1. PRACTICE TEACHING
ON
THIRD STAGE OF LABOUR
SUBMITTED TO:
Mrs.Vinitha Mam
(Professor)
SUBMITTED BY:
Deepali Sharma
M.Sc.Nursing (1st Year)
JINSAR ( 2011-12)
2. INTRODUCTION :
Third stage is the most crucial stage of
labour.
Third stage of labour is characterized by the
separation of the placenta and its explusion.
Third stage of labour lasts from the birth of
foetus until the placenta is delivered.
3. DEFINITION:
Third stage of labor is a stage
which begins after expulsion of
the fetus and ends with
expulsion of the placenta and
membranes.(after-births)
4. DURATION:
Its average duration is about 15-20
minutes in primigravidae and 5-10 min.
in multiparae.
The duration is however reduced to 5
minutes in active management.
5. Cont……………………………..
The duration of third stage of labor may
be as short as 3 to 5 minutes although
upto 30 minutes is considered within
normal limits.
The risk of hemorrhage increases as the
length of third stage increases.
6. EVENTS IN THIRD STAGE
OF LABOR
• The third stage of labour comprises the
phase of placental separation; its descent
to the lower segment and finally its
expulsion with the membranes.
7. - EVENTS ARE:-
Placental Separation
Separation of Membranes
Expulsion of placenta
Mechanism of control of bleeding
8. PLACENTAL SEPARATION:
Mechanism of separation
Progressive uterine retraction
Decrease in the area of placental
attachment
Inelastic placenta cannot keep in pace with
such diminution
Buckling and separation
9. Two ways of separation of
placenta
1) Central Separation
2) Marginal Separation
10. 1) Central separation (Schultze Method)
- detachment of placenta from its uterine
attachment starts at the centre.
2) Marginal separation (Duncan Method)
- separation starts at the margin.
- marginal separation is found more
frequently.
11.
12. SEPARATION OF
MEMBRANES :
- Separation is facilitated partly by uterine
contraction and
- mostly by weight of the placenta as it
descends down from the active part.
13. SIGNS OF PLACENTAL
SEPARATION:
Sudden trickle or gush of blood
Lengthening of the amount of umbilical
cord visible at the vaginal introitus.
Change in shape of uterus from discoid to
globular.
Change on the position of the uterus.
14. EXPULSION OF PLACENTA:
Placenta is expelled out either by:-
- Voluntary contraction of the abdominal
muscles
- manipulative procedures.
15. MECHANISM OF CONTROL
OF BLEEDING
Following separation of the placenta, bleeding
from the large torn maternal sinuses in the
placental site is controlled by:-
1. Contraction and retraction of uterus, action of
interlacing fibres constrict blood vessels running
through the myometrium.
16. 2. Pressure exerted on placental site by walls
of the uterus becomes firmly contracted,
with the walls in apposition, once placenta
and membranes have been delivered.
3. The blood clots at the placental site, in the
sinuses and torn blood vessels.
17.
18. CLINICAL COURSE OF
THIRD STAGE OF LABOUR
-Third stage includes separation, descent and
expulsion of placenta with its membranes.
Pains :For a short time patient experiences
no pain. However, intermittent discomfort
in the lower abdomen reappears,
corresponding with the uterine contractions
19. Before separation :
Per abdomen:
- Uterus becomes discoid in shape, firm in feel
and non-ballotable. Fundal height reaches
slightly below the umbilicus.
Per vaginam:
- There may be slight trickling of blood. Length
of the umbilical cord as visible from outside,
remains static.
20. After separation:-
It takes about 5 minutes in conventional
management for the placenta to separate.
Per Abdomen: Uterus becomes globular, firm and
ballottable.
-The fundal height is slightly raised as the separated
placenta comes down in the lower segment and
the contracted uterus rests on top of it.
-There may be slight bulging in the suprapubic
region due to distention of the lower segment by
the separated placenta.
21. Per vaginam:
There may be slight gush of vaginal bleeding.
Permanent lengthening of the cord is established.
This can be elicited by pushing down the fundus
when a length of cord comes outside the vulva
which remains permanent, even after the pressure
is released.
Alternatively, on suprapubic pressure upwards by
fingers, there is no in drawing of the cord and the
same lies unchanged outside the vulva.
22. EXPULSION OF PLACENTA AND
MEMBRANES:
The expulsion is achieved either by voluntary
bearing down efforts or more commonly aided
by manipulative procedure.
