M.M.

COLLEGE OF NURSING

PRESENTED BY:

SIMARJEET KAUR
M.Sc. NURSING 1ST YEAR
INTRODUCTION
• Series of events that takes place in the genital
organs in an effort to expel the viable products of
conception out of the womb through the vagina
into the outer world is called labour. It begins
after explusion of the fetus and ends with
explusion of the placenta and membranes
THIRD STAGE OF LABOUR

• It begins after explusion of the fetus and ends

with explusion of the placenta and membranes
(after-births). Its average duration is about 15
minutes in both primigravidae and multiparae.
The duration is, however, reduced to 5 minutes
in active management.
EVENTS IN THIRD STAGE OF LABOUR
Placental Separation
Mechanism of Separation
Two ways of separation of placenta
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
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 by either voluntary
contraction of abdominal muscles ( bearing
down efforts) or by manipulative procedure.
MECHANISM OF CONTROL OF
BLEEDING
• After placental separation, innumerable torn
sinuses which have free circulation of blood from
uterine and ovarian vessels have to be
obliterated.
• The occlusion is effected by complete retraction
where by the arterioles, as they pass through the
interlacing intermediate layer of the
myometrium, are literally clamped.
CONT…..
• It is the principal mechanism to prevent
bleeding. However, thrombosis occurs to occlude
the torn sinuses, a phenomenon which is
facilitated by hypercoagulable state of pregnancy

• Apposition of the walls of the uterus following

explusion of the placenta also contributes to
minimise blood loss
CLINICAL COURSE OF THIRD STAGE
OF LABOUR
AFTER SEPARATION
It takes about 5 minutes in conventional
management for the placenta to separate.
• Per abdomen- Uterus becomes globular, firm
and ballottable. 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. There may be slight bulging in
the suprapubic region due to distension of the
lower segment by the separated placenta.
• Per vagina- There may be slight gush of vaginal
bleeding. Permanent lenghthening 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. Alternatively,
on suprapubic pressure upwards by fingers,
there is no indrawing of the cord and same lies
unchanged outside the vulva.
EXPLUSION OF PLACENTA AND
MEMBRANES
The explusion is achieved either by
voluntary bearing down efforts or more
commonly aided by manipulative
procedure. The after-birth delivery is soon
followed by slight to moderate bleeding
amounting to 100-250 ml.
MATERNAL SIGNS
MANAGEMENT OF THE THIRD STAGE
OF THE LABOUR
Principles of the management of third
stage are
• to ensure strict vigilance and
• to follow the management guidelines
strictly in practice
• to prevent the complications
STEPS OF MANAGEMENT

• Expectant management

• Active management
EXPECTANT MANAGEMENT
• Placental separation and descent into the vagina are
allowed to occur spontaneously.
• Minimal assistance may be given for the placental
explusion 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
Explusion of the placenta
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.
• If the patient fails to expel, one can wait safely
upto 10 minutes if there is no bleeding.
• As soon as the placenta passes, 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
twisting movements the rest of the membranes
are delivered
• Gentleness, patience and care are prerequisites
for complete delivery of the membranes

