Third stage of labor: Description, Physiology & Management

Description of third stage of labor

Third stage of labour is defined as the period between birth of the baby to complete expulsion of placenta and membranes. It is the shortest but most dangerous stage of labour since there is for postpartum haemorrhage, uterine inversion and rupture.

Physiology of third stage of Labour

This involves separation, descent, expulsion and control of haemorrhage. The time the placenta actually separates from the uterine wall varies. Separation may start during final expulsive contraction of the second stage or may remain attached some time. 

Third stage of labour lasts between 5 – 15 mins but up to 1 hour is still normal. It comprise of mechanical factors and control of haemorrhage (haemostasis)

Mechanical factors

  • Retraction of uterine muscle: during labour the uterine muscle contract and retract thereby shortening the uterine cavity. Retraction process speeds up during second stage due to emptying of uterine cavity
  • Reduction of placental surface area: By the beginning of third stage placental site has reduced by 75% due to reduction of the area
  • Compression of placenta: space reduction cause the placenta to become compressed forcing blood in the intervillous space into spongy layer of the decidua basalis
  • Oblique muscle layer retracts: this exerts pressure on blood vessels so that blood does not go back into the maternal system causing the veins to distend. This breaks causing blood to drain out in between septa of the spongy and placenta surface causing the placenta to separate and detach. This cause placenta to separate centrally known as Schultz method
  • If placenta starts separating laterally it is known as Matthew Duncan Method and is always associated with ragged and incomplete membranes and greater blood loss
  • Contraction of the uterus: immediately the placenta separates, the uterus contracts strongly to expel the placenta into the lower uterine segment and eventually passes through the vagina.
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Management of the third stage of labour

Placenta could be delivered using physiologic and active management of third stage of labour

Physiologic management or Expectant management

Routine administration of uterotonics is withheld. Signs of separation of cord are observed. 

  • The cord clamped after pulsation or when the mother requested
  • Placenta is delivered under gravity as the woman is encouraged to bear down
  • Uterotonics administered to stop haemorrhage that has occurred maintain consistency of the uterus
  • It is associated with more blood loss than active management of labour

Active management of Third stage of labour

The active management of Third stage of labour is discussed in three (3) steps

Step 1: Give oxytocin

Give oxytocin 10 I.U I.M within one minute of birth of the baby after checking for a second baby

Step2: Controlled cord traction to delivery of placenta

Step 3: Massaging the uterus and control of bleeding

Procedure for Active management of Third stage of labour

  • Palpate the uterus to ensure that there is no other baby
  • Give injection oxytocin 10 I.U I.M at delivery of the baby after confirming there is no other baby
  • Wait for 2 – 3 minutes for strong Uterine contraction to take place
  • Cut the cord
  • Roll the cord over the artery forcep to give a firm grip
  • Deliver the placenta by controlled cord traction
  • Guard the uterus: This is achieved by applying counter traction to prevent inversion as you deliver the placenta. Put the abdominal hand just above the Symphysis pubis, palm facing woman’s face and gently push the uterus upward
  • Hold the cord close to perineum with the other hand
  • With uterine contraction apply gentle cord traction with steady tension in a downward direction. 
  • Be patient: When the bulk of placenta is visible, release the cord and abdominal hand use to guard the uterus.
  • Deliver the placenta and membranes with both hands by turning placenta to make a “rope” of the membranes
  • Immediately after delivery of placenta rub the empty uterus for at least 15 seconds until it is contracted.
  • Inspect the placenta and membranes for completeness
  • Estimate blood loss.
  • Clean and check the woman for lacerations and other problems
  • Put the placenta in a plastic bucket containing decontamination solution for 10 minutes.
  • Dispose wastes appropriately
  • Clean the woman very well
  • Discontaminate the bed and the apron with chlorine (jik) solution
  • Remove gloves gently and appropriately and dispose
  • Wash hands thoroughly with soap and water.
  • Complete records appropriately.
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Advantages of Active management of Third stage of Labour

  • Prevents up to 60 percent of uterine atony (90% of postpartum) haemorrhage is caused by uterine atony
  • Decreases length of 3rd stage so placenta delivers in approximately 5 – 7 minutes
  • Decreases prolonged third stage. If a woman has prolonged third stage of labour (longer than 30 minutes) she has a 6 times greater chance of having PPH
  • Decreases average blood loss, especially important in woman who are anaemic
  • Decreases the number of cases of PPH
  • Decreases need for blood transfusion

STEP TO STEP IMMEDIATE CARE OF THE NEWBORN

  • At the delivery of the head wipe the nose and mouth, the eyes of the baby with clean gauze
  • Note the time the baby is born
  • Dry the baby by placing one cloth or delivery mat on the mother’s abdomen
  • Remove the wet cloth
  • Warm: after drying the baby completely provides warmth by covering the head with a hat. Place skin to skin with the mother and cover with dry cloth or soft dry blanket
  • Clearing of the airways (sunction): this is no longer routine for every child except if the baby is not breathing or not breathing well. If the baby needs suctioning , use bulb syringe or mucus extractor
  • Suction the mouth first before the nose to avoid the baby aspirating the mucus
  • Then suction the nose

Stimulation

The baby that is active does not need stimulation. Rough handling of newborn children should be discouraged. If the baby is not breathing. Stimulate the baby after suctioning by gently rubbing the back. Most babies start to breathe very well after stimulation. Handling a baby roughly like beating the back, turning upside down can cause injury to internal organs and brain

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Assess the Apgar Score at 1 minute and 5 minutes after delivery

  • Cut the cord: it is advisable to cut when the cord stops pulsating, usually between 2 -3 minutes. This allows most blood to flow to the baby instead of remaining in the placenta
  • Separate the baby from the mother by clamping the cord into two places, approximate 8 – 10 cm from the umbilicus
  • Apply gauze over the cord while cutting to avoid splay. The cord is later shortened to 2 – 3 cm after securely applying cord clamp

Apply Olive oil

This helps to maintain warmth. Clean off any blood stain on the baby’s skin. Do not remove vernix  caseosa because it also help to keep baby warm and will later be absorbed

Weigh the baby, measure height, length and head circumference

  • Dress up the baby and cover with a dry cloth or wet blanket and place near the mother
  • Apply identification band: an identification bracelet containing name of the mother, time of delivery, sex, weight, length, head circumference. This is fastened securely on baby’s arm or leg
  • Some hospital policy advocates put on identification band before cutting the cord
  • Ensure that breastfeeding is initiated within 30 minutes to 1 hour after delivery.

Complications of third stage of labour

 Final Notes