Nursing Care during the Third Stage of Labor
Key Points
- Third-stage care centers on placental delivery, uterine tone support, and hemorrhage prevention.
- Placental delivery beyond 30 minutes increases risk for postpartum hemorrhage and manual extraction.
- Active management includes uterotonic use, structured assessment, and rapid response to abnormal bleeding.
Pathophysiology
The third stage starts after newborn birth and ends when the placenta is delivered. Ongoing uterine contraction decreases placental implantation surface and promotes placental separation; effective uterine tone then compresses vessels to reduce blood loss.
Failure of timely separation, retained tissue, or inadequate uterine contraction can cause severe postpartum bleeding. Nursing surveillance during this short but high-risk stage is therefore continuous and intervention-driven.
Classification
- Separation-progress domain: Hallmark signs include uterine shape change, blood gush, and cord lengthening.
- Hemorrhage-risk domain: Excessive blood loss, uterine atony, retained placenta, and laceration-associated bleeding.
- Medication domain: Prophylactic and therapeutic uterotonics.
- Recovery-support domain: Pain support, bonding facilitation, and calm environment maintenance.
Nursing Assessment
NCLEX Focus
Priority questions emphasize early recognition of hemorrhage and retained placenta during third-stage monitoring.
- Assess vital signs at least every 15 minutes in stable patients, watching for trend deterioration.
- Monitor fundal height, firmness, and tone while tracking vaginal bleeding amount and character.
- Identify placental separation signs and time from birth to placental expulsion.
- Assess bladder distention, pain, and perineal status for contributors to poor uterine contraction or hidden bleeding.
Nursing Interventions
- Administer ordered uterotonic prophylaxis promptly (commonly oxytocin) after birth/placental delivery.
- Support placental delivery and provider procedures with sterile setup and focused communication.
- Quantify blood loss whenever possible and escalate immediately for heavy or worsening bleeding.
- Promote skin-to-skin and early feeding efforts to support endogenous oxytocin and bonding.
Hemorrhage Emergency Window
Rapid increase in bleeding, hypotension, tachycardia, or poor uterine tone signals potential postpartum hemorrhage requiring urgent team response.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| uterotonics | Oxytocin, misoprostol, methylergonovine, carboprost | First-line prevention/treatment of uterine atony-related bleeding during third stage. |
| antifibrinolytics | Tranexamic acid context | Supports clot stability in hemorrhage pathways when ordered. |
Clinical Judgment Application
Clinical Scenario
Ten minutes after birth, placental separation is incomplete and bleeding increases while uterine tone becomes less firm.
Recognize Cues: Delayed placental progress, rising blood loss, and reduced uterine firmness. Analyze Cues: Third-stage physiology may be shifting toward atony/retained tissue risk. Prioritize Hypotheses: Immediate risk is progression to postpartum hemorrhage. Generate Solutions: Intensify fundal assessment, quantify blood loss, administer ordered uterotonic measures, and escalate. Take Action: Activate hemorrhage-oriented communication and intervention workflow. Evaluate Outcomes: Placenta is delivered, uterus remains firm, and bleeding trend stabilizes.
Related Concepts
- nursing-care-during-the-fourth-stage-of-labor - Continues hemorrhage surveillance and uterine recovery checks.
- postpartum-hemorrhage - Major third-stage complication requiring immediate intervention.
- uterine-atony - Leading mechanism of postpartum bleeding during placental stage.
- birth-plans - Preference-sensitive communication remains important during rapid care changes.
- uterine-involution - Early post-placental contraction process supports hemostasis.
Self-Check
- Which signs best indicate normal placental separation progression?
- Why does delayed placental delivery increase postpartum hemorrhage risk?
- Which nursing actions are prioritized when bleeding increases before placental expulsion?