This slide share talks about physiology and management of the third stage of labour in obstetrics.

1. 1
PHYSIOLOGY AND
MANAGEMENT OF
THE THIRD AND
FOURTH STAGES
OF LABOUR
Gifty Owusu
Department of Maternal and Child Health
School of Nursing and Midwifery
University of Cape Coast
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2. LESSON OBJECTIVES
By the
end of
the
session
the
student
will be
able to;
describe the physiological changes in the
third stage of labour.
demonstrate the active management of the
third stage of labour (delivery of the
placenta).
manage the client during the fourth stage of
labour.
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3. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR
It nvolves separation, descent, and expulsion
of placenta and membranes and the control
of haemorrhage from the placental site.
It is influenced by mechanical and
haemostatic factors.
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4. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
Mechanical Factors
• During the second stage of labour the uterine
cavity progressively empties, enabling the
retraction process to accelerate
• Placental site is diminished by 75%
4

5. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
Placenta becomes compressed & blood in the
intervillous spaces is forced back into the spongy
decidua basalis
Retraction of oblique uterine muscles exerts pressure
on the blood vessels
This prevents the return of blood to maternal
circulation
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6. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
The vessels become tense & congested
The next contraction results in bursting of the distended
veins and seeping of small amount of blood between the
spongy layer and placental surface causing separation.
As the surface area for placental attachment reduces ,
detachment begins
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7. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
Separation usually begins centrally so that a
retroplacental clot is formed exerting pressure at the
midpoint of the placental attachment & further aiding
separation towards the lateral borders as a result of its
increase in weight
The increased weight also helps to peel the membranes
off the uterine wall
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8. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
The clot formed becomes enclosed in a membranous
bag as the placenta descends with foetal surface first.
This method is called Schultze method
It is associated with more complete shearing of both
placenta and membranes and less blood loss
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9. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
Alternatively the placenta may begin to
detach unevenly at one of its lateral borders.
The blood escapes freely without a
retroplacental clot.
The placenta descends, slipping sideways,
with the maternal surface first.
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10. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
This process takes longer and is associated with ragged,
incomplete expulsion of the membranes and higher blood
loss
This process is called the Matthews Duncan method (dirty
Duncan method
Once separation occurs, uterus contracts strongly, forcing
placenta & membranes to fall into the LUS & into the
vagina.
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11. 11

12. THE DIFFERENCE BETWEEN THE TWO
METHODS OF SEPARATION
SHULTZE’S METHOD DUNCAN’S METHOD
The placenta is delivered like an
inverted umbrella . The foetal
surface comes first followed by
the membranes
The placenta slides down
sideways with maternal surface
first
A blood clot is formed behind the
placenta in a sac
Blood escapes freely and not in a sac
The membranes peel off
neatly and complete
The membranes are ragged and
part can easily be torn or retained
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13. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
Haemostasis
• The normal flow of blood through the
placental site (500-800ml/min) is
arrested within seconds of placental
separation to prevent serious bleeding
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14. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
Factors at play include;
• Retraction & thickening of oblique muscles
(living ligatures) exert pressure on the torn
vessels acting as clamps & securing a ligature
action.
• Vigorous uterine contraction following
separation brings the walls of the uterus into
apposition thus exerting further pressure on the
placental site.
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15. PHYSIOLOGICAL CHANGES IN THE
THIRD STAGE OF LABOUR CON’T
• Increase activation of coagulation and
fibrinolytic system.
• Clot formation in torn vessels are
intensified & the placental site is rapidly
covered by a fibrin mesh resulting in
achievement of haemostasis.
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16. MANAGEMENT OF THIRD STAGE OF
LABOUR
This stage is crucial and life threatening but the actions
of the midwife can help reduce risks of haemorrhage,
infection, retained placenta, and shock.
The position a mother adopts vary according to her
personal preference, the normality of progress,
confidence of the midwife and the need of the midwife
to monitor factors like uterine contractions and blood
loss
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17. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
Adoption of the dorsal position allows for easy
palpation of the uterus and assessment of the mother.
