complications of third stage of labour

1. Mrs. DRISYA.V.R.
2nd Year MSc Nursing

2. • Postpartum hemorrhage
• Placenta accreta, increta, and percreta
• Inversion of the uterus

3. POSTPARTUM HEMORRHAGE
Any amount of bleeding from and into the
genital tract following the birth of the baby up
to the end of the pueperium which adversely
affects the general condition of the patient
evidenced by rise in pulse rate and falling BP is
called post partum haemorrhage”.

4. • Incidence
4-6% of all deliveries.

5. Types
• Primary
Third stage hemorrhage
True PPH
• Secondary PPH/ delayed/late

6. Primary post partum haemorrhage
Causes
• 4 T’s
• Tone
• Tissue
• Trauma
• Thrombin( blood coagulopathy)

7. • High parity
• Over-distension of the uterus
• Malnutrition and anemia
• Antepartum hemorrhage
• General anesthesia
• Poorly perfused myometrium
• Prolonged labour
• Following augmented labour
Uterine atony

8. • Uterine atony in previous labour
• Placenta
• Chorioamnionitis
• Malformation of uterus
• Uterine fibroid
• Very rapid labour
• Mismanaged third stage of labour

9. • Constriction ring:
• Avulsed cotyledon, succenturiate lobe
• Placenta previa
• Placental abruption
• A full bladder

10. Traumatic
Trauma to the genital tract usually occurs
following operative delivery; even after
spontaneous delivery

11. • Retained tissues
• Drugs : tocolytic drugs, MgSO4, nifedipine
• Combination of atonic and traumatic causes
• Blood coagulation disorders

12. Clinical Features
• Visible bleeding
• Maternal collapse
• Pallor
• Rising pulse rate
• Falling BP
• Altered level of consciousness
• May restless/drowsy
• Enlarged uterus, boggy on palpation

13. Diagnosis
• Direct observation in open hemorrhage.
• In concealed case, diagnosis is based on
clinical effects.
• In traumatic hemorrhage- uterus is
contracted.
• In atonic hemorrhage-uterus is flabby and
becomes hard on massaging.

14. Investigations
• Thorough examination of the lower genital
tract. This may require theatre/anaesthesia.
• CBC, clotting screen, cross match, Coagulation
studies
• Hourly urine output
• Continuous pulse/blood pressure or central
venous pressure monitoring
• ECG, pulse oximetry

15. Prevention
Antenatal
• Improvement in health status, keep Hb level
>10gm/dl.
• Screen high risk clients.
• Blood grouping
• Unfractionated Heparin (UH) or Low
Molecular Weight Heparin (LMWH).

16. Intranatal
• In the event of a woman coming to delivery while
receiving therapeutic heparin, the infusion should
be stopped. Heparin activity will fall to safe levels
within an hour. Protamine sulphate will reverse
activity more rapidly, if required.
• Slow delivery of baby.
• Expert obstetric anesthetist.
• Active management of 3rd stage of labour.

17. Immediate care in PPH
• COMMUNICATE.
• RESUSCITATE.
• MONITOR / INVESTIGATE.
• STOP THE BLEEDING.

18. • Communicate to clinical team—Call 6.
• Call experienced midwife
• Call obstetric registrar & alert consultant
• Call anaesthetic registrar, alert consultant
• Alert haematologist
• Alert Blood Transfusion Service
• Call porters for delivery of specimens / blood

19. Resuscitate
• IV access with 14 G cannula X 2
• Head down tilt
• Oxygen by mask, 8 litres / min
• Transfuse
• Crystalloid
• Colloid

20. Management of 3rd stage hemorrhage
The principles in the management are:
• To empty the uterus of its content and to
make it contract.
• To replace the blood. If in shock, then manage
shock.
• To ensure effective hemostasis in traumatic
bleeding.

21. Steps of management:
Placental site bleeding
• Palpate the fundus and massage the uterus to make it
hard.
• To start crystalloid solution (NS or RL) with oxytocin
(1L with 20 units) at 60 drops per minute and to
arrange for blood transfusion
• Oxytocin 10U IM or Ergometrine 0.25mg or
methergine 0.2mg is given intravenously.
• Catheterise the bladder
• Sedation with morphine 15mg intramuscularly.
• To give antibiotics

22. Manual Removal of Placenta
Step 1: The operation is done under GA. In
extreme urgency where anaesthesia is not
available, the operation may have to be done
under deep sedation with IV diazepam 10mg.
The patient is placed in lithotomy position. With
all aseptic measures the bladder is catheterized.

