What should the nurse be aware of with regard to the third stage of labour?

The third stage of labor refers to the period following the completed delivery of the newborn until the completed delivery of the placenta. The length of the third stage and its complications are affected by the uterine contractility and the duration of placental separation. The normal duration of third stage in nulliparous as well as in multiparous women is less than 30 minutes. There is strong evidence supporting the routine administration of uterotonic agents for the prevention of post-partum hemorrhage (PPH), in order to enhance natural uterine contraction in the third stage of labor, thus reducing the occurrence of PPH by 40%.

There is a joint policy statement between the International Confederation of Midwives (ICM), the International Federation of Gynecology and Obstetrics (FIGO) and the World Health Organization (WHO), all of which recommend active management of the third stage of labor in order to prevent PPH. active management led to a reduction in PPH incidence, maternal Hemoglobin<9g/dL and need for blood transfusion. (4-7).

Active management of the third stage of labor involves prophylactic uterotonic treatment, early cord clamping and controlled cord traction to deliver the placenta. (2) Oxytocin is the first agent of choice for PPH prophylaxis because of its high efficacy and a low incidence of associated side effects. (6-9). Cotter et al found that the use of Oxytocin for PPH prophylaxis in the third stage of labor decreased the rate of maternal blood loss greater than 500 ml by approximately 50%. (10).

Oxytocin route of administration is either intravenously (IV) or intramuscularly (IM), with no significant difference in PPH incidence (9). This is based on a pharmacokinetic research from 1972 which found no difference between the absorption rates in both routes of administration. Since then no further research targeting this question was preformed. (11-12). recent guidelines from WHO, FIGO and ICM all recommended the use of 10 IU Oxytocin IM. (4, 7,13).

Previous studies have investigated the effect of intra-umbilical vein Oxytocin injection in reducing blood loss during the third stage of labor. This route of administration directs treatment to the placental bed and uterine wall, resulting in earlier uterine contraction and placental separation. However, limited published literature is available evaluating the effect of umbilical vein oxytocin injection in routine practices for active management of the third stage of labor. A prospective, randomized controlled trial of 412 women found that intra-umbilical injection of oxytocin alongside active management of the third stage of labor significantly reduced postpartum blood loss and the duration of the third stage (14).

Other uterotonic agents including Syntometrine (IM), Ergometrine (IM or IV) and Misoprostol (IM), can be used in active management of the third stage of labor. However, high quality evidence regarding their efficacy compared to Oxytocin is scarce. (9-10)

Labor is the process through which a fetus and placenta are delivered from the uterus through the vagina. Human labor divides into three stages. The first stage is further divided into two phases. Successful labor involves three factors: maternal efforts and uterine contractions, fetal characteristics, and pelvic anatomy. This triad is classically referred to as the passenger, power, and passage. Clinicians typically use multiple modalities to monitor labor. Serial cervical examinations are used to determine cervical dilation, effacement, and fetal position, also known as the station. Fetal heart monitoring is employed nearly continuously to assess fetal well-being throughout labor. Cardiotocography is used to monitor the frequency and adequacy of contractions. Medical professionals use the information they obtain from monitoring and cervical exams to determine the patient's stage of labor and monitor labor progression.

Initial Evaluation and Presentation of Labor

Women will often self-present to obstetrical triage with concern for the onset of labor. Common chief complaints include painful contractions, vaginal bleeding/bloody show, and fluid leakage from the vagina. It is up to the clinician to determine if the patient is in labor, defined as regular, clinically significant contractions with an objective change in cervical dilation and/or effacement. When women first present to the labor and delivery unit, vital signs, including temperature, heart rate, oxygen saturation, respiratory rate, and blood pressure, should be obtained and reviewed for any abnormalities. The patient should be placed on continuous cardiotocographic monitoring to ensure fetal wellbeing. The patient's prenatal record, including obstetric history, surgical history, medical history, laboratory, and imaging data, should undergo review. Finally, a history of present illness, review of systems, and physical exam, including a sterile speculum exam, will need to take place.

During the sterile speculum exam, clinicians will look for signs of rupture of membranes such as amniotic fluid pooling in the posterior vaginal canal. If the clinician is unsure whether or not a rupture of membranes has occurred, additional testing such as pH testing, microscopic exam looking for ferning of the fluid, or laboratory testing of the fluid can be the next step. Amniotic fluid has a pH of 7.0 to 7.5, which is more basic than normal vaginal pH. A sterile gloved exam should be done to determine the degree of cervical dilation and effacement. The measurement of cervical dilation is made by locating the external cervical os and spreading one's fingers in a ‘V’ shape, and estimating the distance in centimeters between the two fingers. Effacement is measured by estimating the percentage remaining of the length of the thinned cervix compared to the uneffaced cervix. During the cervical exam, confirmation of the presenting fetal part is also necessary. Bedside ultrasound can be employed to confirm the presentation and position of the fetal presenting part. Particular mention should be noted in the case of breech presentation due to its increased risks regarding fetal morbidity and mortality compared with the cephalic presenting fetus. 