It also helps in effective contraction of the uterus.
The walls of the vagina are brought in apposition thus
preventing the risk of air embolism
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18. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
However blood is more likely to pool in the uterus and
the vagina, thus disguising the true blood loss
The upright positions may enhance the effect of
gravity and increase intra-abdominal pressure, which
may in turn hasten the placental delivery process.
Blood loss can easily be assessed as it drains out of the
vagina
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19. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
The general condition of the mother is assessed
especially the blood pressure, pulse , respiration and
colour.
Contractions and size of the uterus are observed ( the
uterus is 2.5cm below the umbilicus after delivery of the
baby,1.5cm above the umbilicus during separation and
4cm below the umbilicus after expulsion of the placenta.
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20. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
Ensure the bladder is empty , if not catheterize
Laceration and bruising of the cervix , vagina ,perineum
and vulva provide a route for the entry of micro-organisms
Additionally,the placental site with its raw surface provides
an ideal medium for infections
As a result of this, strict attention should be paid on
infection prevention
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21. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
The mother should be draped with a sterile towel
and the nurse with protective clothes.
The cut end of the cord attached to the placenta
should be placed in a sterile receiver to prevent
infection ascending into the uterus.
All procedures should be done according to
infection prevention strategies.
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22. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
The mother should be draped with a sterile towel and
the midwife/ nurse with protective clothes
The cut end of the cord attached to the placenta
should be placed in a sterile receiver to prevent
infection ascending into the uterus
All procedures should be done according to infection
prevention strategies
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23. MANAGEMENT OF THE THIRD STAGE
OF LABOUR
There are two types of the management
of the third stage of labour.
• Active management of the third stage
of labour.
• Passive management of the third stage
of labour.
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24. ACTIVE MANAGEMENT OF THE
THIRD STAGE OF LABOUR (AMTSL)
AMTSL involves four components.
•The use of oxytocic agent
•Delayed cord clamping
•Control cord traction (CCT)
•Control of bleeding
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25. PROCEDURE FOR AMTSL
Explain the procedure to the client.
Palpate the uterus to rule out the presence of a
second twin
Administer oxytocin 10 IU intramuscularly within 1
min of delivery of baby and after ruling out the
presence of another baby
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26. PROCEDURE FOR AMTSL CON’T
Ensure the bladder is empty.
Place cord clamp as near the vulva as
possible.
Check for uterine contraction by placing
the left hand on the fundus
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27. PROCEDURE FOR AMTSL CON’T
When the uterus is contracted, one hand is placed
above the level of the symphysis pubis with the palm
facing towards the umbilicus exerting pressure in an
upward direction. This is called counter-traction.
Deliver the placenta by control cord traction.
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28. PROCEDURE FOR AMTSL CON’T
Note that some resistance may be felt but it is
important to apply steady tension by pulling the cord
firmly and maintaining pressure.
Avoid jerky movement and the application of force to
prevent the cord been torn.
If the maneuver is not immediately successful pause
check uterine contraction again and make further
attempt.
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29. PROCEDURE FOR AMTSL CON’T
Once the placenta is visible , it may be cupped
in the hands to ease pressure on the friable
membranes
Gently move the cupped placenta upward and
downward or twisting to help coax out the
membranes and increase the chances of
delivering them intact
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30. PROCEDURE FOR AMTSL CON’T
Note the time of delivery of the placenta
Quickly have a look of the placenta and membranes
and place it in the receiver for examination later
Massage the uterus and remove all blood clots from
the uterus
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31. PROCEDURE FOR AMTSL CON’T
Examine the perineum for bleeding and laceration
Repair episiotomy/ laceration if any
Clean perineum and apply a clean pad
Clean the client and make her comfortable
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32. PROCEDURE FOR AMTSL CON’T
Examine placenta and estimate blood loss
Decontaminate all items used for delivery
Wash and dry hands
Record findings
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33. PASSIVE/ PHYSIOLOGICAL
MANAGEMENT OF THE THIRD STAGE
This method allows the physiological changes within
the uterus at the time of birth to take their natural
course with minimal intervention and normally
excluding the administration of oxytocic agents.