The after-birth delivery is soon followed by
slight to moderate bleeding amounting to 100-
250ml.
23.
24. MATERNAL SIGNS:
There may be chills and occassional
shivering.
Slight transient hypotension is not unusual.
25. MANAGEMENT OF 3RD
STAGE OF LABOR:
Third stage is the most crucial stage of
labour. Previously uneventful 1st and 2nd
stage can become abnormal within a minute
with disastrous consequences.
26. PRINCIPLES UNDERLYING THE
MANAGEMMENT OF 3RD STAGE
OF LABOUR
To ensure strict vigilance.
To follow the management guidelines
strictly in practice so as to prevent the
complications(Important one:PPH)
27. RULES OF MANAGEMENT:
Do not massage the uterus before placental
separation.
Do not pull the umbilical cord before the
placenta separates.
Do not try to deliver the placenta before its
complete separation.
Wait for the natural process to occur and do
not interfere.
28. STEPS OF MANAGEMENT:
Two methods of management are currently
in practice:-
EXPECTANT MANAGEMENT
(Traditional Method)
ACTIVE MANAGEMENT
29. EXPECTANT
MANAGEMENT:
Minimal assistance
Constant watch and never leave the mother alone
Catheterize if bladder is full.
Keep the hand over fundus to note the uterine
activity.
Wait for spontaneous expulsion (if no bleeding
upto 10 minutes)
30. If fail to expel go for assisted expulsion.
Fundal pressure
Controlled cord traction(modified brandt
Andrews method)
Examine the placenta and membranes for their
completeness.
Inspect the vulva and perineum for injuries to be
repaired and episiotomy wound is sutured.
31. Clean the wound with antiseptic lotion
and keep sterile pads.
Maternal condition-check pulse, B.P,
behaviour of uterus and any abnormal
vaginal bleeding for one hour.
Send the mother to ward, if condition is
stable.
32. ACTIVE MANAGEMENT
UNDERLYING PRINCIPLE:
To excite powerful uterine contractions which
facilitates not only early separation of placenta
but produces effective uterine contractions
following its separation.
33. The three main components of AMTSL are:
1. Administration of a uterotonic agent within one
minute after the baby is born after ruling out the
presence of another baby (oxytocin is the uterotonic
of choice),
2. Controlled cord traction (CCT) with counter-
traction to the uterus during a uterine contraction.
3. Uterine massage immediately after delivery of the
placenta to help the uterus contract as well as to
assess uterine contraction.
34. ADVANTAGES:-
Minimizes the blood loss in 3rd stage to
approximately 1/5th .
Shortens the duration of 3rd stage to half.
DISADVANTAGES:-
Slight increased incidence of retained
placenta.
35. Procedure:
Inj. Ergometrine 0.25mg or Inj. Methergine 0.4mg is
given I/V following delivery of anterior shoulder.
Placental delivery by controlled cord traction after
delivery of baby availing 1st uterine contractions.
If it fails, Wait & repeat procedure after 2-3 minutes.
If it fails, Wait for 10minutes & repeat the procedure.
If it fails , go for MANUAL REMOVAL OF PLACENTA.
36. CONTROLLED CORD
TRACTION:
CCT helps the placenta to descent into the
vagina after it has separated from the
uterine wall and facilitates its delivery.
This manoeuvre is believed to reduce blood
loss , shorten the 3rd stage of labor and
therefore minimize the time during which the
mother is at risk from haemorrhage. It is
design to enhance the normal physiologic
process.
37. Note: CCT is not designed to separate the
placenta from the uterine wall but to
facilitate its expulsion only. If the birth
attendant keeps pulling on an
unseparated placenta, inversion of the
uterus may occur.
38.
39. If CCT is to be used, there are
several checks to be made before
proceeding:-
That a uterotonic drug has been
administered.
That it has been given time to act.
That the uterus is well contracted.
That counter-traction is applied.
That signs of placental separation and
descent are present.
43. The placenta develops from
two sources:
the chorion frondosum
( foetal origin)
and decidua basalis
( maternal origin).
Origin:
44. Anatomy At Term
Shape : discoid.
Diameter : 15-20 cm.
Weight : 500 gm.
Thickness: 2.5 cm at its center and
gradually tapers towards the periphery.
Position : in the upper uterine segment
(99.5%), either in the posterior surface
(2/3) or the anterior surface (1/3).
