By Dr.M.D.Mazumdar, MD

The third stage of labor starts at the end of the Second Stage after the baby has been delivered.

As soon as the baby is delivered, there is a temporary lull in the uterine contractions.

The uterus contracts to become a firm globular organ reaching upto the mother's umbilicus. Pressure on it causes pain but it is not otherwise painful.

Through the vagina, the cervical opening or os is seen to become partially closed. The baby's umbilical cord is seen snaking out of the os towards the vaginal opening.

An injection of a drug called ergometrine is usually given just after the baby is delivered to stimulate the uterus to contract better. This helps to prevent any excess bleeding.

Uterine contractions start again after about 5 - 10 minutes. The contractions are strong and powerful and show charateristics similar to those in the second stage - they contract and relax alternately. Pain is lesser than in the second stage.

Placental separation from the uterine wall is indicated by a gush of fresh bleeding from the os. The umbilical cord also seems to become longer.

The placenta may be delivered by the woman herself by bearing down during the uterine contractions. But usually, controlled traction or pull is applied on the cord by the obstetrician and the placenta pulled out slowly. This allows the placent to be delivered faster and decrease the amount of bleeding.

Once the placenta is out , it is examined carefully to see that all parts including the membranes are completely out and there are no bits left behind in the uterus. Retained placental bits may cause heavy bleeding or infection later on.

Steps of management of the third stage of labour

The principle of management of this stage is to prevent complications during delivery of the placenta and the membranes.

• After delivery of the baby, the contractions will begin again. These contractions are to expel the placenta. The umbilical cord should not be pulled and no pressure must be aplied on the mother's stomach to expel the placenta. The placenta could take 30 minutes to be expelled after the birth Nothing is to be done at this stage. A 'wait and watch' approach is taken for the placenta to separate from the wall of the uterus spontaneously. The main sign of separation is fresh bleeding from the uterus.

• When the placenta appears, the bleeding can be controlled by massaging the uterus. To do this, one hand is placed on the lower part of the abdomen and the uterus massaged firmly but gently. The uterus will begin to harden as a result of the massage and will contract into a firm mass.

• The separated placenta is delivered from the vagina and examined to see whether it has been delivered intact or whether a part has been retained. It looks like a firm fleshy mass about 15-20 cm in diameter with the cord attached to its center and the surrounded by the membranes.

• If the placenta is not expelled spontaneously in 30 minutes, then manual removal of placenta needs to be carried out.

• Inj. Ergometrine is given to cause the uterus to contract fully and prevent further bleeding.

• If an episiotomy has been done, it is now sutured carefully.

• If there is no episiotomy, the entire vulva and vagina is carefully examined for any tears and injuries.

• The vulva is cleaned with a damp towel and covered wirh a clean fresh pad.

• The mother's pulse, blood pressure, uterine tone and vaginal bleeding is recorded for at least one hour after delivery.

• Complications in the mother during labor.
• Vulvar Hematoma during labor.
• Involution of the Uterus after Childbirth .
• Breastfeeding
• Breast Engorgement