2nd 3rd and 4th

2. Starts with onset of true labour pain &
ends will full cervical dilatation
Begins with full dilatation of the cervix
and ends with the expuslion of the foetus.
:Includes separation,descent, & expulsion
of the placenta with its membrane.
Begins from delivery of placenta &
ends after 2hrs .

3.  Its average duration is 2hrs in primigravidae & 30 minutes in multiparae.
 PRINCIPLE:1.To assist in natural expulsion of the foetus
2.To prevent perineal injuries.
 Has two phases: 1. Propulsive
2. Expulsive

4. • Increasing intensity of uterine contractions
• Complete dilatation of the cervix
• Urge to push or defecate with descent of presenting part
• Bearing down efforts of mother.

5. Preparation for delivery
Monitoring
Conduction of Delivery
Immediate care of Newborn

6. • Universal precautions
• Sterile procedures
• Sterile Labour trolley

7. Check the labour trolley for all instruments & essential items
Baby care corner should be checked
Prepare & keep drugs needed during delivery 10 min prior
1. Inj Lignocaine 10ml 1%
2.Inj Pitocin 10IU for IM & 10 IU for IV
3.Tab Misoprost 600mcg
4. Diclofenac Suppository
5.Inj Tranexamic acid 1gm

8. • Once crowning occurs patient can be shifted to labour room

9. Never leave the woman alone
Bladder emptying
Assisting in position of her choice
Emotional and physical support
Pulse & BP every 15min and record
FHR every 15 min & immediately after contractions

10. • Toileting the external genitalia & inner side of thighs with cotton swabs
soaked in betadine solution
• One sterile sheet is placed beneath buttocks of patient,one over abdomen
& in each thighs

11. Leg cramps can be relieved by massaging the calf muscles,extending leg
and dorsiflexon of foot
Give assurance,advice & instruction to keep up the morale & to avail
maximum cooperation
Sponge the face with soaked towel
Provide oral fluids

12.  Delivery of head
 Delivery of shoulders
 Delivery of trunk

13. • Encourage patient for bearing down
efforts during uterine contractions
• When perineum is fully stretched &
threatens to tear,episiotomy is given
• Prevention of perineal tear by giving
adequate perineal support.

15. Spontaneous forcible delivery of head is to be avoided
Head is born by extension
Nursing responsibilities
Delivery by early extension is to be avoided
To deliver the head in between contractions.
Check the neck for any cord around the neck

16. CORD AROUND THE NECK
If the cord is around the neck,attempt to slip it over the babys head
If the cord is tight around the neck,doubly clamp & cut it before
unwinding it from around the neck

17.  Position hands on either side of head
and exert gentle force
Anterior Shoulder - downwards
Posterior Shoulder -upwards
 Trunk is delivered by Lateral
Flexion

20. CORD CUTTING & CLAMPING
• 2-3 cm from foetal abdomen
• Delay in clamping for 2-3 min or
till cessation of cord pulsation
facilitates transfer of 80-100ml of
blood
• Quick check of any abnormality in
cord vessels

21.  APGAR Score
 Thermoregulation
 Suctioning to clear the air passage
 Oxygen may be given if required
 Clamping & ligature of the cord
 Documenting urination/paasage of meconium
 Administering VIT K & Hep B Vaccine
 Prophylactic eyecare
 Promoting parent newborn bonding
 Quick check is made to detect any gross abnormality

23. Includes separation,descent & expulsion of the placenta with its
membrane.
Average 5-15 min--upto 30 min
Shorter in multi ,slightly longer in primi

24. Separation of placenta
Expulsion of placenta
Haemostasis
PRINCIPLE:
1.To ensure strict vigilance and to follow the management guidelines
strictly in practice so as to prevent complications

25. BEFORE PLACETAL
SEPARATION
AFTER SEPARATION DESCEND OF PLACENTA
PER ABDOMEN PER ABDOMEN  Sudden trickle or gush of blood
 Uterus becomes discoid in
shape,firm in feel and ballotable
 Uterus becomes globular,firm &
ballotable
 Lengthening of umbilical cord
 Fundal height reaches slightly
below the umbilicus
 Fundal height is slightly raised  Change in the shape of
uterus,globular
PER VAGINUM PER VAGINUM  Change in the position of uterus
 There may be slight trickling of
blood
 Slight gush of vaginal bleeding
 Length of umbilical cord as visible
from outside remains static
 Permanent lengthening of cord

26. 3RD STAGE
MGT
EXPECTANT ACTIVE

27. Look for 3 classic signs of placental separation
 Lengthening of U. cord
 A gush of blood from vagina signifying separation of placenta from uterine wall
 Change in shape of uterine fundus from discoid to globular with elevation of
fundal height
 Expulsion of placenta :20 minutes
 Massage the uterus
 Examination of placenta ,membranes, cord
 Inspect vulva, vagina & perineum

28. ACTIVE MANAGEMENT

29. DELIVERY OF THE BABY
INJ OXYTOCIN 10 IU IM & IV
INRL OVER 1-2HRS
CLAMP,DIVIDE & LIGATE THE
CORD
DELIVER PLACENTA BY
CONTROLLED CORD TRACTION
IF FAILS,MANUAL REMOVAL OF
PLACENTA

30. Examination of placenta ,membranes

31. • Also known as Modified Brandt Andrews Method
• Palmar surface of the fingers of left hand is placed above symphysis
pubis
• Body of uterus is lifted upward & backward towards umbilicus
• Umbilical cord is kept taut with right hand in steady tension
downward & backward direction holding the clamp
• this controlled traction is maintained until placenta appears at vulva.

32. • Most crucial
• Life threatening complications

33. FOURTH STAGE OF LABOUR
ASSESSMENT
Placental reminants
Episiotomy repair
uterus midline & firm
Vital signs

35. • The skill of midwife is to support the woman effectively,to guide her
& to enable her to accomplish her birth safely
• Precise assessment in each stage of labour is crucial to identify
deviation from normal course