46. a. Foetal surface
Smooth, glistening and is covered by
the amnion which is reflected on the
cord. (outer chorion & inner amnion)
The umbilical cord is inserted near or
at the center of this surface and its
radiating branches can be seen
beneath the amnion.
47.
48. b. Maternal surface
Dull greyish red in colour and
is divided into 15-20
cotyledons.
Each cotyledon is formed of
the branches of one main
villus stem covered by decidua
basalis.
49.
50. FUNCTIONS OF PLACENTA:
(1) Respiratory function
(2) Nutritive function
(3) Excretory function
(4) Production of enzymes
(5) Barrier function
(6) Endocrine function
52. Structure: It consists of mesodermal connective
tissue called Wharton's jelly, covered by
amnion.
It contains:
1. One umbilical vein carries oxygenated blood
from the placenta to the foetus
2. Two umbilical arteries carry deoxygenated
blood from the foetus to the placenta,
3. Remnants of the yolk sac and allantois.
The Umbilical Cord
53. Here is a normal three vessel umbilical cord.
Note that there are two arteries toward the right and a
single vein at the left.
Most of the cord consists of a loose mesenchyme with
intercellular ground substance (Wharton's jelly).
54.
55. Insertion:
The cord is inserted in the foetal
surface of the placenta near the
center "eccentric insertion" (70%)
Or at the center "central insertion"
(30%).
The Umbilical Cord
60. PLACENTA BIPARTITE
The placenta consists of two equal parts
connected by membranes.
The umbilical cord is inserted in one lobe and
branches from its vessels cross the membranes
to the other lobe.
Rarely, the umbilical cord divides into two
branches, each supplies a lobe.
61. PLACENTA
SUCCENTURIATA:
The placenta consists of a large lobe and a smaller
one connecting together by membranes.
The umbilical cord is inserted into the large lobe
and branches of its vessels cross the membranes
to the small succenturiate (accessory) lobe.
65. PLACENTA FENESTRATA:
A gap is seen in the placenta covered by
membranes giving the appearance of a
window.
66. ABNORMAL DIAMETER
Placenta membranacea:
A great part of the chorion develops into
placental tissue.
The placenta is large, thin and may
measure 30-40 cm in diameter.
It may encroach on the lower uterine
segment i.e. placenta praevia.
69. In this gravid uterus, the placenta implanted over the os. This
is called placenta previa.
70. ABNORMAL ADHESION
Placenta Accreta:
The chorionic villi penetrate deeply into the
uterine wall to reach the myometrium,due
to deficient decidua basalis.
When the villi penetrate deeply into the
myometrium, it is called "placenta increta"
and
When they reach the peritoneal coat it is
called "placenta percreta".
74. Seen in placenta at term, mainly in hypertensive
states with pregnancy.
a. White infracts: due to excessive fibrin deposition.
(Normal placenta may contain white infracts in
which calcium deposition may occur).
b. Red infarcts : due to haemorrhage from the
maternal vessels of the decidua.
(Old red infarcts finally become white due to
fibrin deposition).
1- Placental Infarcts:
78. 1) Marginal insertion :-
- a condition in which the umbilical cord is
attached at the margin of the placenta. It
rarely occurs and does not affect placental
functioning. Also called battledore insertion.
(A) Abnormal cord insertion:
80. 2. Velamentous insertion
: Normally, the umbilical cord inserts into the
middle of the placenta as it develops.
In velamentous cord insertion, the umbilical cord
inserts into the fetal membranes (choriamniotic
membranes), then travels within the membranes to
the placenta (between the amnion and the chorion).
82. (B) Abnormal cord length:
1) Short cord which may lead to :
- Intrapartum haemorrhage due to premature
separation of placenta.
- Delayed descent of the fetus during labour
- Inversion of the uterus
83. 2) Long cord which may lead to:
- Cord presentation and cord prolapse
- Coiling of the cord around the neck.
- True knots of the cord.
84. (C) Knots of the cord:
1) True knot:
- When the foetus passes through a loop of the cord.
- If pulled tight, foetal asphyxia may result.
85. 2) False knot / Pseudoknot:
- Localized collection of wharton’s jelly containing a
loop of umbilical vessels.
86. (D) Torsion of the cord:
-May occur particularly in the position near the foetus
where the wharton’s jelly is less abundant.
88. (F) Single umbilical artery:
May be associated with other foetal congenital
anomalies.
89. COMPLICATIONS OF
THIRD STAGE OF LABOR
1) RETAINED PLACENTA:
-The placenta is said to be retained
when it is not expelled out even 30
minutes after the birth of the baby.
