The third stage of labor involves delivery of the placenta and ends with delivery of the membranes, normally lasting 5-15 minutes. Complications during this stage can include postpartum hemorrhage (PPH), the leading cause of maternal mortality worldwide. PPH is primarily caused by uterine atony, genital tract trauma, retained placental tissue, or uterine inversion. Management involves resuscitation, uterotonics to contract the uterus, examination under anesthesia, and potentially surgical interventions like uterine artery ligation.

1. Third stage of labour
(Normal & abnormal)
Dr. Shazia Amir Khan

2.  Definition :
3rd stage of labor: commences with the delivery of the
fetus and ends with delivery of the placenta and its
attached membranes.
 Duration:
- normally 5 to15 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) :
- Maternal mortality.
. 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 causes anemia or poor iron. Anemia causes
weakness and fatigue. prolonged hospitalization affects the
establishment of breastfeeding.
- Blood transfusion→ transfusion reaction and infection.
- Emergency anesthetic intervention: due to severe PPH,
retained placenta, and uterine inversion.
- Sepsis: due to exploration or instrumentation of the uterus.

4. Mechanism of placental separation
 Uterine contractions and retraction reduce the uterine cavity →
placental detachment and expulsion into the lower uterine
segment.
 Retro-placental hematoma.
* Oxytocin, ergometrin and prostaglandins enhance placental
separation and expulsion by causing uterine contraction .
* Tocolytics/nitroglycerin and some inhalation anesthetics cause
uterine relaxation and delay of placental separation causing
dangerous bleeding following delivery.

5. What to do before delivery of the placenta?

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
1. 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
and forward with the right hand.
2. Active management:
- By using one of the following: Ergometrine, Oxytocin, or
Syntometrine (ergometrine + oxytocin ).
- Given at the delivery of anterior shoulder or after delivery of
the baby.
- Immediate delivery of the placenta with CCT.
 Avoid uterine massage before placental delivery.

8. Mode of drugs administration
 Oxytocin:
- 10 IU, intramuscularly + with intravenous access in
place, 10-20 IU is placed in 500-1000 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 0.25- 0.5 mg IM or IV.
 Syntometrine (0.5 mg of ergometrine with 5 IU of
oxytocin) :
The dose is 2 mg and given IM only.

9. Delivery of membrane
By rotating the placenta about the insertion site as it
descends or grasping the membranes with a clamp
or artery forceps and drawn down.

10. 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:

11. 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
Assessment of size
and tone after delivery
Cord traction None controlled cord
traction when uterus
contracted
Cord clamping Variable Early

12. What to do after delivery of the placenta?

13. Immediately after delivery of the placenta
 Determine the fundal position and size of the uterus.
 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

14. 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.
 repair of an episiotomy or any lacerations.
 Close observation every 15 minute for the next hour.

15. COMPLICATIONS
 Uterine atony.
 Retained placenta.
 Trauma.
 Uterine inversion.
Postpartum hemorrhage

16. 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.

17. 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.

18. Uterine Atony
 Factors predisposing :
 Over-distension of the uterus:
multiple pregnancy, poly-
hydramnios or fetal macrosomia.
 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.

19. 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

20. 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.

21. 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).

22. 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.

23. 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).

24. 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.

25. 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.

26. 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.

27. 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.