The document summarizes the third stage of labor and delivery of the placenta. It describes: - The third stage begins after delivery of the fetus and lasts until delivery of the placenta, usually 10-15 minutes. - There are two mechanisms of placental separation - central (Schultze) and edge (Duncan) separation. Signs that the placenta has separated from the uterus include the Kustner, Alfeld and Schroeder signs. - Methods for delivering the placenta include having the mother push, or using external techniques like the Baier, Genter, or Crede's method which apply pressure to the uterus to express the placenta.

2. Third stage of labor
• When the fetus has been delivered, the third—placental—stage of labor
begins; it lasts until the placenta is expelled. The placental stage lasts 10–15
minutes on average; it should not be protracted by more than 30 minutes.

3. • Mechanism of placenta separation Placenta separation begins in the centre
where a retroplacental hematoma develops, which promotes further
separation of the placenta
• Schultze mechanism
• Duncan mechanism)

4. Schultze mechanism)
• In central separation of the placenta there is no external hemorrhage, and
the retroplacental hematoma is delivered together with the placenta.

5. Duncan mechanism)
• Separation of the placenta can begin at its edge (Duncan mechanism), in this
case no retroplacental hematoma develops; however, each contraction
increases the area of placental separation. In this type of separation there is
vaginal bleeding once the separation process begins

6. Signs of placenta separation
• In certain cases the separated placenta can be retained. That is why it is
essential to know the signs indicating that the placenta has detached from the
uterus and is situated in its lower segment, in the cervix or vagina:
• Kustner sign
• Alfeld sign
• Schroeder sign

7. Kustner sign
• when the sharp of the hand is pressed over the symphysis pubis, the cord is
not pulled into the genital tract

8. Alfeld sign
• the detached placenta sinks to the lower uterine segment or vagina so that
the ligature or clamp placed on the cord when ligating it goes down;

9. Schroeder sign
• change in the shape of uterus or fundal height. Immediately upon delivery
of the fetus the uterus becomes oval and positions itself along the middle
line. The fundus is at the navel level. After placental separation the uterus
extends, shifts to the right, and the fundus rises to the right subcostal space.

10. • As administration of uterotonics at the end of the second and at the
beginning of the third stage of labor has become widespread practice,
Schroeder sign has lost its utility. Other signs of placenta separation were
proposed; however, they did not fi nd recognition in clinical practice
• Dovzhenko sign
• Strassman sign
• Klein sign

11. • Dovzhenko sign: retraction of the cord upon deep respiration indicates that
the placenta has not detached;
• Strassman sign: oscillating motions of blood in the placenta upon tapping
the uterus are transmitted along the cord if the placenta has not detached;
• Klein sign: upon pushing or slight pressing down on the uterus the cord
moves outside and does not retract if the placenta has detached.

12. Methods of delivery of placenta (afterbirth)
• f, according to all signs, placental separation has occurred, it should be
delivered at once: the patient is asked to push. Under the impact of
abdominal muscles the separated placenta is usually delivered without a
problem. If this technique fails, one resorts to delivery of the placenta by
external techniques.
• Baier method
• Genter method
• Crede’s method

13. Baier method
• Baier the abdominal wall is taken by both hands forming a longitudinal fold,
and the patient is asked to push. • The separated afterbirth is then easily
delivered due to a considerable increase in the intraabdominal pressure

14. Genter method:
• the fundus is brought to the middle line. The obstetrician stands at the
patient’s side facing her legs. The obstetrician clenches hands into fi sts and
places the dorsal surface of proximal phalanges at the fundus angles and
gradually presses on the fundus in the downside and inside direction. When
this technique is performed, the patient should not push

15. Crede’s method
• the uterus is brought to median position, applying gentle massage the
obstetrician induces uterine contractions. The fundus is grasped by 4 fi ngers
behind and the thumb in front to squeeze the placenta. After that the
placenta is expressed: the uterus is compressed in the anteroposterior
direction, and the fundus is pushed downwards and backwards along the
pelvic axis to expel the placenta

16. • There is another technique of membrane expression (Genter method). After
the placenta has been delivered, the patient is asked to bear down on her feet
and raise the pelvis. In this case the placenta hangs down, its weight making
the membranes detach and express.