3rd Stage of Labour

Question 1

What is the definition of 3rd stage of labour (NICE 2023)

Answer 1

The third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes

Question 2

What does retraction and contraction do?

Answer 2

Reduces the size of the uterus and the placental site and simultaneously thickens the uterine wall.

Question 3

BY the beginning of the third stage what has happened to the placental site?

Answer 3

Has diminished in size by about 75%. This reduction in size continues after the birth of the baby’s trunk and causes the placenta to shear off.

Question 4

What are the 3 phase of the removal of the placental?

Answer 4

Latent, Detachments, Expulsive.

Question 5

What is the latent phase?

Answer 5

Delivery of infant until beginning of seperation-placenta free wall thickens (intermittent contractions), minimal thickening of uterine wall over placenta.

Question 6

What is meant by detachment?

Answer 6

Period of placental separation and detachment from uterine wall, brought about by gradual thickening of the uterine wall over the site of the placental attachment. Myometrium thickens and reduces its surface area (lower edge off placenta). Leads to shearing off, of placenta in that area. Thickening of myometrium gradually rises to the entire placental area has sheared off (normally about 3 minutes).

Question 7

What is meant by expulsion?

Answer 7

From complete separation to entire expulsion.
* Upper segment contracts strongly.
* Placenta forced to fold on itself.
* Descends into lower segment.
* Then into vagina.
* Gravity and maternal effort, from stimulation of vaginal floor, leads to expulsion of placenta and membranes

Question 8

What do the umbilical veins carry?

Answer 8

Oxygenated blood from the placenta to the fetus

Question 9

What do the umbilical arteries carry?

Answer 9

Nutrient depleted deoxygenated blood away from the fetus to the placenta

Question 10

What is the intervillous space?

Answer 10

Part of the fetal-maternal interfere, where maternal blood enters to provide nutrients and gas exchange

Question 11

What is the physiology between the separation of the placenta from the uterine wall?

Answer 11

Compression of the placenta causes maternal blood in the intervillous spaces* to be forced back into the spongy layer of the maternal uterine tissue (decidua)

• The vessels become congested and burst. A small amount of blood seeps between the vessels, the spongy layer and placental surface aiding separation. This blood begins the formation of a retroplacental clot.

Question 12

What does the retraction of the oblique muscle fibres do?

Answer 12

Constrict the blood vessels so that blood does not drain back into the maternal system.

Question 13

What are the 2 main ways a placenta separates?

Answer 13

Schultze method
Matthew Duncan method

Question 14

What is the schultze method?

Answer 14

Separation starts in the centre of the placenta and this part descends first
* Retroplacental clot forms which aids separation
* Fetal surface appears first at the vulva with membranes trailing behind, the retroplacental clot is enclosed within the membranes
* Associated with less blood loss(quicker separation)
* Most common (80%

Question 15

What is the Matthew Duncan method?

Answer 15

Separation at lower edge of placenta.
* Placenta slips down sideways, and the maternal surface appears at the vulva.
* Associated with longer duration, increased blood loss and ragged membranes.
* Less common (20%

Question 16

After placental expulsion what are the 4 vital mechanisms that come into play to control bleeding at the site of placental atatchment>

Answer 16

1. The empty uterus fully contracts and the uterine walls come into apposition.
2. The myometrium continues to contract and retract. The interlacing muscle fibres become “living ligatures” constricting the torn blood vessels and sealing them.
3. Activation of coagulation and fibrinolytic systems.
4. Breastfeeding and skin to skin increase oxytocin production.

Question 17

What is the package of care involved in the physiological management of third stage?

Answer 17

－ no routine use of uterotonic drugs
－ no clamping of the cord until pulsation has stopped, or after delivery of the placenta
－ delivery of the placenta spontaneously or by maternal effort. [2014, amended2023

Question 18

What is the package of care involved in the active management of the third stage of labour?

Answer 18

routine use of uterotonic drugs
－ cord clamping and cutting of the cord (see recommendation 1.10.14)
－ controlled cord traction after signs of separation of the placenta

Question 19

What are the signs of separation and descent in the physiological 3rd stage?

Answer 19

-fundus rises up and becomes globular
-Bulge just above symphysis pubis
-Gush of blood per vagium
-More cord becomes visible
-Urges to bear down.
-Uterine contractions
-Placenta enters vagina.

Question 20

What should we do for a physiological 3rd stage?

Answer 20

Upright position i.e bag in toilet, container birthing stool.
* Maternal effort with a contraction.
* Encourage woman to empty bladder.
* Put baby to the breast.
* Oxytocin producing environment.

Question 21

What is not considered for us to do in the physiological 3rd stage?

Answer 21

• Administration of oxytocic is not considered part of physiological mngt.(unless heavy bleeding).
• Palpation of uterus‘ Fundus fiddling’.
• Touching the cord or apply cord traction.
• Clamping the cord (unless necessary or requested)

Question 22

What are the observations in the first stage (NICE ‘23)

Answer 22

-Her general physical condition, as shown by her colour, respiration and her own report of how she feels.
-Vaginal blood loss

Question 23

What should you discuss when discussing the choice of uterotoni for active management?

