This document provides information on the management of the third stage of labour and complications. It discusses the three phases of the third stage, signs of placental separation, and mechanisms of controlling bleeding. It describes expectant and active management approaches. For retained placenta, steps include uterine massage, oxytocics, and controlled cord traction. Manual removal under anesthesia may be needed. Complications include postpartum hemorrhage, retained placenta, uterine inversion, and shock. Risk factors, diagnosis, and conservative management are outlined for morbidly adherent placenta such as placenta accreta.

1. MANAGEMENT OF THIRD STAGE OF
LABOUR & COMPLICATIONS
DR RAJEEV SOOD
ASTT. PROF OBG
IGMC SHIMLA
1

2. THIRD STAGE OF LABOUR
 Begins after expulsion of fetus and ends
with expulsion of placenta and
membranes
 It is the most crucial stage of labour
 Average duration is 15 minutes in both
primi and multigravida. With active
management, it is reduced to 5 minutes.
2

3. IT HAS 3 PHASES
I. Phase of Placental seperation
II. Descent of placenta to the lower
segment
III. Expulsion of placenta with
membranes
3

4.  PHASE OF PLACENTAL SEPERATION :-
For some time after delivery of the foetus, patient
experiences no pain. Intermittent discomfort coinciding
with uterine contractions occurs. After the birth of baby
uterus measures 20 cm vertically and 10cm antero
posteriorialy, discoid in shape .
Surface area of placental site is reduced due to retraction.
Placenta is inelastic cannot contract simultaneously,
hence buckling occurs.
Plane of seperation is through the deep spongy layer of
decudia basalis .
4

5. THERE ARE TWO WAYS OF seperation
1. Central (SCHULTZE)
:-detachment starts from
centre, uterine sinuses are
opened, retro placental
collection of blood occurs
resulting in further
seperation.
3. Marginal (Mathew duncan):-
Here seperation starts at
margin, more area get
separated with progressive
uterine contractions. This
occurs more frequently
5

6. SIGNS
Before seperation-
 uterus is discoid, firm, non- ballotable.
 height of uterus is a litle below umblicus.
 Length of cord remains static.

6

7. After seperation –
•uterus becomes globular, firm, ballotable.
• Fundal height is raised
•Sudden gush of blood
•Permanent lengthening of cord occurs.
7

8. EXPULSION OF PLACENTA
Placenta lies in lower uterine segment
or upper vagina by contractions and
retractions of uterus. It is further
expelled out by either voluntary
contractions of abdominal muscles or
by manual procedure
8

9. MECHANISM OF CONTROL OF BLEEDING
• Arterioles passing tortuously through the
interlacing intermediate layer of myometrium are
clamped by retraction. This is called ‘living
ligature’ or ‘physiological sutures of uterus’.
• Thrombosis occurs to occlude the torn sinuses
which is facilitated by hypercoagubable state of
pregnancy.
• Myotamponade due to apposition of walls of
uterus also contribute.
9

10. EXAMINATION OF PLACENTA
Placenta is placed on the pronated hands and examined:-
 Maternal surface is first examined for any missing
cotyledons.
 Completeness of membranes should be assessed.
 Placental foetal surface should be inspected for any
blood vessels that radiate beyond placental edge into
membranes with no corresponding placental tissue.
 Position of insertion of cord is noted.
 Cut end of cord is examined for number of vessels.
 Cord length is seen.
 Placental weight is recorded.
 Any calcification, clots.
 In twins, chorionicity can be determined.
10

11. MANAGEMENT OF THIRD STAGE
OF LABOUR
Two methods of management
 Expectant or traditional
 Active
11

12. EXPECTANT
 In this , placental seperation and its descent
into vagina are allowed to occur spontaneously.
 Normally, placenta is expelled within 15-20
miniutes. With the aid of gravity.
 One hand is kept on fundus to
o Recognise signs of seperation of placenta
o To note uterine contraction and relaxations
o To note cupping of fundus
12

13. EXPECTANT MANAGEMENT
Delivery of the baby
clamp, divide ligate cord
wait & watch
•Guard Fundus
•Empty Bladder
Placenta separated
wait for spontaneous expulsion with aid of
gravity
13

