Quiz 11: The third stage of labour

Question 1

The third stage of labour starts when:

The cervix is fully dilated

The anterior shoulder of the infant is delivered

The infant is born

The placenta is delivered

Answer 1

The infant is born

Question 2

Which statement about the third stage of labour is correct?

This stage of labour is potentially dangerous for the patient.

Complications are uncommon during the third stage.

After normal first and second stages of labour, complications are rare in the third stage.

Postpartum haemorrhage during the third stage of labour is an uncommon cause of maternal death in developing countries.

Answer 2

This stage of labour is potentially dangerous for the patient.

Question 3

The active management of the third stage of labour includes:

Giving an oxytocic drug, after a second twin has been excluded, and then waiting for the uterus to contract

Waiting for signs of placental separation and then pulling on the umbilical cord while pushing the uterus upwards

Pulling on the umbilical cord while pushing the uterus upwards immediately after the infant has been delivered

Giving oxytocin after the signs of placental separation have appeared and then pulling on the umbilical cord while pushing the uterus upwards

Answer 3

Giving an oxytocic drug, after a second twin has been excluded, and then waiting for the uterus to contract

Question 4

Which of the following is a contraindication to giving Syntometrine during the third stage of labour?

An atonic uterus

Hypotension after delivery

Any of the hypertensive disorders of pregnancy

Factors during pregnancy which result in a large uterus

Answer 4

Any of the hypertensive disorders of pregnancy

Question 5

Which oxytocic drug should be given if there is a contraindication to the use of Syntometrine?

Ergometrine

A combination of oxytocin and ergometrine

Oxytocin

Prostaglandin E2

Answer 5

Oxytocin

Question 6

Passive management of the third stage of labour includes:

Giving an oxytocic drug and then waiting for the signs of placental separation

Waiting for the signs of placental separation when the patient is then asked to bear down and spontaneously deliver the placenta

Pulling down steadily on the umbilical cord and pushing the uterus up when the patient has a contraction

Giving an oxytocic drug when the signs of placental separation appear so that the placenta can be spontaneously delivered

Answer 6

Waiting for the signs of placental separation when the patient is then asked to bear down and spontaneously deliver the placenta

Question 7

Which of the following signs do not confirm the diagnosis that the placenta has separated?

Lengthening of the umbilical cord

The fundus of the uterus moves from below to above the umbilicus

A sudden gush of blood runs out of the vagina

Suprapubic pressure does not result in shortening of the umbilical cord when the uterus is pushed upwards

Answer 7

Suprapubic pressure does not result in shortening of the umbilical cord when the uterus is pushed upwards

Question 8

What is an advantage of using the active method of managing the third stage of labour?

Retained placenta is uncommon.

An assistant is not needed.

As the oxytocic drug is given after the delivery of the placenta, complications with a second twin are avoided.

Blood loss during the third stage is reduced

Answer 8

Blood loss during the third stage is reduced.

Question 9

When should the umbilical cord be allowed to bleed before delivering the placenta?

With a multiple pregnancy after the first infant has been delivered

In a patient whose blood group is Rhesus negative and who has a single fetus

If the placenta has still not separated 30 minutes after the infant was delivered

With a retained placenta

Answer 9

In a patient whose blood group is Rhesus negative and who has a single fetus

Question 10

How should a prolonged third stage of labour be managed if the active method had been used?

Wait for a further 30 minutes for placental separation.

A doctor should perform a manual removal of the placenta in theatre as an emergency procedure.

As the active method of managing the third stage of labour has failed, the passive method should be used.

Start an intravenous infusion with a side infusion containing 20 units of oxytocin, make sure that the uterus is well contracted and apply controlled cord traction.

Answer 10

Start an intravenous infusion with a side infusion containing 20 units of oxytocin, make sure that the uterus is well contracted and apply controlled cord traction.

Question 11

When should the diagnosis of postpartum haemorrhage be made?

After a blood loss of more than 250 ml within the first 12 hours after delivery of the infant

After a blood loss of more than 750 ml within the first seven days after delivery of the infant

Only after the patient has lost 1000 ml blood

Any haemorrhage following the delivery of the infant which appears to be excessive must be regarded as a postpartum haemorrhage.

