3rd stage of labor & abnormalities by liza tarca, md


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  • Duncan – dirty
    Schultze - shiny
  • There is still no definite answer to the question concerning the length of time that should elapse in the absence of bleeding before the placenta is removed manually. Obstetrical tradition has set somewhat arbitrary limits on third-stage duration in attempts to define abnormally retained placenta and thus, to reduce blood loss from prolonged placental separation.
    Several measures of hemorrhage, including curettage or transfusion, increased when the third stage was approximately 30 minutes or longer
    Adequate analgesia is mandatory, and aseptic surgical technique should be used. After grasping the fundus through the abdominal wall with one hand, the other hand is introduced into the vagina and passed into the uterus, along the umbilical cord. As soon as the placenta is reached, its margin is located, and the border of the hand is insinuated between it and the uterine wall (Fig. 35-16). Then with the back of the hand in contact with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that used in separating the leaves of a book. After its complete separation, the placenta should be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at the same time by carefully teasing them from the decidua, using ring forceps to grasp them as necessary. Another method is to wipe out the uterine cavity with a laparotomy sponge.
    IVF with 20 unit oxytocin at 10mL/min or 200mU of oxytocin per inute
  • Antepartum – placenta previa or abruptio
    Postpartum – uterine atony or genital tract laceration
  • Late PPH – vaginal bleeding beginning after the 1st 24 hours following delivery, generally within 7-9 days and rarely several months later
    Associated with uterine subinvolution as a consequence of infection, retained placental fragments, abnormal healing of the thrombosed vascular sinuses at the placental site
    Subinvolution: softened uterus larger than expected for the time during puerperium
    Bleeding is not massive – conservative management
    Normal ultrasound: antibiotics and oxytocin
    3rd stage hemorrhage is a PPH before placental delivery caused by attempts to hasten delivery of the placenta thereby causing incomplete placental separation.
    Manual extraction of the placenta is done immediately if there’s massive bleeding after delivery of the fetus
    in the absence of bleeding, manual extraction is not indicated until after 30minutes have elapsed
    oxytocin IV and IM
  • Anytime the postpartum hematocrit is lower than one obtained on admission for delivery, blood loss can be estimated as the sum of the calculated pregnancy hypervolemia plus 500mL for eack 3 volumes percent drop in hematocrit
  • Table 35-2
  • Unrecognized intrauterine, intravaginal or intraperitoneal accumulation of blood
  • Stabilize patient then determine the cause and institute specific treatment depending on the cause
    Primary consideration is to control the bleeding. Paramount is knowing the cause
  • Exploration of the uterus – with the hand still inside the uterus, exploration to determine if there are retained placenta. Bimanual massage is done to promote contraction
    If bleeding continues, bimanual uterine compression is employed, with the fist inside the vagina, the knuckles on the anterior aspect of the uterus and abdominal hand pressing on the posterior aspect of the anteverted uterus.
    Rapid IV oxytocin bolus – not recommended because it will lead to hypotension or cardiac arrest
    Vaginal suppository not given because bleeding will just wash it off
    Packing – not advocated because it may lead to false sense of security and delay in management
    Oxytocin and ergot preparation administered during 3rd stage of labor were more effective than misoprostol in preventing PPH
  • In step 1, beginning below the incision, the needle pierces the lower uterine segment to enter the uterine cavity. In step 2, the needle exits the cavity above the incision. The suture then loops up and around the fundus to the posterior uterine surface. Here, in step 3, the needle pierces the posterior uterine wall to reenter the uterine cavity. The suture then traverses from left to right within the cavity. In step 4, the needle exits the uterine cavity through the posterior uterine wall. From the back of the uterus, the suture loops up and around the fundus to the front of the uterus. In step 5, the needle pierces the myometrium above the incision to reenter the uterine cavity. In step 6, the needle exits below the incision. Finally, the sutures at points 1 and 6 are tied below the incision.