Answer 23

oxytocin plus ergometrine may be more effective than oxytocin alone at reducing the risk of postpartum haemorrhage
* oxytocin plus ergometrine is advised if there are risk factors which could increase the risk of postpartum haemorrhage
* oxytocin plus ergometrine is more likely to lead to nausea and vomiting compared with oxytocin alone
* oxytocin plus ergometrine is contraindicated in women with severe hypertension, pre-eclampsia, eclampsia, or severe cardiac, hepatic or renal disease. [2023]

Question 24

With active management how should oxytocin be delivered NICE 23?

Answer 24

For active management after vaginal birth
* administer 10 units of oxytocin (by intramuscular injection)
* 5 units of oxytocin (by intravenous injection, see recommendation 1.10.12)
* or 5 units of oxytocin plus 500 micrograms of ergometrine (by intramuscular injection)
* immediately after the birth of the baby and before the cord is clamped and cut. [2023].

Question 25

How should oxytocin be administered?

Answer 25

Intramuscular injection or
slow intravenous injection over 3 to 5 minutes for women who have received oxytocin during labour.

Question 26

When should the cord be clamped in active management?

Answer 26

• Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heart rate below 60 beats a minute that is not getting faster #
• Clamp the cord before 5 minutes in order to perform controlled cord traction as part of active management
• If the woman requests that the cord is clamped and cut later than 5 minutes, support her choice. [2023]

Question 27

When should you advise a change from physiological management t active management?

Answer 27

haemorrhage
the placenta is not delivered within 1 hour of the birth of the baby
if the woman wants to shorten the third stage

Question 28

When is active management recommended?

Answer 28

• Previous Postpartum haemorrhage (PPH)
• previous retained placenta
• HB under 8.5 (Symptomatic with less blood loss)
• BMI greater than 35 (Lipid tissue between myometrium cells)
• Grand multiparity
• Antepartum haemorrhage (APH)
• Overly distended uterus i.e multiple births
• Uterine abnormalities
• Low lying placenta
• Maternal age over 35
• IOL or augmentation (intervention already used)
• prolonged first or second stage
• precipitous labour (no evidence!)
  operative birth or LSCS

Question 29

When is optimal cord clamping and how can this help baby?

Answer 29

In active management of the third stage of labour after administering oxytocin, clamp and cut the cord, >1minute but <5 minutes unless the woman requests otherwise (NICE, 2017).
* Delayed or optimal cord clamping expands neonatal blood volume by 20-50%, decreasing anaemia in babies(infants with better iron levels seem to do better on tests of neurodevelopment later in childhood.)
* Reduces a sudden drop in neonatal blood pressure and therefore keeps baby stable

Question 30

What are the steps to perfoming controlled cord traction (CCT)

Answer 30

• A uterotonic drug has been administered, had time to act and signs of separation observed
• Woman preferably in sitting/semi-recumbent position
• Use fingers around cord or a clamp to apply sustained downward traction until placenta visible
• Whilst applying other hand above symphysis pubis to push uterus upwards- guarding the uterus
• Upward traction once visible in the vagina to follow curve of carus
• Sometimes some twisting to create a rope of the membranes.
• Collect placenta and membranes in an appropriate receptacle

Question 31

What is a lotus birth?

Answer 31

The practice of birthing the baby and placenta, and leaving the two attached until the cord falls off on its own. Anecdotally, this can take 3 to 10 days

Question 32

What are the timings of the third stage of labour?

Answer 32

Separation is estimated to be completed within 3 minutes (Harris,2017)
* Active management of 3rd stage is thought to be faster than a physiological third stage of labour.
* Diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth with active management or within60 minutes of the birth with physiological management (NICE,2017)

Question 33

What is the checklist for examination of placenta?

Answer 33

Size and shape (any irregularities?)
Smell and colour
Maternal side- texture?, retroplacental clot any cotyledons missing?
Fetal side- vessels?, lobes?2 membranes
Umbilical cord insertion site?, knots,length?3 vessels (AVA) in umbilical cord within Wharton’s Jelly

Question 34

What could be meant by a retained placenta?

Answer 34

The placenta has separated but is retained (trapped)
The placenta has not separated
The cord has snapped
The placenta is morbidly adhered
consider bladder care

Question 35

How are retained placentas removed?

Answer 35

Manually removed in theatre under spinal anaesthetic by obstertri team.

Question 36

What is the steps of care in the 3rd stage of labour?

Answer 36

-Discussion (advantages & risks) preferably antenatally, birth plan reference and discuss on admission in labour
* Important to stay with woman until third stage completed
* Maintain the environment that supported birth. Often a calm, warm, quiet environment. Maintain privacy.
* Encourage Skin to skin contact and initiate breastfeeding
* Observe blood loss and for signs of separation
* Optimal cord clamping
* Empty bladder
* Document: Time of birth. cord clamped & cut (if being cut).Placenta delivered. Estimated blood loss. Placental examination

Question 37

What is the guide for assessment of maternal wellbeing following third stage of labour?

Answer 37

Maternal observations.
* Inspect for genital tract trauma
* Is uterus well contracted?
* Assess for estimated blood loss (NICE 2017)
* Skin to skin and infant feeding
* Offer analgesia (if required)
* Offer refreshments (birth partner too!)
* Consider comfort and hygiene (bedding/ shower/ bath)
* Documentation