1. Third stage of labor: events &
management
Prophylaxis of PPH

2. Labor
• Physiological process
• The products of conception passed form uterus to
outside world
• Normal labour: spontaneous in onset, at term, vertex
presentation, natural termination without any
complications affecting health of mother &/or
newborn
• Three stages of labor

3. Stages of labour
• First stage : onset of true labour pains to full
dilatation of cervix
• Second stage: full dilatation of cervix to
expulsion of fetus from birth canal
• Third stage: after expulsion of fetus to
expulsion of placenta & membranes
(afterbirths)

4. Third stage: events
• After expulsion of fetus to expulsion of
placenta & membranes (afterbirths)
• Duration :15 min.(primigravida multigravida)
• AMTSL:5 minutes
• Placental separation
• Placental expulsion

5. Placental separation
• Sudden diminution in uterine size following
delivery of fetus
• Limited placental elasticity
• Creates disproportion between two
• Placenta buckles : placental separation
• Spongy layer of decidua basalis
• 2 ways : central, marginal separation

6. Methods of placental separation
Central ( Schultze) separation
Marginal (Mathews Duncan) separation

8. Expulsion of placenta
• Contraction & retraction of Upper Uterine
Segment
• Placenta forced to lie in LUS/upper vagina
• Voluntary contraction of abdominal muscles
• Expulsion of placenta

9. Mechanisms to control bleeding
1. Effective retraction of
uterine muscles :
Living ligatures
2. Thrombosis of torn
sinuses
3. Myotamponade:
apposition of walls of
the uterus

10. Management of third stage
• Most crucial stage
• Strict vigilance
• Follow protocols
• Expectant management
• Active management

11. Expectant management
• 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
• Spontaneous/Controlled cord traction (CCT)
• Expulsion of placenta :20 minutes

12. CCT
• Modified Brandt Andrews method
• Left hand: palmar surface of fingers placed above
pubic symphysis. Body of uterus pushed upwards
& backwards
• Right hand: cord traction in downward &
backward direction
• Uterus feels hard, contracted

13. Expectant management
• Massage the uterus
• Intramuscular Oxytocin : 10 IU
• Examination of placenta ,membranes, cord
• Inspect vulva, vagina & perineum

14. Examination of placenta ,membranes

15. Examination of membranes, cord

16. Active management
• AMTSL: Active Management of Third Stage of Labour
– Prophylactic uterotonic after delivery of baby
( Oxytocin 10 IU ,IM)
– cord clamping, cutting & Controlled cord traction
of U cord
– Uterine massage
• Excites powerful uterine contractions ,aid in early
placental separation, minimises blood loss &
duration of third stage (5 min.)

17. Third stage
• Most crucial
• Life threatening complications
• PPH(postpartum haemorrhage)
• Retained placenta
• Inversion of uterus
• Pulmonary embolism

18. Prophylaxis of PPH

19. PPH: hard facts
• Globally in 10-11% women having live births
• Duration between onset of massive bleeding
& death: 2 hours
• 14 million women worldwide
• 1.4 million women die annually
• India : 15-25% of maternal deaths due to PPH

20. stage Approximate
blood
loss(ml)
Volume
loss(%)
Signs & symptoms
0 <500 <10 none
ALERT LINE
1 500-1000 15 None/minimal
ACTION LINE
2 1000-1500 20-25 ↓ urine output,↑ PR,↑ RR,
postural hypotension,
narrow pulse pressure
3 1500-2000 30-35 Hypotension, tachycardia,
cold clammy extremities
,tachypnea
4 >2000 >40 Profound shock

21. PPH
• Primary PPH
– Haemorrhage <24 hrs of birth
• Secondary PPH
– Haemorrhage >24 hrs till 6 weeks of birth
• Primary PPH: 4T’s
– Tone
– Trauma
– Tissue
– Thrombosis

22. Primary PPH:causes

23. PPH : risk factors

24. Prophylaxis of PPH
• Improvement of health status of mother(Hb>11gm%)
• Identify high risk women
• Plan for institutional delivery /SBA
• Strict vigilance of all women in 3rd
stage labor
• Practice AMTSL in all
• Examination of afterbirths ,should be a routine
• Explore Uterovaginal canal following difficult/
instrumental, destructive delivery

