This document discusses complications of the third stage of labour, specifically postpartum hemorrhage (PPH). It defines PPH as blood loss exceeding 500mL following birth. Causes include uterine atony, trauma, retained placenta. Diagnosis involves examination to assess blood loss, vital signs, uterine firmness and lacerations. Management principles are to control bleeding, replace blood loss, and correct hypovolemia. Prevention strategies like active management of the third stage and treating high risk mothers are also covered.

1. • COMPLICATION OF 3RD STAGE OF LABOUR
Presented By :-
Ramandeep Kaur

2. •Introduction

5. AMOUNT OF BLOOD LOSS

7. DEFINITION
clinical : Any amount of bleeding, from or into
genital tract, following birth of baby.
 The end of puerperium which adversely
affect the condition of patient, evidenced by
rise in Pulse Rate and falling BP.
ACC TO WHO :- Amount of blood loss in
excess of 500mL following birth of baby.

21. •DIAGNOSIS

22. A) GENERAL EXAMINATION:
• The general examination of the patient correspond to
the amount of blood loss .
• In excessive blood loss, manifestation of shock appear as
hypotension, rapid pulse, cold sweaty skin, pallor,
restlessness, air hunger & syncope.
B) ABDOMINAL EXAMINATION:-
• In atonic PPH: Uterus is larger than expected, soft, &
squeezing it lead to gush of clotted blood PV.
• In traumatic PPH: Uterus is contracted.

23. • C) VAGINAL EXAMINATION :-
• In atony: Bleeding is usually started few minutes
after delivery of the fetus.
 It is dark red in colour.
 Placenta may not be delivered.
• In trauma: Bleeding starts immediately after
delivery of fetus.
 It is bright red in colour.
 Lacerations can be detected by local
examination.

24. PREVENTION
• Antenatal :- it include
• Improvement of the health status of the women
and to keep the hb > 10 gm/dl so that pt can
withstand some amount of the blood loss.
• High risk patient:- identify high risk mothers (
such as twin , hydromnios,grand
multipara,APH,h/o prvious PPH, severe anaemia )
are to be screened & delivery in a well equipped
hospital.
• Blood grouping:-it should be done in all women.

25. Conti.........................................
• Placenta localisation:-it should be done in all c
section mothers by USG and MRI to detect
placenta percreta .
• Women with the morbid adherent placenta

26. INTRANATAL CARE:- IT
INCLUDE
• Active management of 3rd stage of labour
• Cases induced with induced or augmented
labour by oxytocin
• Exploration of the utero vagainal canal
• Observation for about 2 hours
• Expert obstetric anaesthetist
• Examination of the placenta

28. •Management of true
postpartum
haemorrhage

29. Principles
Principles are :-
• To diagnose the cause of bleeding.
• To take prompt and effective measures to
control bleeding.
• To correct hypovolemia.

34. SECONDARY HAEMMORAHGE
• DEFINITION :-
The bleeding usually occurs between 8th to 14th
day of delivery.

35. Retained
bits of
cotyledons
or
membrane
s
Infection and
separation of
slough over a
deep cervico-
vaginal
laceration.
Endometri
osis and
sub
involution
of
placental
site.
separation
of slough
exposing a
bleeding
vessel
From
granulatio
n tissues
CAUSES

36. The bleeding is bright red andofvarying amount.
Rarelymay it brisk.
Varying degree of anemiaand evidences of sepsis are
present.
Diagnosis:

37. DIAGNOSIS
• Internal examination :-
• reveals evidences of sepsis, sub involution of
the uterus and often a patulous cervical os.
• Ultrasonography
• Useful in detecting the bits of placenta inside
the cavity
• The bleeding is bright red and of varying
amount.

38. • MANAGENENT

39. PRINCIPLES:
• To assess the amount of blood loss and to replace
the blood loss
• To find out the cause and to take appropriate steps
to rectify it
• Supportive therapy:
• Blood transfusion if necessary to administer
ergometrine 0.5 mg IM
• Conservative :-
• careful watch for a period of 24 hours

40. • ACTIVE TREATMENT:
• THE PRODUCTS ARE REMOVED BY
OVUM FORCEP
• THE GENTLE CURETTAGE IS DONE
BY USING FLUSHING CURETTE.
• ERGOMETRIN 0.5 MG IS GIVEN IM.
CONTI………………………………..

41. CONTI......................................
• Withdrawal bleeding following estrogen
therapy for suppression of lactation
• Other rare causes are: chorionepithelioma-
occurs usually beyond 4 wks. of delivery,
carcinoma cervix, placental polyp, infected
fibroid or fibroid poly and puerperal
inversion of the uterus.

