Learning Objectives
By the end of this section, you will be able to:
- Obtain assessment data on the birthing person during the third stage of labor
- Explain the nursing actions when caring for the birthing person during the third stage of labor
The third stage of labor begins with the birth of the newborn and ends with the separation and expulsion of the placenta. Following the delivery of the newborn, the infant may be placed on the birthing person’s abdomen and then chest to initiate skin-to-skin contact. Initial skin-to-skin contact has been shown to promote bonding and aid in the newborn’s transition to extrauterine life (Bigelow & Power, 2020). While the newborn is on the birthing person’s chest and before the expulsion of the placenta, the umbilical cord is clamped by the health-care provider and cut by the support person or health-care provider. Waiting 30 to 60 seconds for delayed cord clamping in newborns is associated with significant benefits to the newborn, including increased hemoglobin levels and improved circulation, among others (ACOG, 2020a). If the newborn is compromised or if skin-to-skin contact or delayed cord clamping is not appropriate for any reason, the newborn may be taken to the infant warmer for additional support, observation, or resuscitation.
Following the birth of the newborn, the uterus reduces in size, creating a decrease in the placental site and causing it to separate from the placental wall. The separation and expulsion of the placenta may be active or passive, including the use of uterotonics, early cord clamping, or gentle cord traction. Promotion of endogenous oxytocin to aid in the expulsion of the placenta may also be facilitated by encouraging skin-to-skin contact and early efforts to latch the baby to the maternal breast. Placenta delivery time of more than 30 minutes after delivery of the infant is associated with a higher risk of postpartum hemorrhage (PPH) or the need for manual removal of the placenta (Hutchison et al., 2023). Immediately after the birth of the placenta, most health-care providers order intravenous oxytocin to be administered by the nurse.
Assessment during the Third Stage of Labor
During the third stage of labor, the nurse’s responsibilities include the assessment of the patient (Table 18.10) and newborn (Table 18.11). The nurse should continually complete the following patient assessments throughout the duration of the third stage of labor:
- assessment of vital signs
- assessment of the fundus for height, firmness, and tone to ensure uterine contraction and decrease the risk of postpartum hemorrhage
- assessment of pain and discomfort
- assessment of the bladder for any distention that may increase the risk of postpartum hemorrhage
- assessment of the amount and type of vaginal bleeding
| Assessment Data | Third Stage of Labor |
|---|---|
| Vital signs | Every 15 minutes Temperature Every 1 hour |
| Contraction pattern | Manually by palpation, usually by the health-care provider |
| Labor progress | As indicated based on signs of placental separation |
| Pain | As needed |
| Emotional response | Continuous |
| Assessment Data | First 30 Minutes after Birth |
|---|---|
| Apgar Score (see Chapter 22 Immediate Care of the Newborn) |
1 and 5 minutes (10 minutes when newborn is in distress) |
| Temperature | Within first 15 minutes |
| Apical pulse | Low-risk: every 30 minutes after Apgar scoring With risk factors: every 5 minutes |
| Respiratory rate and quality | Low-risk: every 30 minutes after Apgar scoring With risk factors: every 1–5 minutes |
Vital Signs
Vitals signs during the third stage of labor should be obtained at a minimum of every 15 minutes in stable birthing persons. Blood pressure should be closely monitored during the third stage, as a drop in blood pressure could indicate excessive blood loss or other life-threatening complication. The birthing person’s pulse rate should be monitored, and a rapid or weak pulse should be reported immediately, as it could indicate a potential hemorrhage. Respiratory rate and oxygen saturation should be included in the assessment of vital signs during the third stage of labor. Any abnormal findings or changes in trends in the vital signs of the birthing person should be reported to the provider immediately (Hutchison et al., 2023).
The newborn’s temperature should be taken as soon after birth as possible, especially with prolonged rupture of the membranes or increased maternal temperature during the first or second stages of labor. Newborn temperatures below 96.8° F (36° C) or above 100.4° F (38° C) are considered abnormal and should be reported by the nurse to the health-care provider and neonatal team (Lubkowska et al., 2019).
Signs of Placental Separation
The reduction in uterine size, contractions, and cord traction contribute to the separation of the placenta from the uterine wall (Figure 18.5). Separation of the placenta from the uterus results in the following three hallmark signs (Milton, 2024):
- The shape of the uterus changes to a spherical or round shape.
- A gush of blood from behind the placenta appears in the vagina.
- The umbilical cord lengthens as the placenta detaches and moves into the introitus.