Signs of placental separation must be evident before
maternal effort can be used to expedite delivery.
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34. PASSIVE/ PHYSIOLOGICAL
MANAGEMENT OF THE THIRD STAGE
CON’T
This method takes from 20 mins to one hour to complete.
Assuming a sitting or squatting position by the mother at
this stage allows gravity to aid in expulsion.
If good uterine contraction are sustained, maternal effort
i.e. pushing as in 2nd stage, usually brings about expulsion
It is important for the midwife to monitor uterine
contraction by placing hand lightly on the fundus.
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35. PASSIVE/ PHYSIOLOGICAL
MANAGEMENT OF THE THIRD STAGE
CON’T
The mother should be encouraged as she might be
tired and contractions may feel weak.
The midwife should be vigilant since the longer the
placenta remains the greater the risk of haemorrhage.
Encourage the mother to initiate breastfeeding to help
release oxytocin for uterine contraction.
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36. SIGNS OF PLACENTAL
SEPARATION
Gushing out of small fresh blood
Elongation of the cord
The fundus becomes rounder , smaller and more
mobile
It can be palpated above or at the level of the
umbilicus
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37. PROCEDURE FOR AMTSL (IMAGES)
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41. 41

42. EXAMINATION OF PLACENTA
AND MEMBRANES
• This stage is not complete until the
placenta and membranes are
examined and found to be complete

43. REASONS FOR PLACENTAL
EXAMINATION
To determine whether all lobes are
intact.
To determine whether the membranes
are intact.
To identify the type of twins.
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44. REASONS FOR PLACENTAL
EXAMINATION CON’T
To determine whether blood vessels and cord
insertion are in their right place.
To know the weight of the placenta
To detect any pathological abnormalities e.g.
infarcts.
To identify congenital abnormalities e.g.
placenta bipartita
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45. REQUIREMENTS
Good source of light
Gloves
Flat surface
Receiver
Plastic apron
Cotton wool swabs in a gallipot
45

46. EXAMINATION OF THE
PLACENTA
EXAMINATION OF THE MEMBRANES
• The placenta is held by the cord as an
inverted umbrella and the membranes are
inspected to see if torn or retained
• Amnion should be peeled from chorion right
to the insertion of the umbilical on a flat
surface to help have a good view of the
membranes
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47. EXAMINATION OF THE
PLACENTA CON’T
INSPECTION OF THE MATERNAL SURFACE
• Remove blood clots to ensure a clear area and save
for measuring
• Check the surface for depression
• Feel the surface with palm to note gritty/grittiness
(due to deposition of the lime salts)
• Place the placenta on a flat surface or in the palm
with the maternal surface facing upward
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48. EXAMINATION OF THE PLACENTA
CON’T
• Make sure the lobes are intact by
ensuring they fit together without any
gaps with the edges forming a uniform
circle
• The colour of the maternal surface
should be dark-red.
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49. EXAMINATION OF THE PLACENTA
CON’T
INSPECTION OF FOETAL SURFACE
• Observe for position of the insertion of the cord
(mostly centrally located).
• Clean the cut end of the cord with cotton wool
swab and observe for 3 vessels (2 umbilical
arteries and 1 vein)
• Check the whaton’s jelly covering the vessels to
rule out knots or thickness
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50. EXAMINATION OF THE PLACENTA
CON’T
• Note the length of the cord (short/long);
average length is 45-50cm
• Observe for colour of the cord (bluish gray)
• After the examination, discard the placenta,
decontaminate items and document
findings.
