Nursing Care During the Third Stage of Labor

Core Concepts

How the placenta separates

After birth, powerful uterine contractions shrink the area of placental attachment. The placenta separates through the spongy layer of the decidua (the transformed uterine lining), with blood collecting behind it. Separation usually begins within minutes, marked by three classic signs: the uterus becomes globular (firm and rounded) and rises in the abdomen, a sudden gush of blood appears, and the umbilical cord visibly lengthens as the placenta drops into the lower uterine segment.

Schultze versus Duncan separation

In Schultze separation, the center separates first and the fetal (smooth, shiny) surface appears first, with blood collecting behind — the more common pattern. In Duncan separation, the margins separate first and the maternal (rough, red) surface appears first, so blood escapes around the edges and visible loss may be greater. Both are normal; the nurse documents the pattern but treats neither as abnormal.

Expectant versus active management

Management approaches vary by setting and guideline. In expectant (physiologic) management, the team waits for signs of separation and the placenta delivers by maternal effort, aided by gravity and by nipple stimulation or breastfeeding, which releases the person's own oxytocin. In active management, the provider or midwife gives a uterotonic (commonly oxytocin) by order, may use controlled cord traction following the fundus, and clamps the cord earlier in some protocols. Active management is associated with less blood loss and a shorter third stage in many guidelines, but the exact protocol — drug, dose, clamp timing, traction technique — is an institutional and clinical decision. The nurse knows the unit's protocol, prepares ordered medications, and never performs traction or fundal pressure independently unless the care plan and scope of practice authorize it.

Nursing assessment and care

• Vital signs and blood loss: Monitor pulse, blood pressure, and color; estimate blood loss with calibrated drapes or weighed pads per protocol and document it. A sudden increase in bleeding is reported immediately.
• Fundus: The fundus should become firm and rise toward the umbilicus as the placenta separates. A boggy uterus may be massaged per protocol — but massage never substitutes for notifying the provider when bleeding is heavy.
• After expulsion: Gently massage the fundus per protocol to keep it contracted; continue monitoring lochia and vital signs as the fourth stage begins.
• Support the parent: The person may be holding the newborn; the nurse watches for fatigue, chills, or pallor while facilitating skin-to-skin contact if planned.

Inspecting the placenta

The placenta and membranes are examined for completeness: the maternal surface intact with no missing cotyledons (lobes), the fetal surface and membranes present, and the umbilical cord with three vessels — two arteries and one vein. An incomplete placenta or single umbilical artery is documented and reported: retained fragments raise the risk of hemorrhage and infection, and a single umbilical artery may prompt newborn follow-up.

Medication safety and scope of practice

Uterotonics are given per provider order and institutional protocol. The nurse verifies the order, checks allergies and identity, gives the drug, and watches for the intended effect (firm uterus, controlled bleeding) and adverse reactions — never improvising doses, routes, or timing. Scope of practice for procedures such as controlled cord traction and fundal pressure varies by jurisdiction, license type, and institutional policy; when in doubt, the nurse confirms the plan with the attending clinician.

Clinical Scenario: Recognizing Separation and Keeping the Uterus Firm

After Imani gives birth, the nurse notes the cord lengthening and a small gush of blood; the fundus, previously firm, rises and becomes globular — classic signs of separation. Following the unit's active-management protocol, the provider orders a uterotonic, which the nurse verifies and administers after checking identity and allergies. The provider performs controlled cord traction while the nurse supports the fundus, and the placenta delivers intact; the nurse inspects it (maternal surface complete, membranes present, three-vessel cord). The fundus is massaged per protocol until firm; lochia is moderate and vital signs stable. The nurse documents the EBL, delivery time, separation pattern, and medication, then shifts to fourth-stage care. Had the fundus stayed boggy or bleeding increased, the next steps would be per protocol: continue care and notify the provider without delay.

Common Confusions