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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

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If necessary, remove mucus gently from the baby’s nose and mouth.
The mother may wish to touch or watch the baby’s head as it delivers; she may wish to assist with the birth of the trunk.
Following restitution (after the head is born it realigns itself with the shoulders) observe for external rotation of the head, assist in delivery of the shoulders by placing your hands on either side of the baby’s head and applying downwards traction with the next contraction to free the anterior shoulder, and then upwards traction to deliver the posterior shoulder and trunk by lateral flexion.
If the mother is in an upright position, it may be difficult to see the baby, but be ready to receive the baby’s head and body and assist if necessary. Upright positions maximize the diameters of the pelvic outlet and therefore the need for manoeuvres is less likely.
Place the baby directly on to the mother’s abdomen/chest/arms to encourage immediate bonding. Cover the baby and keep him/her warm by maintaining skin-to-skin contact with the mother.
Note the time of birth.
Cut the cord after pulsation has ceased, unless there are specific reasons not to.
Keep contemporaneous records of the labour and birth.
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Normal labour: third stage
‌‌
Chapter 15
287
Care during the third stage of labour
288
Physiological management of the third stage
290
Active management of the third stage
292
Assessing and repairing the perineum
294
Examining the placenta and membranes
298
CHAPTER 15
Normal labour: third stage
288‌‌
Care during the third stage of labour
The third stage of labour is potentially hazardous for the woman due to the increased risk of haemorrhage, particularly immediately following delivery of the placenta. Life-threatening haemorrhage occurs in approxi- mately 1 per 1000 births. However, estimates of PPH vary widely—from 4% to 18%.
¹
Definition of primary postpartum haemorrhage
Primary PPH is traditionally defined as the loss of >500mL of blood from the genital tract within the first 24h after the birth. If haemodynamic changes manifest in the newly delivered woman with loss <500mL, this may also be regarded as a primary PPH. Recently a blood loss of 1000mL has been considered as a more realistic definition of primary PPH.
Causes and risk factors associated with primary PPH
History
- Previous PPH or previous retained placenta
- Previous precipitate, prolonged, or traumatic labour
- Previous APH
- Uterine scar
- HIV/AIDS
- Uterine fibroids or other anomalies.
  Pregnancy
- High parity
- Multiple pregnancy
- Polyhydramnios
- Coagulation disorders
- Anaemia
- Placenta praevia
- APH
- Pre-eclampsia.
  Labour
- Precipitate labour
- Prolonged labour
- Induction of labour or augmentation of labour
- Large doses of narcotics and/or epidural analgesia
- General anaesthesia
- Tocolytic drugs (used to suppress uterine activity in preterm labour)
- Infection—chorioamnionitis
- Ketoacidosis.
  Third stage
  •
  Incomplete separation of the placenta
- Full bladder
- Retained cotyledon, placental tissue, or membranes
- Mismanagement of the third stage, disrupting the rhythm of myometrial activity
- Inversion of the uterus.
  CARE DURING THE THIRD STAGE OF LABOUR
  289
  There are two ways in which the third stage may be managed: either by active management (b see Active management of the third stage,
  1. 292) or by physiological management (b see Physiological manage- ment of the third stage, p. 290). However, it has been suggested that the third stage should not be managed at all, and that attention to creating the right environment to enhance physiological efficiency is far more important; therefore preventing intervention that is likely to lead to complications.
    ²
    General care
You should be proficient with the proposed management of the third stage.
Note the latest haemoglobin results and blood pressure recordings in pregnancy. Review blood pressure recordings and any complications arising in labour before third stage management is determined.
Ensure that the woman is fully conversant with, and understands, the process of the third stage and her involvement.
Maintain positions of comfort and dignity throughout.
Careful observation of blood loss, and arrange for assistance to be available should abnormal bleeding occur.
Blood loss >500mL is considered to be significant. Generally, blood loss tends to be underestimated, especially the greater the blood loss.
