’s head. If its tight clamp it at 2
places and cut in between)

79.  When the head is born allow it to rotate
naturally
 Gently pull the head downwards to deliver the
anterior shoulder and then lift upwards to
deliver the posterior shoulder.
 Then delivery of the rest of the body by lateral
flexion and immediately place on mothers
abdomen and note the time of birth

80. Summary for conduction of normal vaginal
delivery:
 Ensure availability of needed functional
equipment
 Encourage birth companion and teach them
 Encourage woman to take deep breaths during
contractions and bear down only when she feels
the urge for it
 Encourage alternative birthing positions of
women's choice
 Promote the physiological birthing
Never apply fundal pressure to facilitate pushing
the baby
 Perineal support helps prevent tears

81.  By the end of the session, learners will be
able to:
 Explain the thirds stage of labour
 Describe the signs of placental separation
 Describe the critical steps of AMTSL
 Explain the steps of placental examination
 Explain the 4th stage of labour and care of
women during this stage

82.  This stage is from birth of baby and ends
with complete expulsion of placenta and
membranes
 Duration is 15 minutes to half an hour
 Most important stage of labour
 Proper management is important to prevent
complications

83.  Natural process during third stage includes:
 Separation of placenta
 Descend of placenta
 Expulsion of placenta

84.  3 classic signs of separation of placenta from
uterus are:
 The uterus contract and rises
 The umbilical cord suddenly lengthens
 A gush of blood occurs.
After separation, placenta descends into lower
uterine segment and upper vaginal vault.

85. Expulsion of placenta:
1. Mathews Duncan
Mechanism:
 Separation starts at the
lower edge of placenta at
lateral border (20%)
 Maternal surface appears
first at vulva • Usually
accompanied by more
bleeding from placental
site

86. 2. Schultz Mechanism
 Placenta separates in
the center and folds
it on itself as it
descends into the
lower pole of uterus
(80%)
 Fetal surface
appears at vulva
with membranes
trailing behind

87. It includes:
1. Expectant managemen
2. Active management
Expectant management:
Following appearance of signs of placental
separation, spontaneous delivery of placenta is
awaited.
Expectant management is not encouraged now

88.  AMTS helps in expulsion of placenta and
reduction in blood loss to mother
 AMTS recommended for all deliveries and
consists of the three critical steps
 Administration of uterotonic drug(Inj. Oxytocin
of 10 IU, IM or Tab Misoprostol 600 micrograms,
oral)
 Controlled cord traction (CCT)
 Uterine massage
 Approximately 66% cases of PPH can be
prevented if AMTSL is done in all cases after
delivery

89. 1. Palpate mother’s abdomen to rule out the
presence of an additional baby
2. Administer inj. Oxytocin, 10 IU IM or tab.
Misoprostol 600 micrograms orally within
one minute of the delivery of the baby.
3. Check for uterine contractions. Uterus will
be hard and globular reaching up to or just
below the umbilicus
4. Re-clamp the cord close to the perineum

90. 5. Perform CCT during
contraction, by
placing one hand on
lower abdomen (just
above the pubic
symphysis) to
support the uterus
(counter-tractiona)
and gently pulling
the clamped cord
with the other hand
until the placenta
and membranes
delivered
appropriately

91. 6. As the placenta delivers, hold it with both
hands cupped (prevent tearing of the
membranes) and twisting it clockwise to strip
the membranes out completely.
7. Perform uterine massage with a cupped palm
until uterus is contracted
8. Examine the placenta (maternal/fetal surface),
membranes and umbilical cord
9.Examine vagina, labia and perineum for tears.
If found, provide appropriate care

95.  This is first two hours after the delivery of
placenta
 Also called stage of recovery
 In this stage mother is kept under
observational care
 Avoid separating mother and baby

96. Care of women includes:
 Clean the perineum, give her a pad, make her
comfortable
 Assess the mother and monitor the following
every 15minute within first 2hours
o Maternal vital signs
o Uterine contractibility: check fundus to
ensure its contraction.
o Bleeding

97.  AMTSL is recommended over expectant
management.
 AMTSL should be initiated within 1 min of
child birth
 Inj. oxytocin 10 IU is given IM, CCT with
counter traction should be done gently during
contractions
 Uterine massage helps uterus to contract and
prevent PPH
 Observe the woman upto 2 hours after
delivery