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2 min INTRODUCTION: Student teacher
The stages of labor are often thought to be a mystery. In all honesty, it is a introduces topic to
mystery in many ways. Each woman will have a different labor experience, the group by
and yet many parts are the same. Below you will find a crash course in the assessing the
stages of labor, what each does, the parameters, and some average events previous
of each stage. Remember, however, that very few women will follow this knowledge of
to the letter; there will be some variation. students.
Stages of labor:
 First stage: The first stage is the longest part of labor and can last up to
20 hours. It begins when your cervix starts to open (dilate) and ends
when it is completely open (fully dilated) at 10 centimetres.
 Second stage: The second stage of labor begins when cervix is fully
dilated at 10 centimetres. This stage continues until baby passes
through the birth canal, vagina, and is born. This stage may last two
hours or longer.
 Third stage: The third stage of labor begins after the baby is born and
ends when the placenta separates from the wall of the uterus and is
passed through the vagina.
 Fourth stage: the fourth stage begins with the birth of placenta and
ends one hour later.
2 min Explains about THIRD STAGE OF LABOR: Student teacher Describe about
the third stage The third stage of labor begins upon completion of the birth of the birth of explains about the the third stage
of labor. the baby and ends with the birth of placenta. It is known as the placental third stage of labor of labor
stage of labor. The third stage of labor averages between five to fifteen with the help of
minutes but any period up to one hour may be considered within normal ppt.
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limits.
Physiological processes of placental separation and expulsion:
 Placental separation
 Descend of the placenta
 Expulsion of the placenta
 Hemostasis
10 Elucidates MANAGEMENT OF THE THIRD STAGE: Student teacher Describe the
min about the Third stage is the separation, descent and expulsion of the placenta with elucidates about management of
management its membranes. It is the most important stage as many life threatening the management the third stage.
of the third complications can occur during this stage. The management of the third of the third stage
stage. stage of labour in given below in flow chart. One should never try to of labour.
deliver the placenta before its separation to avoid uterine inversion.

METHODS OF PLACENTAL SEPARATION:

 Schultz method: more common, where there is a formation of
retroplacental clot centrally and placental separation starts
centrally and then sideward. Here fetal site comes out first.
 Mathew Duncan’s method: less commonly separation starts at the
lower edge of the placenta. The placenta slips down sideways and
maternal surface appears first at the vulva. The blood clots at the
placental site, in the sinuses and torn blood vessels.

Once signs of placenta separation appear it can be delivered by following

methods:
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EXPECTANT MANAGEMENT:
Wait for the spontaneous placental separation and descent into the
vagina. The patient is then asked to gently bear down at the hardening of
the uterus enabling the raised intra abdominal pressure to deliver the
placenta spontaneously.
When the placenta is visible at introitus, it can be held in hand and
removed by gentle traction and twisting movement to remove complete
placenta and membranes. If membranes start to tear, they should be
grasped with a sponge holding forceps or a clamp and removed by gentle
traction and tearing.
1. Crede’s method in which fundus is squeezed or uterus is pressed to
expel the placenta is contraindicated in modern practice as it may
lead to uterine inversion and can cause shock.
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2. Modified Brandt- Andrew’s technique
(controlled cord traction method)

The fundus is pushed upwards and backwards when uterus becomes firm.
Controlled cord traction by right hand is given to the clamp in downward
and backward directions in a steady and slow manner until complete
expulsion of the placenta occurs. Uterine elevation and not cord traction
assists in the expulsion. If the placenta is undelivered after 30 minutes, it is
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called retained placenta necessitating manual removal of placenta.

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR:

The principle in active management is to stimulate strong uterine
contractions following birth of the fetus by parenteral oxytocin to facilitate
early separation of the placenta and produce effective uterine
contractions for its separation.

