3rd stage of labour and its complications final


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  • 3rd stage of labour and its complications final

    1. 1. 3rd stage of labour and its complications Dr.Mallika Datta Assistant Professor (G&O) Medical College, Kolkata
    2. 2. Objectives • What is the 3rd stage of labour? • Enumerate its complications? • What is the ideal management of 3rd stage? (Active management of 3rd stage of labour) • What is postpartum haemorrhage, its causes and its management? • Management of other complications – retained placenta, uterine inversion
    3. 3. What is 3rd stage of labour • Begins with expulsion of the foetus and ends with expulsion of placenta and membranes • Average duration – 15 min • Reduced to 5 min by Active management
    4. 4. Normal placental separation • At beginning of labour, placental attachment corresponds to an area of 20 cm diameter • From 2nd stage of labour, progressive diminution of the area due to uterine contraction and retraction, esp after the baby is delivered • After birth of the baby, the whole uterus measures 20 cm by 10 cm
    5. 5. Normal placental separation • So placental surface area is halved • Thus the inelastic placenta buckles and separates • The plane of separation runs through the deep spongy layer of decidua basalis • Innumerable torn sinuses with free circulation from uterine and ovarian vessels now left
    6. 6. Control of bleeding • Torn sinuses obliterated by complete retraction of the uterine muscles – arterioles passing through the interlacing fibres are clamped (living ligature) • Also thrombosis • Apposition of the uterine walls (myotamponade) Thus both placental separation and subsequent control of bleeding depend on uterine contraction and retraction
    7. 7. Complications of 3rd stage • Postpartum haemorrhage • Retained placenta • Shock – haemorrhagic or non-haemorrhagic • Pulmonary embolism – amniotic fluid or air • Uterine inversion
    8. 8. Active management of 3rd stage of labour (AMTSL) 3 components • Administration of uterotonic drug within 1 min of delivery of baby • Delivery of placenta by controlled cord traction (CCT) • Massaging the uterus to make it hard
    9. 9. AMTSL contd • Reduces blood loss to 1/5th • Reduces risk of PPH by 60% • Shortens duration of 3rd stage by half • Only disadvantage – slight increase in risk of retained placenta
    10. 10. AMTSL – Uterotonic drug • Within 1 min of delivery, PALPATE THE ABDOMEN to rule out the presence of an additional baby(s) • Give Oxytocin 10U IM (Refrigeration needed, avoid large IV bolus) • Alternative drugs – Ergometrine 0.2mg IM Misoprostol 600μg SL/oral/PR/PV
    11. 11. AMTSL - CCT • One hand to hold cord (clamped close to perineum) • Other suprapubic for counter-traction • Wait for next contraction (2-3min)
    12. 12. AMTSL -CCT • When the uterus contracts, as will be evidenced by the uterus becoming hard and globular, or when the extra-vulval portion of the cord lengthens, gently pull downwards on the cord to deliver the placenta. • If placenta does not descend during 30-40sec of CCT, stop pulling and wait for next contraction
    13. 13. AMTSL -CCT • The signs of placental separation are: * The uterus becomes hard and globular (uterine contraction). * The extra-vulval portion of the cord lengthens * There is a sudden gush of blood when the placenta separates. * If the fundus of the uterus is gently pushed up towards the umbilicus, the cord will not recede into the vagina.