23. Step 2: One hand is introduced into the uterus
after smearing with the antiseptic solution in
cone shaped manner following the cord, which
is made taut by the other hand. While
introducing the hand, the labia are separated by
the fingers of the other hand. The fingers of the
uterine hand should locate the margin of the
placenta.

24. Step 3: Counter pressure on the uterine fundus
is applied by the other hand placed over the
abdomen. The abdominal hand should steady
the fundus and guide the movements of the
fingers inside the uterine cavity till the placenta
is completely separated.

25. Step 4: As soon as the placental margin is
reached, the fingers are insinuated between the
placenta and the uterine wall with the back of
the hand in contact with the uterine wall. The
placenta is gradually separated with a sideways
slicing movement of the fingers, until whole of
the placenta is separated.

26. Step 5: When the placenta is completely
separated, it is extracted by traction of the cord
by the other hand. The uterine hand is still
inside the uterus for exploration of the cavity to
be sure that nothing is left behind.

27. Step 6: Intravenous methergine 0.2mg is given
and the uterine hand is gradually removed while
massaging the uterus by the external hand to
make it hard. After the completion of the
manual removal, inspection of the cervico-
vaginal canal is to be made to exclude any injury.

28. Step 7: The placenta and membranes are to be
inspected for completeness and be sure that the
uterus remains hard and contracted.

29. Difficulties
• Hour – glass contraction
• Morbid adherent placenta

30. Complications
• Haemorrhage due to incomplete removal
• Shock
• Injury to the uterus
• Infection
• Inversion
• Subinvolution
• Thrombophlebitis
• Embolism.

31. Scheme of management
of third stage haemorrhage.
● Control of the fundus, massage and make it hard
● Inj.Methergin 0.2mg I.V
●To start NS drip and arrange for blood transfusion
● Catheterise the bladder
Placenta separated Not separated
Express the placenta Manual removal under GA
out by controlled cord traction

32. Management of true post partum
haemorrhage
Principles
• To diagnose the cause of bleeding.
• To take prompt and effective measures to
control bleeding.
• To correct hypovolemia.

33. Management
• Call for help.
• Put in two large bore, 14 gauge, cannulas.
• Keep patient flat and warm.
• Send blood for grouping and cross matching and ask
for 2 units of blood.
• Oxygen by mask, 10-15 litres / min
• Start 20 units of oxytocin in 1 L of NS at the rate of 60
drops/mt.
• Monitor vital signs
• Monitor type and amount of fluids the patient has
received, urine output, drugs- type, dose and time,
CVP.

34. Actual Management:
Atonic uterus
Step 1:
• Massage the uterus to make it hard and express
the blood clot.
• Inj. Methergin 0.2mg IV.
• Start Inj.oxytocin drip (10 units in 500ml of NS) at
the rate of 40- 60 drops per min.
• Catheterise the bladder
• Examine the expelled placenta and membranes
for completeness. If the uterus fails to contract ,
proceed to the next step.

35. Step 2:
• Explore the uterus under GA. Simultaneous
inspection of the cervix, vagina specially the
para- urethral region is to be done to exclude
co- existent bleeding sites from the injured
area.
• Blood transfusion
• Continue oxytocin drip.

36. In refractory cases:
• Inj. 15 methyl PGF2α 250micro gram IM in
the deltoid muscle every 15 minutes ( upto
maximum of 2 mg) or Misoprostol (PGE1) 1000
microgram per rectum.
• When uterine atony is due to tocolytic drugs,
calcium gluconate (1 gm IV slowly)

37. • Step 3: Uterine massage and bimanual
compression.
• Step 4: Uterine tamponade
(i) Tight intra uterine packing done uniformly
under GA.
(ii) Balloon tamponade

38. Step 5: Surgical methods
• Ligation of uterine arteries
• Ligation of the ovarian and uterine artery
anastomosis
• Ligation of the anterior division of internal iliac
artery (unilateral or bilateral).
• B-Lynch compression suture and multiple square
sutures:
• Angiographic arterial embolisation under
fluoroscopy

39. • Step 6: Hysterectomy

40. Protocol
• Stage 0: normal - treated with fundal
massage and oxytocin.
• Stage 1: more than normal bleeding - establish
large-bore intravenous access, assemble
personnel, increase oxytocin, consider use of
methergine, perform fundal massage, prepare 2
units of packed red cells.