    Complications: uterine necrosis and peritonitis
  • Risk Factors
    Operative Vaginal Delivery
    Breech Extraction
    Internal Podalic Version
  • Usually bleeding occurs late second trimester or after
    Hemorrhage is due to the fact that the placenta is at the internal os and the formation of the lower uterine segment and the dilatation of the intrenal os result inevitably in tearing placental attachments and bleeding is augmented by inherent inability of the lower uterine segment to contract and thereby to constrict the avulsed vessels
    Bleeding continues even after delivery of the placenta since the LUS contracts poorly
  • External hemorrhage – the placenta has detached in the peripherally and the membranes between the placenta and cervical canal are detached from the underlying decidua allowing blood to egress through the vagina
    Concealed hemorrhage – more dangerous because the blood remains within the uterus since the placenta is still adherent to the uterine wall.
    Effusion of blood behid the placenta but the placental margins remains adherent
    Placenta is completely separated yet the membranes retained their attachment to the uterine wall
    Blood gains access to the amniotic fluid after breaking through membranes
    Fetal head is closely applied to the lower uterine segment that blood cannot make its way
  • Significant fetal bleeding is much more likely a traumatic abruption which results from a tear or fracture in the placenta rather than from placental separation itself.
  • Shock – massive blood loss  placental thromboplastin enters maternal circulation  intravascular coagulation  AFE symptoms
    Consumptive coagulopathy – hypofibrinogenemia (plasma level <150mg/dL)  elevated fibrinogen-fibrin degradation products or D dimers  thromboplastin enters circulation  intravascular coagulation  shock  death
    Renal failure – delayed treatment of hypovolemia secondary to massive blood loss  acute renal failure (ACUTE CORTICAL NECROSIS)  monitor UO 30-60mL/hour without diuretics (giving diuretics reults to deranged cardiac output)
    Sheehan Syndrome – severe intrapartum or postpartum hemorrhage rarely followed by pituitary failure or sheehan syndrome characterized as failure of lactation, amenorrhea, breast atrophy, loss of pubic and axillary hair, hypothyroidism and adrenal cortical insufficiency  pituitary gland necrosis  diagnosed by MRI
    Couvelaire uterus – due to widespread extravasation of blood into the uterine musculature and beneath the uterine serosa or uteroplacental apoplexy  REMEMBER COUVELAIRE UTERUS IS NOT AN INDICATION FOR HYSTERECTOMY
  • Blood + crystalloid + delivery
    Delaying delivery if fetus is immature is beneficial  stable mother  tocolysis  12 days meantime to deliver  CS
    If fetus is dead  vaginal delivery except if excessive bleeding and with another complication preventing vaginal delivery
  • CS hysterectomy without removing placenta reduced morbidity
  • The placenta must be routinely examined after delivery.
  • Delivery of the placenta by cord traction especially when the uterus is atonic may cause uterine inversion
  • If still attached, the placenta is not removed until infusion systems are operational, fluids are being given, and a uterine-relaxing anesthetic such as a halogenated inhalation agent has been administered. Other tocolytic drugs such as terbutaline, ritodrine, magnesium sulfate, and nitroglycerin have been used successfully for uterine relaxation and repositioning (Hong and colleagues, 2006; You and Zahn, 2006). In the meantime, if the inverted uterus has prolapsed beyond the vagina, it is replaced within the vagina
    After removing the placenta, steady pressure with the fist is applied to the inverted fundus in an attempt to push it up into the dilated cervix. Alternatively, two fingers are rigidly extended and are used to push the center of the fundus upward. Care is taken not to apply so much pressure as to perforate the uterus with the fingertips. As soon as the uterus is restored to its normal configuration, the tocolytic agent is stopped. An oxytocin infusion is begun while the operator maintains the fundus in its normal anatomical position.
    Initially, bimanual compression as shown in Figure 35-17 aids in control of further hemorrhage until uterine tone is recovered. After the uterus is well contracted, the operator continues to monitor the uterus transvaginally for any evidence of subsequent inversion.
