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The duration of the third stage of labor
THE DURATION OF THE THIRD STAGE OF LABOR HuGH HALSEY II, M.D., NEv\r YoRK, N.Y. (From the Department of Obstetr'ics and Gynecology, Cornell University Medical College, and the New York Hospital)
S a sequel to a study of manual removal of the placenta, the duration of the third stage of labor as managed at the New York Lying-In Hospital was investigated in order to set a practical time for initiating the procedure in the absence of bleeding. The 4,066 deliveries occurring here in 1951 were the source of this information.
A
A search of the textbooks and the recent literature revealed relatively little data on the subject. The earliest reference quotes Dubois who, in 1836, stated that if the third stage were left completely to nature, it lasted 1 to 1% hours. Clarke, in 1875, established the mean duration at 25 minutes. Cazeaux; in 1875, wrote that the placenta was expelled from the uterus within 15 to 25 minutes in most instances, but would lie in the vagina for longer periods of time. Robb, in 1899, found, too, that expulsion was accomplished for the most part in10 to 30 minutes. The more recent literature gives us information relative to the duration of the third stage, in most instances, when oxytocics were employed. Calkins, in 1933, stated that with careful management of the third stage, without oxytocics, the average duration was 4 minutes, and that approximately 88 per cent of the placentas were expressed within 10 minutes. Davis and Boynton, in 1942, in a study of the use of ergonovine in the third stage showed that the duration of the third stage was less than 10 minutes in 96 per cent, less than 3 minutes in 73 per cent, when ergonovine was given intravenously following delivery of the head or shoulder. Danforth, commenting on this paper, stated that the third stage averaged 7 minutes when Pituitrin was given intramuscularly following delivery of the infant, whereas previously it had averaged 15 to 20 minutes. Method and Material A certain variation in the duration of the third stage is to be expected with different methods of management. In general, the third stage of labor is managed in this clinic as follows: The placenta is permitted to separate spontaneously and to be extruded into the lower uterine segment or vagina, from whence it is delivered by gentle pressure on the fundus, using it as a piston, as well as by light traction on the cord. Separation is determined by fundal palpation, the uterus rising in the abdomen and assuming a globular shape, or more accurately by digital exploration of the vagina, cervix, and lower uterine segment to determine actual separation. The Crede maneuver is not performed, manual removal being preferred if the placenta fails to separate spontaneously. Some oxytocic is given following delivery of the infant, either ergonovine or Pitocin, intravenously or intramuscularly, as well as after the placenta. 97
98
HALSEY
·\m. :.
Ob;c. i!<
January,
Fig. 1 is a graph showing the duration of the third stage in all vaginal deliveries. The majority of placentas (62.6 per cent) were delivered within 5 minutes, with the greatest number being delivered in the second and third minutes. The longer third stage, in many instances, is a matter of choice, beeause, in the absence of immediate separation, the episiotomy is repaired. F~r Cent
3J DURATION OF THIRD STAGE IN ALL VAGINAL DELIVERiES
10
Mlnutoe
15
i23~5
19
Fig. 1.
Table I illustrates in chart form the duration of the third stage in all vaginal deliveries. The placenta was delivered in less than 20 minutes in 95.1 per cent. In the next 10 minute period, only 2.9 per cent were delivered. Ninety-nine and three tenths per cent were delivered within 1 hour, and only 23 were delivered after an hour. TABLE
I.
DURATION OF THIRD STAGE IN ALL VAGINAL DELlVERJj
51 23 5
1.3 0.6 0.1
In order to get a clearer picture of the duration of the third stage in spontaneous expulsion as compared to manual removal of the placenta, the remaining tables were prepared. Table II shows that where the placenta was spontaneously expelled, it was accomplished within 30 minutes in 98.7 per cent, and only three were spontaneously expressed after one hour. Table III shows that in manual removal of the placenta, 47.2 per cent were done within 20 minutes, and that 29.3 per cent were done after an hour. This mirrors the trend toward early prophylactic manual removal to shorten the third stage, especially in cases where the patient is already under general anesthesia. In previous years, early manual removal was done principally on tb indication of Bxcessive bleeding prior to completion of the third stage.
