Title of Guideline (must include the word “Guideline” (not

protocol, policy, procedure etc) Guideline for Management of third stage of

labour, Retained Placenta and Acute Uterine
Inversion

Contact Name and Job Title (author) Judith Moore, Consultant Obstetrician, City
Hospital Campus
Harriet Pugsley Specialist Registrar

Directorate & Speciality Family Health, Obstetrics and Gynaecology

Implementation date December 2013 (amend September 2015)

Version 3

Supersedes Version 2

Date of submission November 2013

Date on which guideline must be reviewed (this should be one to November 2018
three years)
Explicit definition of patient group to which it applies (e.g. Women in third stage of labour
inclusion and exclusion criteria, diagnosis)

Abstract This guideline describes the routine

management of women in third stage of labour
as well as the major complications associated
with the third stage of labour.

Key Words Third stage of labour, retained placenta, uterine

inversion, haemorrhage

Statement of the evidence base of the guideline – has the 4

guideline been peer reviewed by colleagues?

Evidence base: (1-5)

1a meta analysis of randomised controlled trials
1b at least one randomised controlled trial
2a at least one well-designed controlled study without
randomisation
2b at least one other type of well-designed quasi-
experimental study
3 well –designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
4 expert committee reports or opinions and / or clinical
experiences of respected authorities
5 recommended best practise based on the clinical
experience of the guideline developer
Consultation Process Obstetricians, Midwives, Anaesthetists,
maternity guideline development group

Target audience
Maternity services staff
This guideline has been registered with the trust. However,
clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using
guidelines after the review date.
Management of the Third Stage of Labour, Retained
Placenta and Acute Uterine Inversion

Third Stage of Labour

The third stage of labour is defined as the time from delivery of the baby
to expulsion of the placenta and membranes.

Observations in the third stage of labour which should be recorded in the

intrapartum booklet include:
 Estimation of vaginal blood loss, the general physical condition of
the woman

 The duration of the third stage

A full early warning score (EWS) documentation if the placenta is not

delivered within 30mins or earlier if excessive blood loss and repeat it
at least every 15 minutes until resolved.

Active Management of the Third Stage

Active management of the third stage of labour reduces rates of major

post-partum haemorrhage (PPH) (blood loss over 1500 ml), mean blood
loss, the length of the third stage, postnatal maternal anaemia and the
need for blood transfusion. There are associated maternal side effects
(nausea, vomiting and headache).

Standard Active third stage consists of:

 Oxytocin (Syntocinon© 10IU given by intramuscular injection after
delivery of the anterior shoulder) followed by Controlled cord
traction (CCT). In cases with a high risk of bleeding, syntometrine
should be considered.
 Controlled cord traction (one hand is used on the abdomen to push
the uterus upward and the other hand is used for controlled
traction on the cord downward and posteriorly). This should only
be carried out after administration of oxytocin and should not be
started until the uterus is well contracted and there are signs of
separation. This combined movement of traction and counter-
traction prevents the possibility of acute uterine inversion.

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  There should be consideration of the use of syntocinon if women
have raised blood pressure.

Historically, active management included immediate cord clamping

(within the first 30 seconds). However, delayed cord clamping between
1-3 minutes may benefit the neonate by increasing iron stores in the first
six months, reducing the need for transfusion and possibly reducing the
risk of intraventricular haemorrhage in pre-term infants. Delayed cord
clamping has not been associated with an increase in the rate of
maternal PPH.
Clinical trials are ongoing, but in the absence of complications (post
partum haemorrhage, placenta praevia, vasa praevia, tight nuchal cord
or the need for immediate resuscitation) immediate cord clamping is no
longer recommended. (RCOG 2011)

Physiological Third Stage

This consists of:

 No use of oxytocics
 Delayed clamping of the cord until pulsation has ceased
 Delivery of the placenta by maternal effort.
The average blood loss is greater than with an actively managed third
stage.

Changing from physiological management to active management of the

third stage is indicated in the case of:
 haemorrhage

 failure to deliver the placenta within 1 hour.

 the woman’s desire to artificially shorten the third stage.