  • Fetal death – spontaneous labor within 2 weeks. Monitor coagulation factor
  • Pathophysio – prevention of blood flow from right to left side of the herat due to pulmonary vasoconstriction
    Diagnosis: detection of fetal squames or other debris of fetal origin in the central pulmonary circulation
  • 3rd stage of labor & abnormalities by liza tarca, md

    1. 1. 3 Stage of Labor & Abnormalities rd Liza A. Tarca-Cruz, MD Department of Obstetrics & Gynecology Emilio Aguinaldo College of Medicine
    2. 2. Stages of Labor 3rd Stage of Labor – begins with the delivery of the fetus and ends with the delivery of the placenta & membranes
    3. 3. Signs of Placental Separation
    4. 4. Placental Separation • Duncan – As the placenta separates, blood from the implantation site may escape into the vagina immediately • Schultze – As the placenta separates, blood from the implantation site is concealed behind the placenta and membranes and will egress as the placenta is delivered
    5. 5. Manual Extraction of Placenta IVF with 20 unit oxytocin at 10mL/min or 200mU of per minute
    6. 6. Obstetrical Hemorrhage
    7. 7. Obstetrical Hemorrhage • Abnormal Placentation – Placenta Previa – Placenta Abruption – Placenta Accreta/Increta/Percreta – Ectopic Pregnancy – Hydatidiform Mole
    8. 8. Obstetrical Hemorrhage • Trauma During Labor and Delivery – Episiotomy – Complicated Vaginal Delivery – Low or Mid Forceps Delivery – Cesarean Delivery or Hysterectomy – Uterine Rupture • • • • • • Previously scarred uterus High parity Hyperstimulation Obstructed labor Intrauterine manipulation Midforceps rotation
    9. 9. Obstetrical Hemorrhage • Small Maternal Blood Volume – Small women – Pregnancy hypervolemia not yet maximal – Pregnancy hypervolemia constricted • Severe Preeclampsia • Eclampsia – Sepsis Syndrome – Chronic Renal Insufficiency
    10. 10. Obstetrical Hemorrhage • Uterine Atony – Overdistended Uterus • • • • Large fetus Multiple fetuses Hydramnios Distention with clots – Labor Induction – Anesthesia and Analgesia • Halogenated agents • Conduction analgesia with hypotension – Exhausted Myometrium • • • • Rapid labor Prolonged labor Oxytocin or prostagladin stimulation Chorioamnionitis – Previous Uterine Atony
    11. 11. Obstetrical Hemorrhage • Coagulation Defects – Intensify Other Causes – Massive Transfusions – Placental Abruption – Sepsis Syndrome – Severe Preeclampsia or Eclampsia – Anti-coagulant Treatment – Congenital Coagulopathies – Amniotic Fluid Embolism – Prolonged Retention of Dead Fetus – Saline Induced Abortion
    12. 12. Obstetrical Hemorrhage • Other Factors – Obesity – Previous Postpartum Hemorrhage
    13. 13. Postpartum Hemorrhage Leading Cause of Maternal Morbidity and Mortality
    14. 14. Pitchard Average Blood Loss • Vaginal Delivery: 500mL • Cesarean Section: 1,000mL • CS Hysterectomy: 1,500mL
    15. 15. Calculation of Maternal Total Blood Volume
    16. 16. Postpartum Hemorrhage
    17. 17. Causes of Postpartum Hemorrhage
    18. 18. Uterine Atony • Failure of the myometrium to contract resulting to significant blood loss.
