The third stage of labour involves the delivery of the placenta after childbirth. It typically lasts 10-20 minutes and involves signs of placental separation like lengthening of the umbilical cord. Controlled cord traction is the standard technique for placental delivery but if not successful within 20 minutes, manual removal is required. Complications can include postpartum hemorrhage, retained placenta, and inversion of the uterus. Postpartum hemorrhage is the leading cause of maternal mortality and morbidity, with uterine atony being the most common cause. Management involves uterine massage, oxytocic drugs, bladder catheterization, and other measures, with blood transfusion and surgery as a last resort.

1. 3rd stage of labour
Group 2

2. Definition of 3rd stage of labour
It starts after the delivery of the fetus ends by the
delivery of the placenta . Its duration is between
10-20 minutes in both primigravida and multipara.

3. Signs of separation of placenta
• lengthening of the cord protruding from the vulva.
• small gush of blood from the placental bed, which normally stops
quickly due to a retraction of the myometrial fibres.
• rising of the uterine fundus to above the umbilicus .
• the fundus becomes hard and globular compared to the broad, softer
fundus prior to separation.

4. Controlled cord traction (C C T):-
One hand is put on the supra pubic area to counter – act the uterus
while the other hand is pulling gently on the cord Never do that if
the uterus is not contracting. (Inversion of uterus).

5. This attempts can be started after the signs of separation of placental
appears and can be repeated every 2 - 3 minutes.
But if delivery of the placental is not achieved by the end of the 20
minutes by this technique manual removal of the placenta is done

6. COMPLICATIONS OF 3rd
STAGE
1-Postpartum haemorrhage
2-Retaind placenta
3-Inversion of the uterus

7. Postpartum haemorrhage
 it is bleeding from the birth canal after delivery of the fetus and should be
more than 500 ml.
 or bleeding accompanied by signs/symptoms of hypovolemia:
↓ blood pressure (BP) and urine output
↑ pulse and respiratory rate
pallor, dizziness, or altered mental status
 Postpartum haemorrhage (PPH) is probably one of the most common
obstetric emergencies

8. • Primary PPH: Loss of 500 mL blood from the genital tract within 24 hours
of delivery
• Secondary PPH: Loss of 500 mL blood from the genital tract between 24
hours and 12 weeks post delivery
is considered to be :
minor if the blood loss is between 500 -1000mL
major if it is greater than 1000 mL

9. Aetiology
The causes of PPH can be remembered as the four ‘Ts’:
1.Tone Uterine atony
2.Tissue Retained placenta and/or membranes
3.Trauma Injury to vagina, perineum and uterine tears at
Caesarean section
4.Thrombin Clotting disorders

10. Risk factors for postpartum haemorrhage
Maternal;
 Raised maternal age
 Primiparity
 Grand multiparity
 Uterine fi broids
 Previous caesarean
 Bleeding disorders
 Obesity
 Antepartum haemorrhage
 Previous PPH

11. Intrapartum
 Prolonged labour
 Caesarean section
 Instrumental delivery
 Pyrexia in labour
 Episiotomy

12. Fetal factors
Large baby
Shoulde rdystocia
multiple pregnancy
polyhydramniuos

13. management of PPH
• In practice, diagnosis and management of PPH
occur simultaneously.
• The structured ABC approach outlined should be instituted

14. 1.Since uterine atony is the most common cause, the uterus should be
massaged to encourage contraction and
2.oxytocics given (oxytocin or Syntometrine) and an infusion of
oxytocinThe(40 IU in 500 mL saline over 4 hours) ergometrine, or
misoprostol.

15. • Nowadays the days of active management of labour, ergometrine is given
1.v at the delivery of the anterior shoulder; hence C.C.T is recommended
as active procedure before the cx close up on the placental.

16. Ergometrine in the 3rd stage of labour:
• Ergometrine is life-saving drug-
• 0.5mg of ergometrine is given I.M after the delivering of the head of the
fetus The ut will start to contract within minutes and full effect after
7minutes and it lowers the hemorrhage.

17. • also ergometrine can be given I.V at the ant shoulder delivery.
• Here ergometrine works in 40.secs.
• Syntometrine (0.5 mg ergometrine and 5units of syntocinon) I.M it works
within 2.5min.