14. fails
Assisted Expulsion
Examine placenta &
membranes
Inspection of vulva,
vagina, perineum
uterus should not be massaged
14

15. ASSISTED EXPULSION
I. Controlled cord traction- Also known as modified
Brandt-Andrew’s method
 Palmar surface of fingers of left hand are
placed above the symphysis pubis. Body of
uterus is pushed upwards & backwards
towards umbilicus
 Right hand gives a steady traction in
downward & backward direction until the
placenta comes outside introitus.
 It is done only when uterus is hard &
contracted
15

16. Placenta is grasped
with hand &
twisted round &
round with gentle
extraction so that
membranes are
stripped intact
16

17. II. Fundal Pressure
 Is preferred in case of premature or
macerated baby
 Four fingers are placed behind the fundus
& thumb in front. fundus is pushed
downwards & backwards. Pressure is
applied when uterus becomes hard and
released as soon as placenta passes
through introitus
17

18. ACTIVE MANAGEMENT OF THIRD STAGE
 Preferred method
 Powerful uterine contraction are initiated within 1
minute of delivery of a baby by giving parenteral
oxytocin
 Controlled cord traction is done
 Fundal massage throughthe abdomen until ut is well
contracted
 It favours early seperation of placenta & produces
effective uterine contractions after seperation
18

19. Delivery of Baby
Inj-oxytocin 10 units i/
m within 1 minute
Cord clamped, cut &
ligated
Placenta delivered by
controlled cord traction
fails
wait for 10 minutes, repeat procedure
19

20. fails
manual removal
Examine placenta &
membranes
Inspection of vulva,
vagina, perineum
20

21.  It minimizes blood loss to about 1/5
 Shorten the duration of 3rd stage to about
half
 1-2% increased chances of retained placenta
 If accidentally given during twin delivery,
after birth of 1st twin can cause asphyxia of
second baby
 Maternal pulse and BP should be
monitored immediately after delivery and
every fifteen minutes for the first hour.
21

22. DRUGS USE IN ACTIVE MANAGEMENT
• Oxytocin
• Carboprost (15-Methyl PGF2 alpha)
• Ergot alkaloids (Ergometrine/Methylergometrine)
• Misoprostol
22

23. DRUG DOSE ROUTE DOSE SIDE CONTRAIN
FREQUEN EFFECTS DICATIONS
CY
Oxytocin 10 units IM (10 units) stat •Nausea •Not as IV
•Water bolus,otherwise
intoxication none.
Methergin 0.2mg First line IM/IV Every 2-4 hours •Nausea •Hypertension.
Second line •Vommiting •Pre eclampsia
PO. •hypertinsion
15-Methly 0.25mg First line IM Every 15-90 •Nausea •Bronchial
PGf-2alfa Second line min(8 doses •Vomiting asthma
intra uterine max) •Diarrhoea •Active
•chills cardiac,renal or
hepatic disease
Misoprostol(PG 400-600mcg First line PR Single dose •Fever None
E-1 second line PO •Tachycardia
23

24. COMPLICATION OF THIRD STAGE
OF LABOUR
• PPH
• Retained placenta
• Uterine inversion
• Amniotic fluid embolism
• shock
24

25. RETAINED PLACENTA
• When the placenta is not expelled out even
after 30 minutes of birth of the baby.
• WHO criteria-15 minutes
• Longer intervals are associated with an
increased risk of PPH with rates doubling after
10 minutes
• Affects 1-2% of all deliveries
• In general 90% of placentas deliver within 15
minutes, 96% within 30 minutes and 98%
within 60 minutes
25

26. PREDISPOSING FACTORS
• Retained placenta in previous pregnancy
• Long acting oxytocic agents, such as
ergometrine or synometrine.
• Uterine fibroids
• Uterine anomaly, such as bicornuate uterus.
• Uterine scar-previous caesarean section,
myomectomy curretage placenta accreta
26

27. COMPLICATIONS
o Hemorrhage
o Shock
o Puerperal sepsis
o Risk of recurrence in next pregnancy
around 6%
27

28. IN CASE OF NON ADHERENT PLACENTA, THE
FOLLOWING STEPS ARE TAKEN
 Uterine massage must be performed to expel
the clots.
 Oxytocics are repeated. 10 units of Oxytocics
are given i/v 500 ml in NS. Ergometrine should
be avoided as it may cause tonic uterine
contractions which may further delay
expulsion.
 Bladder should be emptied
 Controlled cord traction should be repeated to
delivery the placenta.
28

