Third stage is the most crucial stage of labour. Previously uneventful first and second
stage can become abnormal within a minute with disastrous consequences.
Principles -
To ensure strict vigilance and to follow the management guidelines strictly in practice
so as to prevent the complications, the important one being postpartum haemorrhage.
Steps of management -
Two methods of management are
1. 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 recognise the signs of separation of placenta.
b) to note the state of uterine activity - contraction and retraction.
c) to detect, though rare, cupping of the fundus which is an early evidence of intervention
of the uterus.
- Placenta is separated within minutes following birth of the baby. A watchful expectancy can
be extended up to 15-20 minutes. In some institutions, ''no touch'' or ''hands off'' police is
employed. The patient is expected to expel the placenta within 20 minutes with the aid of gravity.
Expulsion of placenta -
When the placenta descent into the lower uterine segment, 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.
Examination of the placenta, membrane and cord -
The placenta is placed in 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 (spongy layer of 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.
Vulva, vagina and perineum are inspected carefully for injuries and to be repaired, if any.
The episiotomy wound is now sutured.
2. Active management of third stage -
Advantages -
- To minimise blood loss in third loss.
- To shorten the duration of third stage.
Procedures -
Inj. ergometrine 0.25 mg or methergin 0.2 mg is given intravenously following the birth of
anterior shoulder. If administered prior to this, there is chance of imprisonment of the shoulder
behind the symphysis pubis. If the placenta is not delivered, it should be delivered by
controlled cord traction technique.
stage can become abnormal within a minute with disastrous consequences.
Principles -
To ensure strict vigilance and to follow the management guidelines strictly in practice
so as to prevent the complications, the important one being postpartum haemorrhage.
Steps of management -
Two methods of management are
- Expectant management
- Active management
1. 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 recognise the signs of separation of placenta.
b) to note the state of uterine activity - contraction and retraction.
c) to detect, though rare, cupping of the fundus which is an early evidence of intervention
of the uterus.
- Placenta is separated within minutes following birth of the baby. A watchful expectancy can
be extended up to 15-20 minutes. In some institutions, ''no touch'' or ''hands off'' police is
employed. The patient is expected to expel the placenta within 20 minutes with the aid of gravity.
Expulsion of placenta -
When the placenta descent into the lower uterine segment, 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.
Examination of the placenta, membrane and cord -
The placenta is placed in 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 (spongy layer of 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.
Vulva, vagina and perineum are inspected carefully for injuries and to be repaired, if any.
The episiotomy wound is now sutured.
2. Active management of third stage -
Advantages -
- To minimise blood loss in third loss.
- To shorten the duration of third stage.
Procedures -
Inj. ergometrine 0.25 mg or methergin 0.2 mg is given intravenously following the birth of
anterior shoulder. If administered prior to this, there is chance of imprisonment of the shoulder
behind the symphysis pubis. If the placenta is not delivered, it should be delivered by
controlled cord traction technique.
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