    19. 19. Uterine Atony • Predisposing Factors – – – – – High Parity Precipitous Labor Prolonged or Protracted Labor General Anesthesia Overdistended Uterus • Macrosomia • Hydramnios • Multifetal Pregnancy – – – – – Oxytocin Augmentation Labor Induction History of Postpartum Hemorrhage Amniotic Fluid Embolism Magnessium Sulfate Use
    20. 20. Uterine Atony • Signs and Symptoms – Uterine bleeding – Soft, boggy uterus – Fundus maybe higher than usual
    21. 21. Management
    22. 22. General Measures
    23. 23. Medical Management
    24. 24. Management
    25. 25. Surgical Management • Uterine Packing – Refractory hemorrhage + uterine atony – Preserve fertility – Complications • • Infection Concealed bleeding – 24F foley catheter with 30mL balloon is guided into the uterine cavity and filled with 60-80mL of saline • Removed after 12-24 hours – Gauze packing
    26. 26. Surgical Management • Ligation of Blood Vessels – Hypogastric Artery (internal iliac): diminish pulsatile blood flow to the pelvis – Uterine Artery: cesarean section extension
    27. 27. Surgical Management B Lynch Compression Suture Technique
    28. 28. Surgical Management • Hysterectomy
    29. 29. Trauma or Birth Canal Injury • Genital Tract Lacerations – – – – Vaginal Perineal Levator Ani Muscles Cervix • Puerperal Hematoma – – – – Vulvar Vulvo-vaginal Paravaginal Retroperitoneal • Uterine Rupture
    30. 30. Degree of Laceration • First degree – fourchette, perineal skin of vaginal mucosa • Second degree – fascia and muscle of the perineal body but not the anal sphincter • Third degree – vaginal mucosa, perineal skin, fascia up to the anal sphincter but not the rectal mucosa • Fourth degree – encompasses extension up the rectal mucosa
    31. 31. Genital Tract Lacerations • Vaginal Lacerations (colphorexxis) – middle or upper third of the vagina + perineum/cervix – forceps, vacuum or spontaneous vaginal delivery – bright red bleeding with contracted uterus without retained placental fragments
    32. 32. Injuries to Levator Ani Muscles • Overdistension of birth canal • Injury to pubococcygeus – urinary incontinence
    33. 33. Injuries to the Cervix • <0.5cm • >2cm - repair • rotation by forceps, forceps delvery, and delivery with incomplete cervical dilatation • Annular or Circular Detachment of the Cervix – entire vaginal portion is avulsed • Diagnosis – visualization • Management – surgical repair with interrupted or continuous absorbable sutures
    34. 34. Puerperal Hematoma • Risk Factors – – – – – • Nulliparity Episiotomy Forceps delivery Rupture blood vessel withour superfical lacerations Coagulopathies – rare Site – – – – Vulvar (branches of pudendal artery) Vulvo-vaginal Paravaginal (descending branch of uterine artery) Retroperitoneal
    35. 35. Vulvar Hematoma • branches pudendal artery – posterior rectal – transverse perineal – posterior labial • Symptoms – excruciating pain – tense, fluctuant and sensitive swelling of varying size covered by discolored skin – urinary incontinence • Management – – – – incision and drainage ligation of bleeders packing (12-24hours) blood transfusion
    36. 36. Vulvo-vaginal Hematoma • Risk Factor – inadequate hemostasis (most common) – vaginal laceration – instrumental (forceps and vacuum) deliveries – vulvo-vaginal varicosities – prolonged 2nd stage of labor
    37. 37. Vulvo-vaginal Hematoma Superficial • • • • Unilateral swelling Overlying edema Ecchymosis Treatment – evacuation with ligation of vessels – elimination of dead space by suturing in layers – vaginal packing Retroperitoneal • Less obvious • More difficult to diagnose – UTZ, IV pyelography, CT scan • Treatment – exploratory laparotomy • identify bleeders • ligation of vessels
    38. 38. Placenta Previa • Total – Internal os completely covered by placenta • Partial – Internal os partially covered by placenta • Marginal – Edge of placenta is at the margin of internal os • Low lying – Placenta is implanted in the lower uterine segment such that the placental edge does not reach the internal os but in close proximity • Vasa Previa – Fetal vessels courses throgh membranes and presents at the cervical os
