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NICE Pathways bring together all NICE guidance, quality standards and other NICE
information on a specific topic.
NICE Pathways are interactive and designed to be used online. They are updated
regularly as new NICE guidance is published. To view the latest version of this pathway
see:
http://pathways.nice.org.uk/pathways/intrapartum-care
Pathway last updated: 27 February 2017
This document contains a single pathway diagram and uses numbering to link the
boxes to the associated recommendations.
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Care in third stage of labour NICE Pathways
The third stage of labour is the time from the birth of the baby to the expulsion of the
placenta and membranes.
Recognise that the time immediately after the birth is when the woman and her birth
companion(s) are meeting and getting to know their baby. Ensure that any care or interventions
are sensitive to this and minimise separation or disruption of the mother and baby.
3 Observations
Record the following observations for a woman in the third stage of labour:
her general physical condition, as shown by her colour, respiration and her own report of
how she feels
vaginal blood loss.
Active management of the third stage involves a package of care comprising the following
components:
Physiological management of the third stage involves a package of care that includes the
following components:
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Care in third stage of labour NICE Pathways
Advise the woman to have active management of the third stage, because it is associated with
a lower risk of a postpartum haemorrhage and/or blood transfusion.
Document in the records the decision that is agreed with the woman about management of the
third stage.
For active management, administer 10 IU of oxytocin by intramuscular injection with the birth of
the anterior shoulder or immediately after the birth of the baby and before the cord is clamped
and cut. Use oxytocin as it is associated with fewer side effects than oxytocin plus ergometrine.
Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is
concern about the integrity of the cord or the baby has a heart rate below 60 beats/minute
that is not getting faster.
Clamp the cord before 5 minutes in order to perform controlled cord traction as part of
active management.
If the woman requests that the cord is clamped and cut later than 5 minutes, support her in
her choice.
Perform controlled cord traction as part of active management only after administration of
oxytocin and signs of separation of the placenta.
Record the timing of cord clamping in both active and physiological management.
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Care in third stage of labour NICE Pathways
Advise a change from physiological management to active management if either of the following
occur:
haemorrhage
the placenta is not delivered within 1 hour of the birth of the baby.
Offer a change from physiological management to active management if the woman wants to
shorten the third stage.
Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage of
labour.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth
with active management or within 60 minutes of the birth with physiological management.
Follow the recommendations on managing a retained placenta [See page 7].
Complications
transfer her to obstetric-led care (following the general principles for transfer of care)
carry out frequent observations to assess whether resuscitation is needed.
6 Postpartum haemorrhage
Immediate management
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Care in third stage of labour NICE Pathways
Allocate a member of the healthcare team to stay with the woman and her birth companion(s),
explain what is happening, answer any questions and offer support throughout the emergency
situation.
First-line treatment
Administer a bolus of one of the following as first-line treatment for postpartum haemorrhage:
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Care in third stage of labour NICE Pathways
Assess the need for adjuvant options for managing significant continuing postpartum
haemorrhage, including:
Be aware that no particular surgical procedure can be recommended over any other for treating
postpartum haemorrhage.
NICE has published diagnostics guidance on detecting, managing and monitoring haemostasis:
viscoelastometric point-of-care testing (ROTEM, TEG and Sonoclot systems).
7 Retained placenta
Secure intravenous access if the placenta is retained, and explain to the woman why this is
needed.
Give intravenous oxytocic agents if the placenta is retained and the woman is bleeding
excessively.
If the placenta is retained and there is concern about the woman's condition:
offer a vaginal examination to assess the need to undertake manual removal of the
placenta
explain that this assessment can be painful and advise her to have analgesia.
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Care in third stage of labour NICE Pathways
If the woman reports inadequate analgesia during the assessment, stop the examination and
address this immediately.
If uterine exploration is necessary and the woman is not already in an obstetric unit, arrange
urgent transfer (following the general principles for transfer of care).
Do not carry out uterine exploration or manual removal of the placenta without an anaesthetic.
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Care in third stage of labour NICE Pathways
Birth settings
home, freestanding midwifery unit, alongside midwifery unit and obstetric unit
Must
in accordance with current health and safety legislation (at the time of publication of NICE
clinical guideline 139 [March 2012]): Health and Safety at Work Act 1974, Management of
Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of
Substances Hazardous to Health Regulations 2002, Personal Protective Equipment
Regulations 2002 and Health and Social Care Act 2008
Transfer of care
transfer between midwifery-led care and obstetric-led care. This may or may not involve
transport from one location to another. Women who are receiving midwifery-led care in an
obstetric unit can have their care transferred to obstetric-led care without being moved
Sources
Intrapartum care for healthy women and babies (2014 updated 2017) NICE guideline CG190
Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.
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Care in third stage of labour NICE Pathways
Copyright
Copyright National Institute for Health and Care Excellence 2017. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
www.nice.org.uk
nice@nice.org.uk
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