This presentation gives general overview of complications associated with labor.

1. Complications of Labour
Iqra Yasin
Resident, Obs/Gyne Unit I
SIMS/Services Hospital, Lahore

2. Uterine Inversion
• Incidence:
• Varies according to geographical locations; ranges from 1:2500 to 1:20000
• Definition:
• Turning of the uterus of its inside out, so that fundus prolapse through the
cervix

3. Uterine Inversion
CLASSIFICATION
According to severity of uterine inversion According to timing of the event
Incomplete
uterine
inversion
First degree Fundus reaches the internal os Acute Occurs within 24 hours of birth
Second
degree
Body or corpus of the uterus is
inverted to the internal os
Subacute Occurs after 24 hours, within 4
weeks
Complete
uterine
inversion
Third degree Uterus, cervix and vagina are
inverted and are visible
chronic Occurs after 4 weeks, rare.

4. Uterine Inversion

5. Uterine Inversion
• Causes and Risk factors:
• Use of fundal pressure when uterine is atony during placental delivery
• Premature or excessive cord traction during active management of 3rd stage of labor
• Others:
• Fundal attachment of placenta
• Abnormally adherent placenta
• Short umbilical cord
• Manual removal of placenta
• Primary parity
• Microsomic baby
• Unicornuate or bicornuate uterus
• Cervical lacerations
• Antepartum use of magnesium sulphate

6. Uterine Inversion
• Signs and Symptoms
• Severe lower abdominal pain
• Feeling of prolapse
• Shock (hemorrhagic, neurogenic)
• Abdominally impalpable(complete) fundus, with plump colored mass felt in
vagina if placenta is separated.
• Versus dimpled(incomplete) fundus

7. Uterine Inversion
MANAGEMENT
• CALL FOR HELP ! ( Senior Obstetrican/staff/anesthestic)
• Maternal resuscitation while attempting uterine replacement should be initiated
simultaneously.
• If the placenta is still in situ, leave in place until uterine replacement is complete.
• Attempt manual replacement of the uterus by re-inverting it and keeping the
hand in the uterus until firm contraction of the uterus is felt.

8. Uterine Inversion
• Management of Shock:
• Insert two 16 gauge intravenous cannula.
• Group and cross-match 4 units of blood and order a full blood picture
• Consider performing coagulation studies.
• Commence intravenous fluids:
• If the woman has blood loss more than 1000mls, continues to bleed, or show signs of clinical
shock7, in consultation with the anesthetist the volume and rate of fluids is adjusted according
to the clinical situation.
• Warming of the solution may be required.

9. Uterine Inversion
• Management of Shock:
• If not already administered, withhold the oxytocic until uterine replacement is
complete.
• Assess vital signs - blood pressure, pulse, respirations, and oxygen saturation
levels 15 minutely (more frequently if maternal conditions necessitates).
• Monitor vital signs continuously as soon as practical with access to continuous
monitoring equipment.
• Administer oxygen via a face mask.

10. Uterine Inversion
• Management of Shock:
• Insert an indwelling catheter. Monitor urine output.
• If the uterus is successfully replaced commence an oxytocic infusion (30iu
Syntocinon® in 500mL Hartmann’s solution commencing at 240mL / hour) as
per PPH therapeutic infusion regimen.
• If the replacement of the uterus is not possible, resuscitate the woman and
transfer her to theatre immediately.

11. Uterine Inversion
MANUAL REPLACEMENT (JOHNSON MANOEUVRE).
The uterus may require relaxation prior to manual replacement.
1. Using the palm of the hand push the fundus of the uterus along the direction
of the vagina towards the posterior fornix.
2. Then lift the uterus towards the umbilicus and return to its normal position.
3. Maintain the hand in situ until a firm contraction is palpated. Oxytocin therapy
should be administered to initiate and maintain contraction of the uterus.

