BSc (N) 2nd year

2. Placenta
 Human placenta develops from two sources
Fetal component- Chorionic frondosum
Maternal component- decidua basalis
 Placental development begins at 6 weeks and is
completed by 12 th week

3. Human placenta is
 Discoid in shape
 Haemochorial
 Deciduate

4. Placenta at Term- Gross Anatomy
 Fleshy
 Weight-500gm
 Diameter- 15-20 cm
 Thickness-2.5 cm
 Spongy to feel
 Occupies 30% of the uterine wall
 Two surfaces- Maternal and fetal
 4/5th of the placenta is of fetal origin and 1/5 is of
maternal origin

5. Fetal surface of the placenta
 Covered by smooth and
glistening amnion overlying
the chorion
 Umbilical cord is attached
at or near its centre
 Branches of the umbilical
vessels are visible beneath
the amnion as they radiate
from the insertion of the
cord

6. Maternal surface of the placenta
 Rough and spongy
 Maternal blood gives it
dull red colour
 Remanants of the
decidua basalis gives it
shaggy appearance
 Divided into 15-20
cotyledons by the septa

7. PLACENTAL SEPARATION
 At the beginning of the labour, the placental attachment
roughly corresponds to an area of 20cm in diameter.
There is no appreciable diminution of the surface area of
the placental attachment during first stage, there is
slight but progressive diminution of the area following
successive retraction, which attains its peak immediately
following the birth of the baby.
 After the birth of the baby,
the uterus measures about 20cm vertically and 10 cm
antero posteriorly, the shape becomes discoid. The wall
of the upper segment is much thickened while the thin
and flabby lower segment is thrown into folds. The cavity
is much reduced to accommodate only the after birth.

8. MECHANISM OF SEPERATION
 Marked retraction reduces effectively the surface area
at the placental site to about its half. But as the
placenta is inelastic, it cannot keep pace with such an
extent of diminution resulting in its bucking.
 A shearing force is instituted between the placenta
and the placental site which brings about its ultimate
separation. The plane of separation runs through deep
spongy layer of decidua basalis so that a variable
thickness of decidua covers the maternal surface of the
separated placenta.

9.  1 .Central separation: Detachment of placenta from its
uterine attachment starts at the centre resulting in
opening up of few uterine sinuses and accumulation of
blood behind the placenta. With increasing contraction,
more and more detachment occurs facilitated by weight
of the placenta and retro placental blood until whole of
the placenta gets detached.
 2 . Marginal separation: Separation starts at the
margin as it is mostly unsupported. With progressive
uterine contraction, more and more areas of the placenta
get separated. Marginal separation is found more
frequently.

10. Separation of the membranes
 The membranes which are attached loosely in the
active part are thrown into multiple folds. Those
attached to the lower segment are already separated
during its stretching. The separation is facilitated
partly by uterine contraction and mostly by weight of
the placenta as a descent down from the active part.
The membranes so separated carry with them
remnants of decidua Vera giving the outer surface of
the chorion its characteristics roughness.

11. EXPULSION OF PLACENTA
 After complete separation of the placenta it is force
down in to the flabby lower uterine segments or upper
part of the vagina by effective contraction and
retraction of the uterus.
 There after it is expelled out by either voluntary
contraction of abdominal muscles (bearing down
effort) or by manipulative procedure.

12. MECHANISM OF CONTROLL OF
BLEEDING
 After placental separation innumerable torn sinuses
which have free circulation of blood from uterine and
ovarian vessels have to be obliterated. The occlusion is
effected by complete retraction where by arterioles, as
they pass tortuously through the interlacing
intermediate layer of the myometrium are literally
clamped. It is the principle mechanism to prevent
bleeding. Apposition of the walls of the uterus
following expulsion of the placenta also contributes to
minimise blood loss.

