What to Know About Complications in the 3rd Stage of Labour

Welcoming a child into the world is such an incredible experience. It’s common to feel a whirlwind of emotions, including some anxiety about what might happen during the process. As you get ready for the big day, it’s helpful to understand the different stages of labour and the challenges that may come up.

Today we're going to talk about the third stage of labour, which happens right after your baby arrives. This stage is super important, and it’s where some complications may occur. By learning about potential issues, you’ll feel more empowered and prepared for your birthing journey. You’ve got this!

The third stage of labour, also known as the placental stage, begins immediately after your baby's birth and ends with the delivery of the placenta. In case you didn't already know, the placenta is a temporary organ that develops in the uterus during pregnancy. It connects the foetus to the mother and facilitates the exchange of nutrients, oxygen, and waste products.

Right after your baby is delivered, your uterus continues to contract, helping to separate the placenta from the uterine wall and expel it through the vagina. This stage is typically managed through one of two approaches:

1. Active management of the third stage of labour: This involves interventions such as administering uterotonic medications, controlled cord traction, and uterine massage to facilitate placental delivery and reduce the risk of complications of 3rd stage of labour.
2. Expectant management: This involves waiting for signs of placental separation and allowing the placenta to be delivered spontaneously, without immediate intervention.

Now let's look at some common complications of the third stage of labour and how they can be managed.

One of the most severe complications during labour, particularly in the third stage, is postpartum haemorrhage (PPH). PPH is defined as excessive blood loss of more than 500 mL following a vaginal delivery or over 1000 mL after a caesarean section.

This delivery complication can be life-threatening if not promptly addressed. The main causes of PPH include an atonic uterus (failure of the uterus to contract adequately), retained placental tissue, and lacerations in the birth canal.

Risk Factors and Prevention of PPH

Several factors can increase the likelihood of experiencing PPH during the third stage of labour:

• Prolonged labour: Lengthy labour can lead to uterine exhaustion, increasing the risk of complications of prolonged labour such as PPH.
• Multiple pregnancies: Carrying twins or triplets can over-distend the uterus, making it harder to contract effectively after delivery.
• Placenta accreta: This condition, where the placenta grows too deeply into the uterine wall, can cause severe bleeding during placental separation.
• Shoulder dystocia: Difficulty delivering the baby's shoulders can lead to uterine atony and subsequent PPH.

To help prevent PPH, your healthcare provider may recommend:

• Active management of the third stage of labour
• Ensuring the complete delivery of the placenta and membranes
• Monitoring your vital signs and blood loss closely
• Massaging the uterus to encourage contraction
• Administering uterotonic medications as needed

While this complication may occur, the vast majority of births proceed without major issues. And if it does, you can rest assured that your healthcare providers are well-equipped to handle any challenges that may arise.

A retained placenta is another complication of the third stage of labour. It occurs when the placenta fails to be expelled within 30 minutes after the baby's birth. This condition can lead to postpartum haemorrhage, as the placenta continues to bleed from its attachment site in the uterus.

Studies show that the risk of complications increases if the third stage of labour extends beyond 30 minutes. Factors associated with a retained placenta include preterm delivery, pre-eclampsia, augmented labour, and nulliparity (first-time mothers).

Manual placental extraction may be necessary if the placenta is not expelled within the recommended time frame, but waiting at least 30 minutes before intervening is generally advised unless there is active bleeding. Proper management of the retained placenta is crucial to prevent further complications during labour.

Management of Retained Placental Remnants

Managing retained placental remnants involves several steps to ensure complete expulsion of the placenta and prevent further delivery complications:

• If the placenta is not expelled within 30 minutes, manual placental extraction may be performed, which involves gently pulling on the umbilical cord while applying gentle traction to separate and remove the placenta from the uterine wall.
• Uterotonic agents such as oxytocin or ergometrine may be administered to help contract the uterus and facilitate placental expulsion.
• External uterine massage can also be applied to control bleeding and promote uterine contraction.
• If significant bleeding occurs or manual extraction is unsuccessful, surgical intervention like dilation and curettage (D&C) may be necessary. D&C is a surgical procedure used to remove tissue from the uterus. 

Uterine inversion is a rare but serious complication of the third stage of labour, where the uterus turns inside out, protruding through the cervix and vagina. This condition can cause severe pain, haemorrhage, and shock. Prompt recognition and management are essential to prevent life-threatening complications during labour.
 

Placental complications can arise during the third stage of labour, posing significant risks to the mother's health. One such complication is retained placenta, as mentioned earlier. This in turn leads to postpartum haemorrhage. Studies have shown that the incidence of PPH, transfusion, and other complications increases significantly if the third stage of labour extends beyond 30 minutes.

Another complication is the incomplete removal of the placenta, which can lead to retained placental remnants, causing continued bleeding or infection. To prevent these complications, active management of the third stage of labour is crucial, involving placing traction on the umbilical cord and the administration of intravenous oxytocin by your doctor.

Placenta Accreta

Placenta accreta is a rare but serious condition in which the placenta grows too deeply into the uterine wall, potentially leading to severe bleeding and life-threatening complications during labour. Unlike a normal placenta that separates easily from the uterus, a placenta accreta may require surgical intervention. 

Recognising and promptly responding to complications of the 3rd stage of labour is essential for ensuring the well-being of both mother and child. Your healthcare providers should be vigilant in monitoring for signs of complications during labour, such as excessive bleeding, prolonged third stage, or difficulty delivering the placenta.

In cases of obstructed labour or shoulder dystocia, swift action is necessary to prevent further complications of prolonged labour. By staying alert and prepared to intervene when needed, healthcare professionals can effectively manage and mitigate the risks associated with complications of induction of labour and the third stage of labour. 

Postpartum care and follow-ups with your doctor are essential to prevent and manage complications of the 3rd stage of labour. Close monitoring enables early detection of issues like postpartum haemorrhage, retained placenta, and uterine inversion. Your doctor might choose to actively manage your third stage of labour if they think you are at risk of serious complications. Identification of potential risks is the only way to ensure you do not have to face more serious issues later on.

Complications in the third stage of labour, such as postpartum haemorrhage, retained placenta, and uterine inversion, are significant risks requiring careful management. Active management of the third stage of labour, including timely placental delivery and uterotonic agents, is superior to expectant management in reducing blood loss and other serious complications.

Identifying risk factors like multiple gestations, operative vaginal delivery, and intrapartum infection can help in proactive management. Prompt medical intervention and thorough postpartum care are essential to ensure the mother's health and safety.

By understanding labour complications and their management, healthcare providers can offer better care to you and reduce the morbidity and mortality associated with the third stage of labour.