Components of active management of third stage

1. Use of oxytocic
2. Delivery of placenta by controlled cord traction (CCT)
3. Uterine massage

Some include delayed cord clamping as part of active management of the

third stage. Latest WHO guide line recommends only oxytocin use for
active management of third stage. It does not recommend sustained
uterine massage if the women have already received prophylactic
oxytocin. However, postpartum abdominal uterine tone assessment for
early identification of uterine atony is recommended for all births.
Controlled cord traction is only recommended if attendant, CCT is not
recommended. Absence of skilled birth attendant, CCT is not
recommended.
Benefits:
1. It can reduce blood loss in third stage by about 80% and prevents
postpartum hemorrhage saving many lives as postpartum
hemmorhage is a major cause of maternal mortality throughout
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the world.
2. The duration of third stage of labour can be shortened to 5
minutes from 15 minutes in both primigravidas and multigravidas.
Drawbacks:
1. Using oxytocics before delivery of placenta may rarely cause
retained placenta necessitating its manual removal.
2. An undiagnosed second twin may be entrapped inside jeopardizing
its health.
Active management is recommended in most cases as there is good
evidence that this reduces the risk of postpartum hemorrhage (level 1A
evidence). Active management is performed by giving 10 units of oxytocin
intramuscularly after delivery of baby. It can also be given as 10 units of
oxytocin in drip. Oxytocin should not be given as IV bolus due to risk of
marked transient fall in blood pressure, abrupt increase in cardiac output,
myocardial ischemia and chest pain.
Ergometrine (0.25) or methylergometrine 0.2 mg which was popular in
olden days is now not commonly recommended. Inj. PGF2α 250µg
intramuscularly or 600 µg of Misoprostol orally or rectally are also
effective. If oxytocin is not available, combination of methylergometrine
and oxytocin intramuscularly or 600 µg of oral Misoprostol can be given. If
placenta does not deliver by controlled cord traction in 30 minutes then
manual removal of placenta is considered. Active management with
ergometrine or methylergometrine is contraindicated in the following
cases:
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 The woman does not want it.
 Severe pre-eclampsia and eclampsia
 The woman has severe cardiac disease.
However, active management with oxytocin can be given in all cases.
Grand multipara and women who were on oxytocin induction or
augmentation should have an oxytocin infusion maintained for at least 1
hour after delivery (20 units oxytocin in 500 ml normal saline).

Assessment and examination of placenta, membranes and cord:

This should be performed as soon as after delivery as possible, so that if
there is doubt about their completeness, further action could be taken
before the mother leaves the labor room or the midwife leaves the home
in case of home delivery. A thorough inspection must
be carried-out in order to make sure that no part of the placenta or
membranes has been retained. The membranes often become torn during
delivery and may be ragged and hence, care must be taken to piece them
together to have an overall picture of their completeness, This is easier to
see if the placenta is held by the cord, allowing the membranes to hang.
The hole through which the baby was delivered can usually be identified
and a hand spread out inside the membranes to aid inspection. The
placenta should then be laid out on a flat surface and both placental
surfaces examined carefully. The amnion should be peeled from the
chorion right up to the umbilical cord, which allows the chorion to be fully
viewed.
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Assessment of the Placenta
Any clots from the maternal surface must be removed and kept for
measuring. Broken fragments of cotyledons must be carefully replaced
before an accurate assessment is made

 Infarctions that are recent or old- these areas on the placental

surface indicate deprivation of blood supply. Recent infarctions
appear bright red and old infarctions as gray patches.
 Localized calcifications- there are seen as flattened white plaques
that feel gritty (as small hard particles of sand) to the touch.
 Lobes- the lobes of a complete placenta fit neatly together without
any gaps, the edges forming a uniform circle.
 Blood vessels- they should not radiate beyond the placental edge.
If they do, this denotes a succenturiate lobe. If the lobe has been
retained, the vessels will end abruptly at a hole in the membrane.
 Insertion of the cord (on the fetal surface) - normal insertion is
central. Lateral insertion is abnormal.
 Umbilical vessels- two umbilical arteries and one vein should be
present. The absence of one artery may be associated with
congenital abnormality, particularly renal agenesis.
 Cord length- average length is 50 cm.
 Weight of placenta- approximately one- sixth of the baby’s weight.

Immediate Care to Mother and Baby

- The mother and baby should remain in the midwife's care for at
least an hour after delivery.
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- In some hospitals, the baby may be in a nursery unit and cared for
by another nurse. Both need careful observation and specific care
during this period.
- The mother should receive cleansing body wash, mouthwash and
perineal care.
- She should be encouraged to empty her bladder and a bedpan
offered.
- Blood pressure, pulse, uterine contraction and bleeding should be
checked every 15 minutes.
- The baby's general well-being and security of the cord clamp needs
to be checked. As the baby will quickly chill after birth, it is
important to thoroughly dry and wrap the baby in a clean, dry
towel or blanket. A full neonatal examination is done at an early
stage and the baby is kept in a warm crib, or cuddled close to the
mother.
- Mothers intending to breastfeed may be encouraged to put their
babies to the breast during early contact. Babies are usually alert
and their sucking reflex strong at this time. For the mother, early
breastfeeding causes a reflex release of oxytocin from the posterior
lobe of the pituitary gland that stimulates the uterus to contract.
The mother may experience a sudden fresh blood loss as the uterus
empties and she should be reassured.

Records:
The midwife is responsible for documentation of all the events of labor
and observations. Her recording should include the following details:
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- All the drugs administered
- Examination of the placenta, membrane and cord
- Amount of blood loss.
- After the specified period of observation the mother and the baby
are transferred to the post-natal ward.

NURSING PROCESS DURING THE THIRD STAGE

 Assessment

1. Determine that normal third stage progress is occurring.

a) Rhythmic contractions until the placenta is born.
b) Birth of placenta occurs 5 to 30 minutes after birth of the baby.
c) Signs of placental separation is seen
- Fundus rises slightly in abdomen
- Uterus changes shape
- Umbilical cord lengthens
- Slight gush of blood noted.
d) P1acental expulsion occurs:
- Schultz mechanism
- Duncan's mechanism.
e) Following birth of placenta, the uterine fundus remains firm and is
located two finger breadths below the umbilicus.
f) The mother may experience chills or shivering.
2. Assess maternal blood pressure following birth of the baby.
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3. Assess status of the uterus: Contractions will continue until birth of
the placenta.
4. 4. Assess the newborn's Apgar score and complete newborn
assessment.
5. Examine placenta to document that all cotyledons and membranes
are present.

