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

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Do not give oxytocic prophylaxis.
Leave the cord unclamped until completion of the third stage. This practice allows the physiological action of contraction and retraction of the uterus to proceed naturally, and is thought to minimize any delay in separation and to prevent excessive bleeding. Delayed clamping of the cord will cause fetal-maternal transfusion and is therefore not advised for Rh-negative women. Some schools of thought suggest that early clamping of the cord shortens the length of the third stage.
Ideally, the baby should be put to the breast to suckle, as this ensures the continued release of oxytocin to assist separation and expulsion of the placenta.
Ensure that the bladder is empty; failure to do this may cause delay in the third stage and possibly predispose to bleeding.
A ‘hands off the abdomen’ approach is crucial, as any manipulation of the uterus disturbs the rhythmical coordination of the uterine muscles, and will negate the physiological process.
Observe vaginal loss to ensure that bleeding is not excessive. A gush of blood indicates the beginning of separation.
A squatting position is most beneficial to aid expulsion of the placenta as this works with gravity and gives increased intra-abdominal pressure.
Await the onset of expulsive contractions—this is usually an indication that the placenta has separated and descended into the lower segment. The weight of the placenta causes stimulation and pressure in the vagina, which triggers off expulsive contractions. Often the woman will involuntarily bear down and push the placenta out.
Advise the woman that expulsive contractions are similar, but often not as strong as the contractions experienced in the second stage, and may easily be missed.
As the uterus descends, it becomes rounder and smaller, the fundus rises and becomes harder and more mobile.
The cord lengthens—this is another indication that the placenta has descended into the lower segment and is ready to be expelled.
If you are sure that the placenta has separated and the woman does not experience contractions, encourage the woman to push down in a similar way to the second stage of labour to expel the placenta.
Once the placenta is delivered, assist with easing the membranes out of
the vagina. Either attach artery forceps or hold the placenta in both hands, rotating it so that the membranes form a rope-like appearance, then use very gentle traction to avoid tearing and retention of membranous material.
Recommended reading
Walsh D (2007).
Evidence-based Care for Normal Labour and Birth
. London: Routledge.
1
Prendiville W, Harding J, Elbourne D, Stirrat G (1988). The Bristol third stage trial: active versus physiological management of third stage of labour.
British Medical Journal
297
, 1295–300.
CHAPTER 15
Normal labour: third stage
292‌‌
Active management of the third stage
The third stage of labour, if managed actively, will usually be a short, passive stage for the woman, lasting no more than 10min, while she will be focused on her baby. However, this is also the most dangerous stage of labour as the risk of haemorrhage is at its greatest. Therefore sound physi- ological knowledge and the expertise of the midwife is essential to ensure a safe outcome for the woman.
Active management for the third stage has been the routine for many decades; however, in recent years women and midwives have increasingly been returning to a physiological managed third stage. In order for women to be fully informed about their care in the third stage, discuss the options prior to labour, so that they can make an informed, unhurried choice.
Active management is associated with less blood loss, shorter duration, fewer blood transfusions, and less need for therapeutic oxytocics. However, there is some debate that when the effect of oxytocic drugs wears off, women may experience heavier postnatal blood loss than those who had a physiological third stage.
^1,2
Management
- Ensure that the woman is comfortable, whether in the dorsal or an upright position.
- Based on an earlier explanation of the third stage, reinforce what the procedure involves, to encourage the woman’s cooperation.
- Maintain a high standard of hygiene and aseptic technique throughout, to prevent contamination and infection.
- An oxytocic drug will have been administered at the birth of the anterior shoulder, intramuscularly into the upper lateral aspect of the thigh. This is usually one ampoule of Syntometrine
  ^®, which contains 5IU oxytocin and 0.5mg ergometrine. Oxytocin acts within 2–3min, whereas ergometrine acts within 6–8min, the effects lasting up to 2h.
- Ergometrine is not recommended for women with the following conditions:
  - Hypertension
  - Cardiac disease
  - Following B-agonist infusion, such as salbutamol or ritodrine
  - Raynaud’s disease
  - Severe asthma.
    In these situations oxytocin 10IU, given intramuscularly, is usually used. Check the local guidelines relating to management of the third stage.
- Ergometrine can cause nausea, vomiting, and hypertension.
- Wait for the signs of separation and descent of the placenta, i.e. the cord lengthening at the vulva, minimal fresh blood loss, and contraction
  of the uterus. The uterus will change from feeling broad to firm, central, and rounded at the level of the umbilicus.
