8.1 Normal third stage of labour

The third stage of labour refers to the period that starts immediately after delivery of the newborn and ends with the completed delivery of the placenta and its attached membranes.

There is a significant risk of haemorrhage during this stage of labour. All patients require close monitoring and active prevention of haemorrhage, whether or not there are risk factors.

8.1.1 Description

The third stage usually lasts 5 to 15 minutes.

– After the newborn is delivered, there is a rest period without contractions that lasts, on average, 10 minutes. Use this time to take care of the newborn. Watch the mother carefully, however, for signs of haemorrhage, which can occur at any time.

– Then, contractions resume, the placenta separates spontaneously. On abdominal palpation the uterine fundus can be felt ascending and then descending again, corresponding to the migration/descent of the placenta. When the entire placenta has reached the vagina, the uterus retracts and forms a hard ball above the pubic bone.

– The blood loss accompanying delivery of the placenta should not exceed 500 ml.

8.1.2 Routine prevention of postpartum haemorrhage

Active management of third stage of labour1

Active management of third stage of labour consists in the administration of oxytocin before placental expulsion, followed by controlled cord traction then uterine massage to help retraction of the uterus.

Administration of oxytocin immediately after the birth (or after the birth of the last infant in a multiple pregnancy) AND before delivery of the placenta accelerates separation of the placenta, facilitates its delivery and helps prevent postpartum haemorrhage.

Immediately after the birth of the infant, palpate the mother's abdomen to be sure she is not carrying twins, then administer oxytocin slow IV or IM: 5 or 10 IU.

Then after clamping and cutting the cord, deliver the placenta with controlled cord traction (during a contraction with counter pressure to the uterus, with a hand placed on the abdomen).

When oxytocin is used prior to delivery of the placenta, there is in theory, and especially if the injection is not done immediately (i.e. within 3 minutes), a risk of retained placenta. For this reason, the birth attendant who administers oxytocin immediately after delivery of the infant must be able to perform manual removal of the placenta, should it be necessary. If these conditions are not met, oxytocin should be administered after placental expulsion.

Use of oxytocin after delivery of the placenta

If oxytocin has not been given prior to placenta delivery, it should be administered after the placenta has been completely delivered. This is less effective in preventing postpartum haemorrhage, however.

oxytocin slow IV or IM: 5 or 10 IU

Uterine exploration to remove any placental fragments will be more difficult after injecting oxytocin. Be sure that the placenta is complete before administering oxytocin.
In addition, massage the uterus to help uterine retraction.

8.1.3 Monitoring

– The birth attendant should check:
• The heart rate and blood pressure, and the amount of vaginal bleeding, while waiting for the placenta to deliver. Monitoring should be maintained after expulsion of the placenta (every 15 minutes for the first hour, then every 30 minutes for the next hour) as the risk of haemorrhage persists.
• The length of the rest period: in the absence of haemorrhage, a maximum delay of 30 to 45 minutes is tolerated for the expulsion of the placenta. After that, the placenta should be removed manually (Chapter 9, Section 9.2).
• That the uterus retracts and remains retracted.
• That the entire placenta has been expelled.

– Uncontrolled traction on the cord (i.e., done without a contraction or counterpressure) is contra-indicated, as it can cause tearing of the placenta and, afterwards, retention of placental fragments (with the attendant risk of haemorrhage and infection).

– Abdominal palpation can be used to determine whether the placenta has separated, by pressing down on the abdomen just above the pubic bone. If the cord does not retract when pressure is applied, the placenta has separated (Figure 8.1).

– To facilitate expulsion from the vagina if it seems to be going slowly after the separation, apply moderate pressure to the uterine fundus, directed toward the vagina.

Figure 8.1 - Placental separation has occurred if the cord fails to retract with abdominal pressure

8.1.4 Examination of the placenta

Always examine the placenta to verify that it has been completely expelled. The uterus can only retract properly if it is empty. Sooner or later, retained debris will lead to haemorrhage or infection.

Examination of the membranous sac

Straighten the sac by inserting a hand into it, looking for a vessel that ends abruptly— indicating that there might be a succenturiate lobe remaining in the uterus—or for a tear pointing to retained membrane. In these cases, manual uterine exploration may be required (Chapter 9, Section 9.3).

Examination of the maternal surface of the placenta

Regular, bright red cotyledons. Any holes, roughened or depressed areas, or any deep cuts that fail to line up when the cotyledons are brought together may suggest retained placenta, requiring uterine exploration for removal.