25. WHO GUIDELINES FOR
PROPHYLAXIS OF PPH

26. WHO guidelines

27. WHO guidelines

28. WHO guidelines

29. WHO guidelines
• Give uterotonics routinely during 3rd
stage labor, in
all births
• Oxytocin 10 IU IM is drug of choice
• Use other uterotonics only when Oxytocin is not
available
• Late cord clamping( 1-3 min after birth) is
recommended
• Early cord clamping (<1min of birth): not
recommended until the neonate is asphyxiated &
needs immediate resuscitation

30. MCQ1
• Labor is said to be normal if all are present
except:
1.At term
2.Breech presentation
3.Spontaneous in onset
4.Healthy mother & neonate after delivery

31. MCQ1
• Labor is said to be normal if all are present
except:
1.At term
2.Breech presentation
3.Spontaneous in onset
4.Healthy mother & neonate after delivery

32. MCQ2
• Regarding the third stage of labor, following is
not true:
1.Most crucial stage of labor
2.Duration is 15 minutes
3.Uterine inversion is most common
complication
4.AMTSL is routine in all

33. MCQ2
• Regarding the third stage of labor, following is
not true:
1.Most crucial stage of labor
2.Duration is 15 minutes
3.Uterine inversion is most common
complication
4.AMTSL is routine in all

34. MCQ3
• The uterotonic of choice for prophylaxis of
PPH in third stage of labor is
1.Syntometrine
2.Oxytocin
3.Misoprostol
4.carboprost

35. MCQ3
• The uterotonic of choice for prophylaxis of
PPH in third stage of labor is
1.Syntometrine
2.Oxytocin
3.Misoprostol
4.carboprost

36. MCQ4
• All are true in relation to AMTSL except:
• 10 IU of Oxytocin , IM
• Uterine massage
• Reduces the duration of third stage
• Perform in only high risk cases

37. MCQ4
• All are true in relation to AMTSL except:
1.10 IU of Oxytocin , IM
2.Uterine massage
3.Reduces the duration of third stage
4.Perform in only high risk cases

38. MCQ5
• Complications during third stage of labor are
all except
1.PPH
2.Chronic Uterine inversion
3.Retained placenta
4.Amniotic fluid embolism

39. MCQ5
• Complications during third stage of labor are
all except
1.PPH
2.Chronic Uterine inversion
3.Retained placenta
4.Amniotic fluid embolism

40. MCQ6
• The most frequently observed method of
placental separation :
1.Marginal separation
2.Central separation
3.None
4.both

41. MCQ6
• The most frequently observed method of
placental separation :
1.Marginal separation
2.Central separation
3.None
4.both

42. MCQ7
• The most important method to control
uterine bleeding following delivery
1.Myotamponade
2.Thrombosis
3.Contraction& retraction of uterine muscle
4.none

43. MCQ7
• The most important method to control
uterine bleeding following delivery
1.Myotamponade
2.Thrombosis
3.Contraction& retraction of uterine muscle
4.none

44. MCQ8
• Following are true regarding misoprostol,
except
1.Low cost
2.Easy storage
3.Administered rectally
4.Drug of choice for AMTSL

45. MCQ8
• Following are true regarding misoprostol,
except
1.Low cost
2.Easy storage
3.Administered rectally
4.Drug of choice for AMTSL

46. MCQ9
• Following is true regarding Oxytocin
1.Given as IV bolus dose
2.Thermolabile
3.Contraindicated in cardiac patient
4.Causes hypertension

47. MCQ9
• Following is true regarding Oxytocin
1.Given as IV bolus dose
2.Thermolabile
3.Contraindicated in cardiac patient
4.Causes hypertension

48. MCQ10
• Prevention of PPH, all are true except
1.Treatment of anemia in antenatal period
2.Practice AMTSL in all
3.Home delivery in high risk cases
4.In forceps delivery, explore uterovaginal canal

49. MCQ10
• Prevention of PPH, all are true except
1.Treatment of anaemia in antenatal period
2.Practice AMTSL in all
3.Home delivery in high risk cases
4.In forceps delivery, explore uterovaginal canal