42. RETAINED PLACENTA :-
• Definition :- placenta is said to retained when
it is not expelled out even 30 minutes after the
birth of the baby.

43. CAUSES
• Placenta completely separated but retained is due to
poor voluntary expulsive efforts.
• Simple adherent placenta is due to uterine atonicity in
cases of grand multipara, over distension of the uterus,
prolonged labour, uterine malformation or due to bigger
placental surface area. The commonest cause of
retention of non-separated placenta is atonic uterus.
• Morbid adherent placenta- partial or rarely incomplete.
• Placenta incarcerated following partial or complete
separation due to constriction ring, premature attempts
to deliver placenta before it is separated.

44. DIAGNOSIS
• It is made by an arbitrary time spent following
delivery of the baby.
• Features of placental separation is assessed.
• The hour glass contraction or the nature of
adherent placenta can only be diagnosed
during manual removal.

45. MANAGEMENT
• Period of watchful expectancy: -
• During the period of arbitrary time limit of an
half an hour, the patient is to be watched carefully
for the evidence of any bleeding, revealed or
concealed and to note the signs of separation of
placenta.
• The bladder should be emptied using a rubber
catheter.
• Any bleeding during the period should be
managed as outlined in third stage bleeding

46. • Retained placenta:
• Separated
• Un-separated
• Complicated

47. • Placenta is separated and retained: - To
express the placenta out by controlled cord
traction.
• Un separated retained placenta: - Manual
removal of placenta is to be done under GA.

48. Complicated retained placenta:-
• Retained placenta complicated with haemorrhage or
shock.
• Retained placenta with shock no haemorrhage.
• Retained placenta with haemorrhage.
• Retained placenta with sepsis.
• Intrauterine swabs are taken for culture and sensitivity
test and broad spectrum antibiotics is usually given.
• Blood transfusion is helpful.
• Manual removal of placenta
• Retained placenta with an episiotomy wound

49. COMPLICATIONS
• Haemorrhage
• Shock is due to blood loss, at times unrelated
blood loss, specially when retained more than
one hour, Frequent attempts of abdominal
manipulation to express the placenta out
• Puerperal sepsis
• Risk of recurrence in next pregnancy.

51. PLACENTA ACCRETA:-
• it is defined as an extreme rare form in which the
placenta is directly anchored to the myometrium
partially or completely without any intervening
deciduas.
• The abnormal adherence may involve all
lobules—total placenta accreta.
• Or, it may involve only a few to several
lobules— partial placenta accreta.
• All or part of a single lobule may be attached—
focal placenta accreta.

52. PLACENTA INCRETA :-
• placenta increta, villi actually invade into the
myometrium and anchored into the muscle
bundles.

53. PLACENTA PERCRETA :-
DEFINITION :-
• with placenta percreta, villi penetrate through
the myometrium upto the serosal layer.
Associated Conditions
• placenta previa
• prior caesarean delivery
• previously undergone curettage

54. DAIGNOSIS
• The diagnosis is made only during attempted manual
removal when the plane of cleavage between the placenta
and the uterine walls cannot be made out.
• USG and colour Doppler:- two factors were highly
predictive of myometrial invasion:
– a distance less than 1 mm between the uterine serosa -bladder
interface and the retro placental vessels.
– identification of large intra placental lakes
• MRI: -
(1) uterine bulging
(2) heterogeneous signal intensity within the placenta.
(3) presence of dark intraplacental bands on T2-weighted
imaging.

55. Pathological confirmation includes: -
• Absence of decidua basalis .
• Absence of nitabuch’s fibrinoid layer
• Varying degree of penetration of the villi into
muscle bundles and upto serosal layers.

56. Management

57. • In the focal placenta
accrete:-
• Remove the placental tissue
as much as possible. Effective
uterine contraction and
haemostasis are achieved by
oxytocics and if necessary by
intrauterine plugging. In cases
of caesarean section the
bleeding areas are over sewed.
If the uterus fails to contract
hysterectomy may have to be
taken and this preferable in
multi paraus woman.
• In the total placenta accrete:-
• Hysterectomy is indicated in
the parous women, while in
patients desiring to have a
child conservative attitude may
be taken. This consists of
cutting the umbilical cord as
close to its base as possible
and leaving behind the
placenta which is expected to
be autolysed during the course
of time. Appropriate antibiotics
should be given. Methotrexate
also is used by some.