90. 2) POST-PARTUM
HAEMORRHAGE:
PPH is the loss of more than 500ml of
blood following delivery of baby.Most
bleeding comes from where the placenta
was attached to the uterus and is bright or
dark blood and usually thick.
91. Clinical definition of PPH:
Any amount of bleeding from or into the
genital tract following birth of the baby upto
the end of the puerperium which adversely
affects the general condition of the patient
evidenced by rise in pulse rate and falling
blood pressure is called PPH.
92. 3) UTERINE INVERSION:
It is an extremely rare but a life threatening
complication in 3rd stage in which the
uterus is turned inside out partially or
completely.
93. 4) UTERINE RUPTURE:
Dissolution in the continuity of the uterine
wall any time beyond 28wks of pregnancy
is called rupture of uterus.
94. 5) SHOCK:
Collapse resulting from acute peripheral
circulatory failure caused by ante-or
postpartum hemorrhage, uterine rupture or
inversion etc.
95. ALERT SIGNS IN 3RD STAGE
OF LABOR:
Observe for the signs of :-
Excessive blood loss, including:
Alteration in vital signs
Pallor
Light headache
Restlessness
Decreased urinary output
Alteration in level of consciousness and
orientation.
96. NURSING MANAGEMENT:
Following delivery of placenta, continue observation
of the fundus.
Ensure that fundus remains contracted.
Massaging the fundus gently will ensure that it
remains contracted.
Show the infant to the mother and allow her to hold
the infant.
Initiate lactation.
97. Record the following
information:-
Time the placenta is delivered.
How delivered( spontaneously or manually
removal by the physician)
Type, amount, time and route of administration of
oxytocin.Oxytocin is never administered prior to
delivery of the placenta because the strong uterine
contractions could harm the fetus.
If the placenta is delivered complete and intact or
in fragments.
98. Nursing Diagnosis:
1) Impaired tissue integrity related to
placental separation.
Nursing interventions:
-Ask the women to bear down gently.
-Observe for the signs of placental
separation.
-Evaluate the placenta for size , shape and
cord site implantation and intact cotyledons.
-Note any abnormalities of placenta and
cord present or not.
99. Nursing Diagnosis:
2) Risk for injury related to potential hemorrhage.
Nursing Interventions:
- Ensure accurate measurement of intake and output
maintained throughout labor and delivery.
- Immediately after delivery of placenta, administer
oxytocin either I/V or I/M as directed by facility
policy and provider.
- Immediately after initiating pitocin, massage
uterine fundus until firm.
- Check placenta and membranes for completeness.
- Evaluate vaginal bleeding.
100. Nursing Diagnosis:
3) Risk for deficient fluid volume related to blood
loss occuring after placental separation and
expulsion.
Nursing Interventions:
- Monitor fluid loss, vital signs; inspect skin turgor
and mucous membrane for dryness to evaluate
hydration status.
- Administer parenteral fluid or offer oral fluids as
per physician orders to maintain hydration.
- Monitor the fundus for firmness after placental
separation to ensure adequate contraction and
prevent further blood loss.
101. Nursing Diagnosis:
4) Anxiety related to occurrence of perineal trauma
and need for repair.
Nursing Interventions:
- Provide reassurance to the client.
- Explain procedure to the patient for the repair of
perineal trauma.
- Assess perineal area for deep tears and trauma.
-Give xylocaine at the trauma site then repair the
perineal trauma; so that the patient may not feel
anything.
-After suturing or repair, clean the area & apply pad.
- Instruct the patient to do perineal care regularly.
102. Nursing Diagnosis:
5) Fatigue related to energy expenditure associated
with childbirth and the bearing-down efforts of the
2nd stage of labor.
Nursing Interventions:
- Educate the mother and partner about the need for
rest & help them to plan strategies that allow
specific time for rest and sleep to ensure that women
can restore depleted energy levels in preparation for
caring for a new infant.
- Group care activities as much as possible to allow
for uninterrupted periods of rest.
- Provide noise free & dark room for mother to take
103. CONCLUSION:
Third stage of labor is a stage which begins after
expulsion of the fetus and ends with expulsion of the
placenta and membranes(After-births).
During third stage of labor, careful monitoring of
placental signs of separation and appropriate
management is necessary to avoid the
complications.
Enhancement of parent newborn relationship should
be initiated during this stage.
