Complications in Third and Fourth Stage of Labor

Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

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Complications in Third and Fourth Stage of Labor

Post Partum HemorrhagePlacenta AdherentUterine Inversion

Shock


Post Partum HemorrhageÄ is a maternal blood loss from the

genital tract at any time following the baby’s birth up to 6 weeks after delivery.

2 TypesPrimary PPH if it occurs during the 3rd stage of

labor or within 24hrs of deliverySecondary PPH if bleeding occurs after 24hrs

following birth up to 6 weeks postpartum


Main Causes of PPH

• Uterine Atony (Atonic Uterus)• Lacerations (Trauma)• Retained Placenta• Blood Coagulation Disorder


Uterine AtonyÄ A failure of the

myometrium to contract and retract to compress torn blood vessels and control blood loss.

Normal postpartum condition with

contracted uterus preventing

hemorrhage.


Causes of atonic uterine action1. Incomplete placental separation2. Retained cotyledon, placental fragment or membranes3. Precipitate labor4. Prolonged labor5. Polyhydramnios or multiple pregnancy6. Placenta previa7. Placenta abruption8. General anesthesia (e.g.: halothane, cylopropane)9. Mismanagement of third stage of labor10. A full bladder


Predisposing Factors

1. Previous history of PPH or retained placenta

2. High parity3. Presence of fibrosis4. Maternal anemia5. Ketoacidosis


Signs and Symptoms

• Visible bleeding > 500 mL• Pallor• Rising pulse rate• Falling BP• Maternal collapse • Altered LOC (restless or drowsy)• Boggy uterus (soft, distending and lacking tone)

– may be little of no visible blood loss


Prophylaxis• Screening – thorough and accurate health

history• Delivery arrangements must be explained

carefully• Early detection and treatment of anemia (Hgb >

10 g/dl)• Good management during the first and second

stage of labor to prevent prolonged labor and ketoacidosis

• Prophylactic administration of oxytocic agent• Prepare 2 units of cross-matched blood for

placenta previa


Treatment of PPH3 Basic Principles (CSR)

1. Call a doctorF So that help in on the way whatever happens; pt’s condition can deteriorate

very rapidly which urgently requires physician’s assistance.2. Stop the bleeding

• Fundal massageF To increase uterine contraction and tone.

• Administer oxytocic agent (Methergine, Oxytocin, Carboprost thromethamine)F To stimulates contraction of uterine smooth muscles.F Caution: Ergometrine should NOT be given more

than 2 doses as it may cause pulmonary hypertension.• Empty the uterus

F To ensure constriction of the uterine blood vessels.3. Resuscitate the mother

F Competent action will be crucial in reducing the risk of maternal morbidity or even death.


Resuscitating the mother1. Initiate IV infusion while peripheral veins are easily negotiated. To

provide a route for oxytocic agents or fluid replacement.2. Lift the legs to allow blood to drain from into the central circulation.3. The foot of the bed should NOT be raised as this encourages

pooling of blood in the uterus, which prevents contraction.4. Offer bedpan or insert catheter. Full bladder may interfere with

uterine contraction and to minimize trauma during operative procedure.

5. Do not move a collapsed woman prior to resuscitation.6. Withdraw 10mL of blood for hemoglobin estimation and for cross-

matching compatible blood. In preparation for blood loss replacement. If bleeding is uncontrolled, further action is required.

7. Infuse oxytocic agent 40 units in 1L of dextrose/saline to run over 8-12hrs, will ensure continued uterine contraction.


Nursing Diagnoses• Fluid volume deficit r/t decrease in blood

volume/loss of ECF.• Altered tissue perfusion r/t reduction in tissue

oxygenation and rapidity of blood loss.• Anxiety r/t feelings of uncertainty and

apprehension.• Risk for infection r/t retention of placental

tissue and excessive blood loss.• Knowledge deficit r/t the cause of the

excessive bleeding.


Treatment

• Bimanual compression of the uterus and D&C to remove clots.

• Repair of lacerations • IV replacement of fluids and blood• If bleeding persist, uterine rupture must

be suspected• Hysterectomy


Nursing Interventions• Monitor v/s to assess for complications. Continue to monitor

24-48hrs.• Inspect the placenta and membranes for completeness

since retained fragments are often responsible for uterine atony.

• Massage the fundus, and express clots from the uterus.• Perform a pad count to assess the amount of vaginal

bleeding.• Monitor lochia, including amount, color, and odor to assess

for infection.• Monitor fundus for location to assess for uterine

displacement.• Provide emotional support to help alleviate fear and anxiety.• Provide quiet period, private room, restricted to visitors to

promote recovery.• If bleeding at home, lie down flat until help arrives.


Placenta AdherentÄ A condition where the placenta remains

attached to the uterus for an abnormally long time following birth.

2 Types1. Partially adherent. The uterus is well contracted. Deliver

the placenta by applying controlled cord traction or manually if unsuccessful.

2. Complete adherent. Does not usually bleed however, the longer the placenta remains in situ the greater the risk of partial separation, which may cause profuse hemorrhage.


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Management

• Bimanual compression of the uterus

• Manual removal of the placenta


Uterine Inversion

Ä A rare complication of vaginal delivery in which the uterus partially or completely turns inside out.