- Do not manipulate the uterus in any way, in order to avoid overstimulation or incoordinate activity.
ACTIVE MANAGEMENT OF THE THIRD STAGE
293
Once you are happy that the uterus is contracted and separation has occurred, deliver the placenta and membranes by controlled cord traction.
Cover the woman’s abdomen with a sterile towel. Place one hand (usually the left) above the level of the symphysis pubis, with the palm facing towards the umbilicus. Apply firm upwards pressure to achieve counter traction and to guard the uterus.
With the other hand, grasp the cord firmly and wrap it around your index and middle finger. Maintain firm, steady, and consistent traction in a downwards and backwards direction in line with the birth canal to guide the placenta and membranes into the vagina.
If strong resistance is felt, or you feel that the membranes are breaking, then cease traction and use maternal effort instead.
The object is to deliver the placenta in one continuous, controlled movement; however, there may need to be pauses in the process until the placenta is visible. Always reinstate your guarding hand before attempting traction after such a pause.
Once the bulk of placenta is visible, the direction of the traction becomes horizontal and upwards, to follow the contour of the birth canal.
Once the whole of the placenta has become visible, cup it in both hands to gently ease it out of the vagina without causing damage to the delicate membranes.
In order to prevent tearing of the membranes, with two hands holding the placenta, help to coax the membranes out of the vagina with an upwards and downwards movement or a twisting action, forming a rope. This action is repeated until the membranes are completely free.
Collect the placenta and membranes in a sterile receiver placed near the perineum.
Assess the blood loss as accurately as possible.
Inspect the perineum for trauma.
Ensure the comfort and hygiene of the woman by cleaning the immediate perineal area, applying clean sanitary towels, etc.
Check the placenta and membranes to ensure they are complete. Report any abnormalities to a senior doctor and to the receiving midwife on the postnatal ward.
1. Wickham S (1999). Further thoughts on the third stage.
  Practising Midwife
  2
  (10), 14–15.
2. Harris T (2001). Changing the focus for the third stage of labour.
  British Journal of Midwifery
  9
  (1), 7–12.
  CHAPTER 15
  Normal labour: third stage
  294‌‌
  Assessing and repairing the perineum
  Women who require suturing to the perineum following childbirth may well experience confused and turbulent emotions, from exhilaration to tiredness and anxiety. The prospect of the repair may well prove to be daunting and stressful for her. Midwives are increasingly trained and fully supervised to carry out perineal repair as this is now covered in midwifery training. Not only is it important for the midwife to carry out the proce- dure in a skilful and competent manner, but it is also important to ensure that the woman’s experience is not a lonely, undignified, and threatening ordeal. This can be achieved by considering the following:
  - The environment
  - The comfort and position of the woman
  - Presence of supportive carers
  - Information and explanation about the procedure
  - Consideration of the woman’s birth experience
  - Thorough assessment of the perineal damage, and referral to obstetrician if necessary
  - Satisfactory pain relief.
    Midwives involved in perineal repair should be aware of their limitations in suturing more complex trauma. It is not the midwife’s responsibility to repair the following, and these should be referred to an obstetrician:
  - Third/fourth degree tears
  - Extended episiotomy
  - Vulval varicosities
  - Severe haemorrhoids
  - Severe bruising of the perineum or a haematoma
  - Labial lacerations
  - Vulval warts
  - Following previous third degree tear or extensive scar tissue.
    Assessing perineal trauma
  - Anterior labial tears: there is some debate about the merits of leaving these unsutured. This depends very much on the degree of bleeding. Oozing immediately following childbirth may resolve itself after a short period if a sanitary towel is placed securely between the legs, however, sometimes just one suture may be required to stabilize haemostasis.
  - Posterior perineal trauma: spontaneous tears are classified by degrees of trauma relating to the anatomical structures involved.
    - First degree tears: this involves the skin of the fourchette only. This may be left to heal spontaneously or a single suture inserted— discussion with the woman about her options may determine the management.
    - Second degree tear and episiotomy: this involves the skin of the
      fourchette, the perineum, and perineal body. The superficial
muscles affected are the bulbocavernosus and the transverse perineal muscles. Deeper muscle layer trauma may involve the pubococcygeus.
ASSESSING AND REPAIRING THE PERINEUM
295
- Third degree tear: in addition to second degree trauma, there is damage to the anal sphincter.
- Fourth degree tear: this describes trauma that involves all of the above structures which extends into the rectal mucosa.
Preparation for perineal repair