• If the spontaneous explusion fails or is not

practicable, because of delivery under
anaesthesia, any one of the following methods
can be used to expedite explusion
ASSISTED EXPLUSION:
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 upwards and
backwards, towards the umbilicus while by the
right hand steady tension is given in downward
and backward dirction holding the clamp until
the placenta comes outside the introitus.
FUNDAL PRESSURE
• The fundus is pushed downwards and
backwards after placing four fingers behind the
fundus and the thumb infront using the uterus
as a sort of piston.
• The 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 premature, this method is
preferable to cord traction as the tensile strength
of the cord is much reduced in both the
instances
• The uterus is massaged to make it hard, which
facilitates explusion of retained clots if any.
Injection of oxytocin 5-10 units I.V. or methergin
0.2 mg is given I.M. Oxytocin is more stable and
has lesser side effects as 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 greyish
decidua. 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. The
amnion is shiny but the chorion is shaggy.
• The cut end of the cord is inspected for number
of blood vessels. There are two umbilical arteries
and one umbilical vein.
• The absence of cotyledons or evidence of missing
membranes demands exploration of the uterus
urgently.
VULVA, VAGINA AND PERINEUM
• INSPECTED carefully for injuries and to be
required, 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
• Principles in active management is to
excite powerful uterine contractions following
birth of the anterior shoulder by parenteral
oxytocin which facilitates not only early
separation of placenta but produces effective
uterine contractions following its separation.
Advantages
• To minimise blood loss in third stage
approximately to 1|5th
• To shorten the duration of third stage to half
Disadvantages
• Increased incidence of retained placenta and
increased incidence of manual removal of
placenta
• Accidental administration during delivery of the
first baby in undiagnosed twins produces danger
to the unborn second baby caused by asphyxia
due to tetanic contraction of the uterus
PROCEDURE
• Inj. Ergometrine o.25mg or methergin 0.2mg is
given intravenously following the birth of
anterior shoulder.
• If administered prior to this, there is chance of
imprisonment of the shoulder behind the
symphsis pubis.
• This is followed by slow delivery of the baby
taking atleast 2-3 minutes.
• The placenta is expected to be delivered
following the delivery of the buttocks.
• If the placenta is not delivered, it should be
delivered forthwith by controlled cord traction
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 10 minutes. If this still fails, manual
removal is to be done.
Limitation
To be effective, it should be administered in
proper time followed by slow delivery of the
baby and followed by rapid delivery of the
placenta
It should not be used in cardiac cases or severe
pre-eclampsia, for fear of precipitating cardiac
overload in the aggravation of the blood
pressure.
MANUAL REMOVAL OF THE PLACENTA
NURSING MANAGEMENT OF THE
THIRD STAGE OF LABOUR
Identification of the third stage
Placental separation is indicated by the following, in
sequence
• A firmly contracting fundus
• A change in the uterus from a discoid to a globular shape
• A visible and palpable rounded bulge above the symphysis
• A sudden gush of dark blood
• Apparent lengthening of the umbilical cord
• A vaginal fullness noted on vaginal or rectal examination,
or fetal membranes seen
• After the placenta is explused, it is examined for intactness
to be certain that no portion of it remains in the uterine
cavity.
MATERNAL PHYSICAL STATUS
• Cardiac output is increased rapidly as maternal
circulation to the placenta ceases and the pooled
blood from the lower extremities is mobilized
• The pulse rate slows to the change in cardiac
output. Pulse rates tend to remain slightly slower
than before pregnancy during the first 7 to 10
days after delivery.
• The nurse observes the mother for signs of an
altered level of consciousness or alteration in
respirations due to change in rapid
cardiovascular changes
NURSING CARE IN THE DELIVERY AREA
• To assist in the delivery of the placenta , the nurse
instructs the mother to push as contractions are felt
• If an oxytocin medication is ordered, the nurse
administers the medication in the dosage and by
the route indicated by the physician
• When the delivery of the placenta is complete and
the episiotomy is sutured, the vulva is gently