Volume 65 Number 1
DlJRATION OF THIRD STAGE OF LABOR
TABLE II.
99
DURATION OJi' THIRD STAGE IN SPONTANEOUS EXPULSION OF PLACENTA
42 3
99.8 99.9 100
5 3,99._8_ _ _ _ _ _ _ 10_0 TABLE III.
DURATION OF THIRD STAGE IN 1\:IANUAL RniOVAL OF THE PLACENTA
Table IV shows the comparative incidence of the method of placental delivery relative to the duration of the third stage. In the cases where the third stage was completed within 19 minutes, 99 per cent were spontaneously expelled. As the duration of the third stage increases, the percentage of the placentas spontaneously expelled decreases, and the percentage manually removed increases, so that in the 23 cases where the third stage lasted over one hour, 87 per cent were manually removed. TABLE IV.
COMPARATIVE INCIDENCE OF METHODS OF PLACENTAL DELIVERY RELATIVE TO DURATION OF THE THJRD STAGE
Summary and Conclusions The average duration of the third stage of labor in this series was 8.4 minutes; in spontaneous expression of the placenta, 3.9 minutes; in manual removal, 42.7 minutes. The time-honored indication for manual removal of the placenta, retention for one hour in the absence of bleeding, is basically sound. Manual removal as early as 30 minutes after the birth of the child, however, will not increase the incidence of the procedure markedly, but should not be undertaken till all measures to combat hemorrhage and infection have been taken. Acknowledgment is made to Miss Frances A. :McDonald for her aid in compiling the statistics used in this study.
References Cazeaux, P.: A Theoretical and Practical Treatise on Midwifery, Philadelphia, 1875, Lindsay and Blakiston. Jewett, Charles: The Practice of Obstetrics by American Authors, New York and Philadelphia, 1899, Lea Brothers' Company. Calkins, L.A.: J. A.M. A. 101: 1128,1933. JDavis, :M. E., and Boynton, M. W.: A:M:, J. OBST. & GYNEC. 43: 775, 1942. Halsey, H.: AM. J. 0BST. & GYNEC. 64: 38, ~9~2.
S a sequel to a study of manual removal of the placenta, the duration of the third stage of labor as managed at the New York Lying-In Hospital was investigated in order to set a practical time for initiating the procedure in the absence of bleeding. The 4,066 deliveries occurring here in 1951 were the source of this information.
A
A search of the textbooks and the recent literature revealed relatively little data on the subject. The earliest reference quotes Dubois who, in 1836, stated that if the third stage were left completely to nature, it lasted 1 to 1% hours. Clarke, in 1875, established the mean duration at 25 minutes. Cazeaux; in 1875, wrote that the placenta was expelled from the uterus within 15 to 25 minutes in most instances, but would lie in the vagina for longer periods of time. Robb, in 1899, found, too, that expulsion was accomplished for the most part in10 to 30 minutes. The more recent literature gives us information relative to the duration of the third stage, in most instances, when oxytocics were employed. Calkins, in 1933, stated that with careful management of the third stage, without oxytocics, the average duration was 4 minutes, and that approximately 88 per cent of the placentas were expressed within 10 minutes. Davis and Boynton, in 1942, in a study of the use of ergonovine in the third stage showed that the duration of the third stage was less than 10 minutes in 96 per cent, less than 3 minutes in 73 per cent, when ergonovine was given intravenously following delivery of the head or shoulder. Danforth, commenting on this paper, stated that the third stage averaged 7 minutes when Pituitrin was given intramuscularly following delivery of the infant, whereas previously it had averaged 15 to 20 minutes. Method and Material A certain variation in the duration of the third stage is to be expected with different methods of management. In general, the third stage of labor is managed in this clinic as follows: The placenta is permitted to separate spontaneously and to be extruded into the lower uterine segment or vagina, from whence it is delivered by gentle pressure on the fundus, using it as a piston, as well as by light traction on the cord. Separation is determined by fundal palpation, the uterus rising in the abdomen and assuming a globular shape, or more accurately by digital exploration of the vagina, cervix, and lower uterine segment to determine actual separation. The Crede maneuver is not performed, manual removal being preferred if the placenta fails to separate spontaneously. Some oxytocic is given following delivery of the infant, either ergonovine or Pitocin, intravenously or intramuscularly, as well as after the placenta. 97
98
HALSEY
·\m. :.