Women at low risk of postpartum haemorrhage who request

physiological management of the third stage should be supported in their
choice. It is better suited for women who do not have the following risk
factors:

1. Previous PPH

2. Over-distended uterus:

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  multiple pregnancy

 polyhydramnios

 suspected fetal macrosomia

 fibroids uterus

3. Maternal condition:
 obesity BMI>35

 Grand multiparity :four and above

 Existing anaemia: Hb<10 at the onset of labour

 Pre-eclampsia

 Abnormal coagulation

 Obstetric cholestasis

4. Physiological third stage would not be recommended in the following

conditions:
 Use of oxytocin in labour

 Prolonged first or second stage of labour.

 Pyrexia in labour
 Operative delivery
 Antepartum / intrapartum bleeding
 Abruption

Prolonged Third Stage:

The third stage of labour is diagnosed as prolonged if not completed

within 30 minutes of the birth of the baby with active management and
60 minutes with physiological management.

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 Management of Third Stage of Labour

Physiological 3rd stage (60 minutes) Active management(30 minutes)

Placenta not delivered Placenta not delivered

Syntometrine (5IU/0.5mg) / Syntocinon (10IU) IM

Placenta not delivered in 30 minutes

RETAINED PLACENTA

Actions for midwives to encourage delivery of the placenta

Active management of the third stage.
30 minutes and placenta not delivered - no active bleeding and cord
intact. This is then a retained placenta.
 Keep woman warm.

 Encourage baby to breast feed if breast feeding.

 Remain in attendance in order to observe for haemorrhage until

the placenta has delivered.

 Start an Early warning score (EWS) chart.

 Apply aromatherapy - clary sage in inhalation, abdominal

compress or abdominal massage.

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  Empty urinary bladder

 Palpate the uterus - if well contracted attempt to deliver the

placenta using controlled cord traction. If cord separated
encourage maternal effort.

 A vaginal examination can be made in order to assess whether the

placenta is in the vagina. If it is then maternal effort can be used to
assist in the delivery - ensure that controlled cord traction is NOT
deployed at the same time.

Physiological third stage- whilst waiting for the placenta to deliver

naturally
60 minutes and placenta not delivered - no active bleeding and cord
intact.

Convert to active management as described on page 3. After 30 minutes

and placenta not delivered, this is a retained placenta.

 Keep woman warm.

 Encourage baby to feed if breast feeding.

 Remain in attendance in order to observe for haemorrhage until

the placenta has delivered.

 Apply aromatherapy - Clary sage inhalation, abdominal compress

or abdominal massage.

 Empty urinary bladder

 Palpate the uterus - If uterus contracted, attempt to deliver

placenta using CCT. If cord detached, encourage maternal effort.

 A vaginal examination can be made in order to assess whether the

Placenta is in the vagina. If it is then maternal effort can be used to
assist in the delivery - ensure that controlled cord traction is NOT
deployed at the same time.

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For Births at Home:

The initial management is the same as above.

If a woman has had an active third stage, begin arrangements for

transfer into hospital after 30 minutes (inform labour suite co-ordinator
and arrange for an urgent paramedic ambulance) or earlier if there is
evidence of haemorrhage. Start an EWS chart at this time.

If a woman has a physiological third stage it is reasonable to remain at

home for 60 minutes but a EWS chart should be commenced after 30
minutes. Arrangements for transfer into hospital should be commenced
after 60 minutes and earlier if any signs of haemorrhage.

Management of Retained Placenta:

If the placenta is retained or is incomplete, the woman should be

reviewed by the Registrar on call and the labour suite coordinator should
be informed. If the birth has occurred at home the woman should be
transferred into hospital (as above).
Once the diagnosis of retained placenta is made by the medical
professional, they must record the time and name of the obstetrician
who has been contacted in the intrapartum booklet.
 Intravenous access should always be secured in women with a
retained placenta. If not already done, blood should be taken for
Full Blood Count, Group and Save, and Cross Match if bleeding is
heavy (see Postpartum Haemorrhage guideline).

 The bladder should be emptied using an ‘in-out’ urethral catheter.

 Intravenous infusion of Syntocinon should not be used to assist the

delivery of the placenta.

 There is some evidence that Syntocinon injection into the umbilical

vein, followed by proximal clamping of the cord, may reduce the
risk of operative management. Use 20IU of Syntocinon diluted in
20ml of 0.9% saline (NICE).