 Analysis/Nursing Diagnosis
1. Anxiety related to knowledge deficit
2. Risk for infection
3. Pain
4. Fatigue
5. Impaired skin integrity
6. Anxiety
7. Ineffective individual coping
8. Powerlessness
9. Impaired adjustment
10. Self care deficit: Bathing/hygiene.

 Planning
1. Complete initial assessment of the newborn.
2. Monitor maternal and newborn status.
3. Provide support in parental newborn interactions.
4. Provide support and comfort measures during the third stage.
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 Implementation
1. Observe and record birth of placenta
2. Monitor maternal blood pressure
3. Dry the baby completely
4. Complete initial newborn assessments
5. Provide initial newborn care
a) Provide warmth
b) Prevent infection
c) Promote mother-baby attachment
6. Administer oxytocic drugs as per physician's order.

 Evaluation
1. See that the newborn establishes and maintains adequate
respiratory pattern.
2. Be sure that mother and newborn maintain normal physical
parameters.
3. Monitor mother-baby attachment/bonding.
4. Make sure that mother feels comfortable and supported during the
third stage.
15 Explain the MANAGEMENT OF THE FOURTH STAGE: Student teacher Describe the
min management The fourth stage of labor begins with the birth of the placenta and ends explains the management of
of the fourth one hour later. This stage marks the completion of the tasks associated management of the fourth stage.
stage. with the first- three stages of labour. The mother may have expressions of the fourth stage
relief and accomplishment, intermingled with excitement. with the help of
ppt.
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EVALUATION AND INSPECTION:
The first postpartal hour is a critical time of initial recovery from the stress
of labor and delivery and requires close observations of the mother. A
portion of this hour will be spent in activities directly related to the
intrapartal period. These activities may include the
following
1. Evaluation of the uterus.
2. Inspection and evaluation of the perineum, vagina and cervix.
3. Inspection and evaluation of the placenta, membranes and
umbilical cord.
4. Repair of episiotomy and laceration, if any.

In addition to these, vital signs and other physiologic manifestations are

checked and evaluated as indicators of recovery from the stress of labor.
This period is the beginning of family relationships and mother-baby
bonding.

NURSING PROCESS DURING THE FOURTH STAGE OF LABOUR:

 Assessment
1. Physical assessment
Determine that fourth stage is progressing within the normal limits.
a) Blood pressure returns to prelabour state.
b) Pulse is slightly lower than in labor
c) Fundus remains contracted in the midline and is located 1 to 2
finger- breadths below the umbilicus.
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d) Lochia is scant to moderate
e) Bladder is non palpable
f) Perineum is intact

2. Psychological assessment
a) Assess the mother’s emotional state. May vary from exhaustion to
euphoria.
b) Some mothers may want to interact with their baby, and others
may wish to rest at this time.

 Nursing Diagnosis

1. Rest and sleep deprivation

2. Altered parenting
3. Anxiety.
4. Risk to altered homeostasis.

 Planning

1. Frequent assessments to monitor maternal recovery from delivery.

2. Enhance maternal-newborn attachment.
3. Teach self care measures to prevent bleeding and enhance
comfort.
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 Implementation

1. Complete maternal assessment every 15 minutes for the first hour,

every 30 minutes for the second hour and then hourly for the next
2 hours.
2. Provide comfort measures
a) Provide warm blankets and/or hot drinks for shivering or
chilling.
b) Place ice packs on perineum to decrease swelling and
increase comfort.
c) Carry out perineal cleansing.
d) Offer sponge bath.
e) Provide clean linen.
3. Massage and express fundus.

 Evaluation
Ensure that the mother:
1. Has physical parameters monitored at frequent intervals.
2. Had uneventful recovery period and does not develop
complications.
3. Has opportunity to interact with newborn as desired.
4. Can demonstrate fundal massage and practice comfort measures.
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2 min Summarization Summarization of
of the topic the topic :
Today we have
studied about the
management of
third and fourth
stage of labor. In
third stage we
learned that there
are two methods of
separation one is
Schultz method
and other one is
Mathews Duncan’s
method and there
are various
measures of
management
which are as
Crede’s method
and modified
Brandt- Andrew’s
technique. And
then we studied
about fourth stage
of the labour
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where we studied
that it is a stage of
observation and
which extends for
about 1-2 hours
where we observe
the mother and the
newborn.
2 min Conclusion of Conclusion of the
the topic topic:
The process of
labor is a natural
process though and
does not require
much interventions
but any normal
labor can turn into
abnormal at an
stage of labour
therefore it is
needed to learn
about the various
measure that are
required to
maintain a safe
labor practice.