Self-Assessment Questions (SAQs) for Study Session 6

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 6.1 (tests Learning Outcomes 6.1 and 6.2)

  • a.How do you define the third stage of labour?
  • b.What physiological changes happen during the third stage of a normal uncomplicated labour?


  • a.The third stage of labour begins with the birth of the baby and ends with the delivery of the placenta and its attached membranes.
  • b.The physiological changes are:
    • As the placenta separates from the wall of uterus blood from the vessels in the placenta bed begin to clot between the placenta wall and the myometrium (the muscular wall of the uterus).
    • The placenta moves down the birth canal and through the dilated cervix before being expelled.
    • Once expelled, the muscles of the uterus contract and compress the torn blood vessels so that any postpartum bleeding is stopped, and the uterus becomes hard and round.

SAQ 6.2 (tests Learning Outcomes 6.1 and 6.3)

Alemitu is a Health Extension Practitioner (HEP) in a village Health Post. She has just delivered a baby at her Health Post and the mother is in the third stage of labour, and has begun breastfeeding. Alemitu has been trained to use AMTSL. What, in detail, are the six steps that she must follow in order to do this?


Six steps to follow:

1  Check: is there a second baby?

2  Give a uterotonic drug to help the uterus contract:

  • Misoprostol 600 μg (micrograms) tablets given orally with water, or
  • Oxytocin 10 IU injected intramuscularly.
  • Do NOT give ergometrine.

3  Deliver the placenta by controlled cord traction with counter-pressure (see Box 6.3 for details of how to do this).

4  Massage the uterus.

5  Examine the placenta and fetal membranes to check nothing is missing (i.e. check the maternal surface and the lobules, put your hand inside the membranes to make sure they are complete, and check that the position of the cord is normal).

6  Examine the women’s vagina and external genitalia for signs of tears and active bleeding.

SAQ 6.3 (tests Learning Outcome 6.3)

Imagine that you have managed the third stage of labour for a woman in your community by correctly using AMTSL, but she has developed continuous bleeding.

  • a.Do you provide additional misoprostol? If yes, what dose should you give her and in what form?
  • b.What else could you do?
  • c.What should you do if the woman continues to bleed?


  • a.Yes, so long as you do not exceed 1,000 μg of misoprostol in total, you can give up to a further 400 μg if you have already given 600 μg. You should give the second dose by inserting the tablets into the rectum.
  • b.As the mother has already begun breastfeeding, rub the uterus using the two-handed pressure method to stimulate contractions.
  • c.If the bleeding does not stop quickly after the second dose of misoprostol, you need to refer the woman to the nearest health facility as quickly as possible, starting her on IV fluids before you go.

SAQ 6.4 (tests Learning Outcome 6.6)

What are the warning signs for the complications that may arise during the third stage of labour?


Warning signs of potential complications during the third stage of labour are:

  • A retained placenta or a placenta that has only been partially expelled
  • A cervix which has closed before the delivery of the placenta
  • Weak uterine contractions
  • A soft uterus felt on palpation
  • Third stage of labour lasting over 30 minutes
  • Perineal, vaginal or cervical tearing
  • Excessive bleeding (postpartum haemorrhage).

Summary of Study Session 6