29.  If placenta appears to be trapped in lower uterine
segment, a vaginal examination should be done to
remove the placenta.
 Injection of the umbilical vein with 20 ml solution of
0.9% saline with 20 units of oxytocin can be tried.
 Alternatively, Pipingas technique can be used in which
a size 10 nasogastric tube is passed along the umbilical
vein till resistance is felt. The tube is then withdrawn
by 5cm and then the solution is injected. It results in
complete filing of the placental bed resulting in
adequate delivery of oxytocin to retroplacental bed.
29

30.  Intra-umbilical injection of 20 mg of PG F2α in 20
ml saline has also been tried.
 If placenta does not deliver within 30mts by these
techniques, patient should be taken to O.T. for
manual exploration of placenta under GA.
 If a distinct clevage plane can be located between
placenta and uterine wall MROP should be tried.
If not located then morbidly adherent placenta
should be considered.
30

31. MANUAL REMOVAL OF PLACENTA
 A written informed consent
 At least 2 units of blood should be arranged
 It is done under GA
 Patient is placed in lithotomy position and bladder catheterized
 Labia are separated by fingers of one hand and the other hand
is introduced into uterus in a cone shaped manner, following
the cord which is made taut by other hand. Margin of placenta
is located.
 Counter pressure is applied on uterine fundus to steady the
fundus and guide the movements of fingers inside the uterine
cavity.
31

32. Fingers are insinuated
b/w the placenta and
uterine wall with the
back of hand in contact
with the uterine wall.
Placenta is separated
with slicing sideways
movement of fingers till
it is completely
separated.
32

33.  It is extracted by traction of cord by other hand.
 If removal is difficult : ‘piecemeal removal’ of
placenta should be done.
 i/v Methergin 0.2 mg is given
 Inspection of cervico-vaginal canal should be
done. Placenta should be examined
 10 units oxytonic in 500 ml NS is started to
initiate & maintain contraction.
 A broad spectrum antibiotic is given for 12-24
hrs to prevent infection.
33

34. COMPLICATIONS
o Hemorrhage :- due to incomplete removal
o Shock
o Injury to uterus
o Infection
o Inversion
o Sub- involution
o Thrombophlebitis
o Embolism
34

35. DIFFICULTIES ENCOUNTERED
Hour glass contraction- there is a localized
contraction of circular muscles of uterus either
at the junction of lower and upper segment or
may be placed in 1 cornu. It occurs due to
premature attempts in removing of placenta or
due to administration of methergin. It is
managed by deepning the plane of anesthesia.
35

36. •Morbid Adherent Placenta- Also K/A Placenta
Accreta
•Placenta is directly anchored to myometrium
without any intervening decidua.
•due to absence of decidua basalis or imperfect
development of fibrinoid or nitabuch’s layer.
•It is an area of fibrinoid degeneration where
trophoblasts cells meet the decidua. The layer
inhibits further invasion of decidua by
trophoblast .
36

37. TYPES
Placenta accreta:- Placenta
adheres to myometruim (Fig.
A)
Placenta increta:- Placenta
invades myometruim (Fig. B)
Placenta percreta:- placenta
penetrates myomentruim to
or beyond serosa (Fig. C)
Incidence is 1 in 2500 deliveries 37

38. RISK FACTORS
 Placenta previa and prior caesarean delivery
o Risk of placenta accreta with placenta previa in
an unscarred uterus is 3%
o Women with placenta previa with previous 1
caesarean section has 14% risk of accreta.
o Women with 3 caesarean have 44% risk
 Prior myomectomy
 Manual removal of placenta
 D&C
 Increasing maternal age and parity . 38

39. DIAGNOSIS
During pregnancy
USG is only 33% sensitive. The findings suggestive are
 Loss of normal hypoechoic retroplacental myometrial zone.
 Thinning and abruption of uterine serosa:- Bladder interface
and focal exophytic masses within the placenta.
Colour Doppler has a sensitivity of 100%
 A distance less than 1 mm between the uterine serosa-
bladder interface and retro placental vessels
 Identification of large intraplacental lakes 39