    39. 39. Placenta Previa • Risk Factors – Increase maternal age and parity – Multifetal gestation – Prior cesarean delivery – Prior uterine incision – Cigarette smoking (carbon monoxide hypoxemia  placental hypertrophy) • Symptoms – Painless hemorrhage
    40. 40. Placental Migration • Placenta has no actual circumferential villi invasion that reached the internal cervical os. • Repeat scanning at 32 weeks or so showed no previa
    41. 41. Placenta Previa • Management – fetus is preterm and no other indication for delivery • tocolysis & control of bleeding (close observation) – fetusCESAREANmature is reasonably DELIVERY is necessary in practically all women • stabilize mother then deliver – labor withensued has PLACENTA PREVIA. • delivery – hemorrhage is severe regardless of gestational age • delivery
    42. 42. Placental Abruption - Effusion of blood behind the placenta but the • Premature remains adherent placental marginsseparation of the normally implanted placenta - Placenta is completely separated yet the membranes retained their attachment to the uterine wall - Blood gains access to the amniotic fluid after breaking through membranes - Fetal head is closely applied to the lower uterine segment that blood cannot make its way
    43. 43. Placental Abrubtion • Cause – Unknown • Risk Factors – – – – – – – – – – – – Increase Age and Parity Bleeding is almost always Preeclampsia MATERNAL. Chronic Hypertension PROM (infection) Multifetal Gestation Low Birthweight Hydramnios Cigarette Smoking Thrombophilia Coccaine Use Prior Abruption Uterine Leiomyoma Ethnicity (African-American and Caucasian)
    44. 44. Placental Abruption • No clinical symptoms – circumscribed depression on the maternal surface – few centimeters in diameter – dark, clotted blood – normal looking placenta if recent abruption – age of retroplacental clot cannot be determined exactly
    45. 45. Placental Abruption • Signs and symptoms vary – profuse external bleeding – no bleeding + dead fetus – bloody amniotic fluid • Amniotomy: diminished AF volume allow spiral artery compression thus reduce entry of thromboplastin and decrease bleeding – uterine tenderness, back pain + fetal distress – tachysystole – painful uterine bleeding
    46. 46. Placental Abruption
    47. 47. Placental Abruption • Clinical evident placental abruption is CONTRAINDICATED to tocolysis • Dead fetus can be delivered vaginally EXCEPT if with massive bleeding or other complications
    48. 48. Placental Adherence • Placenta Accreta – placental implantation in which there is abnormally firm adherence to the uterine wall as a result of partial or total absence of the decidua basalis and imperfect development of Nitabuch layer – Placental villa ATTACHED to the myometrium • • • TOTAL – all lobules PARTIAL – few or several lobules FOCAL – single lobule
    49. 49. Placenta Accreta • Placenta Accreta – Placental villus attached/adheres in the myometrium • Placenta Increta – Placental villus invades the myometrium • Placenta Percreta – Placental villus penetrates the myometrium and serosa
    50. 50. Placenta Accreta • “double set up” • sonographic placental localization – simplest, safest and most accurate • • • • transabdominal utz transvaginal utz transperineal utz MRI – MSAFP >2.5MoM
    51. 51. Placenta Accreta • UTZ + Doppler – distance <1mm between uterine serosa & bladder interface & retroplacental vessels – large intraplacental lakes • MRI – uterine bulging – heterogenous signal intensity within placenta – dark intraplacental bands on t2 weighted imaging
    52. 52. Placenta Accreta • Risk factors – – – – – – – – Age High parity Placenta previa Previous CS History of curettage Prior manual extraction Prior retained placenta Infection
    53. 53. Placenta Accreta • Management – Preoperative Arterial Catheter Placement • balloon tipped catheters placed into internal iliac arteries prior to surgery • inflated after delivery of fetus • hysterectomy • embolization – Cesarean Section • placenta left in situ • Methotrexate – infection, necrosis, bleeding  hysterectomy
    54. 54. Retained Placental Fragments • examine placenta routinely after delivery • uterine exploration – recognize and remove retained cotyledon or succenturiate lobe
