RAK COLLEGE OF NURSING

PEER TEACHING ASSIGNMENT ON PHYSIOLOGY AND

MANAGEMENT OF THIRD AND FOURTH STAGE OF LABOUR

SUBMITTED TO- SUBMITTED BY-

ANUGRAH MILTON PRABHDEEP KAUR
ASSISTANT PROFESSOR MSC FIRST YEAR
RAKCON RAKCON

Subject: Obstetrical and gynaecological nursing

Topic :Physiology and management of third and fourth stage of labour
Course:MSc nursing
Student: Prabhdeep kaur
Group:MSc first year
Date:10/02/2023
Setting:classroom
Time:2pm
Av aids:PPT
Teacher : Anugrah Milton

Previous knowledge
Students have acquired knowledge about third and fourth stage of labour in thier bsc curriculum.

General objectives

To devlop knowledge in students regarding third and fourth stage of labour ,its clinical course ,management , to the
students.

TIME SPECIFIC TL A EVALUATION

OBJECTIVES CONTENT ACTIVITY V
 A
I
D
INTRODUCTION S What is
2 To define labour?
MIN labour Series of events that take
place in the genital organs
in an effort to expel the
viable products of
conception (fetus, placenta
and the membranes) out
of the womb through the
vagina into the outer world
is called Labor. It may
occur prior to 37 P
completed weeks, when it P
is called the preterm labor. T
To annouce
1 the topic . ANNOUNCEMENT OF
min TOPIC

We shall be discussing

third and fourth stage of

labour ,along with its

Define third
DEFINITION: stage and
 management .
To define Third stage: It begins after expulsion of the fetus and ends fourth stage
2 the third with expulsion of the placenta and membranes (afterbirths). of labour.
min stage and Its average duration is about 15 minutes in both
fourth stage primigravidae and multiparae. The duration is, however,
of labour. reduced to 5 minutes in active management.

Fourth stage: It is the stage of observation for at least 1 hour

after expulsion of the afterbirths. During this period maternal
vitals, uterine retraction and any vaginal bleeding are
monitored. Baby is examined. These are done to ensure that
both the mother and baby are well.

What are the

PHASES OF THIRD STAGE OF LABOUR phases of
To The third stage of labor comprises the phase of third stage of
placental separation;
5 elaborate labour?
its descent to the lower segment
min about
and finally its expulsion with the membranes.
phases of
third stage PLACENTAL SEPARATION:
of labour. At the beginning of labor, the placental attachment roughly
corresponds to an area of 20 cm (8") in diameter.

After the birth of the baby, the uterus measures about 20 cm

(8") vertically and 10 cm (4") anteroposteriorly, the shape
becomes discoid. The wall of the upper segment is much
thickened while thin and flabby lower segment is thrown into
folds. The cavity is much reduced to accommodate only the
afterbirths.
Mechanism of separation: .
There are two ways of separation of placenta.
(1) Central separation (Schultze):
Detachment of placenta from its uterine attachment starts at
the center resulting in opening up of few uterine sinuses and
accumulation of blood behind the placenta (retroplacental
hematoma). With increasing contraction, more and more
detachment occurs facilitated by weight of the placenta and
retroplacental blood until whole of the placenta gets
detached.

(2) Marginal separation (Mathews-Duncan): Separation

starts at the margin as it is mostly unsupported. With
progressive uterine contraction, more and more areas of the
placenta get separated. Marginal separation is found more
frequently.

SEPARATION OF THE MEMBRANES:

The separation is facilitated partly by uterine contraction
and mostly by weight of the placenta as it descends down
from the active part. The membranes so separated carry with
them remnants of decidua vera giving the outer surface of the
chorion its characteristic roughness.

EXPULSION OF PLACENTA:
After complete separation of the placenta, it is forced down
into the flabby lower uterine segment or upper part of the
vagina by effective contraction and retraction of the uterus.
 Thereafter, it is expelled out either by voluntary contraction
of abdominal muscles (bearing down efforts) or by manual
procedure .

CLINICAL COURSE OF THIRD STAGE OF LABOR

Third stage includes separation, descent and expulsion of the What is the
To elucidate placenta with its membranes. clinical course
10 the clinical of third stage
min course of PAIN: For a short time, the patient experiences no pain. of labour ?
However, intermittent discomfort in the lower abdomen
third stage
reappears, corresponding with the uterine contractions.
of labour.
BEFORE SEPARATION: Per abdomen—Uterus becomes
discoid in shape, firm in feel and nonballottable. 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.