40. MRI findings suggestive of accreta are:-
 Uterine bulging
 Heterogeneous signal intensity within the placenta
 Presence of dark intraplacental bands on T2 weighted
imaging.
There is an unexplained rise of MSAFP and B-HCG
greater than 2.5 MOM.
40

41. HISTO PATHOLOGICAL EXAMINATION
 Absence of decidua basalis
 Absence of nitabuch’s fibrinoid layer
 Varying degree of peneteration of the villi
into the muscle bundles or upto serosa.
41

42. MANAGEMENT
1. CONSERVATIVE
IN PARTIAL PLACENTA ACCRETA :-
As much as possible of placental tissue is removed manually.
Oxytocics are given for effective uterine contraction and
haemostasis, or by intrauterine plugging.
 Remaining trophoblast is usually reabsorbed spontaneously.
 Levels of B-HCG should be monitored.
 During caesarean bleeding areas can be undersewed.
42

43. IN TOTAL PLACENTA ACCRETA : -
 After explaining the risks of hemorrhage and
failure
o Cord is cut as near to placenta which is left as such
o Patients vitals and bleeding is monitored
o Antibiotics are given
o B-HCG values are monitored
o Methotrexate 50 mg i/v on alternate days can be given
43

44. SURGICAL MANAGEMENT
If bleeding remains uncontrollable
then:-
 Uterine art embolisation
 Low and high b/l uterine vesseles ligation
 Ligation of internal iliac arteries
If all these methods fail or patient in shock :-
hysterectomy
.
44

45. INVERSION OF UTERUS
 A rare complication of third stage with incidence
being .05% of deliveries
 Uterus is turned inside out either completely or
partially
Acute - With in 24 hrs
subacute - 24 hrs - 4wk
Chronic > 4 wk
Incidence - 1 in 2000 to 1,20,000
Maternal survival rate is 85%
45

46. DEGREE OF INVERSION
I. Dimpling of fundus which still remains
above the level of internal os.
II. Fundus passes through cervix but is
inside vagina
46

47. • Also called
complete:-
Endometrium
with or without
the attached
placenta is visible
outside the vulva.
The cervix and
part of vagina may
also be involved.
47

48. ETIOLOGY
I. SPONTANEOUS – Occurs is about 40%
 caused by local atony on placental site over the
fundus associated with increase in intra abdominal
pressure as in coughing, sneezing or bearing down
effort.
 Fundal attachment of placenta (75%), short cord,
placenta accreta may be associated.
48

49. IATROGENIC
 Fundal pressure on a relaxed uterus
 Strong traction on cord
 Faulty techniques in manual removal of placenta
ASSOCIATED RISK FACTORS ARE
 Uterine over distention
 prolonged labour > 24 hrs
 Uterine malformations
 Short cord
 Collagen diseases
 Use of magnesium sulphate during labour
49

50. DIAGNOSIS
Symptoms :- Acute lower abdominal pain with
bearing down sensation
Signs:-
1. Varying degree of shock
2. On P/A –cupping or dimpling of fundal surface.
On bimanual examination :- Crater like depression on abdomen
along with vaginal palpation of fundal wall in lower segment of
cervix
Sound Test – Confirmatory absent uterine cavity
50

51. In complete
variety, a pear
shaped bluish grey
mass protudes
outside vulva with
the broad end
pointing
downwards
51

52. COMPLICATIONS
• Shock:- is mainly neurogenic
 Tension on nerves due to
stretching of infundibulopelvic
ligament.
 Ovaries are dragged along causing
pressure on then.
 Peritoneal irritation.
52

53. • Hemorrhage –more if placenta is
separated
• Pulmonary embolism
• If not treated - infection, uterine
sloughing can occur. It becomes
chronic
53

54. MANAGEMENT
• Immediate assistance is summoned
• Two large bore intravenous infusion systems are
started, crystalloids, blood should be arranged bladder
is cathertized.
• Urgent manual replacement is the mainstay of
treatment, preferably under GA. Uterine relaxant
anaesthetics such as halothane is preferred. Injection
pethidine/ diazepamis given
• If the placenta is still attached, it should not be
removed
54