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51. IMAGES OF THE PARTS OF THE
PLACENTA
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52. EXAMINATION OF THE GENITAL
TRACT
Explain procedure to the mother
Check the uterus for contraction. If not massage
the uterus and give oxytocics if needed
Quickly and gently clean the perineum with
antiseptic lotion
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53. EXAMINATION OF THE GENITAL
TRACT
Put a clean cloth under the woman
Gently separate the labia and Inspect the walls of
the vagina, the vulva and perineum for tears or
haematomas.
Repair laceration or episiotomy if any
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54. EXAMINATION OF THE GENITAL
TRACT
Thank client
Remove soiled dressing towels
Decontaminate items used
Wash and dry hands
Record findings
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55. RECORDINGS TO MAKE AFTER
DELIVERY IS COMPLETE
Type of delivery, time of delivery
Time placenta was expelled, Condition of placenta and
membranes after expulsion
The state of the perineum whether tears or cracks
Any episiotomy
Drugs given to mother
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56. RECORDINGS TO MAKE AFTER
DELIVERY IS COMPLETE
• Perinium if sutured or not
• Condition of the baby at birth, any
resuscitation, if yes or no record.
• Weight of the baby
• Any abnormalities. Record the type of
abnormalities such as cleft lip(hare lip),
cleft palate, oligodactyly, polydactyl,
syndactyly etc.
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57. COMPLICATIONS OF THE THIRD
STAGE
Retained placenta
Postpartum haemorrhage
Uterine inversion
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58. MANAGEMENT OF THE FOURTH
STAGE OF LABOUR
It is the first 6 hours after delivery
of the placenta and membranes.
It involves continuous vigilant
observation of both mother and
baby to help detect deviation
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59. MONITORING VITAL SIGNS
The mother’s blood pressure, respiration
and pulse should be monitored every 15
minutes for the first hour.
Monitoring should continue every 30
minutes for the next 2 hours then every
hour for the subsequent 3 hours
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60. MONITORING VITAL SIGNS CON’T
Temperature can be done once in the 1st hour and continued 4
hourly.
It is not necessary to undertake observation of temperature
routinely for a woman who appear to be physically well and who
do not complain of any symptoms associated with infection.
However if there is complain of feeling unwell with flu-like
symptoms or any sign of possible infections, temperature should
be taken frequently and recorded for further investigations to be
made
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61. EXAMINATION OF THE UTERUS
The uterus should be palpated every 15
minutes for the first 2 hours to ensure
it remains firmly contracted.
Monitoring should continue every 30
minutes for the next 2 hour and hourly
for the last 2 hours in the fourth stage.
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62. On palpation of the uterus;
• The fundus should be located centrally and
should be slightly below the umbilicus.
• The uterus should feel firm under the palpating
hand.
• The uterus should not be tender during this
process.
• Although women may feel after pains, it should
be differentiated.
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63. VULVAL INSPECTION AND VAGINAL
BLOOD LOSS
Inspection of the vulva is done at
the time of the uterus.
The quantity ,colour ,consistency
and odour of blood loss should be
noted during inspection.
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64. VULVAL INSPECTION AND VAGINAL
BLOOD LOSS CONT
It is important to note the presence
of clots for it can be associated with
episodes of PPH.
Inspect vulva and the episiotomy
site for haematoma or abscess
formation.
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65. URINARY OUTPUT
The client should be encouraged to
empty the bladder frequently as full
bladder impedes uterine contraction.
This can lead to increased vaginal
blood loss.
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➢Read on the nutritional
needs of the mother and
pain relief during the
fourth stage of labour
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68. REFERENCE
Macdonald, S., & Johnson, G. (Eds.). (2017). Mayes' Midwifery E-
Book: Mayes' Midwifery E-Book. Elsevier Health Sciences
Marshall, E. J., & Raynor, D. M. (Eds.). (2020). Myles textbook for
midwives. Elsevier Health Sciences.
Verrals, S. (1998). Anatomy and Physiology Applied to Obstetrics.
New York: Churchill Livingstone.
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