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  If these measures fail, or sooner if there is concern about the
woman’s condition, the Registrar should examine the woman to
ensure the placenta is not in the vagina or cervix. The woman
should be offered pain relief (usually Entonox) for this. If she is
unable to tolerate the examination it should be performed in
theatre

 If it is impossible to deliver the placenta in the room, arrangements

should be made to transfer the woman to theatre. The senior
resident obstetrician, obstetric Anaesthetist and theatre staff
should be informed. The reasons for this should be explained to
the woman and consent should be obtained.

 Management should be expedited as bleeding may start at any

time.

Manual Removal of Placenta:

 It is preferable to carry out this procedure in theatre under regional

anaesthesia. General anaesthetic may be necessary, for example
if there is heavy bleeding or there are contraindications to regional
anaesthesia.

 The procedure must be performed by a suitably trained

obstetrician.

 The bladder must be emptied prior to the procedure

 The operating obstetrician must hold the uterus back at supra-

pubic area to provide a counter-traction reducing the risk of uterine
inversion. There must be a thorough check to ensure the cavity is
empty.

 If the plane between placenta and uterus is not easily defined,

consider placenta accreta and inform the Senior Registrar and
Consultant. DO NOT pull on placenta and cord.

 It is important to ensure the uterus is well contracted after removal

of the placenta. Syntocinon infusion (40IU in 500mL 0.9% saline)

Page 9 of 16
 should be started at the end of the procedure and run over four
hours.

 A single dose of prophylactic antibiotics should be given, normally

1.2g Co-amoxiclav IV or clindamycin 900mgs IV (If penicillin
allergic).

Placenta Accreta and Percreta

 Women thought to be at risk of placenta accreta and percreta

should be investigated antenatally using colour Doppler ultrasound
and/or MRI.

 Clinically, placenta accreta is diagnosed when manual removal of

the placenta is partially or totally impossible and no cleavage plane
exists between part or the entire placenta and the uterus.

 When placenta accreta or percreta is suspected the Senior

Registrar and Consultant should be informed, blood should be
cross-matched, and other specialities involved depending on the
preferred treatment options, e.g. anaesthetics, critical care,
haematology, vascular surgery, urology.

 There are numerous management strategies for this scenario,

although there is little evidence to support one over another. Most
are from case reports or small case series.

Conservative options (i.e. placenta left in situ) include:

 ‘Wait and see’

 Uterine artery embolisation

 Methotrexate

 Internal iliac artery ligation

Surgical options include:

 Hysterectomy (it is known that there is less bleeding when there is
no attempt to remove the placenta first)

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  Hysteroscopic resection of the placenta

Acute Uterine Inversion

This is a very rare and serious obstetric emergency. Causes include:

 Mismanagement of the third stage of labour (i.e. premature cord
traction and fundal pressure before separation of the placenta) is
the commonest cause.

 Uterine atony

 Fundal implantation, especially if the placenta is morbidly adherent

 Manual removal of placenta

 Short umbilical cord

 Precipitate labour

 Placenta praevia

 Connective tissue disorders such as Ehlers-Danlos syndrome

 No risk factors in 50%

Uterine inversion is classified according to severity:

First degree The inverted fundus extends to, but not beyond, the
cervical ring
Second The inverted fundus extends through the cervical ring but
degree remains within the vagina
Third degree The inverted fundus extends down to the introitus
Fourth The vagina is also inverted
degree

Acute uterine inversion presents with shock and or haemorrhage. The

shock is neurogenic (i.e. vasovagal) and is therefore out of proportion to
the blood loss. There is bradycardia and hypotension. If not treated,
postpartum haemorrhage will ensue. There may be severe lower
abdominal pain. Examination will show a mass in the vagina and the
uterus will not be felt abdominally.

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Management involves treatment of shock and repositioning of the
uterus. This requires teamwork as both should occur simultaneously.
First: call for help. In hospital call the obstetric emergency team via 2222
as this is a life threatening emergency. In the community call for a
paramedic ambulance and arrange transfer into labour suite.

 If the placenta is in situ do not attempt to remove it

 Attempt immediate replacement of uterus. The chances of success

are quoted as 43-88% with immediate manual replacement. If
successful give 10IU Syntocinon IM.