58. In rare cases: -
• Placenta accrete may invade bladder. In that case try to
avoid placental removal. It may need hysterectomy and
partial cystectomy. Methotrexate therapy may be tried.
• Preoperative Arterial Catheter Placement.
• Delivery of the Placenta.
• Complications:-
• Haemorrhage
• Shock
• Infection
• Inversion of uterus

59. INVERSION OF THE UTERUS:-
• Definition: It is extremely rare but a life
threatening complication in third stage in
which the uterus is turned inside out partially
or completely.
• Etiology:-
• Spontaneous: 40%
• Iatrogenic:

60. VARIETIES:-
• First degree: there is dimpling of the fundus
which still remains above the level of internal
os.
• Second degree: the fundus passes through the
cervix but lies inside the vagina.
• Third degree: the endometrium with or
without the attached placenta is visible outside
the vulva. The cervix and part of vagina may
be also involved in the process.

62. DIAGNOSIS
Symptoms:
• Acute lower abdominal pain with bearing down
sensation
Signs:
• Varying degree of shock is a constant feature .
• Abdominal examination .
• Bimanual examination .
• In complete variety pear shaped mass protrudes
outside the vulva with broad end pointing
downwards and looking reddish purple in colour

63. • Prevention:
• Do not employ any method to expel placenta
out when the uterus is relaxed.
• Puling the cord simultaneously with fundal
pressure should be avoided.
• Manual removal in a safe manner.

64. MANAGEMENT
• Immediate assistance is summoned to include
anaesthesia personnel and other physicians .
• The recently inverted uterus with placenta
already separated from it may often be replaced .
• Adequate large-bore intravenous infusion
systems .
• If still attached, the placenta is not removed until
infusion systems are operational, fluids are being
given, and a uterine-relaxing anaesthetic such as a
halogenated inhalation agent has been
administered.

65. Conti....................................
• Other tocolytic drugs such as terbutaline,
ritodrine, magnesium sulphate, and nitro-
glycerine have been used successfully for
uterine relaxation and repositioning .
• 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.
• Care is taken not to apply so much pressure as
to perforate the uterus with the fingertips

67. • Surgical Intervention :-
• the uterus cannot be reinverted by vaginal
manipulation because of a dense constriction
ring . In this case, laparotomy is imperative.

68. BEFORE SHOCK DEVELOPS:
• To replace the part first which is inverted last with the
placenta attached to the uterus by steady firm pressure
exerted by the fingers.
• To apply counter support by the other hand placed on
the abdomen.
• After replacement the hand should remain inside the
until the uterus become contracted by parentral
oxytocin or PGF2α
• The placenta is to be removed manually after the uterus
became contracted .
• Usual treatment of shock including blood transfusion
should be arranged.

69. AFTER SHOCK DEVELOPS:
• Urgent dextrose saline drip and blood
transfusion.
• To push the uterus inside the vagina if possible
and pack the vagina with antiseptic roller gauze.
• Foot end of the bed is raised.
• Replacement of uterus either manually or
hydrostatic method (o sullivan’s) . Hydrostatic
method is less shock producing.

71. SUB ACUTE STAGE:
• Improve general condition by blood
transfusion.
• Antibiotics to control sepsis.
• Reposition of uterus either manually or
hydrostatic method.
• If fails abdominal reposition by operation-
Haultain operation.

72. COMPLICATIONS:-
• Shock
• Tension on the nerves due to stretching of the infundibulo-
pelvic ligament.
• Pressure on the ovaries as they dragged with the fundus
through cervical ring.
• Peritoneal irritation .
• Haemorrhage, specially after detachment of placenta .
• Pulmonary embolism If left uncared it leads to: -
 Infection
 Uterine sloughing
 A chronic one

73. •MANAGEMENT
OF 3RD STAGE OF
LABOUR

74. PRINCIPLES ARE :-
• To empty the uterus of its contents & to make
it contract
• To replace the blood
• To ensure effective haemostasis in traumatic
bleeding

77. DIFFICULTIES :-

78. COMPLICATION :-
• Haemorrhage due to the incomplete removal
• Shock
• Injury to the uterus
• Infection
• Inversion
• Sub involution
• Thrombophletitis
• Embolism :- in such cases placenta is removed in
fragments using an ovum forcepe or a flushing curette.

79. Nursing Management:-
• Deficient fluid volume r/t excessive blood loss
secondary to uterine atony, lacerations, incisions,
coagulation defects, retained placental fragments,
hematomas.
• Fear and anxiety r/t threat to physical being,
deficient knowledge of treatment .
• Pain r/t uterine contractions, distention from
blood between uterine wall and placenta.
• Risk for complication, shock related to excessive
bleeding

80. Conti..........................................
• Interrupted breast feeding r/t mother’s health
state during the PPH.
• Risk for impaired parent/ infant bonding r/t
lack of early parent/ infant contact.
• Interrupted family process r/t change in family
roles, inability to assume usual role and
prolonged recovery period.