Answer 11

Any haemorrhage following the delivery of the infant which appears to be excessive must be regarded as a postpartum haemorrhage.

Question 12

What is the management of a retained placenta following the active management of the third stage of labour, if a portion of the placenta is not palpable in the vagina or lower segment of the uterus?

Pethidine and diazepam (Valium) must be given intravenously and a manual removal of the placenta done in the labour ward.

An intravenous infusion with a side infusion containing 20 units of oxytocin should be started to ensure a well-contracted uterus and then the patient should be referred to hospital for a manual removal under general anaesthesia.

Allow a further 30 minutes of observation before referring the patient.

Apply fundal pressure together with traction on the cord to deliver the placenta.

Answer 12

An intravenous infusion with a side infusion containing 20 units of oxytocin should be started to ensure a well-contracted uterus and then the patient should be referred to hospital for a manual removal under general anaesthesia.

Question 13

What should be done if a severe haemorrhage occurs before the delivery of the placenta and the third stage of labour is being managed by the passive method?

Wait until the signs of placental separation appear and then ask the patient to bear down.

Pull on the umbilical cord while pushing upwards on the uterus to get the placenta to separate as soon as possible.

A rapid intravenous infusion of 20 units oxytocin in 1000 ml Basol or normal saline must be started to ensure that the uterus is well contracted. The active method is then used to deliver the placenta.

Give 1 mg konakion by intramuscular injection and call a doctor to take over the management of the patient.

Answer 13

A rapid intravenous infusion of 20 units oxytocin in 1000 ml Basol or normal saline must be started to ensure that the uterus is well contracted. The active method is then used to deliver the placenta.

Question 14

What should be the first steps in the management of a postpartum haemorrhage when the placenta has already been delivered?

Call for help and the uterus must immediately be rubbed up.

A rapid intravenous infusion of 20 units of oxytocin should be started.

The patient’s bladder must be emptied.

The cause of the bleeding must be looked for.

Answer 14

Call for help and the uterus must immediately be rubbed up.

Question 15

Which sign suggests that the bleeding is caused by an atonic uterus?

The vaginal bleeding consists of a continuous stream of bright red blood.

The membranes are not complete.

The vaginal bleeding is intermittent and consists of dark red clots.

No uterus can be palpated on abdominal examination.

Answer 15

The vaginal bleeding is intermittent and consists of dark red clots.

Question 16

Which of the following is the most common cause of a postpartum haemorrhage due to an atonic uterus?

Abruptio placenta

The use of oxytocin during the first stage of labour

Polyhydramnios

A uterus full of blood clots

Answer 16

A uterus full of blood clots

Question 17

Which of the following statements about the placenta is correct?

The uterus should be evacuated if the membranes are found to be incomplete.

If a placental cotyledon is found to be missing when the placenta is examined, the uterus should be evacuated.

A single retained cotyledon is unlikely to cause a postpartum haemorrhage.

It is of no clinical value to examine the placenta after delivery to determine whether it is complete or not.

Answer 17

If a placental cotyledon is found to be missing when the placenta is examined, the uterus should be evacuated.

Question 18

What clinical finding indicates that the bleeding is from a tear?

The bleeding consists of a continuous stream of bright red blood.

The uterus is atonic on abdominal examination.

The patient is shocked and pale.

Dark red clots of blood are passed when the uterus is rubbed up.

Answer 18

The bleeding consists of a continuous stream of bright red blood.

Question 19

What is the probable diagnosis if a patient suddenly becomes shocked without any sign of vaginal bleeding during the third stage of labour, and on abdominal examination the uterus cannot be palpated?

An atonic uterus
A ruptured uterus
An inverted uterus
A cervical tear

Answer 19

An inverted uterus

Question 20

Which of the following statements about the prevention of HIV infection is correct?

Goggles should be worn by everyone involved with a delivery as the virus is present in both blood and liquor.

Goggles are not necessary as the virus cannot cause infection by contamination of the eyes.

Preventative measures are only needed with patients who are at high risk of HIV infection.

Needles should be replaced in their sheath as soon as possible after use in order to prevent needle stick injuries.

Answer 20

Goggles should be worn by everyone involved with a delivery as the virus is present in both blood and liquor.