delivery of placenta:
- physiologic Mx for PPH low risk patients who have consented to the potential increased risk of PPH
- active Mx of 3rd stage for PPH high risk patients, those not consenting to, or failed, physiologic Mx
Mx of prolonged 3rd stage labour

ED Mx of 3rd stage of labour

delivery of placenta:

if mother Rh negative then take cord blood to determine need for maternal Rh Anti-D

physiologic Mx for PPH low risk patients who have consented to the potential increased risk of PPH

do not clamp cord until after delivery of placenta
ensure maximal skin-to-skin contact of baby on mother in a warm environment to encourage oxytocin release
ensure empty bladder
upright position expedites delivery of placenta without assistance
if there are no signs of maternal vaginal haemorrhage, await signs of placental separation:
- “lengthening” of cord
- a sudden gush of blood
- globular appearance of uterus
encourage mother to bear down
record and WEIGH ALL blood loss
palpate uterus to ensure it is contracted every 15 minutes, and consider uterine massage prin in 1st 2hrs
if placenta not delivered within 60min or there is excessive blood loss, commence active Mx as below

active Mx of 3rd stage for PPH high risk patients, those not consenting to, or failed, physiologic Mx

oxytocin 10U slow IV or IM within 1 minute of birth
delay clamping the cord for up to three minutes or until pulsations have ceased – whichever is shorter
after a maximum of 3 minutes, double clamp the cord close to the perineum using sponge forceps/clamps
hold the clamped cord with one hand. Place the other hand on the abdomen to detect uterine contraction and placental separation
avoid fundal massage which may lead to partial separation of the placenta and excessive bleeding.
consider Controlled Cord Traction (CCT):
- a lack of evidence surrounds the benefit of CCT in preterm gestations and when the cord appears friable
- stabilise the uterus by placing a hand just above the symphysis pubis and apply CCT when there is a uterine contraction
- continue to apply counter-pressure to the uterus throughout CCT as this helps prevent inversion of the uterus, do not release support of the uterus until the placenta is visible at the vulva
- if the placenta does not descend during 30-40 seconds of CCT or resistance is felt, do not continue to pull on the cord but await another contraction
  - gently hold the cord and wait until the uterus is well contracted and repeat CCT
delivery of the placenta:
- as the placenta delivers, hold the placenta in two hands and gently turn it until the membranes are twisted. Slowly pull in an upward direction to follow the curve of the birth canal to complete the delivery.
- If the membranes tear, gently examine the upper vagina and cervix wearing sterile gloves and use sponge forceps to remove any pieces of membrane that are present.
- document the time the placenta and membranes were delivered
- examine the placenta and membranes for completeness and record total weighed blood loss.
ALL blood loss is to be ascertained by weighing
care after placental delivery
- following placental delivery, palpate the uterus and massage the fundus if atony is present - fundal massage is not necessary if the uterus is well contracted, central, and at or below the umbilicus
- palpate the uterus every 15 minutes and repeat uterine massage as needed during the first 2 hours

if the placenta is not delivered within 30 minutes of birth, notify the on-call obstetric registrar and plan for transfer to theatre to prevent post-partum haemorrhage (PPH)

Oxytocin 10 units is the preferred uterotonic agent for active management of the third stage. It is preferred over other uterotonic drugs as it is effective straight away if administered IV, and within 2 to 4 minutes of administration if given IM. It has minimal side effects and can be used in almost all women (except where there is a history of allergy to oxytocin or carbetocin).
Do not give ergometrine or combined oxytocin/ergometrine (Syntometrine®) to women with pre-eclampsia, eclampsia or high blood pressure because it increases the risk of convulsions and cerebrovascular accidents.

Mx of prolonged 3rd stage labour

defined as > 30 minutes if actively managed or > 60 minutes if physiological management (ie. not actively managed)
if oxytocin has previously been withheld, administer oxytocin 10units slow IV injection over 3 to 5 minutes (or IM if there is no IV access)
undertake a vaginal examination to determine if the placenta is trapped in a partially closed cervix or truly retained
insert an IDC and ensure accurate fluid balance charting
if the placenta and membranes are retained and are unable to be removed on birth suite then the woman should be taken to theatre for an EUA and MROP
- commence oxytocin infusion- 40 units oxytocin in 40mL of sodium chloride 0.9% at 10mL/hour via a syringe adapter
- book the case with theatre / on-call anaesthetist as category 2 - to be undertaken within 30 minutes
- transfer to theatre for an EUA and MROP.
- expedite by calling an obstetric alert if there is active bleeding

The absence of revealed active bleeding should not delay surgical management
Delay to MROP is associated with an increased risk of severe post-partum haemorrhage (PPH)

Table of Contents

ED Mx of 3rd stage of labour

delivery of placenta:

physiologic Mx for PPH low risk patients who have consented to the potential increased risk of PPH

active Mx of 3rd stage for PPH high risk patients, those not consenting to, or failed, physiologic Mx

Mx of prolonged 3rd stage labour