AFTER SEPARATION: It takes about 5 minutes in

conventional management for the placenta to separate.
Per abdomen:
1. Uterus becomes globular, firm, and ballottable.
2. 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.
3. Slight bulging in the suprapubic regiondue to distension
of the lower segment by the separated placenta.
 Per vaginum:
4. Slight gush of vaginal bleeding.
5. 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.

EXPULSION OF PLACENTA AND MEMBRANES:

The expulsion is achieved either by voluntary bearing down
efforts or more commonly aided by manipulative procedure.
The afterbirth delivery is soon followed by slight to
moderate bleeding amounting to 100–250 mL.

MANAGEMENT OF THE THIRD STAGE

Third stage is the most crucial stage of labor. Previously
uneventful first and second stage can become abnormal
within a minute with disastrous consequences.
The principles underlying the management of third stage are What is the
to ensure strict vigilance and to follow the management
management
guidelines strictly in practice so as to prevent the
10 To explain of third stage
complications, the important one being postpartum
min the hemorrhage. of labour?
managemen
t of third STEPS OF MANAGEMENT: Two methods of
stage of management are currently in practice.
labour.  Expectant management
 Active management (preferred)
 Expectant management (traditional):
In this management, the placental separation and its descent
into the vagina are allowed to occur spontaneously. Minimal
assistance may be given for the placental expulsion if it
needed.
 Constant watch is mandatory and the patient should not
be left alone.
 If the mother is delivered in the lateral position, she
should be changed to dorsal position to note features of
placental separation and to assess the amount of blood
loss.
 A hand is placed over the fundus—
(a) to recognizethe signs of separation of placenta,
(b) to note the state of uterine activity—contraction and
relaxation and
(c) to detect, though rare, cupping of the fundus which is an
early evidence of inversion of the uterus.
 Desire to fiddle with the fundus or massage the
uterus is to be strongly condemned. Placenta is
separated within minutes following the birth of the baby.
A watchful expectancy can be extended up to 15–20
minutes. In some institutions, “no touch” or “hands off”
policy is employed. The patient is expected to expel the
placenta within 20 minutes with the aid of gravity.
 Expulsion of the placenta: Only when the features of
placental separation and its descent into the lower
segment are confirmed, the patient is asked to bear down
simultaneously with the hardening of the uterus. The
raised intra-abdominal pressure is often adequate to
expel the placenta.
If the patient fails to expel, one can wait safely up to 10
minutes if there is no bleeding. As soon as the placenta
passes through the introitus, it is grasped by the hands and
twisted round and round with gentle traction so that the
membranes are stripped intact. If the membranes threaten to
tear, they are caught hold of by sponge-holding forceps and
in similar twisting movements the rest of the membranes are
delivered.

Assisted expulsion:
(a) Controlled cord traction (modified Brandt-Andrews
method)—The palmar surface of the fingers of the left hand
is placed (above the symphysis pubis) approximately at the
junction of upper and lower uterine segment . The body of
the uterus is pushed upward and backward, toward the
umbilicus while by the right hand steady tension (but not too
strong traction) is given in downward and backward
direction holding the clamp until the placenta comes outside
the introitus. It is thus more an uterine elevation which
facilitates expulsion of the placenta. The procedure is to be
adopted only when the uterus is hard and contracted.
(b) Fundal pressure—The fundus is pushed downward and
backward after placing four fingers behind the fundus and
the thumb in front using the uterus as a sort of piston.
Pressure must be given only when the uterus becomes hard.
If it is not, then make it hard by gentle rubbing. The pressure
is to be withdrawn as soon as the placenta passes through the
introitus. If the baby is macerated or premature, this method
is preferable to cord traction as the tensile strength of the
cord is much reduced in both the instances.
The cord may be accidentally torn which is not likely to
cause any problem. The sterile gloved hand should be
introduced, and the placenta is to be grasped and extracted.
— The uterus is massaged to make it hard, which facilitates
expulsion of retained clots if any. Injection of oxytocin (5–
10 units) IV slowly/IM or methergine 0.2 mg is given
intramuscularly. Oxytocin is more stable and has lesser side
effects compared to ergometrine.

— Examination of the placenta membranes and cord:

The placenta is placed on a tray and is washed out in running
tap water to remove the blood and clots. The maternal
surface is first inspected for its completeness and anomalies.
The maternal surface is covered with grayish decidua
(spongy layer of the decidua basalis). Normally the
cotyledons are placed in close approximation and any gap
indicates a missing cotyledon. The membranes—chorion and
amnion are to be examined carefully for completeness and
presence of abnormal vessels indicative of succenturiate
lobe. The amnion is shiny but the chorion is shaggy. The cut
end of the cord is inspected for number of blood vessels.
Normally, there are two umbilical arteries and one umbilical
vein. An oval gap in the chorion with torn ends of blood
vessels running up to the margin of the gap indicates
a missing succenturiate lobe. The absence of a cotyledon or
evidence of a missing succenturiate lobe or evidence of
significant missing membranes demands exploration of the
uterus urgently.
— Vulva, vagina and perineum are inspected carefully for
injuries and to be repaired, if any. The episiotomy wound is
now sutured. The vulva and adjoining part are cleaned with
 cotton swabs soaked in antiseptic solution. A sterile pad is
placed over the vulva.

