Abnormal Third Stage of Labour

8/10/2019 Abnormal Third Stage of Labour

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POSTPARTUM HEMORRHAGE

Definitions:

Primary postpartum hemorrhage:

Blood loss at delivery within 24 hours

exceeding:

Vaginal delivery: > 500 ml ( 500 ml isconsidered

physiological)

Cesarean delivery: > 1000 ml ( 1000 ml is

considered

physiological).


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Secondary postpartum

hemorrhage:

Excessive blood loss > 24 hours

and < 12 weeks postpartum


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Etiology:

Lack of efficient uterine contraction (uterine atony)

commonest cause of primary PPH.

Retained parts of the placenta.

Vaginal or cervical lacerations. Uterine rupture rare.

Clotting disorders, uterine inversion, or rupture

extremely rare.

Risk


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Risk factors:

Risk factors for primary PPH include first pregnancy,maternal obesity, a large baby, twin pregnancy, prolonged

or

augmented labor, and antepartum hemorrhage. High

multiparitydoes not appear to be a strong risk factor, either in

high- or low-income countries, even after controlling for

maternal age. Despite the identification of risk factors,

primary

PPH often occurs unpredictably in low-risk women.


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Complications:

Hypovolemic shock, disseminated

intravascular coagulation

(DIC), renal failure, hepatic failure,adult respiratory

distress syndrome, and death.


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Management

:Primary postpartum hemorrhage

Obtain help (multidisciplinary approach).

Vigorous uterine massage until firm.

Identify and repair any vaginal and cervical lacerations.

Place initial suture above the apex. Ensure adequateexposure; if necessary, transfer patient to surgical suite.

Manually explore the uterus; ensure adequate intravenous

(IV) access.

Laboratory tests: complete blood count with plateletconcentration,

blood type, antibody screen, fibrinogen, fibrin split

products, prothrombin time, and partial prothrombin time.


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Administer uterotonic drugs :

1. Oxytocin 2080 IU in 1000 ml of normal saline

(NS),fast IV drip, and/or

2. Misoprostol 8001000 g rectally

3. Methergine 0.2 mg intramuscular (IM) (if

evidence ofhypertension do not administer) every 24 hours,

and/or

4. Carboprost tromethamine (Hemabate;

prostaglandinF2 *PGF2+) 0.25 mg IM every 1590 minutes.

Maximum dose is 2 mg (do not administer if asthma


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Rectal misoprostol is a useful first-line drug for

the treatmentof PPH. Compared with a combination of IM

syntometrine

injection and oxytocin infusion, rectal

misoprostol 800 g is associated with astatistically significant

reduction in the number of women who

continued to

bleed after the intervention and those who

required medical

co-interventions to control the bleeding.


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During the administration of

uterotonic agents, bimanualcompressionmay control

hemorrhage. The physician

places his or her fist in the

vagina and presses on theanterior surface of the uterus

while an abdominal hand

placed above the fundus

presses on the posterior wall.

Thiswhile the Blood for

transfusion made available.


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suture bleeding sites.

uterine artery ligation.

B-Lynch stitch for uterine compression.

Hysterectomy.


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B-Lynch compressive sutures


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Uterine Artery Ligation


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RETAINED PLACENTA

Definition:

The placenta is undelivered at > 30 minutes

after deliverydespite active management of the third

stage.


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Etiology: Preterm birth: incidence is inversely

proportional to gestational

age.

Cord avulsion: incidence is 3% with controlled

cord traction. Placenta accreta.


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Complications:Hemorrhage

infection,

genital tract trauma


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Management: Provide adequate anesthesia.

Attempt manual extraction.

Once placental margin is identified, gently peel the

placenta from the uterine wall and remove it.May

considerultrasound to ascertain if placental removal is

complete.

Palpate and massage the fundus until firm.

injection of oxytocin (10 or 20 IU in 1 or2 ml) in NS (1819 ml) is effective in the management of

retained placenta at 2030 minutes by decreasing the

need for manual placental removal compared with NS

alone or expectant management.


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Removal of Abnormal

Placenta


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UTERINE INVERSION

:Definition

Collapse of the uterine fundusinto the endometrial cavity.


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Risks:Excess cord traction.

fundal pressure.

fundal cord insertions.

abnormal placentations.


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Summon anesthesia and nursing staff.

Provide large-bore access and IV fluid therapy.

Withhold uterotonic agents.

To decrease bleeding, avoid separating theplacenta.

Consider pharmacological uterine relaxation:

magnesium sulfate IV bolus

terbutaline IV 0.25 mg subcutaneously 1 nitroglycerin 50500 g orally or by anesthesia

Management


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Manual manipulation of the uterus

Rare surgical intervention (laparotomy) if cannot

correctby vaginal manipulation alone:

Huntington procedure clamps are placed on

the round ligaments 2 cm deep in the inversion andgentle

upward traction applied. Repeat clamping as

necessary.

Haultain procedure an incision is made in the

posterior

portion of the inversion ring to increase its size

and to reposition the uterus.


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Uterotonic agents when uterus repositioned:

Oxytocin 2040 IU/L NS IV, Methergine 0.2 mgIM

every 6 hours as needed, or Hemabate 0.25 mg

IMrepeated every 2560 minutes as needed.

Treat PPH or retained placenta as mentioned

above.


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Abnormal Third Stage of Labour