Spontaneous delivery of the placenta occurs following the separation from the uterus. If the placenta is not delivered spontaneously, the health-care provider may manually extract the placenta from the uterine wall. Manual extraction increases the risk of infection and postpartum hemorrhage (PPH). Following spontaneous or manual expulsion of the placenta, the health-care provider inspects that the placenta is intact. Any piece of the placenta that remains inside the uterus or attached to the uterine wall interferes with the effective contraction of the uterus and increases the risk of PPH (Agrawal et al., 2018).
Vaginal Bleeding
Following placental separation from the uterus, contractions cause the expulsion of the placenta. Once the placenta is expelled, uterine massage is performed by the health-care provider, ensuring the uterus is firm to aid in the constriction of uterine blood vessels. Median blood loss in a vaginal birth is approximately 125 mL, with up to 500 mL considered acceptable, while in a cesarean birth, blood loss may measure up to 1,000 mL (Rabie et al, 2018). Any blood loss greater than 1,000 mL or causing symptoms in the birthing person is considered a postpartum hemorrhage (PPH). A PPH is an obstetric emergency and requires interventions to reduce risks associated with morbidity and mortality. Careful monitoring by direct measurement of the blood loss (quantitative blood loss) has been shown to be more accurate than a visual estimation (EBL) of the blood loss during the process of labor and birth (ACOG, 2022).
Link to Learning
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) provides guidelines for quantifying blood loss during childbirth. Accurate measurement of blood loss is crucial for identifying postpartum hemorrhage and ensuring timely interventions. This video describes how to accurately quantify blood loss.
Nursing Interventions during the Third Stage of Labor
Nursing care during the third stage of labor focuses on the initial assessment of the newborn, the administration of uterotonics, assessment of the uterus and lochia, and promotion of parent-newborn bonding. During this time, the nurse may assist the health-care provider while caring for the mother and newborn.
Monitoring the Physical Response during the Third Stage of Labor
The nurse will assess the birthing person’s vital signs, including blood pressure, pulse, respiratory rate, and pain while awaiting the delivery of the placenta. The uterus continues to contract following the birth of the newborn, which may result in the birthing person experiencing mild to moderate pain. The nurse may need to administer pain medication to the birthing person or guide them in nonpharmacologic pain management techniques. (See the full discussion in Chapter 17 Pain Management During Labor and Birth.) The nurse may guide the birthing person in bearing down to aid in the delivery of the placenta. After the placenta is delivered, the nurse will assess the vaginal bleeding for color, consistency, and amount, and the uterus for firmness, location, and tone (Milton, 2024).
Promoting Relaxation and Rest during the Third Stage of Labor
With the birth of a newborn comes many emotions. The birthing person may experience joy, sadness, or excitement. The nurse can support the birthing person through these emotions and promote rest and relaxation. Promoting relaxation during the third stage of labor can be done in many ways, including the following:
- encouraging deep breathing
- providing a calm, quiet environment
- offering warm blankets
- gently massaging the birthing person’s abdomen
- encouraging the birthing person to close their eyes and use imagery to relax
- offering emotional support
- offering reassurance
Providing a relaxed environment during the third stage of labor can help provide a safe and healthy delivery experience for the birthing person and their partner.
Administering Uterotonics
Active management of the third stage of labor is aimed at preventing postpartum hemorrhage (PPH). Medications that increase the tone and contractility of the uterus, called uterotonics, are administered immediately following the birth of the newborn or delivery of the placenta. The first-choice oxytocic medication for the prevention of PPH is oxytocin (Pitocin). Administered through intravenous or intramuscular routes, prophylactic use of oxytocin during the third stage of labor reduces maternal blood loss and the need for additional oxytocic medications (Salati et al., 2019). When the use of additional uterotonics is required, a provider may opt to administer misoprostol (Cytotec), methylergonovine (Methergine), carboprost (Hemabate), or tranexamic acid (Lysteda) to decrease the complications of PPH.
Perineal Cleansing
After the delivery of the placenta, the health-care provider may perform perineal cleansing to view the vagina and perineum for lacerations. Nursing actions include providing the health-care provider with sponges and cleansing solutions. Perineal cleansing practices may vary based on the health-care provider’s preference and the birthing person’s need. During this time, the health-care team will count the used blades and needles, sponges, and vaginal packing, if used, to ensure that no foreign bodies are retained.
Monitoring the Newborn
Immediately upon birth, assessment of the newborn begins and will continue until the newborn is discharged. Initial observation allows the health-care providers to monitor for any distress or complications. At 1 and 5 minutes of life, an Apgar score is assigned to the newborn; five specific parameters are assessed to evaluate the physiologic state of the newborn, starting with (1) heart rate, (2) respiratory effort, (3) muscle tone, (4) response to irritating stimuli, and (5) color. For a full discussion of Apgar scoring, refer to Chapter 22 Immediate Care of the Newborn.
