Once the placenta delivers, clinical focus shifts rapidly from preventing hemorrhage to stabilization and initial assessment. The midwife must firmly palpate the uterus to ensure it remains well-contracted, often termed a retraction ring or the hard, round 'contraction ball.' At this juncture, vital signs are recorded to establish a baseline for the postpartum period. Inspection of the vulva and perineum begins immediately to gauge the extent of any trauma sustained during the second stage. Simultaneously, the newly delivered placenta and membranes are placed in a basin for systematic examination. Delaying this assessment risks missing retained products of conception or unrecognized genital tract lacerations, which are leading causes of immediate postpartum hemorrhage.
A rigorous inspection of the placenta protects the postpartum woman from sepsis and hemorrhage. The midwife lays the maternal surface face up to count the cotyledons, ensuring none are missing or torn off. Inspecting the edges confirms that no dark, rough patches indicate a succenturiate lobe left behind. Next, the fetal surface is examined by holding the umbilical cord and letting the membranes hang free. The amnion and chorion are checked for completeness and to see if the tear margin reaches the edge.
The umbilical cord provides crucial clues about fetal well-being and placental health. Midwives routinely inspect the cord insertion site, noting whether it is central, eccentric, or battledore (marginal). A rare velamentous insertion, where vessels travel across the membranes unprotected before reaching the placenta, carries a high risk of vessel rupture during labor. Normal cords contain three distinct blood vessels: two thick-walled umbilical arteries and one larger, thin-walled umbilical vein. Finding only two vessels—one artery and one vein—signals a potential congenital anomaly that warrants pediatric review. The length of the cord and the presence of true knots or excessive twisting must also be documented.
Following the expulsion of the placenta, systematic inspection of the vagina, cervix, and perineum is mandatory. Good lighting and proper positioning are essential to visualize lacerations clearly. Perineal tears are graded by depth: first-degree tears involve only the skin, second-degree involve the perineal muscles, third-degree affect the anal sphincter complex, and fourth-degree extend through the rectal mucosa. Cervical tears often present with heavy vaginal bleeding despite a well-contracted uterus. Midwives repair first- and second-degree tears using local infiltration anesthesia, ensuring anatomical alignment to restore normal function and reduce postpartum pain.
Repairing perineal trauma requires aseptic technique and gentle tissue handling. Using absorbable synthetic sutures, the midwife closes the trauma layer by layer, starting slightly above the apex of the vaginal wound. Accurate approximation of the muscles prevents gaps where hematomas can form, while loose mucosal suturing minimizes tension and pain. Before finishing, a rectal examination is performed to confirm that no suture material has accidentally pierced the rectal mucosa. Post-procedure care focuses on hygiene, pain relief, and encouraging early mobilization.
Comprehensive documentation completes the management of the third and fourth stages of labor. The midwife records the exact time of placental delivery, its completeness, membrane status, cord vessel count, and any abnormalities noted. If a perineal repair was performed, the record must detail the type of tear, local anesthetic used, suture material, and the midwife's name. Post-procedure evaluation involves monitoring vital signs, uterine tone, and lochia over the subsequent hours. Clear notes protect the patient's health record and provide vital communication for the wider healthcare team.