1. Third stage of labourThird stage of labour
(Normal & abnormal)(Normal & abnormal)
Fahad zakwanFahad zakwan

2. •DefinitionDefinition ::
• 33rdrd
stage of labor: commences with the deliverystage of labor: commences with the delivery
of the fetus and ends with delivery of theof the fetus and ends with delivery of the
placenta and its attached membranes.placenta and its attached membranes.
• DurationDuration::
- normally 5 to15 minutes.- normally 5 to15 minutes.
- 30 minutes have been suggested if there is no- 30 minutes have been suggested if there is no
evidence of significant bleeding.evidence of significant bleeding.
• The risk of complications continues for someThe risk of complications continues for some
period after delivery of the placenta.period after delivery of the placenta.
• Fourth stage of laborFourth stage of labor:: begins with thebegins with the
delivery of the placenta and lasts for 1 hour.delivery of the placenta and lasts for 1 hour.

3. SignificanceSignificance
Postpartum haemorrhage (PPH) :Postpartum haemorrhage (PPH) :
- Maternal mortality.- Maternal mortality.
-- AnemiaAnemia: PPH causes anemia or poor iron. Anemia causes: PPH causes anemia or poor iron. Anemia causes
weakness and fatigue. prolonged hospitalization affects theweakness and fatigue. prolonged hospitalization affects the
establishment of breastfeeding.establishment of breastfeeding.
- Blood transfusion- Blood transfusion transfusion reaction and infection.→ transfusion reaction and infection.→
- Emergency anesthetic intervention: due to severe PPH,- Emergency anesthetic intervention: due to severe PPH,
retained placenta, and uterine inversion.retained placenta, and uterine inversion.
-- SepsisSepsis: due to exploration or instrumentation of the uterus.: due to exploration or instrumentation of the uterus.

4. Mechanism of placentalMechanism of placental
separationseparation
• Uterine contractions and retractionUterine contractions and retraction reduce thereduce the
uterine cavityuterine cavity →→ placental detachment and expulsionplacental detachment and expulsion
into the lower uterine segment.into the lower uterine segment.
• Retro-placental hematoma.Retro-placental hematoma.
** OxytocinOxytocin,, ergometrineergometrine andand prostaglandinsprostaglandins enhanceenhance
placental separation and expulsion by causingplacental separation and expulsion by causing
uterine contraction .uterine contraction .
** Tocolytics/nTocolytics/nitroglycerinitroglycerin and some inhalationand some inhalation
anesthetics cause uterine relaxation and delay ofanesthetics cause uterine relaxation and delay of
placental separation causing dangerous bleedingplacental separation causing dangerous bleeding
following deliveryfollowing delivery..

6. What to do before delivery of theWhat to do before delivery of the
placenta?placenta?
1.1. Look for signs of placental separation:Look for signs of placental separation:
 lengthening of the umbilical cord outside.lengthening of the umbilical cord outside.
 The uterus becomes firm and globular.The uterus becomes firm and globular.
 The uterus rises in the abdomen.The uterus rises in the abdomen.
 A gush of blood.A gush of blood.
2.2. Assess the uterusAssess the uterus::
• To exclude an undiagnosed twinTo exclude an undiagnosed twin
• To determine a baseline fundal heightTo determine a baseline fundal height
• to detect the signs of placenta separationto detect the signs of placenta separation
• to detect an atonic uterus.to detect an atonic uterus.

7. Delivery of the placentaDelivery of the placenta
11.. Physiological or expectantPhysiological or expectant
management:management:
-- Wait for the signs of placental separationWait for the signs of placental separation
- Make sure that the uterus is contracted.- Make sure that the uterus is contracted.
-- Controlled Cord tractionControlled Cord traction: the body of the: the body of the
uterus is supported above the symphysis pubisuterus is supported above the symphysis pubis
by the left hand directed upward andby the left hand directed upward and
backward. Then cord traction is appliedbackward. Then cord traction is applied
continuously downward and forward with thecontinuously downward and forward with the
right hand.right hand.

8. 2.2. Active management:Active management:
- By using one of the following:- By using one of the following: ErgometrineErgometrine,,
OxytocinOxytocin, or, or SyntometrineSyntometrine (ergometrine +(ergometrine +
oxytocin ).oxytocin ).
- Given at the- Given at the delivery of anterior shoulder ordelivery of anterior shoulder or
after delivery of the baby.after delivery of the baby.
- Immediate delivery of the placenta with- Immediate delivery of the placenta with
CCT.CCT.
Avoid uterine massage before placentalAvoid uterine massage before placental
deliverydelivery..

