1. Third stage of labour
Dr.Roaa H. Gadeer MD

2. Definition
commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes.
The length of the third stage is 5-15 minutes. 30 minutes have been suggested if there is no evidence of significant bleeding.
The risk of complications continues for some period after delivery of the placenta.
Fourth stage of labor: begins with the delivery of the placenta and lasts for 1 hour

3. Significance
Postpartum haemorrhage (PPH) : It is a leading cause of maternal mortality.
Maternal death: The maternal mortality rate in the United States is approximately 7-10 women per 100,000 live births; 8% of these deaths are caused by PPH. The maternal mortality rates in developing world exceeded 1000 women per 100,000 live births, 25% of these deaths are due to PPH.
Anemia: PPH may cause anemia or poor iron. Anemia may cause weakness and fatigue. prolonged hospitalization may affect the establishment of breastfeeding.
transfusion reaction and infection: Due to blood transfusion.
Emergency anesthetic intervention: due to severe PPH, retained placenta, and uterine inversion.
Sepsis: due to exploration or instrumentation of the uterus.

4. What to do before delivery of the placenta ?
Inspect the cervix and vagina for lacerations.
Look for signs of placental separation.

5. Mechanism of placental separation
Uterine contractions and retraction reduce the surface area → placental detachment and expulsion into the lower uterine segment.
Retro placental hematoma.
* Agents causing uterine contraction (uterotonic): oxytocin, ergometrin and prostaglandins enhance placental separation and expulsion .
* Agents (tocolytics/nitroglycerin and some inhalation anesthetics) cause uterine relaxation and delay of placental separation causing dangerous bleeding following delivery.
* As the placenta detaches, the spiral arteries are exposed in the placental bed; massive hemorrhage would occur if not for the structure of uterus. The vessels supplying the placental bed traverse a latticework of crisscrossing muscle bundles that occlude and kink-off the vessels as they contract and retract following expulsion of the placenta. This arrangement of muscle bundles has been referred to as the "living ligatures" or "physiologic sutures" of the uterus (Baskett, 1999).

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

7. Delivery of the placenta
Physiological or expectant management:
-Wait for the signs of placental separation
- Make sure that the uterus is contracted.
- Controlled Cord traction: the body of the uterus is supported above the symphysis pubis by the left hand directed upward and backward. Then cord traction is applied continuously downward with the right hand.
active management:
- By using 1 of 3 uterotonic agents: ergometrine, oxytocin, or ergometrine- oxytocin (Syntometrine
- Given at the delivery of anterior shoulder or after delivery of the baby.
- Immediate delivery of the cord with CCT.
Avoid uterine massage before placental delivery.

8. Delivery of membrane :
by rotating the placenta about the insertion site as it descends or grasping the membranes with a clamp.

9. Umbilical cord management
cord clamping: Delayed until the cord is pulseless, usually 2-4 minutes, →↑Hb, ↑iron stores in the newborn and ↓levels of early childhood anemia.
Method of cord clamp:

10. Physiological Versus Active Management
Physiological Management
Active management
Uterotonic agent
None or after placenta delivered
With delivery of anterior shoulder or baby
Uterus
Assessment of size and tone after delivery
Cord traction
None
controlled cord traction when uterus contracted
Cord clamping
Variable
Early

11. Mode of uterotonic administration
Oxytocin dose is 10 IU, intramuscularly. with intravenous access in place, IU is placed in mL of crystalloid and run quickly. With cesarean deliveries, 5 IU is administered as an intravenous bolus, followed by a similar infusion.
Ergometrine dose: is mg, some used 0.5 mg ; IM or IV.
Syntometrine (contains 0.5 mg of ergometrine with 5 IU of oxytocin); IM, 2 mg.

12. What to do after delivery of the placenta?
Determine the fundal position and size of the uterus. why?
Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine massage).
Examine the placenta for completeness and detection of abnormalities.
Suturing of lacerations.
Uterine exploration:
- No longer recommended for normal deliveries or those following previous cesarean delivery.
- Is justified in patients with bleeding originating high in the genital tract.
- The cervix should be visualized after all forceps deliveries

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

14. COMPLICATIONS
Postpartum hemorrhage.
Retained placenta.
Uterine inversion.

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