1. Introduction

The third stage of labour begins after the delivery of the baby and ends with the delivery of the placenta and membranes. This stage typically lasts between 5-15 minutes but can extend up to 30 minutes. Postpartum hemorrhage (PPH) is a significant cause of maternal morbidity and mortality worldwide, with approximately 14 million cases occurring annually. More than 70% of all PPH cases are due to uterine atony (failure of the uterus to contract effectively after delivery).

Active management of the third stage of labour (AMTSL) is an evidence-based intervention that significantly reduces the risk of postpartum hemorrhage by 60-70% compared to expectant management. Understanding the components of AMTSL and proper examination of the placenta and membranes is crucial for all healthcare providers attending births.

2. Active Management of Third Stage of Labour (AMTSL)

AMTSL is a sequence of interventions designed to speed the delivery of the placenta by increasing uterine contractions and preventing PPH by averting uterine atony. It is recommended by the World Health Organization (WHO), the International Federation of Gynecology and Obstetrics (FIGO), and the International Confederation of Midwives (ICM) for all births to prevent postpartum hemorrhage.

3. Components of AMTSL

3.1 Administration of Uterotonic Drugs

Uterotonic drugs should be administered within 1 minute after the birth of the baby, after excluding the presence of another baby. These drugs stimulate uterine contractions, helping to prevent postpartum hemorrhage.

3.2 Controlled Cord Traction (CCT)

Controlled cord traction involves applying gentle traction to the umbilical cord while providing counter-pressure to the uterus. This should only be performed during a contraction and after signs of placental separation are observed.

Signs of Placental Separation:

• Lengthening of the visible portion of the umbilical cord
• A small gush of blood
• The uterus becomes more globular and rises in the abdomen
• The uterus becomes firmer and smaller

Procedure for CCT:

1. Clamp the cord close to the perineum
2. Hold the clamped cord with one hand
3. Place the other hand just above the woman’s pubic bone to stabilize the uterus and provide counter-traction during CCT
4. Maintain gentle tension on the cord while waiting for a strong uterine contraction
5. During the contraction, encourage the mother to push while gently pulling downward on the cord
6. As the placenta descends, move the cord upward to follow the axis of the birth canal

3.3 Uterine Massage

Immediately after delivery of the placenta, the uterus should be massaged through the abdominal wall to stimulate uterine contractions and expel blood clots. This helps prevent postpartum hemorrhage by ensuring the uterus remains contracted.

Technique:

1. Place one hand on the lower abdomen to support the lower uterine segment
2. Place the other hand on the fundus (top) of the uterus
3. Massage the fundus in a circular motion until the uterus is firm
4. Check the uterus every 15 minutes for 2 hours after delivery
5. Massage the uterus if it becomes soft

4. Examination of Placenta, Membranes, and Vessels

Thorough examination of the placenta, membranes, and vessels is essential to ensure complete delivery and detect potential abnormalities. Retained placental fragments increase the risk of postpartum hemorrhage, infection, and subinvolution of the uterus.

4.1 Placental Examination

Maternal Surface (Decidual Side):

• Dark red, rough appearance with 15-20 cotyledons
• Inspect for completeness and integrity
• Check for missing cotyledons or irregular areas suggesting retained fragments
• Examine for abnormal calcifications, infarcts, or hematomas

Fetal Surface (Chorionic/Amnion Side):

• Shiny, gray-white surface with visible blood vessels
• Examine the umbilical cord insertion site
• Check for abnormal cord insertion (velamentous, marginal, etc.)
• Look for any color changes, meconium staining, or abnormal lesions

4.2 Membrane Examination

Hold the placenta up by the cord, allowing membranes to hang down. The membranes should be:

• Intact or torn in a single site (where the baby emerged)
• Complete with no missing pieces
• Shiny and translucent

Reconstruct the membranes to ensure they form a complete sac. Incomplete membranes suggest retained placental tissue, which increases the risk of postpartum hemorrhage and infection.

4.3 Umbilical Cord Examination

• Normal length is approximately 40-60 cm
• Diameter is typically 1-2 cm
• Normally contains 3 vessels: 2 arteries and 1 vein
• The vein carries oxygenated blood to the fetus (larger lumen)
• The arteries carry deoxygenated blood from the fetus (smaller lumens)
• Note and document any abnormalities in the number of vessels

5. Placental Abnormalities and Clinical Significance

6. Best Practices and Recent Updates

7. Nursing Implications

7.1 Nursing Responsibilities

• Prepare and administer uterotonic drugs according to protocol
• Monitor vital signs and blood loss during the third stage
• Assist with controlled cord traction when indicated
• Perform thorough examination of the placenta and membranes
• Document findings and report abnormalities immediately
• Monitor for signs of postpartum hemorrhage (excessive bleeding, uterine atony)
• Provide patient education on postpartum warning signs

7.2 Risk Assessment and Prevention

Identify women at increased risk for postpartum hemorrhage:

• Previous PPH
• Multiple gestation
• Polyhydramnios
• Macrosomia
• Prolonged labor
• Grand multiparity (≥5 previous pregnancies)
• Placenta previa or accreta
• Pre-eclampsia
• Use of oxytocin for labor induction/augmentation

7.3 Documentation Requirements

Comprehensive documentation should include:

• Time of placental delivery
• Method used (spontaneous or CCT)
• Uterotonic drug administered (type, dose, route, time)
• Placental examination findings
• Completeness of placenta and membranes
• Number of vessels in umbilical cord
• Cord insertion type
• Any abnormal findings
• Estimated blood loss
• Uterine tone assessment
• Any complications and interventions