9. Mode of drugs administrationMode of drugs administration
• Oxytocin:Oxytocin:
- 10 IU, intramuscularly + with intravenous access in place,- 10 IU, intramuscularly + with intravenous access in place,
10-20 IU is placed in 500-1000 mL of crystalloid and run10-20 IU is placed in 500-1000 mL of crystalloid and run
quickly.quickly.
- With cesarean deliveries: 5 IU is administered as an- With cesarean deliveries: 5 IU is administered as an
intravenous bolus, followed by a similar infusion.intravenous bolus, followed by a similar infusion.
• ErgometrineErgometrine:: dose is 0.25- 0.5 mgdose is 0.25- 0.5 mg IM or IV.IM or IV.
• SyntometrineSyntometrine (0.5 mg of ergometrine with 5 IU of(0.5 mg of ergometrine with 5 IU of
oxytocin)oxytocin)
The dose is 2 mg and given IM only.The dose is 2 mg and given IM only.

10. Delivery of membraneDelivery of membrane
ByBy rotatingrotating the placentathe placenta
about the insertion site as itabout the insertion site as it
descends ordescends or graspinggrasping thethe
membranes with a clamp ormembranes with a clamp or
artery forceps and drawnartery forceps and drawn
down.down.

12. Umbilical cord managementUmbilical cord management
Cord clampingCord clamping:: Delayed until theDelayed until the
cord is pulseless, usuallycord is pulseless, usually 2-42-4
minutesminutes,,
•↑↑Hb,Hb,
•↑↑iron stores in the newborn andiron stores in the newborn and
•↓↓levels of early childhood anemia.levels of early childhood anemia.

13. Physiological Versus ActivePhysiological Versus Active
ManagementManagement
PhysiologicalPhysiological
ManagementManagement
ActiveActive
managementmanagement
Uterotonic agentUterotonic agent None or afterNone or after
placenta deliveredplacenta delivered
With delivery ofWith delivery of
anterior shoulder oranterior shoulder or
babybaby
UterusUterus Assessment of sizeAssessment of size
and tone afterand tone after
deliverydelivery
Assessment of sizeAssessment of size
and tone afterand tone after
deliverydelivery
Cord tractionCord traction NoneNone controlled cordcontrolled cord
traction when uterustraction when uterus
contractedcontracted
Cord clampingCord clamping VariableVariable EarlyEarly

14. Immediately after delivery of theImmediately after delivery of the
placentaplacenta
1.1. Determine the fundal position and size ofDetermine the fundal position and size of
the uterus.the uterus.
2.2. Ensure that the uterus is contracted (canEnsure that the uterus is contracted (can
be enhanced with oxytocin and uterinebe enhanced with oxytocin and uterine
massage).massage).
3.3. Examine the placenta for completenessExamine the placenta for completeness
and detection of abnormalities.and detection of abnormalities.
4.4. Suturing of lacerations.Suturing of lacerations.

15. Fourth stageFourth stage
• Observe the vital signs.Observe the vital signs.
• palpate the abdomen to assess and monitor uterine tonepalpate the abdomen to assess and monitor uterine tone
and size.and size.
• Do uterine massage.Do uterine massage.
• Ensure continuous infusion of oxytocin.Ensure continuous infusion of oxytocin.
• Encourage early breastfeeding to promote endogenousEncourage early breastfeeding to promote endogenous
oxytocin release.oxytocin release.
• assess the lower genital tract for bleeding.assess the lower genital tract for bleeding.
• repair of an episiotomy or any lacerations.repair of an episiotomy or any lacerations.
• Close observation every 15 minute for the next hour.Close observation every 15 minute for the next hour.

17. COMPLICATIONSCOMPLICATIONS
• Uterine atony.
• Retained placenta.
• Trauma.
• Uterine inversion.
Postpartum hemorrhagePostpartum hemorrhage

18. Postpartum hemorrhage ( PPH)
Def: is an excessive blood loss from the genital tract after delivery
of the baby. It is divided into primary and secondary PPH.
Primary PPH: blood loss of 500 ml or more in the first 24 hours
after delivery.
• Causes:
Uterine atony.
Genital tract trauma.
retained placental tissue.
Uterine inversion.
Coagulation disorders:
- Inherited coagulopathy.
- Abruptio placentae.
- Retained dead fetus.
- Amniotic fluid embolism.

19. Uterine Atony
• Inability of the uterus to contract and retract effectively.
• The uterus increases in size (retained products) and is felt soft
and boggy.
• The patient has a rapid, thready pulse with a decrease in BP.
The patient may also looks pale and apprehensive.

20. Uterine Atony
• Factors predisposing :
• Over-distension of the uterus:Over-distension of the uterus:
multiple pregnancy, poly-
hydramnios or fetal macrosomia.
• Retained products of conception:Retained products of conception:
the placenta , placental cotyledon or
fragments or a large amount of
membranes.
• large placental site: multiple
pregnancy.
• Prolonged labor: weak or
incoordinate uterine action or
mechanical difficulty will leading to
uterine exhaustion and atony.
• Placenta praevia: inability of the
lower uterine segment to contract
and retract.
• Abruptio placentae: interstitial
uterine hemorrhage and later
hypofibrinogenaemia.
• Grand-multiparity: (a parity of 5
or more) ↑ fibrous tissue of the
uterus ↓ muscular tissue.
• Operative deliveries: C/S &
general anaesthesia that relax the
myometrium, such as Halothane
and Cyclopropane.
• multiple fibromyomata
(leiomyomata), especially of the
interstitial type resulting in
ineffective uterine contraction and
retraction.
• full bladder.

