Katlyn Carter

Protocol: Management of the Third Stage

Third stage encompasses both delivery of the placenta and the shift of the newborn “from
complete in utero dependence on the mother via the placenta for life-sustaining nutrients and
oxygen—to dependence on the newborn herself (Simkin, p. 211).
Signs of Placental Separation

 Change in FH and consistency on palpation

 Diminishing pulsing and BP in cord vessels
 Newborn response
 A sudden trickle or small gush of blood
 Lengthening of the umbilical cord at the introitus
(Frye, p. 509)

Expectant (Physiologic) Management & Guidelines:

Await the signs of placental separation. Separation is diagnosed as prolonged at >60 mins.
(Oxorn-Foote, p. 358)

Normally, after a brief resting phase after the birth of the baby, contractions resume, and the
placenta is delivered. The woman may feel a slight amount of pressure in the vagina that
precedes the birth of the placenta. After the placenta is delivered, the uterus clamps down and
bleeding from the placental site stops. (Frye, p. 371)
Indicated in low risk women.

Active Management & Guidelines:

Separation is diagnosed as prolonged at >30 mins with active management. (Oxorn-Foote, p.
358)

 Delayed cord clamping

 Controlled cord traction (CCT) ONLY with uterotonics or with signs of placental
separation. Overly vigorous CCT may lead to cord evulsion or life-threatening uterine
inversion
 Uterine massage is recommended ONLY after the placental delivery and especially if
uterotonic medications are not used. Uterine massage before separation of the placenta
can lead to partial separation of the placenta and increase risk of PPH.
 Prophylactic administration of uterotonic medications
 o Pitocin (synthetic oxytocin)
o Methergine (methylergonovine maleate)
o Cytotec (misoprostol)
 WHO prefers prophylactic oxytocin to misoprostol

Indicated for women who are a higher risk of postpartum hemorrhage (incidence of PPH is 5-
15%) and to shorten the third stage.
Women who may be at higher risk:

 Have large babies

 Long labors
 Hx of PPH
 Multiple gestation
 Hx of 5 or more births
During a PPH the birth attendant will ask for the following things:

 Large-bore IV line
 Vigorous uterine massage
If these strategies do not succeed...
 Bimanual compression
 Additional uterotonic medication
Careful examination of the placenta for completeness

Examination of the cervix, vagina, and perineum for lacerations and/or

hemotomas
The “Four Ts”

 Tone
 Trauma
 Tissue
 Thrombin
(Simkin, Ch. 7)
According to Frye, p. 514.....
Actively assist the birth of the placenta when:

 Uterine atony (little or no contraction

 Significant bleeding
 Poor nutrition during pregnancy (not optimal blood volume)
  Mother’s hemoglobin at term (below 10 grams the woman cannot tolerate
much blood loss)
 Length of labor-tired uterus will not contract as effectively
 Mother’s stamina-tired does not tolerate blood loss well
 Contraction pattern prior to birth
 Any s/s of shock
 Polyhydramnios, very large baby, or multiple gestion
 Baby’s enthusiasm for nursing
 Gestational age of baby-earlier baby=less blood volume
 Compromised newborn-if there is a problem with baby, mother tends to be
more emotional and distracted, expect more bleeding and third phase
problems
How to Actively Assist Placenta: (Frye, p. 515-522)

 Skin-to-skin mother-baby contact

 Check the bladder
 Stimulate the nipples
 Stroke the sides of the uterus
 Acupressure
 Give cotton root bark tincture
 Allopathic drugs (Pitocin)
 Continue as Simkin

Maternal & Neonatal Monitoring & Assessment

Maternal HR and BP may rise slightly as the placenta is expelled but should return to normal
once the placenta is out. Vitals not necessary unless she is showing signs of blood loss or other
distress or placental expulsion is unduly delayed. (Frye, p. 511)

Birth of the Newborn

Skin-to-skin allowing >5 mins for the baby to receive all the placental blood (Simkin, p. 214)

Estimation of Blood Loss

2 cups = 454 ml
Ideal is less than 500ml
Measure in a pan with measuring cup (Frye, p. 514)
Laceration Assessment
Once the placenta is delivered, bleeding is controlled, and mother is bonding with baby, ask
permission to check for tears. There may be minor abrasion that do no require stitches. If
bleeding can be controlled with a bit of pressure (using sterile gauze), they don’t need stitched.
Most first degree perineal tears will heal by themselves if the woman takes care. If it needs
stitched, stitch it. Suture if the mother will feel more comfortable. If the pieces don’t
approximate well, suture. (Heart & Hands, p. 173)

First-degree tears include the vaginal mucosa, the fourchette, or the skin of the perineum just
below it. Repair.

Second-degree tears are deeper, mainly in the midline and extend through the perineal body.
Repair in layers.

Third-degree tears extend through the perineal body the transverse perineal muscle, and the anal
sphincter. Repair in layers.
(Oxorn-Foote, p. 399-403)

References:
Davis, E. (2012). Heart and hands: a midwife's guide to pregnancy and birth. Random House.

Frye, A. (2013). Holistic midwifery volume II: care during labor and birth. Portland, Oregon:
Labrys Press.

J. M., & Fahey, J. O., Gegor, C. L., Varney, H. (2015). Varney's midwifery. Jones & Bartlett
Learning.

Posner, G. D., Black, A. Y., Jones, G. D., & Dy, J. (2013). Oxorn-Foote human labor and birth,
6th edition. New York: McGraw Hill.

Simkin, P., Hanson, L., & Ancheta, R. (2017). The labor progress handbook: early interventions
to prevent and treat dystocia. John Wiley & Sons.