18. Side effects of ergometrine
1. Headache.
2. Nausea and vomiting

19. Contraindications
1.PIH.
2. Hypertension.
3. Migraine.
4 . Mitral stenosis

20. Misoprostol tab 800Mcg rectaly

21. 3..The bladder should be catheterized as an empty bladder aids uterine
contraction.
4.vaginal examination should be conducted to expel clots which will prevent
contraction of the uterus and assess for genital tract trauma

22. 5.The placenta should be delivered if retained and inspected.
6.If bleeding continues, the patient should be transferred to theatre to allow a
further thorough examination under anaesthesia
(vaginal,cervical tears ,episiotomy)

23. •
7.laparotomy for bilateral iliac artery ligation, uterine compression sutures,
and, as a last resort, hysterectomy

24. • Massive PPH will require correction of clotting factors using fresh frozen
plasma, platelets and cryoprecipitate.

25. Secondary P. P. H:
This is bleeding which occurs after an interval of 24 hrs. or more following the birth of the child .
Causes :
1.Retained product of conception e.g. cotyledon a large blood clot (
2.sup mucous fibroid
3. infection
4.Choriocarcinoma

26. Management
- Admit
- i.v. line
- Hb and blood for grouping and Rh and cross match blood
- Give ergametrine
- Evacuation _ perforation of uterus is a complication. Send for H.P. to exclude choriocarcinoma
- Give antibiotics

27. Inversion of the uterus
Types:-
1- Acute
2- Chronic
The acute type is the serious complication and considered to be an emergency
- Incidence: Rare reports in the literature
- Estimate 1:17.000 – 1: 200.000

28. • Degrees of inversions:-
• There are 3 degrees of uterus inversion :-
• 1st degree: which is likely to be missed : in that in which the fundus is turning itself inside
out but does not herniate through the level of the internal OS.
2rd degree: the fundus passes through
•

29. • the internal OS and lies within the vagina
3rd degree: the entire uterus is turned inside out and hangs outside the
vulva taking much of the Vagina with it .

30. Causes:
1.Mismanagement of the 3rd stage of labour
2.The insertion of the placenta into the fundus is a factor for inversion
3. Atony of the uterus .a hard well contracted uterus doesn’t invert .

31. • (A) The Inversion occurs , if any pull on the cord to Deliver the placenta while the
uterus is atonic .
• (B) If one push on the fundus of the UT to expel a clot ,while the UT is still atonic.
• (C) Also short cord might initiate inversion during the second stage of lab our

32. Risk of inversion :
1. Shook : usually severe and comes quickly and acute inversion of UT is a diagnosis of post partum collapse .
2. Haemmorhage .
3. Latent Purepenal sepsis .
4. Shock lead to anurea and Sheehan’s syndrome.
5. death in patient if patient not managed properly

33. Symptoms:
1.Severe lower abdominal pain
2. sesatian of beaning down .
but usually the pt. is too ill to mention that
signs :

34. on Abd exam: the fundus of the UT might not be found on palpation or found but to be dipped
down (cupped)
vaginal examination :
- inspection: in the 3rd stage of inversion . UT would be seen
- In 1st and 2nd through P.V UT will be felt

35. Treatment :
-Immediate replacement of the uterus without attempting to remove the
placenta from The
.
inverted fundus unless
- to reduce the mass
- already separated

36. • 2- If the pt. is already shocked , then 1st treat shock
1. morphine
2. i.v. drip
3. blood transfusion

37. Replacement of the inversion :
-Any delay in replacing the inverted ut, will cause more tightening of the cervical ring.
the cervical ring.
- underG.A the UT is replaced by manual of digital pressure . once the ut in corrected
ergometrin is given I.V.

38. Sullivan hydraulic method
If the above method failed , the intravaginal hydraulic pressure is used .
Surgical :
This usually resorted to if the a/m method failed the failure is due to tightening up
the CXring

39. Vaginal approach
Ant. Incision if the CX alter disecting the bladder ...........
Post incision (Spinelli ) (Kustner )
Abdominal approach
Incision the cx post .(hauttain method )