cleansed with sterile water by the physician
• The nurse then performs the following:
• Applies a sterile perineal pad
• Removes the drapes
• Repositions the delivery table or bed
• Lowers the mother’s legs simultaneously from
the stirrups
• Assists the woman onto her bed if she is to be
transferred from the delivery area to the
recovery area
• Dresses the woman in a clean gown and covers
her with a warmed blanket
• Raises the side rails of the bed during the
transfer
DEFINITION
It starts with the explusion of
placenta and ends one hour later.
This stage marks the completion of
the tasks associated with the first
three stages of labour. The mother
may have expressions of relief and
accomplishment, intermingled with
excitement.
Activities may include
• Evaluation of the uterus
• Inspection and evaluation of the cervix and
vagina
• Inspection and evaluation of the placenta,
membranes and umbilical cord
• Repair of episiotomy and laceration, if any.
• Vital signs and other physiological
manifestations are checked and evaluated as
indicators of recovery from the stress of labour
Evaluation of the Uterus
• The uterus is normally found in the midline of
the abdomen approximately two- third to three-
fourth of the way up between the symphysis
pubis and umbilicus.
• A uterus found above the umbilicus is indicative
of blood clots inside, which need to be expressed
and expelled.
• A uterus found above the umbilicus and to one
side, usually the right side indicates full bladder.
• A firm uterus is indicative of effective uterine
homeostasis.
Inspection of the Cervix and
Upper Vaginal Vault
The cervix and upper vaginal vault must be
inspected in the presence of any or a
combination of the following indications.
• The uterus is well contracted but there continues
to be a steady trickle or flow of blood from the
vagina
• The mother was pushing prior to complete
dilatation of the cervix
• The labour and delivery were rapid and
precipitous
• There was manipulation of the cervix during
labour, such as manually pushing back an
edematous anterior lip of cervix
• Traumatic procedures were necessary such as
forceps application
• Traumatic second stage of delivery such as
prolonged shoulder dystocia or large baby
• Following normal, spontaneous, vaginal
deliveries, if none of these indications is present,
it is not necessary to do a cervical and upper
vaginal vault inspection.
REPAIR
• The repair of any laceration or an episiotomy is
done after examination of the placenta and
membranes. If a uterine exploration for retained
placental fragments is necessary, it is done prior
to the repair. The uterus is checked again for
consistency and repair is begun.
• Inspection and evaluation of the placenta,
membranes and umbilical cord are done before
repairing any lacerations or an episiotomy.
CONTINUING CARE AND
MONITORING
• Throughout of the fourth stage of labour the
mother’s vital signs, uterus, bladder and lochia
are monitored and evaluated. This monitoring is
maintained until all are stabilized within normal
range.
 The technique of monitoring should be
organised and include the following:
• Check the Vital signs
• Palpation of the fundus of the uterus for
contractility
• Massage of the fundus in relation to the
umbilicus
• Inspection of the bladder
• Inspection of the perineal pad and change if
necessary
• Offering food and fluids if allowed and comfort,
and safety measures
VITAL SIGNS
• The mother’s blood pressure, pulse and
respirations are evaluated every 15 minutes until
stable at pre-labour levels.
• The temperature is taken at least once during the
fourth stage of labour.
• The temperature continues to be elevated with
normal being less than 20 f increase, or below
100.40 f
• In assessing the blood pressure and pulse rate, it
must be remembered that, the excitement after
delivery may cause an elevation in some
mothers.
PALPATION OF THE FUNDUS
• During fourth stage of labour, the uterus
continues to contract and relax.
• The uterus controls postpartum hemorrhage by
contracting and compressing the patent blood
vessels at the site where the placenta was
implanted.
• Medications such as ergometrine, methargin,
pitocin may have been given to the mother IM
OR IV during the delivery of the anterior
shoulder or immediately after the placenta is
delivered.
• It stimulates the uterine contractions.
Contractions of the uterus occur when the
mother hears her newborn baby’s cry or when
she can see or hold the baby.
The fundus of the uterus is palpated by placing
the side of one hand on top of, and slightly
cupped above the fundus while other hand is
