Book Reading

THIRD AND FOURTH STAGE OF LABOR

Presented By :
Dr. Octaria Saputra

Moderator :
Dr. Abarham Martadiansyah, SpOG(K)

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

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 CONTENTS
01 THIRD STAGE OF LABOR
• Delivery of the Placenta
• Manual Removal of Placenta
• Management of the Third Stage

02 FOURTH STAGE OF LABOR

• Birth Canal Lacerations
• Episiotomy
 THIRD STAGE OF LABOR
Delivery of the Placenta

• Third-stage labor begins immediately after fetal birth

and ends with placental delivery

• Goals include delivery of an intact placenta and

avoidance of uterine inversion or postpartum
hemorrhage

• Signs of separation include a sudden gush of blood into

the vagina, a globular and firmer fundus, a lengthening
of the umbilical cord as the placenta descends into the
vagina, and a rise of the uterus into the abdomen.

Expression of placenta
 THIRD STAGE OF LABOR
Delivery of the Placenta

• The umbilical cord is kept slightly taut but is not pulled.

• Concurrently, the heel of the hand exerts downward

pressure between the symphysis pubis and the uterine
fundus.

• Once the placenta passes through the introitus,

pressure on the uterus is relieved.

• The placenta is then gently lifted away

The placenta is removed from the vagina by lifting the cord

 THIRD STAGE OF LABOR
Delivery of the Placenta

• Care is taken to prevent placental membranes from

being torn off and left behind

• If the membranes begin to tear, they are grasped with a

clamp and removed by gentle teasing

Membranes that were somewhat adhered to the

uterine lining are separated by gentle traction with a ring forceps
 THIRD STAGE OF LABOR
Manual Removal of Placenta

• Occasionally, the placenta will not separate promptly

• If there is brisk bleeding and the placenta cannot be delivered by the above
technique, manual removal of the placenta is indicated

• The benefits of this practice, however, have not been proven, and most
obstetricians await spontaneous placental detachment unless bleeding is
excessive.

• When manual removal is performed, some administer a single dose of intravenous

antibiotics similar to that used for cesarean infection prophylaxis
 THIRD STAGE OF LABOR
Management of the Third Stage
Practices within the third stage of labor may be broadly considered as either
physiological or active management

Physiological management Active management

Waiting for placental separation signs • early cord clamping

and allowing the placenta to deliver • controlled cord traction during
either spontaneously or aided by placental delivery
nipple stimulation or gravity • immediate administration of
prophylactic uterotonics
 THIRD STAGE OF LABOR
Management of the Third Stage
High-Dose Oxytocin

• Synthetic oxytocin is identical to that produced by the posterior pituitary

• Its action is noted at approximately 1 minute, and it has a mean half-life of 3 to 5 minutes

• When given as a bolus, Oxytocin can cause profound hypotension

• Water intoxication can result from the antidiuretic action of high-dose oxytocin if administered in
a large volume of electrolyte-free dextrose solution

• no standard prophylactic dose has been established for its use following either vaginal or
cesarean delivery.
 THIRD STAGE OF LABOR
Management of the Third Stage
Ergonovine and Methylergonovine

• These ergot alkaloids have similar activity levels in myometrium, and only methylergonovine
is currently manufactured in the United States

• Whether given intramuscularly or orally, both are powerful stimulants of myometrial

contraction, exerting an effect that may persist for hours

• Ergots are dangerous for the fetus and mother when given before delivery.

• Ergot alkaloid agents do not provide superior protection against postpartum hemorrhage
compared with oxytocin.
 THIRD STAGE OF LABOR
Management of the Third Stage
Misoprostol

• This prostaglandin E1 analogue has proved inferior to oxytocin for postpartum hemorrhage
prevention

• Although oxytocin is preferred, in resource-poor settings that lack oxytocin, misoprostol is

suitable for hemorrhage prophylaxis and is given as a single oral 600-μg dose

• Side effects include shivering in 30 percent and fever in 5 percent.

 FOURTH STAGE OF LABOR

The hour immediately following delivery of the placenta is critical, and

it has been designated by some as the fourth stage of labor

During this time, lacerations are repaired

 FOURTH STAGE OF LABOR
Birth Canal Lacerations

Classification of perineal lacerations.

A. First-degree lacerations
involve the fourchette, perineal skin, and
vaginal mucous

B. Second degree
Lacerations involve, in addition, the fascia and
muscles of the perineal body but not the anal
sphincter.

C. Third-degree lacerations extend

farther to involve the external anal sphincter.

D. Fourth-degree lacerations
extend completely through the rectal mucosa to
expose
 FOURTH STAGE OF LABOR
Episiotomy

• Episiotomy is incision of the pudendum—the

external genital organs.

• Perineotomy is incision of the perineum.

• The incision may be made in the midline,

creating a median or midline episiotomy

• It may also begin off the midline and directed

laterally and downward away from the rectum,
termed a mediolateral episiotomy.
 FOURTH STAGE OF LABOR
Episiotomy
Episiotomy Indications and Consequences

• episiotomy did not protect the perineal body but contributed to anal sphincter
incontinence by increasing the risk of higher-order lacerations

• restricted use of episiotomy is preferred to routine use

• episiotomy should be considered for indications such as shoulder dystocia, breech

delivery, macrosomic fetuses, operative vaginal deliveries, persistent occiput
posterior positions, and other instances in which failure to perform an episiotomy
will result in significant perineal rupture.

• The final rule is that there is no substitute for surgical judgment and common sense.
 FOURTH STAGE OF LABOR
Episiotomy
Technique
 FOURTH STAGE OF LABOR
Episiotomy
Repair of Episiotomy or Perineal Laceration

Repair of midline episiotomy.

A. Disruption of the hymenal ring and

bulbocavernosus and superficial transverse
perineal
B. An anchor stitch is placed above the wound
apex to begin
 FOURTH STAGE OF LABOR
Episiotomy
Repair of Episiotomy or Perineal Laceration

C. After closing the vaginal incision and

reapproximating the cut margins of the
hymenal ring, the needle and suture are
positioned to close the perineal incision.
D. A continuous closure with absorbable
2–0 or 3–0 suture is used to close the
fascia and muscles of the incised
perineum. This aids restoration of the
perineal body for long-term support.
E. The continuous suture is then carried
upward as a subcuticular stitch.
The final knot is tied proximal to the
hymenal ring.
 FOURTH STAGE OF LABOR
Episiotomy
Repair of Episiotomy or Perineal Laceration

Mediolateral episiotomy repair

 FOURTH STAGE OF LABOR
Episiotomy
Fourth-Degree Laceration Repair

• Two methods are used to repair a laceration

involving the anal sphincter and rectal mucosa.

• The first is the end-to-end technique, which we

prefer, and the second is the overlapping
technique.

The end-to-end technique

 FOURTH STAGE OF LABOR
Episiotomy
Fourth-Degree Laceration Repair

The end-to-end technique