The document discusses the third stage of labour and its complications. It begins by defining the third stage of labour as beginning with the birth of the baby and ending with the delivery of the placenta. It then discusses normal placental separation and how bleeding is controlled after birth. Complications of the third stage including postpartum hemorrhage, retained placenta, and uterine inversion are enumerated. The document thoroughly explains the steps and benefits of active management of the third stage of labour. Causes and management of postpartum hemorrhage and other complications are provided in detail.
VACUUM DELIVERY - OBSTETRICS AND GYNAECOLOGY-
DEALS WITH THE DELIVERY OF HUMAN BABY BY VACUUM IN SPECIAL OBSTETRIC CONDITIONS.
VACUUM is an instrumental device designed to assist delivery by creating a vacuum between it and the fetal scalp.
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
VACUUM DELIVERY - OBSTETRICS AND GYNAECOLOGY-
DEALS WITH THE DELIVERY OF HUMAN BABY BY VACUUM IN SPECIAL OBSTETRIC CONDITIONS.
VACUUM is an instrumental device designed to assist delivery by creating a vacuum between it and the fetal scalp.
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
This topic contains definition, instruments, indications, contraindications, prerequisites, advantages, procedure, complications and hazards of ventouse or vaccum delivery.
The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby
Manual placenta removal is a procedure to remove a retained placenta from the uterus after childbirth.
Mannual removal of placenta is done under GA.
Patient placed in lithotomy position
Bladder is catheterized
This topic contains definition, instruments, indications, contraindications, prerequisites, advantages, procedure, complications and hazards of ventouse or vaccum delivery.
The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby
Manual placenta removal is a procedure to remove a retained placenta from the uterus after childbirth.
Mannual removal of placenta is done under GA.
Patient placed in lithotomy position
Bladder is catheterized
NURSING MANAGEMENT OF THIRD AND FOURTH STAGE OF LABOUR.docx.pptxAyushi958023
In this ppt you will learn about Nursing management of third stage of labor(expected and active management) and Nursing management fourth stage of labor.
THIRD STAGE OF LABOUR AND ITS MANAGEMENT.pdfDolisha Warbi
definition, duration, events, (placenta separation, descend of placenta, expulsion of placenta , the Schultz mechanisms, Mathew Duncan mechanisms, signs of separation, expectant management, active management, complexion , examination of placenta and its membrane, complication.
A Partograph is a graphical record of progress during labor.
Progress is measured by cervical dilatation against time in hours, as well as by providing a record of the important conditions of the mother and fetus that may arise during the process
Similar to 3rd stage of labour and its complications final (20)
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
1. 3rd
stage of labour and its
complications
Dr.Mallika Datta
Assistant Professor (G&O)
Medical College, Kolkata
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. 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. 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. 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. 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. Complications of 3rd
stage
• Postpartum haemorrhage
• Retained placenta
• Shock – haemorrhagic or non-haemorrhagic
• Pulmonary embolism – amniotic fluid or air
• Uterine inversion
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. 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. 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. AMTSL - CCT
• One hand to hold cord (clamped close to
perineum)
• Other suprapubic for counter-traction
• Wait for next contraction (2-3min)
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. 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. AMTSL - contd
• Twist placenta while delivering so that
membranes do not tear off
• EXAMINE the placenta and membranes after
delivery for complete removal
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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. Atonic uterus - laparotomy
• B-Lynch suture
or multiple square
sutures
Work by
compression/tamponade
Avert hysterectomy in
80% of cases
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. 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. 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. 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. 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
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
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. 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. 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. 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. 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. 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. 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. 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. 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. Morbid adherent placenta
• Accreta – No
decidua or
Nitabuch’s layer
• Increta –
penetration of
villi in to
myometrium
• Perceta –
penetration up
to serous layer
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.