The document discusses the third and fourth stages of labor. It defines the third stage as occurring from the birth of the baby until the delivery of the placenta. The placenta separates from the uterine wall either centrally or marginally. Active management of the third stage of labor (AMTSL) involves administering oxytocin after birth, clamping and cutting the umbilical cord, and controlled cord traction to deliver the placenta within 5 minutes to reduce bleeding risk. Complications of the third stage include postpartum hemorrhage.

1. 1
THIRD & FOURTH
STAGE OF LABOUR

2. OVERVIEW
• INTRODUCTION
• DEFINITION
• PHISIOLOGY
• SIGNS OF PLACENTAL EXPULSION
• CLINICAL COURSE OF 3 STAGE OF LABOUR
• EVENTS IN THIRD STAGE OF LABOUR
• MANAGEMENT OF 3RD STAGE OF LABOUR

3. 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

4. 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

5. 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
• 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

20. 20
Postpartum care : 10 Bs
• Blood pressure
• Bladder
• Bloody discharge
• Basket
• Bowel
• Breast engorgement
• Breast feeding
• Baby
• Blue
• Brain

21. THANK YOU

22. 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

23. 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

24. 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

25. 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

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

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

28. 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

29. 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

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

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

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

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

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

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

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

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

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

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

40. 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

41. 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