placed suprapubically with the exertion of slight
pressure. Ideally, the fundus should lie on the
mid – plane of the pelvis at or below the
umbilicus.
MASSAGE OF THE UTERUS AND
EXPRESSION OF CLOTS
• If the uterus is found boggy on palpation, it is
massaged until it contracts and becomes firm.
Care must be taken not to over massage or over
stimulate the fundus. Over stimulation can
result in undue muscle fatigue with subsequent
relaxation of the organ and possible
haemorrhage.
• During expression, pressure is applied to the
fundus with one hand while equal pressure is
applied suprapubically with the other hand until
the nurse is sure that clots and free blood held in
the uterus is expressed sufficiently. After
palpation, massage and expression have been
completed, the uterus usually stays firm for a
period.
MEASUREMENT OF THE FUNDUS
• A measurement of the height of the fundus is
taken after the fundus is expressed, measuring
from the top of the fundus to the umbilicus. The
fundus of the uterus tends to lie closer to the
umbilicus in mother’s who are multiparous than
in those who are primiparous.
 Some factors which affect the size, placement and
muscular tone of the uterus include
• Antepartum hydramnios
• Multiple births
• Uterine inertia
• Amount of urine in the bladder
INSPECTION OF THE BLADDER
• The bladder must be evaluated and emptied if it
is full and displacing the uterus. If the bladder is
full, a bladder bulge will be evident. It feels and
appears as a spongy, fluid filled mass below the
uterus and above the symphysis pubis. It is
important for the bladder to be emptied, because
a full bladder displaces the uterus and decreases
its ability to contract properly.
INSPECTION AND CHANGE OF
PERINEAL PAD
• keep the area as clean and dry as possible.
• Regular change of perineal pad and linens under
her buttocks is required in order to keep the
lochia from becoming dry and adhering to
mother’s body.
• wash the perineal area and buttocks with mild
soap and water to remove lochia not absorbed by
the perineal pad.
• The lochia during the fourth stage of labour is
rubra, neither dark red nor bright red.
• The lochia consist of blood from the placental
site, shreds of membranes, vernix, lanugo,
decidua and meconium.
• If the bleeding is more than normal, the midwife
must keep a perineal pad count, so that
estimation of blood loss is more accurate.
• Notations must be made in the mother’s chart of
how many pads were used, the degree of
saturation of each pad, the size and character of
clots and the colour of lochia.
FLUIDS AND FOOD
• She should be encouraged to take water, juices
and tea or coffee with sugar.
• After her condition has stabilized within the
limits of normal, which will usually be by the end
of the first hour postpartum, she may also eat
solid foods.
• Mothers must be encouraged to eat a small
amount first and to eat slowly. Comfort
measures should be supplied and include warm
blankets, gown and warm fluids by mouth if not
contraindicated.
NURSING MANAGEMENT
ASSESSMENT
• Physical assessment
• Blood pressure returns to pre-labour state
• Pulse is slightly lower than in labour
• Fundus remains contracted in the midline and is
located 1-2 fingerbreadths below the umbilicus
• Lochia is scant to moderate
• Bladder is non-palpable
• Perineum is intact
• Psychosocial assessment
• Assess the mother’s emotional state. May vary
from exhaustion to euphoria
• Some mothers may want to interact with their
baby, and others may wish to rest at this time.
NURSING DIAGNOSIS

• Pain
• Anxiety
• Imbalance nutritional pattern
• Disturbed sleeping pattern
• Risk for altered homeostasis
PLANNING
• Frequent assessments to monitor maternal
recovery from delivery
• 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
• Enhance maternal newborn attachment
• Teach self care measures to prevent bleeding and
enhance comfort
• Provide warm blankets and hot drinks for
preventing shivering and chilling
• Provide clean linen
• Offer sponge bath
• Place ice packs on perineum to decrease swelling
and increase comfort
• Massage and express the fundus
Summary
Third stage of labour starts after the explusion
of fetus and ends with the explusion of the
placenta with its membranes. Today we
discussed about the definition, its events, clinical
course and management of third and fourth
stage of labour.
CONCLUSION:

Atlast, I conclude my topic, third and fourth

stage of labour are the crucial stage of labour. In
these stages we prevent the patient from
postpartum complications. Prevent the client
from infection and also educate the client
regarding diet and its management.