14. CLINICAL COURSE OF THIRD STAGE
OF LABOUR
 Third stage includes separation, descent and expulsion
of the placenta with its membranes.
PAINS
 For a short time, the patient experiences no pain.
However, intermittent discomfort in the lower abdomen
reappears, corresponding with the uterine contractions.
BEFORE SEPARATION
 Per abdomen – Uterus become discoid in shape, firm in
feel and non-ballottable. Fundal height reaches slightly
below the umbilicus.
 Per vagina – There may be slight trickling of blood.
Length of the umbilical cord as visible from outside,
remains static.

15. AFTER SEPARATION
It takes about 5minutes in conventional management for the
placenta to separate.
 Per abdomen – Uterus becomes globular, firm and
ballottable. The fundal height is slightly raised as the
separated placenta comes down in the lower segment and
the contracted uterus rests on top of it. There may be slight
bulging in the suprapubic region due to distention of the
lower segment by the separated placenta.
 Per vagina – There may be slight gush of vaginal bleeding.
Permanent lengthening of the cord is established. These
can be elicited by pushing down the fundus when a length
of cord comes outside the vulva which remains permanent,
even after the pressure is released. Alternatively, on
suprapubic pressure upwards by fingers, there is no
indrawing of the cord and the same lies unchanged outside
the vulva.

16. EXPULSION OF PLACENTA AND
MEMBRANES
 The expulsion is achieved either by voluntary bearing
down efforts or more commonly aided by manipulative
procedure. The “after-birth” delivery is soon followed by
slight to moderate bleeding amounting to 100-250ml.
MATERNAL SIGNS
 There may be chills and occasional shivering. Slight
transient hypotension is not unusual
 When these signs have appeared the placenta is ready for
expression.
 The patient is asked to bear down while gentle traction is
made on the umbilical cord.
 If the patient is unable to bear down. Pressure is made
in the suprapubic region to expel the placenta.

17. SIGN OF PLACENTAL SEPARATION
Placental separation takes place within 3-5 min of the
end of the second stage. The signs suggesting that
detachment has taken place include:
 Gush of blood from the vagina
 Lengthening of the umbilical cord outside the vulva
 Rise of the uterine fundus in the abdomen as the
placenta passes from the uterus into the vagina and
the uterus becomes firm and globular.

18. ACTIVE MANAGEMENT OF THIRD
STAGE
 It has been common practice to give an intramuscular injection
of 0.5 mg ergometrine as the shoulders are being delivered or
immediately after the fetus has been completely expelled.
 Ergometrine causes a prolonged contraction of the uterus
without any retraction and as such is very effective in the control
of excessive bleeding in the third stage. Bleeding in excess of
500ml is considered abnormal.
 Ergometrine may cause a significant rise in blood pressure and
therefore should be used with caution in hypertensive patients it
may also cause nausea in some patient.
 Oxytocin may also be given by I/M or I/V injection with delivery
of the anterior shoulder, but its action is not as strong as that of
ergometrine.

19. Steps of AMTSL
 Check the uterus for the presence of a second baby.
 In less than one minute, administer a uterotonic
drug (a hormone-like chemical that makes the uterus
contract more powerfully).
 Apply controlled cord traction.
 After delivery of the placenta, immediately start
massaging the uterus.
 Examine the placenta to make sure it is complete and
none of it has been retained in the uterus.
 Examine the woman’s vagina, perineum and external
genitalia for lacerations and active bleeding.

20. How to do controlled cord traction
with counter-pressure
 Clamp the umbilical cord close to the perineum (once pulsation
of the blood vessels stops in the cord of a healthy newborn) and
hold the cord in one hand.
 Place the other hand just above the woman’s pubic bone and
stabilise the uterus by applying counter-pressure to the abdomen
during controlled cord traction.
 Keep slight tension on the cord and await a strong uterine
contraction (usually every 2–3 minutes).
 With the strong uterine contraction, encourage the mother to
push and very gently pull downward on the cord to deliver the
placenta. Continue to apply counter-pressure to the uterus.
 Between contractions, gently hold the cord and wait until the
uterus is well contracted again.
 With the next contraction, repeat controlled cord traction with
counter-pressure.
 If the placenta does not descend during 30–40 seconds of

