Mother Initiative Tutorial

Normal labor: The third stage –

physiological and active management

Alison James Midwifery Lecturer

Margaret Fisher Associate Professor in Midwifery

Plymouth University and The Royal College of Midwives,

United Kingdom

This tutorial is designed to re-inforce previous training – and should,

therefore, not be regared as sufficient guidance by itself 1

To find out more about the first and second stages of labor, see the two separate tutorials on these topics

Normal labor:

“The first stage” tutorial

describes labor progress and

maternal care until cervix is fully

dilated

Normal labor:

“The second stage” tutorial

describes the birth of the baby

2

The third stage of labor

Third stage of labor

Starts from when the baby

is born

Third stage of labor:

Finishes when the placenta

(afterbirth) has come away from

the mother, and when her

bleeding stops

3

Typical duration of the third stage

The third stage of labor can

take 20-60 minutes and

sometimes longer if no

intervention is used and the

placenta delivers naturally

(physiological or expectant

management)

If active management

(uterotonic and controlled cord

traction) is used the placenta

should be delivered within

5-30 minutes

Physiological Management

Active Management

4

How the placenta separates from the womb

This diagram shows what happens

when the placenta (afterbirth)

separates from the uterus (womb):

Step 1 – The placenta is still

attached to the uterus

Step 2 – The muscles in the uterus

tighten and clamp down on the blood

vessels, causing them to burst

(rupture), forcing the placenta off the

wall of the uterus.

Step 3 – The placenta separates

from the uterus as the muscles

tighten more and a clot forms behind

the placenta (retroplacental clot).

Step 1 Step 2

Step 3 5

Illustrating the third stage of labor

After birth, the placenta at first

remains attached to the top of

the uterus

Later the uterine muscles contract

tightly, expelling the placenta

The lower picture shows the uterine

muscles tightly contracted, pushing

the placenta out. Note how the fundus

(top) of the uterus becomes rounder

and firmer and lower in the woman’s

abdomen as the placenta separates

6

Skin-to-skin contact

Place the baby in skin-to-skin

contact on the abdomen of the

mother, dry the baby, assess

the baby’s breathing and

perform resuscitation if

needed

Cover the baby’s head with

a cloth or, preferably a

hat/bonnet

Cover the woman and baby

7

There are two alternative options for the management of the third stage of labor

Option 1:

Physiological management

Physiological (expectant)

management – where contraction

of the uterus, separation of the

placenta

and delivery of the placenta and

membranes takes place naturally

8

Physiological management (1)

Clamp and cut the cord after

cord pulsations have ceased

It is not necessary to clamp and

cut it until after the placenta

and membranes have been

fully delivered if the cord is long

enough for the baby to reach

the mother’s breast

Cover the cord with a piece of

gauze when cutting the cord to

avoid splashing blood

9

Physiological management (2)

The mother may be

encouraged to stand, squat,

pass urine or breastfeed to

help this to happen. The cord

must NOT be pulled, but the

mother should be encouraged

to push the placenta and

membranes out.

Stand Squat

Pass urine Breastfeed

10

There are two alternative options for the management of the third stage of labor

Option 2:

Active management

Reason for considering the

active management of the third

stage of labour (AMTSL)

This option is recommended to

reduce the risk of postpartum

haemorrhage but can only be

performed by a skilled birth

attendant and if the uterotonic

drugs are available

11

Active management Step 1: Uterotonic

Administer a uterotonic (oxytocin or

misoprostol) within 1 minute after the

baby’s birth and after ruling out the

presence of another baby (the uterotonic

of choice is oxytocin 10 IU IM)*

OR

Give 600 μg of misoprostol by mouth within

1 minute after the baby’s birth and after

ruling out the presence of another baby

OR

Give synometrine 1 ampoule IMI or

ergometrine 0.2mg IMI

* IM = intramuscular 12

Active management Step 2: Controlled cord traction (1)

To perform controlled cord traction (CCT):

Place the clamp near the woman’s

perineum to make CCT easier. Hold the

cord close to the perineum using a clamp.

Place the palm of the other hand on the

lower abdomen just above the woman’s

pubic bone to assess for uterine

contractions. If a clamp is not available,

CCT can be applied by encircling the cord

around the hand

When performing controlled cord traction,

at the same time, support the uterus by

applying external pressure on the uterus

in an upward direction towards the

woman’s head

13

Active management Step 2: Controlled cord traction (2)

When there is a contraction, apply

external pressure on the uterus in an

upward direction (toward the woman’s

head) with the hand just above the pubic

bone. At the same time with your other

hand, pull with firm, steady tension on the

cord in a downward direction (follow the

direction of the birth canal).

Avoid jerky or forceful pulling. Do not

release support on the uterus until the

placenta is visible at the vulva. Deliver the

placenta slowly and support it with both

hands

Only release support of the uterus when

the placenta is visible at the vulva

14

Active management Step 3: Delivery of the Placenta

As the placenta is delivered,

hold and gently turn it with both

hands until the membranes are

twisted

Slowly pull to complete the

delivery

Gently move membranes up

and down until delivered

15

Massage

Massage the uterus

immediately after delivery of the

placenta and membranes until

it is firm

During recovery, assist the

woman to breastfeed if this is

her choice, monitor the

newborn and woman closely,

palpate the uterus through the

abdomen every 15 minutes for

2 hours to make sure it is firm

and monitor the amount of

vaginal bleeding. Provide

prevention of mother-to-child

transmission care as needed 16

What else should the midwife do?

1. Check that the mother’s uterus

stays firm – check this every 15

minutes for 2 hours and show the

mother how to do this too

2. Check that the vaginal blood loss

is normal – it should not be

trickling or flowing and she should

not be passing clots.

3. Check that the mother’s blood

pressure, pulse and temperature

are normal

See the tutorial ‘Postpartum hemorrhage’

for management if there are concerns.

The woman may need to be transferred

urgently to a place where medical aid is

available. 17

What else should the midwife do?

4. Check the placenta to see if

it is complete. If there is a

piece missing, the woman will

need to be transferred to a

place where medical aid is

available. See tutorial on

‘Postpartum hemorrhage’

18

What else should the midwife do?

5. Check the mother’s perineum

for labial, vaginal wall or

perineal tears.

If these involve the muscle (are

2nd degree tears or more) or

bleeding they should be sutured

as soon as possible

3rd and 4th degree tears

(involving the anal sphincter)

should only be sutured by a

highly skilled midwife or doctor

trained to do this

6. Check that the mother is able

to pass urine within 6 hours of

the birth

19

Summary of third stage of labour

It should not last more than

about 1 hour if physiological/

expectant management and

30 minutes if active

management (AMTSL)

AMTSL with controlled cord

traction must only be performed

by a skilled birth attendant

Feel the woman’s uterus

frequently to see that it stays

firm

Vaginal blood loss should

not be more than 500 ml and

the mother should feel well.

If any concerns, see tutorial on

‘Postpartum haemorrhage’

Suture any perineal or labial

tears quickly

Help the mother to feed and

care for her baby

Provide PTMCT* care as

needed

* PTMCT = Preventing Mother To Child Transmission 20