41. • Stage 2: bleeding continues - check coagulation status,
assemble response team, move to operating room,
place intrauterine balloon, administer additional
uterotonics(misoprostol, carboprost tromethamine),
consider: uterine artery embolization, dilatation and
curettage, and laparotomy with uterine compression
stitches or hysterectomy.

42. • Stage 3: bleeding continues - activate massive transfusion protocol,
mobilize additional personnel, recheck laboratory tests, perform
laparotomy, consider hysterectomy
• Following PPH keep the patient in labour room and observe for 24-
48 hrs.
• Traumatic PPH
• The trauma to the perineum, vagina and the cervix is to be
searched under good light by speculum examination and
haemostasis is achieved by appropriate catgut sutures. The repair is
done under GA, if necessary.

43. Secondary PPH
Causes:
• Retained bits of placenta or membranes.
• Infection and separation of slough over a deep
cervico- vaginal laceration.
• Endometritis and subinvolution of the placental
site
• Withdrawal bleeding following oestrogen therapy
for suppression of lactation.
• carcinoma of cervix, infected fibroid or fibroid
polyp and puerperal inversion of uterus.

44. Management
• Principles—
(1) To assess the amount of blood loss and to
replace the lost blood.
(2) To find out the cause and to take
appropriate steps to rectify it.

45. • Call doctor
• Reassure woman and support person
• Rub up contraction by massaging uterus if it is
still palpable
• Express any clots
• Encourage to empty bladder
• Give an uterotonic
• Keep all pads and linen to assess blood loss
• If bleeding persists transfer women

46. • Supportive therapy:
• Blood transfusion, if necessary;
• Inj Ergometrine 0.5mg IM, if the bleeding is
uterine in origin
• Antibiotics as routine.

47. Complications
• Shock
• Collapse
• Disseminated intravascular coagulation

48. RETAINED PLACENTA
The placenta is said to be retained when it is not
expelled out even 30 minutes after the birth of
the baby.(WHO 15mnts)

49. Causes
• There are three phases involved in the normal
expulsion of placenta.
• Separation through the spongy layer of the
decidua
• Descent into the lower segment and vagina
• Finally the expulsion to outside

50. Management
• Separated
• Un-separated
• Complicated

51. Complications
• Haemorrhage
• Shock
• Puerperal sepsis
• Risk of recurrence in next pregnancy.

52. PLACENTA ACCRETA, INCRETA,
AND PERCRETA

53. • The term placenta accreta is used to describe
any implantation in which there is abnormally
firm adherence to the uterine wall.
• With placenta increta, villi actually invade into
the myometrium and anchored into the
muscle bundles.
• with placenta percreta, villi penetrate through
the myometrium upto the serosal layer.

54. Management
• In the focal placenta accreta
• In the total placenta accreta
• In rare cases

55. Complications
• Haemorrhage
• Shock
• Infection
• Inversion of uterus

56. INVERSION OF THE UTERUS
• It is extremely rare but a life threatening
complication in third stage in which the uterus
is turned inside out partially or completely.

57. Varieties
• First degree
• Second degree
• Third degree

58. Etiology
• Spontaneous
• Iatrogenic:
This is due to the mismanagement of third stage
of labour.
Pulling the cord when the uterus is atonic
specially when combined with fundal pressure.
Fundal pressure while the uterus is relaxed
Faulty technique in manual removal

59. 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

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

61. Management
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 to reduce the bulk which facilitates
replacement or if partially separated to minimize blood
loss.
• Usual treatment of shock including blood transfusion
should be arranged.

62. After shock develops:
• urgent normal 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) under GA.

63. Complications
• Shock
• Peritoneal irritation
• Haemorrhage
• Pulmonary embolism
• If left uncared it leads to:
o Infection
o Uterine sloughing
o A chronic one