    55. 55. Uterine Inversion • Turning inside out of the uterus during or after delivery of the placenta • Consequence of strong traction on the umbilical cord attached to a placenta implanted in the fundus
    56. 56. Uterine Inversion • • Life threatening Consequence of mismanagement of 3rd stage of labor – Excessive traction on the cord and fundal pressure (Crede’s maneuver) – Relaxed uterus – Adherent placenta – Short cord – Congenital predisposition – Increase intraabdominal pressure – Manual removal of placenta – General anesthesia
    57. 57. Uterine Inversion
    58. 58. Uterine Inversion
    59. 59. Uterine Inversion
    60. 60. Uterine Inversion • If cannot reinvert uterus vaginally  LAPAROTOMY – due to the dense constriction ring – fundus is pushed upward from below – fundus is pulled from above using a deep traction suture – oxytocin infusion
    61. 61. Uterine Rupture • preexisting injury or anomaly • trauma • complicated labor • dehiscence of previous uterine scar (most common) • excessive uterine stimulation
    62. 62. Uterine Rupture • Uterine Injury or Anomaly Sustained before Current Pregnancy – Surgery involving the myometrium: • • • • • – Cesarean delivery or hysterotomy Previously repaired uterine rupture Myomectomy incision through or to the endometrium Deep cornual resection of interstitial oviduct Metroplasty Coincidental uterine trauma: • Abortion with instrumentation—curette, sounds • Sharp or blunt trauma—accidents, bullets, knives • Silent rupture in previous pregnancy – Congenital anomaly: • Pregnancy in undeveloped uterine horn
    63. 63. Uterine Rupture • Uterine Injury or Abnormality During Current Pregnancy – Before delivery: • • • • • • • – During delivery: • • • • • • • – Persistent, intense, spontaneous contractions Labor stimulation—oxytocin or prostaglandins Intra-amnionic instillation—saline or prostaglandins Perforation by internal uterine pressure catheter External trauma—sharp or blunt External version Uterine overdistension—hydramnios, multifetal pregnancy Internal version Difficult forceps delivery Rapid tumultuous labor and delivery Breech extraction Fetal anomaly distending lower segment Vigorous uterine pressure during delivery Difficult manual removal of placenta Acquired: • • • • Placenta increta or percreta Gestational trophoblastic neoplasia Adenomyosis Sacculation of entrapped retroverted uterus
    64. 64. Uterine Rupture
    65. 65. Uterine Rupture Traumatic • abruptio placenta • difficult forceps delivery • unusual fetal enlargement – hydrocephaly • breech extraction Spontaneous • high parity • oxytocin use • prostaglandin e2 or e1 use
    66. 66. Uterine Rupture • Symptoms – non reassuring fetal heart rate pattern with variable deceleration, late deceleration, bradycardia, fetal death (most common) – pain or tenderness – loss of station • Management – Hysterectomy vs Repair
    67. 67. Consumptive Coagulopathy • Temporary Hemophilia – Placenta abruption – Long dead macerated fetus in utero • Hypofibrinogenemia • DIC • Pregnancy is HYPERCOAGULABLE state – Increase factors I, VII, VIII, IX, X, plasminogen, fibrinopeptide A, Beta-thromboglobulin, platelet factor 4, fibrin-fibrinogen degradatiob products • Compensate the accelerated intravascular coagulation to maintain uteroplacental interface
    68. 68. Consumptive Coagulopathy • • • • • Prolonged retention of dead fetus Sepsis Labor induction with prostaglandin Instrumental delivery Intrauterine installation of hypertonic saline or urea solutions
    69. 69. Amniotic Fluid Embolism
    70. 70. Amniotic Fluid Embolism • Risk Factors – – – – – maternal age minority race placenta previa preeclamosia forceps or cs delivery – meconium staining – rapid labor detection of fetal squames or other debris of fetal origin in the central pulmonary circulation
    71. 71. LATE POSTPARTUM HEMORRHAGE Uterine Subinvolution Uterus empty Retained products Uterotonics Antibiotics controlled persists CURETTAGE ANTIBIOTICS
    72. 72. Post Test 1. signs of placental separation 2. 3. 4. 5. degrees of laceration and anatomical 6. structure it affects 7. 8.
    73. 73. Post Test 9. Causes of postpartum hemorrhage 10. 11. 12. What is late PPH? 13. What is 3rd Stage Hemorrhage 14. Mode of delivery for placenta previa 15. Why can’t we give oxytocin in bolus?