Download Normal Labor – the third stage

Mother Initiative Tutorial
Normal labor:
The third stage –
physiological and active
management
Alison James Midwifery Lecturer
Margaret Fisher Associate Professor in Midwifery
Plymouth University and The Royal College of Midwives,
United Kingdom
This tutorial is designed to re-inforce previous training – and should,
therefore, not be regared as sufficient guidance by itself
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To find out more about the first and
second stages of labor, see the two
separate tutorials on these topics
Normal labor:
“The first stage” tutorial
describes labor progress and
maternal care until cervix is fully
dilated
Normal labor:
“The second stage” tutorial
describes the birth of the baby
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The third stage of labor
Third stage of labor
 Starts from when the baby
is born
Third stage of labor:
 Finishes when the placenta
(afterbirth) has come away from
the mother, and when her
bleeding stops
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Typical duration of the third stage
 The third stage of labor can
take 20-60 minutes and
sometimes longer if no
intervention is used and the
placenta delivers naturally
(physiological or expectant
management)
 If active management
(uterotonic and controlled cord
traction) is used the placenta
should be delivered within
5-30 minutes
Physiological Management
Active Management
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How the placenta separates from the womb
 This diagram shows what happens
when the placenta (afterbirth)
separates from the uterus (womb):
 Step 1 – The placenta is still
attached to the uterus
 Step 2 – The muscles in the uterus
tighten and clamp down on the blood
vessels, causing them to burst
(rupture), forcing the placenta off the
wall of the uterus.
 Step 3 – The placenta separates
from the uterus as the muscles
tighten more and a clot forms behind
the placenta (retroplacental clot).
Step 2
Step 1
Step 3
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Illustrating the third stage of labor
 After birth, the placenta at first
remains attached to the top of
the uterus
 Later the uterine muscles contract
tightly, expelling the placenta
 The lower picture shows the uterine
muscles tightly contracted, pushing
the placenta out. Note how the fundus
(top) of the uterus becomes rounder
and firmer and lower in the woman’s
abdomen as the placenta separates
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Skin-to-skin contact
 Place the baby in skin-to-skin
contact on the abdomen of the
mother, dry the baby, assess
the baby’s breathing and
perform resuscitation if
needed
 Cover the baby’s head with
a cloth or, preferably a
hat/bonnet
 Cover the woman and baby
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There are two alternative options for the
management of the third stage of labor
Option 1:
Physiological management
Physiological (expectant)
management – where contraction
of the uterus, separation of the
placenta
and delivery of the placenta and
membranes takes place naturally
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Physiological management (1)
 Clamp and cut the cord after
cord pulsations have ceased
 It is not necessary to clamp and
cut it until after the placenta
and membranes have been
fully delivered if the cord is long
enough for the baby to reach
the mother’s breast
 Cover the cord with a piece of
gauze when cutting the cord to
avoid splashing blood
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Physiological management (2)
 The mother may be
encouraged to stand, squat,
pass urine or breastfeed to
help this to happen. The cord
must NOT be pulled, but the
mother should be encouraged
to push the placenta and
membranes out.
Stand
Squat
Pass urine
Breastfeed
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There are two alternative options for the
management of the third stage of labor
Option 2:
Active management
Reason for considering the
active management of the third
stage of labour (AMTSL)
 This option is recommended to
reduce the risk of postpartum
haemorrhage but can only be
performed by a skilled birth
attendant and if the uterotonic
drugs are available
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Active management Step 1: Uterotonic
 Administer a uterotonic (oxytocin or
misoprostol) within 1 minute after the
baby’s birth and after ruling out the
presence of another baby (the uterotonic
of choice is oxytocin 10 IU IM)*
OR
 Give 600 μg of misoprostol by mouth within
1 minute after the baby’s birth and after
ruling out the presence of another baby
OR
 Give synometrine 1 ampoule IMI or
ergometrine 0.2mg IMI
* IM = intramuscular
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Active management Step 2:
Controlled cord traction (1)
 To perform controlled cord traction (CCT):
Place the clamp near the woman’s
perineum to make CCT easier. Hold the
cord close to the perineum using a clamp.
Place the palm of the other hand on the
lower abdomen just above the woman’s
pubic bone to assess for uterine
contractions. If a clamp is not available,
CCT can be applied by encircling the cord
around the hand
 When performing controlled cord traction,
at the same time, support the uterus by
applying external pressure on the uterus
in an upward direction towards the
woman’s head
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Active management Step 2:
Controlled cord traction (2)
 When there is a contraction, apply
external pressure on the uterus in an
upward direction (toward the woman’s
head) with the hand just above the pubic
bone. At the same time with your other
hand, pull with firm, steady tension on the
cord in a downward direction (follow the
direction of the birth canal).
 Avoid jerky or forceful pulling. Do not
release support on the uterus until the
placenta is visible at the vulva. Deliver the
placenta slowly and support it with both
hands
 Only release support of the uterus when
the placenta is visible at the vulva
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Active management Step 3:
Delivery of the Placenta
 As the placenta is delivered,
hold and gently turn it with both
hands until the membranes are
twisted
 Slowly pull to complete the
delivery
 Gently move membranes up
and down until delivered
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Massage
 Massage the uterus
immediately after delivery of the
placenta and membranes until
it is firm
 During recovery, assist the
woman to breastfeed if this is
her choice, monitor the
newborn and woman closely,
palpate the uterus through the
abdomen every 15 minutes for
2 hours to make sure it is firm
and monitor the amount of
vaginal bleeding. Provide
prevention of mother-to-child
transmission care as needed
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What else should the midwife do?
1.
Check that the mother’s uterus
stays firm – check this every 15
minutes for 2 hours and show the
mother how to do this too
2.
Check that the vaginal blood loss
is normal – it should not be
trickling or flowing and she should
not be passing clots.
3.
Check that the mother’s blood
pressure, pulse and temperature
are normal
See the tutorial ‘Postpartum hemorrhage’
for management if there are concerns.
The woman may need to be transferred
urgently to a place where medical aid is
available.
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What else should the midwife do?
4. Check the placenta to see if
it is complete. If there is a
piece missing, the woman will
need to be transferred to a
place where medical aid is
available. See tutorial on
‘Postpartum hemorrhage’
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What else should the midwife do?
5. Check the mother’s perineum
for labial, vaginal wall or
perineal tears.
If these involve the muscle (are
2nd degree tears or more) or
bleeding they should be sutured
as soon as possible
3rd and 4th degree tears
(involving the anal sphincter)
should only be sutured by a
highly skilled midwife or doctor
trained to do this
6. Check that the mother is able
to pass urine within 6 hours of
the birth
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Summary of third stage of labour
 It should not last more than
about 1 hour if physiological/
expectant management and
30 minutes if active
management (AMTSL)
 Vaginal blood loss should
not be more than 500 ml and
the mother should feel well.
If any concerns, see tutorial on
‘Postpartum haemorrhage’
 AMTSL with controlled cord
traction must only be performed
by a skilled birth attendant
 Suture any perineal or labial
tears quickly
 Feel the woman’s uterus
frequently to see that it stays
firm
 Help the mother to feed and
care for her baby
 Provide PTMCT* care as
needed
* PTMCT = Preventing Mother To Child Transmission
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