Active Management of Third Stage of Labor

(AMTSL)
The underlying principle in active management is to
excite powerful uterine contractions within 1 minute of
delivery of the baby (WHO) by giving parenteral oxytocin.
This facilitates not only early separation of the placenta but
also produces effective uterine contractions following its
separation.
The advantages are—(a) to minimize blood loss in third
stage approximately to one-fifth and
(d) to shorten the duration of third stage to half.

The only disadvantage is slight increased incidence of What are the

retained placenta (1–2%) and consequent increased incidence steps of
10 To explain of manual removal. Of course, accidental administration active
mins about active during delivery of the first baby in undiagnosed twins management
managemne produces grave danger to the unborn second baby caused by of third stage
t of third asphyxia due to tetanic contraction of the uterus. Thus, it is of labour?
stage of imperative to limit its use in twins only following delivery
labour. of the second baby.

Procedures: Injection oxytocin 10 units IM (preferred) or

methergine 0.2 mg IM is given within 1 minute of delivery
of the baby (WHO). The placenta is expected to be delivered
soon following delivery of the baby. If the placenta is not
delivered thereafter, it should be delivered forthwith by
controlled cord traction (Brandt-Andrews) technique after
clamping the cord while the uterus still remains contracted. If
the first attempt fails, another attempt is made after 2–3
minutes failing which another attempt is made at 10minutes.
If this still fails, manual removal is to be done. Oxytocin may
be given with crowning of the head, with delivery of the
anterior shoulder of the baby or after the delivery of the
placenta.

Management of Fourth Stage of Labor

The fourth stage can be defined as starting after the delivery
of the placenta and ending when the mother's physical status
has stabilized.
This usually occurs within 1-2 hours. The weary work of
labor is completed, and the mother and father or partner
should be commended by the nurse on the good job they did.

Assessment
The first maternal assessment is to be done in the delivery
room before transfer. If the delivery has taken place in the
LDR, assessment begins as soon as the mother's legs are
down and the warm blanket has been placed on her.
The immediate postpartum checks, per- formed every 15
minutes for the first hour, include blood pressure, pulse, What are the
respirations, massaging the fundus and observing the vaginal steps of
10 flow, inspecting the perineum, and assessing for bladder managemnet
mins To elucidate distention. A temperature reading is usually taken within the in fourth
about first hour . stage of
managemen Fourth-Stage Assessment labour?
t of fourth • Vital signs • Fundus• Amount of lochia, presence of clots
stage of lab
Our • Perineum Bladder distention Family interaction

During the first hour, with every assessment, the fundus is

massaged and its condition and position are documented.
Vaginal bleeding is assessed and documented in regard to
amount, color, and presence of clots or foul odor.
The amount of bleeding is noted scant, light, moderate, or
heavy.
Scant: Blood on tissue only when wiped or less than 1-inch
stain
Light: Less than 4-inch stain on peripad.
Moderate: Less than 6-inch stain on peripad
Heavy: Saturated peripad within 1 hour

Nursing Diagnosis
During the third and fourth stages of labor, the nursing
goal of maintaining maternal and newborn well-being is
ongoing. Once the nurse has confirmed that physical systems
are stabilized and that the woman is comfortable, he or she
can begin to prepare the client for the new (or renewed) role
of mothering.
Possible nursing diagnoses at this stage include the following
⚫ Pain related to involution of uterus, episiotomy
  Sleep pattern disturbance related to length of labor
 Altered nutrition: Less than body requirements related
to nothing by mouth status during labor and delivery
 Altered parenting related to inexperience, Grieving
related to labor and delivery not occurring models
the way client wanted it to be, newborn not desired.
 Risk for infection: Vaginal, perineal related to bacterial
ately after birth invasion secondary to trauma during
labor and delivery and episiotomy
 Health seeking behaviors related to newborn care,
To discuss newborn behavior, self-care, normal postpartum sex, What are the
5 the possible pregnancy over physiologic occurrences possible
mins nursing  Risk for fluid volume deficit related to uterine diagnosis in
diagnosis in hemorrhage case of
third and patient in
fourth stage thirs stage of
of labour. Management of Potential Complications labour?
According to WHO, every minute, at least one woman dies
from complications related to childbirth in developing
countries (WHO, 2013).