    14. 14. AMTSL - contd • Twist placenta while delivering so that membranes do not tear off • EXAMINE the placenta and membranes after delivery for complete removal
    15. 15. AMTSL - Uterine massage • Massage the uterine fundus until well contracted • Repeat massage every 15 min for first 2 hrs • Ensure that uterus does not become flabby when massage is stopped
    16. 16. Postpartum haemorrhage • Blood loss in excess of 500 ml following birth of the baby • Any amount of bleeding from or into the genital tract following birth of the baby up to the end of puerperium which adversely affects the general condition of the patient as evidenced by rise in pulse rate and falling blood pressure
    17. 17. Importance • APH untreated leads to death in 12 hrs • Obstructed labour untreated leads to death in 2 days • Infection untreated leads to death in 6 days • PPH untreated leads to death in 2 hrs
    18. 18. PPH – definition contd • Primary PPH – within 24 hrs of delivery – 3rd stage haemorrhage : before expulsion of placenta – True PPH : after expulsion of placenta • Secondary PPH – Beyond 24 hrs and within puerperium ( 12 wks ) • Minor <1L; Major >1L; Severe >2L
    19. 19. Causes of Primary PPH • Atonic (70-80%) • Traumatic (20%) • Retained placenta (10%) and retained bits • Blood coagulopathy
    20. 20. Atonic PPH - causes • Grand multipara • Over-distension of uterus – hydramnios, twin • Anaemia and malnutrition • Antepartum haemorrhage • Prolonged labour • Precipitate labour • Anaesthesia and drugs (tocolytics, magsulph, nifedipine) • Labour induction/augmentation with Oxytocin • Uterine malformation • Uterine fibroid • Mismanaged 3rd stage of labour • Morbidly adherent placenta
    21. 21. Management of PPH • Shout for help • Rapid evaluation of general condition – look for shock • Massage the uterus to make it hard • Give Oxytocin 10 U IM
    22. 22. Management of PPH • 2 large bore (14 gauge) IV cannulas • Draw blood for Group and Cross-match, other tests, requisition 4 units blood • Rapidly infuse 2L of NS or RL – initial 1L over 20 min. May subsequently give 1.5L colloid (Haemaccel) while waiting for blood • Start Oxytocin infusion 20 U in 500 mL at 60 drops/min
    23. 23. Management of PPH • Catheterise the bladder – Foley’s • Check if placenta has been expelled • Examine the placenta and membranes to see if it is complete • Examine the cervix, vagina and perineum for tears
    24. 24. Management of PPH • Oxygen by mask 10-15 L/min • Keep the patient warm • Non-pneumatic anti-shock garment esp during transfer • Commence monitoring and recording – pulse, bp, respiratory rate, oximeter, type and amount of fluids infused, urine output, drugs- type,dose,time, CVP if sited
    25. 25. Transfusion • Main therapeutic goals is to maintain Hb > 8g/dl Platelet count > 75,000/cumm Prothrombin time < 1.5 times mean control APTT < 1.5 times mean control Fibrinogen > 1.0 g/L • Nowadays recommendation is to infuse PRBC and FFP in 1:1 ratio
    26. 26. Evaluation • Immediate PPH • Uterus soft and not contracted • Placenta examined - complete • May be shock • Atonic uterus • Immediate PPH • Placenta examined – complete • Uterus contracted • Tears of cervix, vagina or perineum
    27. 27. Evaluation • Placenta not delivered within 30min of delivery • Immediate PPH • Retained placenta • Immediate PPH • Uterus contracted • Portion of maternal surface of placenta missing or torn membranes with vessels • Retained placental fragments
    28. 28. Evaluation • Immediate PPH • Uterine fundus not felt on abdominal palpation • Slight or intense pain • Inverted uterus (may appear at vulva) • Immediate PPH (bleeding is intraabdominal or vaginal) • Severe abdominal pain • Tachycardia, Shock • Tender abdomen • Ruptured uterus
    29. 29. Evaluation • Bleeding occurs more than 24 hrs after delivery • Uterus softer and larger than expected for elapsed time since delivery • Bleeding is variable, may be foul smelling • Anaemia • Delayed/Secondary PPH
    30. 30. Atonic uterus – Oxytocic drugs Drug Dose and route Continuing dose Maximum dose Precautions & contraindication s Oxytocin (Syntocinon) IV infusion: 20-40 units in 1L 60 drops/min IV infusion: 20U in 1L 40 drops/min Not more than 3L IV fluids containing Oxytocin Do not give as large IV bolus Methyl ergometrine (Methergin) IM or IV slowly 0.2mg Repeat 0.2mg after 15min. If required, 0.2mg repeated 4hrly Five doses (Total 1mg) High blood pressure, pre-eclampsia, heart disease 15-methyl Prostaglandin F2α = Carboprost (Prostodin) IM 250μg IM 250μg Repeated every 15min Eight doses (Total 2mg) Asthma
    31. 31. Oxytocic drugs contd • Prostaglandins should not be given intravenously – the may be fatal. • Alternative drug – Misoprostol 1000μg per rectum • Carboprost 500μg may be given intramyometrially • Assess clotting status with bedside clotting test – failure of clot to form after 7 min or soft clot that breaks down easily = coagulopathy
    32. 32. Atonic uterus – bleeding continues • Bimanual compression of uterus • Aortic compression
    33. 33. Atonic uterus – bleeding continues • Balloon tamponade Has superseded uterine packing Foley’s catheter, Bakri balloon, Sengstaken- Blakemore oesophageal catheter, condom catheter, urological Rusch balloon Averts hysterectomy in 78% cases
    34. 34. Balloon Tamponade contd.