This would be the same in the community setting. The sooner this is
achieved the more likely it is to be successful.
 The whole hand, plus two-thirds of the forearm, is placed in the
vagina. Holding the fundus in the palm and keeping the tips of the
fingers at the uterocervical junction, the fundus is raised above the
level of the umbilicus. It may be necessary to apply digital pressure
constantly, sometimes for several minutes. This places the uterine
ligaments under tension. The tension generated relaxes and
widens the cervical ring and facilitates the passage of the fundus
though the ring. The inversion is, thus, corrected.

 Once help arrives begin simultaneous management of shock and

replacement of the uterus.

 Assess ABC, give 15L O2 with a non-rebreathe (trauma) mask.

Establish monitoring of heart rate and rhythm, blood pressure and
oxygen saturation.

 Insert two large bore cannulae (at least grey or 16G).

 Send blood for FBC, Clotting and Cross match at least four units of
red cells.

 Give IV crystalloids (0.9% saline or Hartmanns), warmed if

possible.

 If the patient is shocked without excessive blood loss, consider

Atropine 0.6mg IM (or IV if cardiac monitoring / defibrillator
present).
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 Establish analgesia

 Insert urethral catheter.

 If the diagnosis is delayed or it is impossible to replace the uterus,

inform the Consultant obstetrician, Consultant anaesthetist and
Theatre Coordinator.

 If replacement of the uterus is unsuccessful, arrange urgent

transfer to theatre to attempt replacement under general
anaesthetic.

 If the woman is not shocked, give tocolysis (0.25mg Terbutaline

SC or IV: can increase risk of bleeding) and make further attempt
at uterine replacement.

 Uterine rupture should be excluded before commencing

hydrostatic replacement. Under General anaesthetic, the inversion
is corrected by hydrostatic replacement. This involves infusing
warm saline from a height of approximately 1 metre above the
patient into the vagina. The infusion tube should be held in the
vagina, the hand blocking the vaginal orifice to minimise leakage.
As so much fluid is lost this may be many litres. A silastic ventouse
cup can be used to reduce the leak. A laryngeal mask airway may
also be used to instil the fluid into the vagina while providing a
better seal.

 If these measures fail, laparotomy may be necessary. At

laparotomy,

1. Huntington’s procedure: Allis forceps are placed within the

dimple of inverted fundus & gentle upward traction exerted
with the clamps with further placement of forceps on the
advancing fundus.

2. Haultain’s procedure: Make a posterior incision in the

cervical ring and manually reduce the inversion. Repair the
incision after giving oxytocin and manually remove the
placenta.

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  Once the uterus is replaced, give 10IU IM Syntocinon, deliver the
placenta, and commence a Syntocinon infusion (40IU Syntocinon
in 500mL 0.9% Saline over four hours).

 Further bleeding should be managed as per the postpartum

haemorrhage guideline.

 A single dose of prophylactic antibiotics should be given, normally

1.2g Co-amoxiclav IV (or clindamycin 900mgs IV If penicillin
allergic).

 All actions taken must be recorded in the intrapartum booklet.

 Debriefing by a senior obstetrician should take place prior

discharge and a subsequent visit should be offered in ANC at six
weeks post partum.

 The management should be documented in the patient records.

The management of acute uterine inversion is summarised in the flow

diagram below.

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Monitoring Plan:

The management of the third stage of labour, retained placenta and

acute uterine inversion guideline will be monitored in conjunction with
the NUH Maternity Services Clinical Operational Monitoring Plan.

Page 15 of 16
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uterus. The Obstetrician & Gynaecologist 2009;11:13–18.

Green Top Guideline No. 27: Placenta Praevia and Placenta Praevia
Accreta: Diagnosis and Management. October 2005 RCOG Press.

Johnson AB. A new concept in replacement of the inverted uterus and

report of nine cases. American Journal of Obstetrics and Gynecology
1949;57:557–62.

NICE Intrapartum Care: care of healthy women and their babies during
childbirth. September 2007

Paterson-Brown S. Chapter 18 Obstetric emergencies. In Dewhurst’s

Textbook of Obstetrics and Gynaecology 7th edition. Blackwell
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Scientific Advisory Committee opinion Paper 14: Clamping of the

umbilical cord and placental transfusion. May 2009 RCOG Press.

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A, Jafri H, Nardin J, Carroli G, Fairlie F, Raashid Y, Mirembe F, Alfirevic
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Management. May 2009 RCOG Press. (Amendment 2011)

McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of

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