21. Control Cord Traction

22. ADVANTAGES OF ACTIVE
MANAGEMENT
 The active management of the third stage minimizes
the blood loss significantly and shortens its duration
by half.
 Followed by control cord traction with uterine
contraction.
 The only disadvantage is a slight increase in the
incidence of retained placenta resulting in manual
removal

23. EXAMINATION OF THE PLACENTA
AND MEMBRANES
 The placenta and the membranes are washed in a bowl
of water to wash away the blood and clots. The maternal
surface is inspected first by the holding the placenta in
both hands.
 The surface of the placenta is grayish brown in colour,
covered by the decidual layer, any gaps indicate a missing
cotyledon. The membranes, chorion and the amnion is
now checked for completeness.
 It shows a round hole when the entire membranes have
been delivered. It is now examined for any abnormal
vessels, which may indicate the presence of a
succenturiate lobe of the placenta.

24. Placental abnormalities
Placenta succenturiata
(3%)
 One or more small lobe or
cotyledon of placenta may be
placed at a varying distance from
the main placental margin
 A leash of vessels connecting the
main to the small lobe traverse
through the membranes
 Accessory lobe is developed from
activated villi on the chorionic
laeve

25. Clinical significance-
If succenturiate lobe is retained following birth of
placenta it may lead to
PPH
Subinvolution
Uterine sepsis
Poly formation
Treatment- exploration of the uterus and removal of
the lobe

26. Circumvallate placenta
Development-
 Due to smaller chorionic
plate than the basal plate
 The chorionic plate does
not extend into the
placenta margin
 The amnion and chorion
are folded and rolled back
to form a ring leaving a rim
of uncovered placental
tissue

27. Morphology
 Fetal surface has a central
depressed zone surrounded by a
usually complete thickened
white ring made up of double
fold of amnion and chorion
 Branching vessels radiate from
the cord insertion upto ring only
 Area outside the ring is thicker,
elevated and rounded

28. Clinical significance
 There are more chances of –
 Miscarriage
 Hydrorrhoea gravidarum
 Antepartum haemorrhage
 Preterm delivery
 Fetal growth restriction
 Retained placenta or membrane

29. Placenta marginata
 A thin fibrous ring is present at the margin of the
chorionic plate where the fetal vessels appear to
terminate

30. Membranous placenta
 The whole of the chorion is covered by functioning
villi and thus placenta appears as thin membranous
structure on ultrasonography

31. Chorioangioma
 Are the most common benign tumors of the placenta
and are hamartomas of primitive chorionic
mesenchyme
 Small tumors may be asymptomatic but large tumors
may be associated with hydroamnios and antepartum
haemorrhage

32. EXAMINATION OF THE MOTHER
 The vulva, vagina and the perineum are inspected for
any injuries after careful cleaning with cotton swabs
soaked in antiseptic solution.
 The episiotomy is now sutured. The mother is kept in
the labour ward for an hour to observe the vital signs,
and guard against any abnormal vaginal bleeding.
 She is sent to the ward after a further examination to
ensure that the uterus is contracted and the vaginal
loss is normal.

33. Summarize the management of the
third stage:
 Third stage begins with the expulsion of the fetus and
ends when the placenta and membranes are delivered.
 The expulsion of the placenta and the membranes are
usually achieved by active intervention
 Intravenous ergometrine [0.5mg] may be given with the
delivery of the anterior shoulder or 10 unit Oxyctocin IM
at Buttocks of Mother .
 Controlled cord traction, after ensuring that the uterus is
contracted, to deliver the placenta.
 Inspect the placenta and membranes for completeness.
 Examine the patient for any injury to the birth canal and
watch for any abnormal vaginal bleeding
 If placenta not delivered within 15min arrange for
manual removal of the placenta.