    35. 35. Balloon Tamponade contd. 200-500 mL normal saline Kept 4-6 hrs In daytime, with senior staff present, deflate balloon and see • Tamponade test: A +ve test (=control of PPH following inflation of balloon) indicates that laparotomy is not required.
    36. 36. Atonic uterus – bleeding continues • Take to OT • Under anaesthesia, explore uterus for placental fragments and remove clots • Repeat uterine massage – if still atonic, proceed to laparotomy
    37. 37. Atonic uterus - laparotomy • B-Lynch suture or multiple square sutures Work by compression/tamponade Avert hysterectomy in 80% of cases
    38. 38. Stepwise uterine devascularization 1. Ligation of uterine arteries – at lateral border of uterus, junction of upper and lower uterine segments, 2cm inside myometrium 2. Ligation of utero- ovarian anastomoses – Just below ovarian ligament
    39. 39. Ligation of internal iliac arteries • 2-3cm distal to bifurcation of common iliac. • Reduces pelvic blood flow by 50%. • Drop in arterial pulsation, with pressure reduced to that of venous system. • Average decrease in pulse pressure is 77% with one side and 85% with both sides ligated. • Venous bleeding is easily controlled by temporary pressure and clot formed remains there.
    40. 40. Atonic uterus – Hysterectomy • If all else fails, hysterectomy. • Second consultant to be involved in decision • May be subtotal – rapidly done, less duration of exposure to anaesthesia • Must be total if placenta praevia, uterine rupture involving lower segment, etc
    41. 41. Angiographic arterial embolization • Angiographic arterial embolization usually with gelatin sponge • Either internal iliac or more usually uterine arteries embolized • Only in haemodynamically stable patients • Takes time, usually 60min • Must be done in radiology department • Requires experienced radiologist, fluoroscopy, correct arterial catheters
    42. 42. Angiographic arterial embolization • Temporary distal occlusion for 4 wks • Some materials may provide permanent occlusion • 90-95% success rate • Best to perform prophylactically • Or put angiographic catheters in place pre- operatively/predelivery for high risk cases like suspected placenta accreta
    43. 43. Traumatic PPH
    44. 44. Traumatic PPH contd. • Tears of birth canal are the 2nd most frequent cause of PPH • May coexist with atonic uterus • Examine and carefully repair • If bleeding continues assess clotting status with bedside clotting test
    45. 45. Repair of cervical tear
    46. 46. Retained placenta • When placenta is not expelled even 30 min after delivery of the baby • Causes: Placenta completely separated but retained due to poor expulsive efforts Simple adherent placenta due to uterine atonicity – commonest cause Morbidly adherent placenta Placenta incarcerated following separation due to constriction ring
    47. 47. Retained placenta • Accounts for 10% of PPH cases and occurs in 0.5 to 3% of all deliveries • Risks: Haemorrhage Shock – due to blood loss, when prolonged, frequent attempts to express the placenta Puerperal sepsis Recurrence in subsequent pregnancy
    48. 48. Retained placenta • Check for signs of placental separation – if present, remove placenta by controlled cord traction • Avoid forceful traction or fundal pressure – may cause uterine inversion • Give Oxytocin 10U IM if not already given for AMTSL • Empty the bladder • DO NOT give ergometrine for retained placenta as it causes tonic uterine contractions which may delay expulsion
    49. 49. Retained placenta – Manual removal under GA • Catheterization, prophylactic antibiotic • Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor. • Insert the other hand (long gloves) into the vagina and up into the uterus
    50. 50. Manual removal under GA • Let go of the cord and move the other hand to abdomen in order to support the fundus and to provide counter-traction during removal to prevent inversion of the uterus • Move the fingers of the hand in the uterus laterally until the edge of the placenta is located.
