1. Complications of the Third Stage
of Labour
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2. Complications of the Third Stage of
Labour
Include:
* Postpartum haemorrhage.
* Retained placenta.
* Inversion of the uterus.
* Obstetric shock (collapse).
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3. POSTPARTUM HAEMORRHAGE
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4. POSTPARTUM HAEMORRHAGE
• Definition:It is excessive blood loss, from the
genital tract after delivery of the foetus exceeding
500 ml or affecting the general condition of the
patient.
• Types:
a.Primary postpartum haemorrhage:> Bleeding
occurs during the 3rd stage or within 24 hours
after childbirth. It is more common.
b. Secondary postpartum haemorrhage:> Bleeding
occurs after the first 24 hours until 6 weeks (the
end of puerperium).
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5. PRIMARY POSTPARTUM HAEMORRHAGE
Aetiology:a.Placental site haemorrhage
* Atony of the uterus:
> is the cause of primary postpartum haemorrhage in more than 90% of
cases.
>The factors that predispose to uterine atony are:
• Antepartum haemorrhage.
• Severe anaemia.
• Overdistension of the uterus.
• Uterine myomas.
• Prolonged labour exhausting the uterus.
• Prolonged anaesthesia and analgesia.
• Full bladder or rectum.
• Idiopathic.
* Retained placenta.
* Disseminated intravascular coagulation (DIC).
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6. PRIMARY POSTPARTUM HAEMORRHAGE
• Aetiology:Traumatic haemorrhage
• Rupture uterus, cervical, vaginal, vulval or
perineal lacerations.
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7. Diagnosis
General examination
* The general condition of the patient is
corresponding to the amount of blood loss.
* In excessive blood loss, manifestations of
shock appear as hypotension, rapid pulse, cold
sweaty skin, pallor, restlessness, air hunger
and syncope.
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8. Diagnosis
• General examination
* The general condition of the patient is
corresponding to the amount of blood loss.
* In excessive blood loss, manifestations of
shock appear as hypotension, rapid pulse, cold
sweaty skin, pallor, restlessness, air hunger
and syncope.
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9. Diagnosis
Abdominal examination
* In atonic postpartum haemorrhage: The
uterus is larger than expected, soft and
squeezing it leads to gush of clotted blood per
vagina.
* In traumatic postpartum haemorrhage: The
uterus is contracted. Combination of the 2
causes may be present.
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10. Diagnosis
• Vaginal examination
>In atony: Bleeding is usually started few minutes
after delivery of the foetus.
* It is dark red in colour.
* The placenta may be not delivered.
>In trauma: Bleeding starts immediately after
delivery of the foetus.
* It is bright red in colour.
* Lacerations can be detected by local
examination.
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11. Management
• Prevention
• Treatment
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12. Management
• Prevention:
During pregnancy:
a. Detection and correction of anaemia.
b. Hospital delivery with ready cross-matched
blood for high risk patients as:
Antepartum haemorrhage.
Previous postpartum haemorrhage.
Polyhydramnios and multiple pregnancy.
Grand multipara.
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13. Management
Prevention:
• During labour:
a. Proper use of analgesia and anaesthesia.
b. Avoid prolonged labour by proper oxytocin which should be
extended to the end of the 3rd stage if used.
c. Avoid lacerations by:
> Proper management of the 2nd stage.
>Follow the instructions for instrumental delivery (see later).
d. Routine use of ecbolics in the 3rd stage of labour.
e. Routine examination of the placenta and membranes for
completeness.
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14. Management
• Prevention:
*Postpartum:
> Exploration of the birth canal after difficult or
instrumental delivery as well as precipitate
labour.
> Careful observation in the fourth stage of
labour (1-2 hours postpartum).
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15. Treatment
(I) Restoration of blood volume:
Urgent cross-matched blood transfusion with
the other antishock measures is given.
Colloids and/or crystalloids therapy can be
started till availability of the blood.
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16. Treatment
(II) Arrest of bleeding:
i) Placental site bleeding:
a) Before delivery of the placenta:
b) The placenta should be delivered by;
* Ergometrine and massage with gentle cord
traction if failed,
* Brandt -Andrews manoeuvre if failed do,
* Crédé’s method if failed do,
* manual separation of the placenta
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17. Treatment
(b) After delivery of the placenta:
The following steps are done in succession if
each previous one fails to arrest bleeding:
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18. Treatment
• Inspection of the placenta and membranes: any
missed part should be removed manually under
anaesthesia.
• Massage of the uterus and ecbolics as:
> Oxytocin drip: 10-20 units in 500 ml glucose 5% or
normal saline. It may be given (5 units) directly
intramyometrial in case of C.S.
> Ergometrine (Methergin): 1-2 ampoules (0.250.50 mg) IV or IM.
> Syntometrine 0.5 mg IV if available.
