3 stage of labour

rd
 Definition

The third stage of labour is the time from the

birth of the baby to the expulsion of the
placenta and membranes
Active management of the third stage
includes all of these three components
– routine use of uterotonic drugs
– early clamping and cutting of the cord
– controlled cord traction
Physiological management of the third stage
includes all of these three components:
– no routine use of uterotonic drugs

– no clamping of cord until pulsation has ceased

– delivery of the placenta by maternal effort.

 Prolonged third stage

• The third stage of labour is diagnosed

as prolonged if not completed within
30 minutes of the birth of the baby
with active management and
60 minutes with physiological
management.
 Observations in the third stage
of labour include
• general physical condition of parturient,
as shown by her colour, respiration and
her sense of well being
• vaginal blood loss
In addition, in the presence of haemorrhage,
retained placenta or maternal collapse,
frequent observations to assess the
need for resuscitation are required
• Active management of the third stage
is recommended, which includes the
use of oxytocin (10 international units
[IU] by intramuscular injection),
followed by early clamping and
cutting of the cord and controlled
cord traction
• Active management of the third stage
reduces the risk of maternal
haemorrhage and shortens the third
stage.
• Pulling the cord or palpating the uterus
should only be carried out after
administration of oxytocin as part of
active management.
• Changing from physiological management to
active management of the third stage is
indicated in case of:

1. Haemorrhage

2. Failure to deliver the placenta within 1 hour

• In the third stage of labour neither umbilical

oxytocin infusion nor prostaglandin should
be used routinely.
 Treatment of retained placenta

• Intravenous access should be secured

• Intravenous infusion of oxytocin should not be
used to assist the delivery of the placenta
• For women with a retained placenta oxytocin
injection into the umbilical vein with 20 IU of
oxytocin in 20 ml of saline is recommended,
followed by proximal clamping of the cord
• If manual removal of the placenta is

required, this must be carried out

under effective regional anaesthesia

(or general anaesthesia when

necessary)
• Women with risk factors for postpartum
haemorrhage should be advised to give birth in
a higher centre
Antenatal risk factors:
– previous retained placenta or postpartum haemorrhage
– maternal Hb level below 8.5 g/dl at onset of labour
– body mass index greater than 35 kg/m2
– grand multiparity (parity 4 or more)
– antepartum haemorrhage
– overdistention of the uterus (for example, multiple
pregnancy, polyhydramnios or macrosomia)
– existing uterine abnormalities
– low-lying placenta
– maternal age (35 years or older).
• Risk factors in labour:
– induction
– prolonged first, second or third stage of labour
– oxytocin use
– precipitate labour
– operative birth or caesarean section

The unit should have strategies in place in

order to respond quickly and appropriately
should a postpartum haemorrhage occur.
Management of postpartum haemorrhage

• Immediate treatment for postpartum

haemorrhage should include:
1. Mobilising extra hands/staff
2. uterine massage
3. intravenous fluids
4. uterotonics
• Treatment combinations for postpartum
haemorrhage might include repeat bolus
of oxytocin (intravenous), ergometrine
(intramuscular, or cautiously
intravenously), intramuscular oxytocin
with ergometrine (Syntometrine),
misoprostol, oxytocin infusion
(Syntocinon) or carboprost
(intramuscular)