Monitoring and maintaining the newborn’s body temperature is essential to the transition to extrauterine life. At birth, the fetal body temperature is dependent on the maternal temperature. The delivery room temperature and the evaporation of fluid from the newborn’s skin result in a rapid drop in temperature (approximately 2o C or 2o to 3o F) following birth and during the first half hour of life. Immediately following the birth, the nurse will dry the newborn, place them skin-to-skin, cover their head with a cap, and cover them with warm blankets (Lubkowska et al., 2019).
Promoting Parental Attachment to the Newborn
To promote bonding, skin-to-skin contact is initiated by placing the newborn directly on the skin of a parent. In many cases, the newborn is placed on the abdomen of the birthing person immediately after birth. After the cord is clamped, the newborn is moved up to the birthing person’s chest to continue skin-to-skin contact. This immediate contact has significant benefits for the newborn and the birthing person. One of the most important needs of the newborn, temperature regulation, is promoted through early skin-to-skin contact with the parent. Physiologic and metabolic adaptation and maintenance of glucose blood levels are positively impacted when the newborn is placed immediately skin-to-skin and continues there for their first hour of life (Safari et al., 2018). In cases where skin-to-skin is not feasible or possible, the newborn will be moved to a radiant warmer for further assessment, observation, and interventions, if needed.
In addition to the benefits of skin-to-skin for the transitioning newborn, skin-to-skin has positive effects on the third stage of labor. The skin contact of the baby with the birthing person induces the maternal secretion of endogenous oxytocin, resulting in increased levels of oxytocin and uterine contractions. Skin-to-skin contact between the birthing person and newborn decreases the duration of the third stage of labor (Karimi et al., 2019).
Monitoring for Complications during the Third Stage of Labor
Nursing care of the birthing person during the third stage of labor requires thorough assessment and active management of the third stage of labor.
Lacerations
Soft tissue trauma during the third stage of labor is common and can vary in severity. It is not uncommon for a birthing person to experience edema or ecchymosis of the soft tissue. Some birthing persons may experience significant lacerations to the cervical, vaginal, and perineal tissues that require repair. Perineal and vaginal lacerations are described as first, second, third, or fourth degree (Figure 18.6). A first-degree laceration of the labia and perineum affects the skin and subcutaneous tissue. A second-degree laceration affects the skin, subcutaneous tissue, and muscle of the perineum as well as the vagina. When a perineal tear extends to or through the anal sphincter, this designates a third-degree laceration. A fourth-degree laceration includes damage to the pelvic floor and surrounding anal and rectal mucosa (Ramar & Grimes, 2023). Specific suture needles for perineal repair may be requested by the provider, depending upon the degree of laceration and provider preference.
Retained Placenta
A retained placenta after vaginal birth, a complication responsible for obstetric morbidity in 1 percent to 3 percent of deliveries, is diagnosed when the placenta fails to spontaneously separate from the uterus during the third stage of labor within 30 minutes after birth. Excessive bleeding in the absence of placental separation or placental tissue that remains after the placenta is delivered can lead to maternal complications such as postpartum hemorrhage and uterine infection (Perlman & Carusi, 2019). A retained placenta is the second leading cause of PPH, and the nurse must recognize risk factors as well as signs and symptoms and understand the management of the condition. Sometimes, only a small portion (single cotyledon) of the placenta is retained. This is why the placenta is inspected by the health-care provider after delivery. (For a full discussion, see Chapter 21 Postpartum Complications.)
Postpartum Hemorrhage
Annually, approximately 14 million birthing persons worldwide experience postpartum hemorrhage (PPH), or severe bleeding following childbirth, which is postpartum bleeding that exceeds 500 mL for a vaginal delivery and 1,000 mL for a cesarean birth. Of these birthing persons, about 70,000 die (World Health Organization [WHO], 2022). PPH requires active management to prevent complications. Prevention of PPH during the third stage should target multiple aspects, including the administration of uterotonics after delivery, controlled cord traction, and uterine massage after delivery of the placenta (Masuzawa et al, 2018). The nurse at the bedside during the third stage of labor should be prepared to administer uterotonics, provide uterine massage, monitor vital signs, and continually assess the need for further interventions in the case of PPH. (For a full discussion, see Chapter 21 Postpartum Complications.)