55. TWO METHODS OF MANAGING ACUTE
INVERSION
I. MANUAL – called
JOHNSON’S
METHOD.
 The part of
the uterus
which is
inverted last is
to be replaced
first
55

56.  The protruding mass is thoroughly cleaned with
antiseptic solution.
 Protruding fundus is grasped with the palms of
hands with the finger directed towards post fornix.
 Uterus is lifted through pelvis into the abdomen
while applying countersupport over the abdomen.
Too much pressure should not be given so as to
cause perforation of uterus.
 Once the uterus is reverted an oxytocin drip is
started to increase uterine tone and prevent
recurrence. Hand should remain inside uterus till
it is well contracted.
Placenta should then be removed manually
56

57. II. HYDROSTATICS OR O’ SULLIVAN’S METHOD
 Place the patient in lithotomy position
57

58.  Head end is lowered 0.5 mt below the level of perineum
 Prepare a disinfected douche system with large nozzle with a
long tube (2 meters) and 3 - 5 ltr warm NS
 Identity post Fx – easily done in partial inversion & in
others identify the point where rugosed vagina becomes
smooth vagina.
 Place nozzle in post Fx. At the same time with other hand
hold labia sealed.
 Ask assistant to start the douche with full pressure
 Raise reservoir to 2 meters.
 NS distends post Fx gradually so that it is stretched-
circumference of orifice increases- cervical constriction
relived - uterus is repositioned
 Ogueh and Ayida technique:- In this similar procedure is
done by using silicon cup in vagina attached with iv tubing
58

59. SURGICAL INTERVENTIONS
 May be required in presence
of a dense constriction ring.
 Laprotomy is required.
 Initially Huntington's
procedure is done in which
alli’s forceps are used to
grasp the myometrium just
inside dimple of fundus
systematically and
sequentially using forceps on
both sides, inverted fundus
is then withdrawn from
crater to fully correct the
inversion
59

60. IF IT FAILS
HAULTAIN'S OPERATION:- DONE ABDOMINALLY
• Ring of tissue is grasped
by Alli’s joreeps
• A vertical incision is
made in middle at the
post rim.
• A finger is passed
through the incision and
inverted fundus is
pushed up.
• Assistant may also push
up inverted fundus
through vagina 60

61. Kustner’s Operation:- Done
vaginally
• Uterus is drawn upwards and
forwarded with a valsellum
holding at fundus.
• POD is opened by a transverse
incision on the post vaginal wall
• Lt. index finger is introduced
along hollow of inverted uterus.
Post uterine wall is cut through by
a scapel from fundus to ext os.
• Inverted uterus is turned inside
out and inversion is corrected.
• In spinelli’s operation, uteroveseial
pouch is opened and uterine
incision is made on anterior wall.
61

62. AFTER REPOSITIONING
• Discontinue uterine relaxant/GA
• Start infusion of oxytocics
• Bi manual ut. Massage is maintained until ut is
well contracted and bleeding stops.
• Remove placenta if retained.
• Careful manual exploration to rule out trauma to
genital tract.
• Antibiotics
• Oxytocics for 24 hrs
• Monitor for reinversion
62

63. AMNIOTIC FLUID EMBOLISM
• Complex disorder characterized by abrupt
oneset of hypotension, hypoxia and
consumptive coagulopathy.
• Risk factor include advanced maternal age,
placenta previa, pre eclampsia, forceps or
caesarean delivery.
• Women in late stages of labour or immediately
post partum begin gasping for air, suffers
seizures or cardiorespiratory arrest occurs
63

64. MECHANISM
Amniotic fluid is forced into circulation either through a
rent in membranes or placenta. Thromboplastin rich
liquor containing the debris blocks pulmonary arteries
and triggers coagulation mechanism leading to DIC.
There is massive fibrin deposition along the entire
pulmonary vasculature leading to cardiopulmonary
arrest.
If patient survives this there can be residual neurological
damage severe bleeding per vaginun or from veno-
puncture sites.
64

65. MANAGEMENT
• There are no data that any type of intervention
improves maternal prognosis with amniotic
fluid embolism.
• Oxygenation, circulatory support blood
transfusion is required.
• Case fatality rate is 22%
65

66. THANK YOU
66