The placenta may be expelled by:

• The Schultz mechanism
• Mathew Duncan mechanism

HAEMOSTASIS It is achieved through:

• Retraction of the oblique uterine muscle fibres
• Vigorous uterine contraction following placental separation
• Transitory activation of the coagulation and fibrinolytic systems

MANAGEMENT OF THIRD STAGE OF LABOUR

• Do not massage the uterus before placental separation, except when partial separation has occurred by natural processes and excessive bleeding evident

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

• Ensure Active Management of the third stage of labor is offered to all mothers
• Administer a uterotonic agent within 1 minute of childbirth:
  • Oxytocin (10 IU IV/IM)
  • Misoprostol (400-600 μg orally)
  • Carbetocin (100 mcg IV/IM)
  • Ergometrine (0.2 mg IM)
• Delay cord clamping and cutting for 3 minutes or until the cord stops pulsating
• Clamp and cut the cord
• Put ties tightly around the cord at 2 cm and 5 cm from baby’s abdomen
• Cut between ties with sterile instrument
• Observe for oozing blood

CONTROLLED CORD TRACTION

• Wait for a contraction and then place left hand above the symphysis pubis hold back the uterus
• Wind the cord around the clamp and with the right apply firm steady traction on the cord in a downward, outward and then upward movement
• Receive the placenta with both hands when it appears at the vulva
• Deliver the membranes slowly
• Perform examination of the placenta immediately for completeness
• Massage the uterine fundus and expel clots from the uterus and vagina

POST-DELIVERY CARE

• Clean the vulva, and examine vaginal walls, cervix and perineum for tears and lacerations
• Repair episiotomy and/or tears after infiltrating with 1% lignocaine
• Assess blood loss (one kidney dish is approximately 500 mls of blood)
• Examine placenta for infarcts, retro placental clot, cord vessels, etc.
• If the mother has chosen to breastfeed, put the baby on breast within the first one hour

MONITORING MOTHER AND BABY EVERY 15 MINUTES FOR 2 HOURS

Mother:

• For emergency signs, e.g., difficulty in breathing, central cyanosis and shock using rapid assessment and management (RAM)
• Feel if uterus is well contracted
• Mood and behavior
• Record findings, treatments and procedures in Labor Progress Chart
• Give supportive care
• Do not leave the woman alone. Encourage her to be with her birth companion

Baby:

• Breathing: listen for grunting, look for chest in-drawing and fast breathing
• Warmth: Ensure the baby is kept warm by wrapping it in a dry clean cloth and put a cap on the head also check the temperature every after 30 minutes
• Feeding: Ensure that the baby is feeding adequately
• Check the cord for bleeding and ensure it is well ligatured

At the end of the third stage following the expulsion of the placenta, the fundus is expected to be about 4 cm below the umbilicus

COMPLICATIONS OF THE THIRD STAGE

• Postpartum haemorrhage
• Hematoma formation
• Retained placenta
• Inversion of uterus
• Shock