Ob;c. i!<
January,
Fig. 1 is a graph showing the duration of the third stage in all vaginal deliveries. The majority of placentas (62.6 per cent) were delivered within 5 minutes, with the greatest number being delivered in the second and third minutes. The longer third stage, in many instances, is a matter of choice, beeause, in the absence of immediate separation, the episiotomy is repaired. F~r Cent
3J DURATION OF THIRD STAGE IN ALL VAGINAL DELIVERiES
10
Mlnutoe
15
i23~5
19
Fig. 1.
Table I illustrates in chart form the duration of the third stage in all vaginal deliveries. The placenta was delivered in less than 20 minutes in 95.1 per cent. In the next 10 minute period, only 2.9 per cent were delivered. Ninety-nine and three tenths per cent were delivered within 1 hour, and only 23 were delivered after an hour. TABLE
I.
DURATION OF THIRD STAGE IN ALL VAGINAL DELlVERJj
51 23 5
1.3 0.6 0.1
In order to get a clearer picture of the duration of the third stage in spontaneous expulsion as compared to manual removal of the placenta, the remaining tables were prepared. Table II shows that where the placenta was spontaneously expelled, it was accomplished within 30 minutes in 98.7 per cent, and only three were spontaneously expressed after one hour. Table III shows that in manual removal of the placenta, 47.2 per cent were done within 20 minutes, and that 29.3 per cent were done after an hour. This mirrors the trend toward early prophylactic manual removal to shorten the third stage, especially in cases where the patient is already under general anesthesia. In previous years, early manual removal was done principally on tb indication of Bxcessive bleeding prior to completion of the third stage.
Volume 65 Number 1
DlJRATION OF THIRD STAGE OF LABOR
TABLE II.
99
DURATION OJi' THIRD STAGE IN SPONTANEOUS EXPULSION OF PLACENTA
42 3
99.8 99.9 100
5 3,99._8_ _ _ _ _ _ _ 10_0 TABLE III.
DURATION OF THIRD STAGE IN 1\:IANUAL RniOVAL OF THE PLACENTA
Table IV shows the comparative incidence of the method of placental delivery relative to the duration of the third stage. In the cases where the third stage was completed within 19 minutes, 99 per cent were spontaneously expelled. As the duration of the third stage increases, the percentage of the placentas spontaneously expelled decreases, and the percentage manually removed increases, so that in the 23 cases where the third stage lasted over one hour, 87 per cent were manually removed. TABLE IV.
COMPARATIVE INCIDENCE OF METHODS OF PLACENTAL DELIVERY RELATIVE TO DURATION OF THE THJRD STAGE
Summary and Conclusions The average duration of the third stage of labor in this series was 8.4 minutes; in spontaneous expression of the placenta, 3.9 minutes; in manual removal, 42.7 minutes. The time-honored indication for manual removal of the placenta, retention for one hour in the absence of bleeding, is basically sound. Manual removal as early as 30 minutes after the birth of the child, however, will not increase the incidence of the procedure markedly, but should not be undertaken till all measures to combat hemorrhage and infection have been taken. Acknowledgment is made to Miss Frances A. :McDonald for her aid in compiling the statistics used in this study.
References Cazeaux, P.: A Theoretical and Practical Treatise on Midwifery, Philadelphia, 1875, Lindsay and Blakiston. Jewett, Charles: The Practice of Obstetrics by American Authors, New York and Philadelphia, 1899, Lea Brothers' Company. Calkins, L.A.: J. A.M. A. 101: 1128,1933. JDavis, :M. E., and Boynton, M. W.: A:M:, J. OBST. & GYNEC. 43: 775, 1942. Halsey, H.: AM. J. 0BST. & GYNEC. 64: 38, ~9~2.