21. Genital tract trauma:
Causes:
• perineal laceration or episiotomy: obvious bleeding.
• Vaginal or cervical lacerations or tears: tend to occur over the
perineal body, periurethral area and over the ischial spines al.
• Lacerated or ruptured uterus.
Predisposing factors:
• Difficult labor.
• Precipitate labor.
• previous caesarean section.
• Instrumental delivery: forceps, Ventouse or CS.
Genital tract trauma is suspected when there is continuous bleeding
and the uterus is well contracted, particularly after an oxytocic drug
has been given

22. Retained placental tissue
• Uterine atony
• Morbidly adherent placenta:
- Due to abnormal development of decidua basalis.
- Causes: previous CS, placenta previa, manual removal of placenta or uterine
curettage.
- Degrees: 1) accreta (80%). 2) increta. 3) percreta.
- Diagnosis: 1) antenatally: U/S & MRI
2) in 3rd
stage: commonly
• Caught of placenta by the retraction ring at the junction of the upper and lower
segments: following an Ergometrine injection than Syntometrine or Oxytocin
injections.

23. Inversion of the uterus
 the fundus of the uterus descends through the uterine body and
cervix into the vagina, and sometimes protrudes through the
vulva. This → traction on peritoneal structures → vasovagal
vasodilatation + neurogenic chock.
Predisposing factors:
• mal-management of the third stage: inappropriate traction
during CCT or too rapid removal during MRP.
• ↑intra-abdominal pressure + relaxed uterus (fundal pressure).
• Previous history of inversion ( 33%).
• Cornual placenta ( cornual pockets).

24. Management of (PPPH)
 Two important principles:
• The bleeding must be stopped.
• the blood volume must be restored.
 guidelines for PPH management:
• Call for help ( senior staff, midwives, anesthetists and hematologists).
• Ensure at least two peripheral infusion lines with large-bore IV
canulae.
• Blood sample should be taken for a full blood count, coagulation studies
and blood group and cross-matching.
• Start intravenous fluid ( Hartmann’s or saline).
• Give blood when it is available.
• Give intravenous oxytocic drugs ( methergine or syntocinon).
• Examination to determine the cause.

25. Management of (PPPH)
Uterine atony: the placenta has delivered:
• Resuscitate the patient as mentioned above.
• Stimulate uterine contraction by:
- Uterotonics: IV ergometrine (0.5 mg), IV Syntocinon (5 iu) or
IM syntometrin ( 1ml) + 30-40 units of syntocinon in 40 ml of
normal saline run at 10 ml/hr.
- uterine massage and bimanual compression.
• Packing of the uterine cavity (gauze/balloon insufflation).
• If no response: give prostaglandin analogues e.g. Carboprost
Hemabate, 0.25 mg every 15-90 min. up to 8 doses given by
deep IM or Gemeprost intramyometrial or misoprostol
rectally.
• If still no response, then go for examination under anesthesia
and surgery ( uterine arteries ligation, infundibulo-pelvic
vessels ligation internal iliac artery ligation, compression
sutures or hysterectomy).

26. Management of (PPPH)
Uterine atony: the placenta not delivered:
• Resuscitate the patient as
mentioned above.
• Ensure uterine contraction.
• try to deliver the placenta by
controlled cord traction.
• if the placenta not delivered,
then take the patient to the theatre
for manual removal of the
placenta under general
anesthesia.
• Ergometrine should be given and
syntocinon in a drip should be
set.

27. Management of (PPPH)
• Trauma:
• Is suspected when the bleeding persists, with well contracted uterus.
• Full exploration under general anesthesia for the vulva, the vagina,
cervix and uterus.
• Vaginal and cervical lacerations should be sutured.
• Ruptured uterus is treated by repair or subtotal hysterectomy.

28. Management of (PPPH)
Uterine inversion:
The condition is diagnosed in various ways:
- Acute complete inversion: absent uterus on abdominal
examination.
- Incomplete inversion: presence uterine dimpling on abdominal
examination.
The treatment includes:
• Resuscitation + manual replacement prior to onset of shock.
• manual replacement under general anesthesia (shock) if fails
• O’Sullivan’s hydrostatic method: the vagina is filled with
warm saline which is gradually instilled into the vagina by
means of a douche can and tubing. The introitus is blocked with
assistant’s fist. 4 to 5 L of saline will balloon the vagina,
distend the uterus and so, reverse the inversion.
• Laparotomy (Haultain’s): incision in the muscular ring in the
posterior uterine wall and correction.

29. Management of (PPPH)
• DIC:
1. Maintain the intravascular volume.
2. Administer fresh frozen plasma(FFP) at a rate to
keep the activated partial thromboplastin: control
ratio < 1.5.
3. Administer packed platelet to maitain a platelet
count > 50 × 109
/L.
4. Administer cryoprecipitate to keep the fibrinogen
level > 1 gm/L.