34. FOURTH STAGE OF LABOR
 The first 1 to 2 hours after birth referred as the fourth
stage of labor in a crucial time for the mother and
newborn. During this period maternal organs start to
undergo readjustment to the non pregnant state, And
the function of the body system begin to stabilize.
 The nurse’s role during the fourth stage of labor is to
monitor the recovery of the new mother and infant
and to promptly identify and manage any deviation
from the normal process than may occurs.

35. ASSESSMENT
 Physical finding
 Vital sign
 Fundal Height
 Lochia estimation
 Pernieal Inspection
 Psychological
 Joy: sense of peace and excitement
 Excitement: wide awake, talkative, hungry and thirsty
 Attachment process begins

36. Vital sign
 Blood pressure is taken every 15 minutes
 Transient changes are secondary to decreased blood
volume after delivery
 Excitement may elevate BP
 How reading is often a late sign of blood loss.
 Pulse is checked every 15 minutes
 Low reading often compensate for decreases vascular bed
and decreased intra abdominal pressure
 Rapid pulse may indicate an increase in blood loss or
temperature elevation
 Temperature: slightly elevation is normal (1000 F or 37.80
C)as the result of dehydration and fatigue of labor.

37. Fundal Height
 Fundal Height checks: every 15 minutes
 Fundus is firm and well contracted
 Fundus is midway between umbilicus and symphsis after
delivery of placenta.
 Fundus rises slowly to the level of umbilicus during the
fist hour after placenta delivery

38. Lochia
 Lochia estimation: every 15 minutes
 Nature of flow
 Intermittent
 Trickle
 Clots
 Amount of flow: greater than 500 ml indicates postpartum
haemorrhage
 Character and odor of flow

39. Pernium
 Pernieal Inspection
 Intact
 Episiotomy laceration or both
 Check for(REHDDA) redness, edema, hematoma,
discharge, dehiscence, Alignment.
 Number of suture
 Clean

40. Psychological
 Psychological
 Joy: sense of peace and excitement
 Excitement: wide awake, talkative, hungry and thirsty
 Attachment process begins
 Mother inspect the newborn
 Mother wants to cuddle the infant and begin breastfeeding
 Mother feels the needs to “ let the world know”

41. NURSING MANAGEMENT
 Nursing Diagnosis: High risk for altered family
proces related to acceptance of newborn.
 Intervention:
 Provide for early infant contact
 Assist with early breast feeding
 Call attention to quiet, alert, state of infant
 Provide information about infant ability to see and hear
 Postpone eye prophylaxis

42. NURSING MANAGEMENT
 Nursing Diagnosis: Altered urinary elimination
related to process of labor and delivery
 Intervention:
 Encourage to take plenty of oral fluids
 Encourage emptying of bladder frequently
 Monitor fundal height
 Catheterize distended bladder if the client is unable to
void
 Monitor intake and output

43. NURSING MANAGEMENT
 Nursing Diagnosis: Pain related to early uterine
involution process or episiotomy
 Intervention:
 Assist with nonpharmacological method of relief
 Apply ice bag to soothe the perineum
 Supply a warm blanket if client is chilled
 Provide analgesic as ordered

44. NURSING MANAGEMENT
 Nursing Diagnosis: High risk for fluid volume deficit
related to fluid shift in early postpartum period or
fluid loss due labor process, blood loss sweating etc.
 Intervention:
 Monitor vital sign every 15 minute
 Administer I/V and oral fluids as indicate
 Monitor vaginal discharge for excessive bleeding
(further blood loss)
 Monitor fundal height and firmness

45. NURSING MANAGEMENT
 Nursing Diagnosis: High risk for infection related to
labor and delivery process
 Intervention:
 Use clean or strict aseptic technique as appropriate
 Apply sterile pad after delivery
 Clean the perineum area from front to back
 Inspect the perineal area for broken/ episiotomy/
laceration
 Emphasis good hand washing technique to client
 Monitor client pulse and temperature for any deviation.