Some schools of thought suggest that healthy women can cope
with a blood loss of up to 1000mL.
³However, accurate estimation of blood loss is crucial for both active and physiological management.
If blood loss is significant, watch the woman’s condition carefully, looking for symptoms of shock and observing the lochia and vital signs regularly following or during the third stage.
Check the placenta and membranes thoroughly following delivery, to ensure there are no abnormalities and that they are complete. Retained products can result in sepsis and secondary PPH. Any suspicion of ragged membranes or missing placental tissue should be recorded in the notes and the information passed on to the receiving midwife taking over the woman’s care.
The woman should be alerted to monitor her lochia and report any abnormally heavy bleeding or clots.
1. Harrison K (1998). Management of postpartum haemorrhage.
  Prescriber Update
  16
  , 4–9.
2. Odent M (1998). Don’t manage the third stage of labour!
  Practising Midwife
  1
  (9), 31–3.
3. Bose P, Regan F, Paterson-Brown S (2006). Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions.
  BJOG International Journal of Obstetrics and Gynaecology
  113
  , 919–24.
  CHAPTER 15
  Normal labour: third stage
  290‌‌
  Physiological management of the third stage
  A physiological third stage of labour may be the choice for women who prefer to avoid intervention during childbirth. Placental separation occurs physiologically without resorting to oxytocic drugs, and expulsion of the pla- centa is achieved by maternal effort The average length of the third stage is 15–60min, although in some cases, provided there are no abnormal signs, it may occasionally last up to 120min. The Bristol trial indicated that there is a higher incidence of PPH with a physiological third stage.
  ¹However, criticisms of the trial suggest that inexperience in managing the third stage of labour was a serious flaw. More recent studies have found no difference in the incidence of PPH between active and physiological management of the third stage.
  Physiology of the third stage
  - Detachment of the placenta commences with contractions that deliver the baby’s trunk.
  - Once the baby is born, the uterus is greatly reduced in size due to the powerful contraction and retraction of the uterine muscles.
  - Consequently, the placental site is also greatly reduced. When the placental site is reduced by one-half it becomes puckered and starts to peel away from the uterine wall.
  - This is assisted by the tightly compressed and contracted uterus. As a result, fetal blood is pumped into the baby’s circulation. Maternal blood is driven back into the spongy layer of the decidua.
  - The congested veins are then forced to rupture. The effused blood from the congested veins results in detachment of the placenta. The veins are caused to rupture as the blood in these veins cannot return to the maternal circulation.
  - Bleeding is controlled by the presence of ‘living ligatures’. Plain muscle fibres of the uterus entangle around the exposed bleeding blood vessel site, preventing further blood loss.
  - When separation of the placenta is complete (usually 3–5min), the upper segment of the uterus contracts strongly, forcing the placenta into the lower segment and then the vagina.
  - Detachment of the membranes commences in the first stage of labour, when the membranes rupture they are shorn from the internal os. This is then completed in the third stage when the weight of the descending placenta allows them to peel away from the wall of the uterus.
Methods of detachment
Schultze method
: approximately 80% of cases detach by this method. The placenta starts to detach from the centre and leads its descent down the
vagina. The fetal surface of the placenta therefore appears first at the vulva,
with the membranes trailing behind. The retroplacental clot is situated inside the membrane sac. Minimal visible blood loss is the result.
Matthews Duncan method
: separation of the placenta commences at the lower edge, which allows the placenta to slide down sideways, exposing the maternal surface. This usually results in increased bleeding due to the slower rate of separation and no retroplacental clot being formed.
PHYSIOLOGICAL MANAGEMENT OF THE THIRD STAGE
291
Expectant or physiological management of the third stage
It is important that midwives familiarize themselves with the principles and practice of the physiological third stage (as opposed to active manage- ment, with which they may have more experience). It is equally impor- tant to ensure that consent from the woman has been obtained, and that she understands her role. A physiological third stage is not recommended when the preceding stages have not been conducted physiologically.
Management