Pharmacology Connections
Uterotonics
Uterotonics are medications that increase the tone and contractility of the uterus. Different uterotonics can be prescribed for cervical ripening, induction and augmentation of labor, and postpartum hemorrhage. Uterotonics used after birth and in the postpartum period include oxytocin, misoprostol, methylergonovine, and carboprost. Tranexamic acid does not increase uterine tone, but it is prescribed to assist blood clotting in the event of a postpartum hemorrhage.
Oxytocin (Pitocin)
- Indication: prevention and treatment of postpartum uterine atony and hemorrhage
- Mechanism of Action: acts on the receptors in the myometrial cells, causing rhythmic contractions of the uterus
- Adverse Effects: uterine hyperstimulation (most common), nausea, vomiting, dysrhythmias
- Contraindications: hypersensitivity
- Patient Education: Oxytocin reduces the bleeding from postpartum hemorrhage by making the uterus contract. It is administered intravenously or intramuscularly. Side effects include nausea, vomiting, and abdominal cramping. Adverse effects include irregular heart rate.
- Classification: oxytocic
- Dose: IV: 10 to 40 units (diluted for continuous infusion); IM: 10 units
Misoprostol (Cytotec)
- Indication: treatment of postpartum uterine atony and hemorrhage
- Mechanism of Action: acts on prostaglandin receptors to increase uterine tone to decrease postpartum bleeding
- Adverse Effects: shivering/chills, diarrhea, abdominal pain, hyperthermia, nausea and/or vomiting, flatulence, headache, increased blood pressure
- Contraindications: hypersensitivity, active cardiac, pulmonary, renal, or hepatic disease; use with caution in patients with asthma
- Patient Education: Misoprostol reduces the bleeding from postpartum hemorrhage by making the uterus contract. It is administered rectally. Side effects include nausea, vomiting, diarrhea, and flatulence. Adverse effects include shivering/chills, abdominal cramping, fever, headache, and increase in blood pressure.
- Classification: prostaglandin
- Dose: 400 to 1,000 mcg per rectum
Methylergonovine (Methergine)
- Indication: prevention and treatment of postpartum uterine atony and hemorrhage
- Mechanism of Action: acts on smooth muscle of the uterus (via dopamine, α-adrenergic, and 5-HT3 receptors stimulating a constant contraction of the uterus)
- Adverse Effects: pain, sweating, vomiting, headache, increased blood pressure, stroke, tingling or numbness in the hands or feet, tachycardia, cardiac dysrhythmia
- Contraindications: hypersensitivity, hypertension, cardiovascular disease
- Patient Education: Methylergonovine reduces the bleeding from postpartum hemorrhage by making the uterus firmly contract. It is administered intramuscularly. Side effects include pain, sweating, vomiting, and headache. Adverse effects include increased blood pressure, stroke, tingling or numbness in the hands or feet, tachycardia, and cardiac dysrhythmia.
- Classification: ergot alkaloid
- Dose: IM: 0.2 mg every 2 to 6 hours
Carboprost (Hemabate)
- Indication: treatment of postpartum uterine atony and hemorrhage
- Mechanism of Action: acts on prostaglandin receptor sites in the uterine muscle to stimulate uterine contractions
- Adverse Effects: nausea, vomiting, diarrhea, abdominal cramps and pain, temperature increase greater than 2° F (1.1° C), flushing
- Contraindications: hypersensitivity, asthma or active cardiac, pulmonary, renal, or hepatic disease
- Patient Education: Carboprost reduces the bleeding from postpartum hemorrhage by making the uterus contract. It is administered intramuscularly. Side effects include nausea, vomiting, diarrhea, and flushing. Adverse effects include abdominal cramping and fever.
- Classification: prostaglandin
- Dose: IM: 0.25 mg (may be administered directly into the uterus by the health-care provider)
Tranexamic acid (TXA) (Lysteda)
- Indication: prevention and treatment of postpartum hemorrhage
- Mechanism of Action: reduces blood loss by inhibiting the breakdown of fibrin by enzymes
- Adverse Effects: anxiety, confusion, headache, visual changes, back pain, abdominal pain, dizziness, deep vein thrombosis, pulmonary embolus, seizures, fatigue
- Contraindications: hypersensitivity, seizure disorder, high risk of venous or arterial thrombosis, or preexisting coagulopathy or oral anticoagulant treatment
- Patient Education: TXA reduces the bleeding from postpartum hemorrhage by making sure the blood clots. It is administered intravenously. Side effects include fatigue, headaches, visual changes, confusion, and anxiety. Adverse effects include blood clots in the leg or lung and seizures.
- Classification: antifibrinolytic
- Dose: IV: 1 g
(Brenner et al., 2019; Drew & Carvalho, 2022; Vallerand & Sanoski, 2022)