This document discusses the management of the third stage of labor. It describes signs that the placenta is separating, including the uterus becoming more mobile. It recommends controlled cord traction using the Brandt-Andrews technique to deliver the placenta within 20 minutes to reduce blood loss. If the placenta is not delivered by this method, manual removal may be necessary, especially if there is morbid adherence of the placenta. An injection of syntometrine after delivery can also help reduce postpartum hemorrhage risk. The fundus and blood loss should be monitored after delivery to ensure no placenta fragments are retained.

1. MANAGEMENT OF THE
THIRD STAGE
Signs of the placental sepration
Irreversible lenghtening of the cord
Fundus of the uterus gloublar
Uterus become more mobile
Level of fundus rises after expulsion of the placenta from the upper segment
A bulge is sometimes visible above the symphysis pubis
Small gush of blood

2. • A hand gently laid up on abdominal wall
over the fundus to observe uterine activity
as the uterus hardens &softens with the
return of uterine contractions
• Secondly subsidiary signs of placental
separations
• Thirdly the most important reason the
fundus does not get lost

3. Delivery of the placenta
• Controlled cord traction (Brandt-andrews
technique)
• The uterus pushed upwards & backwards with
the flat of the left hand while the right hand
draws the cord downwards & backwards this has
the effect of straightening out the genital canal in
line with the pull on the placenta
• By this method,the third stage is appreciably
shortened &the total amount of blood lost is
much reduced
•

4. These attempts can be repeated every two or
three minutes only synchronously with complete
hardening of the uterus ,but if delivery of the
placenta if not achieved within 20 minutes by
this technique one must recognize the possibility
of manual removal of placenta
Controlled cord traction will not succeed if the
placenta is still attached to the uterine wall & this
is certainly true wherever there is morbid
adherence of the placenta , in such cases
nothing short of manual removal is likely to
succeed

5. • An intramuscular injection of syntometrine
(1ml containing 0.5mg ergometrine & 5
unit of synthetic oxytocin ) at the end of
the second stage reduces the risk of
postpartum haemorrhage

6. RETATION OF PLACENTAL
TISSUE
• Placenta & if it is found that a cotyledon or
a succenturiate lobe is missing the only
safe thing to do is to anaethetisethe
patient & explore the uterine cavity
• The possibility of a retained succenturiate
lobe will be indicated by the appearance of
torn vessels running up to the edge of the
rent in the membranes

7. • Before leaving the patient ,there for the
fundus should be examined and ensured
that it is well contracted
• The amount of blood appearing at the
vulva which is permissible should be no
more then sufficient to soak a pad in the
course of an hour or two any bleeding in
excess of this amount demands treatment

8. Active management of the third
stage of labour
• Good evidence shows that active
management of the third stage of lobour
provides abetter balance of benefits &
harms &