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19. Treatment
• Prostaglandins (PGs):
> 0.25 mg methyl PG F2a IM (Prostin methyl
ester) or
>1 mg PG F2a intramyometrial in case of C.S. or
>20 mg PG E2 (Prostin E2) rectal suppositories
every 4-6 hours.
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20. Treatment
• Bimanual compression of the uterus:
> Under general anaesthesia, the uterus is firmly
compressed for 5-30 minutes between the closed
fist of the right hand in the anterior vaginal fornix
and the left hand abdominally behind the body of
the uterus.
> The compression is maintained until the uterus is
firmly contracted. During this period, blood
transfusion, oxytocin and ergometrine are given.
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21. Treatment
• Bilateral uterine artery ligation:
> The surgeon stands on the left side of the patient
to control the procedure more.
>The uterus is grasped by the assistant and elevated
upwards and to the opposite side of the uterine
artery which will be ligated to expose the vessels
coarse through the broad ligament.
> A large atraumatic needle with no. 1 chromic
cutgut, O-vicryl or O-Dexon is passed through and
into the myometrium from anterior to posterior
2-3 cm medial to the uterine vessels.
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22. Treatment
> The needle is brought forward through
avascular area in the broad ligament lateral to
the uterine artery and vein. The suture is tied
anteriorly.
> In case of caesarean section, the sutures are
placed 2-3 cm below the level of uterine
incision under the reflected peritoneal flap
which should be displaced downwards with
the bladder to avoid ligation of the ureters.
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23. Treatment
 If caesarean section was not done, peritoneal
incision is not indicated and bladder can be
simply pushed downwards.
 Uterine artery ligation is haemostatic by reducing
the pulse pressure to the uterus as 90% of its
blood supply is from the uterine vessels.
 Collateral circulation and recanalization of the
uterine vessels will be established within 6-8
weeks.
 It has a success rate of 95%.
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24. Treatment
• Bilateral ligation of ovarian supply to the
uterus:
> If bleeding continues after uterine arteries
ligation a second mass bilateral ligation is
done high up in the site of anastomosis
between the uterine and ovarian arteries near
the cornua of the uterus.
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25. Treatment
• Bilateral internal iliac artery ligation:
>The posterior peritoneum lateral to the infundibulopelvic vessels is opened.
>The ureter is indentified on the posterior leaf of the
broad ligament and retracted medially.
>The bifurcation of the common iliac artery at the level of
the sacroiliac joint is identified and the internal iliac
vessels are identified and ligated with no.1 nonabsorbable silk suture.
>Most surgeons do not close the peritoneum over this
area.
> It has a success rate of 40%.
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26. Treatment
• Hysterectomy:
Subtotal hysterectomy which is more rapid
and easy than total hysterectomy is done.
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27. Treatment
• Other less commonly used methods to arrest
bleeding: 1. Uterine packing:
>Under general anaesthesia.
> Foley's catheter is applied.
> Packing the whole uterus, cervix and vagina with
a sterile gauze starting from the fundus
downwards in tightly packed layers where each
roll of gauze is tied to the next.
> It is removed after 6-12 hours.
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28. Treatment
• 2.Foley’s balloon:
> A large Foley’s catheter balloon is inflated to
control haemorrhage from lower uterine
segment which may result from placenta
praevia or cervical pregnancy.
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29. Treatment
• 3.Aortic compression:
The aorta is compressed manually against the
lumbar spines through the abdomen providing
temporary control of heavy bleeding till
preparing for surgical interference.
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30. Treatment
• 4. Radiographic trans-arterial immobilisation:
>By a trained radiologist selective
immobilisation of the pelvic vessels may be
done using the angiographic technique.
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31. Complications
Maternal death in 10% of postpartum
haemorrhages.
• Acute renal failure.
• Embolism.
• Sheehan’s syndrome.
• Sepsis.
• Anaemia.
• Failure of lactation.
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32. SECONDARY POSTPARTUM
HAEMORRHAGE
• Aetiology:
a. Retained parts:
of the placenta, membranes, blood clot or
formation of a placental polyp.
b. Infection:
> separation of infected retained parts.
>infected C.S. wound
> infected genital tract lacerations.
> infected placental site.
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33. SECONDARY POSTPARTUM
HAEMORRHAGE
•
•
•
•
Aetiology:
Fibroid polyp: necrosis and sloughing of its tip.
Subinvolution of the uterus.
Local gynaecological lesions: e.g. cervical ectopy
or carcinoma.
• Choriocarcinoma.
• Puerperal inversion of the uterus.
• Oestrogen withdrawal bleeding: if oestrogen was
given for supression of lactation.
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34. SECONDARY POSTPARTUM
HAEMORRHAGE
Treatment
It depends on the cause:
* Retained parts:with minimal bleeding:
can be spontaneously expelled using:
>ergometrine and
> antibiotics.
• Retained parts: with severe bleeding:
> vaginal evacuation under anaesthesia is indicated.
* Infection: antibiotics.
* Other causes: treatment of the cause.
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