12. Uterine Inversion
MANUAL REPLACEMENT (JOHNSON MANOEUVRE).

13. Uterine Inversion
HYDROSTATIC REDUCTION (O’SULLIVAN’S TECHNIQUE)
• Warm saline is administered into the vagina through a nozzle from a can held one
meter above the patient.
• Leakage from vagina is prevented by holding the labia together.
• Pressure built by fluid pushes the uterine fundus gradually to its normal site.

14. Uterine Inversion
Surgical management:

16. Perineal tear
• Definition:
• Spontaneous laceration of skin and/or soft tissue in woman which separates
vagina from anus.
• Incidence:
• UK (overall 2.9 %, 6.1 % in primiparae versus 1.7 % in multiparae)

17. Perineal tear
Classification

18. Perineal tear
• Causes and predisposing factors

19. Perineal tear
• All women having vaginal delivery at risk of obstetric anal sphincter
injuries and should be examined
• All women have DRE after the repair

20. Perineal tear
• Complications of repair
• Hemorrhage
• Hematoma
• Fistula due to deep suturing involving rectal mucosa
• Dyspareunia
• Misaligned repair  increased scarring and distrotion of area

21. Perineal tear
• Post repair care:
• Analgesia
• Antibiotics
• Laxatives
• Sitz bath
• Physiotherapy
• Pelvic floor exercises
• Keep clean dry and change sanitary pads
• Cotton underwear

22. Perineal tear
• Follow up after 6-12 weeks
• Prognosis
• 60-80 %
• Asymptomatic after 12 months of repair

23. Perineal tear
Prevention:
Several techniques are used to reduce the risk of tearing, but with little evidence for
efficacy.
1. Antenatal digital perineal massage is often advocated, and may reduce the risk of
trauma only in nulliparous women.
2. ‘Hands on’ techniques employed by midwives, in which the foetal head is guided
through the vagina at a controlled rate have been widely advocated, but their efficacy
is unclear.
3. Waterbirth and labouring in water are popular for several reasons, and it has been
suggested that by softening the perineum they might reduce the rate of tearing.
However, this effect has never been clearly demonstrated.

24. Perineal tear
• Risk Management

25. Puerperal genital hematomas

26. Puerperal genital hematomas

27. Puerperal genital hematomas

28. Puerperal genital hematomas

29. Puerperal genital hematomas

30. Puerperal genital hematomas

31. Puerperal genital hematomas

32. Puerperal genital hematomas

33. Puerperal genital hematomas

34. Puerperal genital hematomas

35. Puerperal genital hematomas

36. Puerperal genital hematomas

37. Puerperal genital hematomas

38. Puerperal genital hematomas

39. Puerperal genital hematomas

40. Puerperal genital hematomas

41. Puerperal genital hematomas
• Investigations
• Blood : CBC, Coagulation profile, blood group/matching
• US, CT, MRI

42. Puerperal genital hematomas

43. Puerperal genital hematomas

44. Puerperal genital hematomas

45. Puerperal genital hematomas

46. Puerperal genital hematomas

47. Cervical tear/laceration

48. Cervical tear/laceration
• CAUSES
• Rigidity of cervix
• Abnormal structure due to scarring from previous surgery
• Rapid delivery of head in breech presentation
• Lack of antenatal care
• Unsupervised delivery
• Delivery by inexperienced/untrained health worker
• Manual dilation of cervix
• Improper selection of patient for instrumental delivery
• Application of vacuum/forceps before cervical dilation

49. Cervical tear/laceration
• Important to identify apex of cervical tear
• Deep blind sutures at fornix  leads to damage of ureter
• Failure of identification of apex leads to suspicion of broad ligament hematoma
• In severe bilateral tear  extend to broad ligament  leading to rupture of uterine vessels
• Anterior tear  can extend into bladder
• Suspected when continuous bleeding in absence of contracted uterus and perineal trauma

50. Cervical tear/laceration
TREATMENT

51. Uterine Rupture

52. Uterine Rupture

53. Uterine Rupture

56. Uterine Rupture