    51. 51. Manual removal under GA • Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall (slicing movements)
    52. 52. Manual removal under GA • Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall. • Remove the placenta by traction on cord • Uterine hand remains inside to explore the cavity • Give Oxytocin infusion/ IV methergin • Assistant massages fundus • Examine the placenta • Examine for tears of cervix or vagina
    53. 53. Problems encountered during Manual removal • Hour-glass contraction/constriction ring:  Localized contraction of circular muscles  Often at junction of upper and lower segment  Can be relaxed by deepening the plane of anaesthesia- halothane is useful • Morbidly adherent placenta - no plane of cleavage found
    54. 54. Morbid adherent placenta • The placenta is directly anchored on to the myometrium either partially or completely without any intervening decidua • Absence of decidua basalis and poor development of Nitabuch’s fibrinoid layer • 1 in 550 deliveries
    55. 55. Morbid adherent placenta • Accreta – No decidua or Nitabuch’s layer • Increta – penetration of villi in to myometrium • Perceta – penetration up to serous layer
    56. 56. Morbid adherent placenta • Risk factors:  Prior Caesarean delivery  Placenta praevia Risk of placenta praevia being accreta in unscarred uterus: 3% With one prior CS, risk of pl praevia being accreta is 11% With two prior CS, 40% With 4 or more prior CS, 67%  Prior uterine surgery like D&C, manual removal, myomectomy, synechiolysis  Increasing maternal age and parity
    57. 57. Morbid adherent placenta - management • With prior CS and placenta praevia, try to diagnose accreta by imaging (USG and MRI) and prepare pre-delivery • Partial/focal accreta – Remove placenta piecemeal and give oxytocics. If bleeding continues, hysterectomy • Total placenta accreta – Hysterectomy in parous women. Otherwise clamp cord close to attachment and leave placenta to be autolyzed. • Uterine artery embolization, methotrexate
    58. 58. Uterine inversion • Rare and life- threatening • Uterus is turned inside out, partially or completely • 1 in 20,000 deliveries • Leads to shock, haemorrhage, embolism, chronic- infection
    59. 59. Uterine inversion degrees • First degree – dimpling of uterine fundus, remains above level of internal os • Second degree – fundus passes through cervix but remains in vagina • Third degree (complete) – endometrium visible outside vulva
    60. 60. Uterine inversion contd. Spontaneous 40% - due to sudden cough, sneeze, bearing down when uterus still atonic Iatrogenic – faulty management of 3rd stage sith pulling the cord or fundal pressure when uterus is atonic
    61. 61. Uterine inversion - management • Call for help • Treat shock • Correction under deep sedation or GA • Thoroughly cleanse the inverted uterus using antiseptic solution. • Apply compression to the inverted uterus with a moist, warm sterile towel until ready for the procedure
    62. 62. Manual correction • Wearing high-level disinfected or sterile gloves, grasp the inverted uterus and push it through the cervix in the direction of the umbilicus to its normal anatomic position, using the other hand to stabilize the uterus
    63. 63. Manual correction contd. • The part of the uterus that came out last (the part close to the cervix) should go in first. • After replacement, leave hand inside until the uterus becomes contracted by parenteral oxytocic • If the placenta is still attached, manually remove it after correction of inversion and after uterus becomes contracted
    64. 64. Hydrostatic correction – O’Sullivan’s method • Woman in deep Trendelenburg position • Sterile douche system with large nozzle, long tubing, warm water reservoir 3-5L • Nozzle in posterior fornix • Seal labia with other hand • Douche with pressure raising reservoir to 2 m
    65. 65. Uterine inversion contd. • If fails, Laparotomy under GA • Haultain’s operation • Incise the constricting cervical ring vertically, posteriorly • Apply traction while assistant also attempts correction vaginally • After correction, close the posterior cervico-uterine incision
    66. 66. To summarize • AMTSL is recommended for ALL deliveries, with 10 U Syntocinon IM, CCT and uterine massage • PPH is a dire emergency. Management involves t/t of shock with IV fluids, other supportive t/t including blood transfusion, uterotonics, ensuring complete removal of placenta, detection and repair of injuries.
    67. 67. To summarize • A placenta not separated within 30 min requires manual removal. Failure to find a cleavage during removal indicates morbid adherent placenta, which may need hysterectomy • Uterine inversion is rare but produces shock. Manual or hydrostatic correction is needed.
    68. 68. • Any questions ? THANK YOU