Hypothermic Reactions
Chilling accompanied by uncontrollable shaking often occurs
in the early period after birth. It is uncomfortable and
sometimes embarrassing or frightening for the client, but it is
self-limiting and is not considered an ominous sign.
Clean, dry, warm gowns and blankets and a warm,
environment help in the prevention and control of this
 phenomenon. Warm fluids by mouth can be given and are
much appreciated for their hydrating and energy-giving
effects.
What the
Postpartum Hemorrhage potential
To Constant massage of the uterus during the period immedi- complications
elaborate ately after birth is unnecessary and undesirable. However, if in
the organ shows any tendency to relax, it is to be mas- saged
on the managemnet
immediately with firm but gentle circular strokes until it
10 managemne of third and
contracts effectively. Relaxation of the uterus is a prime
mins t of cause of postpartum hemorrhage, and surveillance of the fourth stage
potential uterus and the amount of bleeding is of extreme importance of labour and
complicatio at this time. how can you
ns in third prevent it ?
and fourth The most predictive factors associated with postpartum
stage of bleeding are conditions that have tired or overstretched the
labour. uterine muscle or otherwise interfered with its ability to
continue actively contracting

Rapid labor
⚫ Prolonged first and second stages of labor
• Operative delivery (ie, forceps extraction)
• Overdistention of the uterus (hydramnios, multiple
pregnancy, overly large newborn)
• Previous uterine atony or associated previous postpartum
hemorrhage
 Advanced maternal age and high parity Other
hemorrhagic complications, such as abruptio placentae
or placenta previa.
Induced labor
⚫ Heavy medication during labor or general anesthesia

Preeclampsia and eclampsia

The nurse has an intravenous infusion with an oxytocin,
immediate administration ready in the event that the
attendants suspect hemorrhage is imminent.

Psychosocial Considerations
For every woman, pregnancy and childbirth are very
important life events. There are various factors such as the
personality characteristic of the woman, emotional stability,
family support, environmental pressures, parity, etc., that
influence the psychological reaction of the expectant or
recent mother. Fear and anxiety affect the be mother in
pregnancy and childbirth. Mothers showing psychological
reactions require family and promotional support throughout
pregnancy and childbirth.

Emotional Reactions
Immediately after childbirth, or perhaps later, the parents,
particularly the mother, may relieve tension by giving way to
some emotional displays, such as laughing, crying, talking
incessantly, or expressing anger. These emotions often are
unexpected, and a calm, accepting, nonjudgmental attitude
on the part of the nurse is effective in allaying any
embarrassment.
This is not the end, but the beginning of a new role. In
addition, she is physically and emotionally exhausted from
the labor and birth and is at risk for potential sleep and rest
disturbance.

Several comfort measures can be used to restore calm and to

help the mother relax enough to get some much needed rest
and sleep.
A soothing back rub, change of gown and linen, a quiet
conversation with the nurse or the father or partner in which
the client is allowed to ventilate her feelings, and an
environment conducive to rest may be helpful.
In addition, if she is stable after the first hour, a warm
beverage can be offered to help relaxation. Because the
mother is apt to be extremely hungry and thirsty, this is
welcome nourishment.

Some clients experience a great need for sleep and drop off
as soon as they know that the newborn is normal and healthy.
the client is sleeping continuously or intermittently, she
hould be allowed to do so, being disturbed only for nurs- ng
observations that are necessary.
When she indicates readiness, her newborn can be presented
and she can be allowed to examine and explore it to her
heart's content.

Family Interaction
The nurse attending the birth and giving care in recov ery
can assist the couple with the first interactions. The nurse
may help the mother with her first breast-feeding or the as he
holds the newborn for the first time. These interactions are
important as the beginning foundation for their family
relationship continues to develop Assessment of Family
Integration

The postpartum nursing staff can work closely with

community health nurses . This is a time when the nurse
needs to use all the observational skills, time, and laying on
of hands to foster initial integration and begin prescribing
future care aimed at consolidating the family unit.

BIBLIOGRAPHY
1. DC Dutta ,Textbook of obstetrics ,Jaypee publication,8th
edition,
pg 50-52
2. Reeder,Martin,Koniak-Griffin,Maternity nursing,Wolters
Kluwer,19 th edition, pg 124-126
3. Adele Pillitteri,Maternal and child health
nursing,Lippincott, 3rd edition,Pg 104-106
4.www.obsterticsatips.com
SUMMARY
We discussed about third
and fourth stage of
labour ,its clinical
course ,its management
and prevention of its
complications .