Management of Normal Labor

Labor is a natural process, but it can suffer interruption by complicating factors, which at times necessitate clinical intervention. The management of low-risk labor is a delicate balance between allowing the natural process to proceed while limiting any potential complications. During labor, cardiotocographic monitoring is often employed to monitor uterine contractions and fetal heart rate over time. Clinicians monitor fetal heart tracings to evaluate for any signs of fetal distress that would warrant intervention as well as the adequacy or inadequacy of contractions. Vital signs of the mother are taken at regular intervals and whenever concerns arise regarding a clinical status change. Laboratory testing often includes the hemoglobin, hematocrit, and platelet count and is sometimes repeated following delivery if significant blood loss occurs. Cervical exams are usually performed every 2 to 3 hours unless concerns arise and warrant more frequent exams. Frequent cervical exams are associated with a higher risk of infection, especially if a rupture of membranes has occurred. Women should be allowed to ambulated freely and change positions if desired. An intravenous catheter is typically inserted in case it is necessary to administer medications or fluids. Oral intake should not be withheld. If the patient remains without food or drink for a prolonged period of time, intravenous fluids should be considered to help replace losses but do not need to be used continuously on all laboring patients. Analgesia is offered in the form of intravenous opioids, inhaled nitrous oxide, and neuraxial analgesia in those who are appropriate candidates. Amniotomy is considered on an as-needed basis for fetal scalp monitoring or labor augmentation, but its routine use should be discouraged. Oxytocin may be initiated to augment contractions found to be inadequate.

First Stage of Labor

The first stage of labor begins when labor starts and ends with full cervical dilation to 10 centimeters. Labor often begins spontaneously or may be induced medically for a variety of maternal or fetal indications. Methods of inducing labor include cervical ripening with prostaglandins, membrane stripping, amniotomy, and intravenous oxytocin. Although precisely determining when labor starts may be inexact, labor is generally defined as beginning when contractions become strong and regularly spaced at approximately 3 to 5 minutes apart. Women may experience painful contractions throughout pregnancy that do not lead to cervical dilation or effacement, referred to as false labor. Thus, defining the onset of labor often relies on retrospective or subjective data. Friedman et al. were some of the first to study labor progress and defined the beginning of labor as starting when women felt significant and regular contractions. He graphed cervical dilation over time and determined that normal labor has a sigmoidal shape. Based on the analysis from his labor graphs, he proposed that labor has three divisions. First, a preparatory stage marked by slow cervical dilation, with large biochemical and structural changes. This is also known as the latent phase of the first stage of labor. Second, a much shorter and rapid dilational phase is also known as the active phase of the first stage of labor. Third, a pelvic division phase, which takes place during the second stage of labor.

The first stage of labor is further subdivides into two phases, defined by the degree of cervical dilation. The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. Cervical effacement refers to the cervical length in the anterior-posterior plane. When the cervix is completely thinned out, and no length is left, this is referred to as 100 percent effacement. The station of the fetus is defined relative to its position in the maternal pelvis.  When the bony fetal presenting part is aligned with the maternal ischial spine, the fetus is 0 station. Proximal to the ischial spines are stations -1 centimeter to -5 centimeters, and distal to the ischial spines is +1 to +5 station. The first stage of labor contains a latent phase and an active phase. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women, respectively, without being considered prolonged. Sedation can increase the duration of the latent phase of labor. The cervix changes more rapidly and predictably in the active phase until it reaches 10 centimeters and cervical dilation and effacement are complete. Active labor with more rapid cervical dilation generally starts around 6 centimeters of dilation. During the active phase, the cervix typically dilates at a rate of 1.2 to 1.5 centimeters per hour. Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation. The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions is considered the arrest of labor and may warrant clinical intervention. 

Second Stage of Labor

The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. The fetus passes through the birth canal via 7 movements known as the cardinal movements.  These include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. In women who have delivered vaginally previously, whose bodies have acclimated to delivering a fetus, the second stage may only require a brief trial, whereas a longer duration may be required for a nulliparous female. In parturients without neuraxial anesthesia, the second stage of labor typically lasts less than three hours in nulliparous women and less than two hours in multiparous women. In women who receive neuraxial anesthesia, the second stage of labor typically lasts less than four hours in nulliparous women and less than three hours in multiparous women. If the second stage of labor lasts longer than these parameters, then the second stage is considered prolonged. Several elements may influence the duration of the second stage of labor, including fetal factors such as fetal size and position, or maternal factors such as pelvis shape, the magnitude of expulsive efforts, comorbidities such as hypertension or diabetes, age, and history of previous deliveries. 

Third Stage of Labor

The third stage of labor commences when the fetus is delivered and concludes with the delivery of the placenta. Separation of the placenta from the uterine interface is hallmarked by three cardinal signs, including a gush of blood at the vagina, lengthening of the umbilical cord, and a globular shaped uterine fundus on palpation. Spontaneous expulsion of the placenta typically takes between 5 to 30 minutes. A delivery time of greater than 30 minutes is associated with a higher risk of postpartum hemorrhage and may be an indication for manual removal or other intervention. Management of the third stage of labor involves placing traction on the umbilical cord with simultaneous fundal pressure to effect faster placental delivery. 

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