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Classifications• According to severity

1. First degree – fundus reaches the internal os.

2. Second degree – uterus body is inverted to internal os.

3. Third degree – uterus, cervix and vagina are inverted and are visible.

• According to timing of the prolapse

1. Acute – prolapse occur within 24 hours of delivery.

2. Subacute – over 24hrs up to 30th postpartum day.

3. Chronic – more than 30 days after delivery.


CausesAssociated with uterine atony and cervical dilation:

• Mismanagement in the 3rd stage of labor• Combining fundal pressure and cord traction to deliver

the placenta• Use of fundal pressure while the uterus is atonic• Pathologically adherent placenta• Primiparity• Fetal macrosomia (abnormally large size of body)• Short umbilical cord• Sudden emptying or distended uterus


Interventions1. Call the physician including appropriate medical support.2. STAT attempt to replace to the uterus by pushing with the palm

along the direction of the vagina.


Interventions

3. Initiate IV access and fluid replacement.4. If placenta is still attached, it SHOULD

be left in situ as attempts to remove it at this stage may result in uncontrollable hemorrhage.

5. Once the uterus is repositioned, the nurse/midwife should keep the hand in situ until firm contraction.

6. Administer oxytocic agents.


Medical Management

If manual replacement fails• Hydrostatic method of replacement – instillation

of warm saline infused into the vagina• Medications to relax the constriction and

facilitate the return.• Throughout the events, the mother and partner

should be kept informed of what is happening.• V/S including LOC is of utmost importance.


ShockÄ A complex syndrome involving a reduction in blood

flow to the tissues with resulting dysfunction of organs and cells.

3 Types1. Hypovolemic – the result of a reduction in intravascular

volume2. Cardiogenic – impaired ability of the heart to pump

blood3. Distributive – an abnormality in the vascular system

that produces a maldistribution of the circulatory system (septic and anaphylactic shock)


Hypovolemic Shock Loss of circulating fluid volume or blood

↓Decrease venous return to the heart

↓Ventricles of the are inadequately filled

↓Reduction in stroke volume and cardiac output

↓Decrease blood pressure

↓Decrease oxygen supply to the tissues

↓Altered cell function


Hypovolemic Shock Decrease blood pressure

↓SNS activation (receptors at aorta and carotid arteries)

↓Adrenaline is released from the medulla and aldosterone from the adrenal cortex

↓Vasoconstriction and ↑ cardiac output

↓↑ venous return to the heart


Hypovolemic Shock Compensatory mechanism fails

↓Inadequate perfusion to vital organs

↓Further fall in BP and cardiac output

↓Insufficient supply to coronary arteries

↓Poor peripheral circulation

↓Multisystem failure and irreparable cell damage

↓Death


Effects of Shock on Vital Organs

• Brain. ↓cerebral flow = LOC deteriorates, increasingly unresponsive, ↓ pain response

• Lungs. ↑ dead spaces, ischemia alters surfactant production, edema, failure.

• Kidneys. Ischemia, ↓ urine output • GI tract. Ischemia • Liver. Altered metabolism of drug and

hormone


Management of Shock1. Maintain the airway. Turned unto side

and administer 40% oxygen at 4-6 LPM.2. Replace fluids. Plasma expander or

fresh frozen plasma of pt’s blood cross-matched.

3. Avoid warmth. Constriction of the peripheral blood supply occurs in response to the shock and keeping the mother warm may interfere with this response, causing further deterioration in condition.


Clinical Observations1. Assessment of LOC.2. Continuous monitoring of blood pressure (q 30mins)

note any drop.3. Cardiac rhythm may be monitored continuously.4. Measurement of UO hourly, using indwelling catheter.5. Assessment of skin color, core and peripheral

temperature hourly.6. Hemodynamic measure of pressure in right atrium.

Fluid balance is maintained accurately.7. Observation of the occurrence of further bleeding,

including oozing from wound or puncture site.


Central Venous Pressure

• The pressure in the right atrium or superior vena cava. It is an indicator of the volume of blood returning to the heart and reflects the competence of the heart as a pump and the peripheral vascular resistance.

• Normal: 5 – 10 cmH2O• Below 5 cmH20 = shock


Method of Measuring CVP• Pt should be lying flat• Base of manometer calibrated in 0 cmH20

aligned with the level of the right atrium.• 3-way tap is opened and filled with IV fluid. The

fluid will fall and rise with respiratory effort and should be allowed to stabilize before reading.

• The highest level the fluid reaches is used for the CVP measurement.

• Once completed, fluid is returned to the infusion position.


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Principles of Care of CVP1. Prevention of infection. Strict asepsis, regular

inspection for signs of infection and precautions to prevent contamination during clinical procedures.

2. Maintaining a closed system. Caution catheters should not be disconnected as it may cause profuse bleeding or possible air embolus.

3. Maintaining patency of the catheter by preventing clot formation.


Septic Shock

• A form of distributive shock where an overwhelming infection develops commonly from gram negative organisms (E. coli, Proteus, or Pseudomonas pyocyaneus).


Septic Shock Overwhelming infection

↓Damaged cells release histamine and enzymes

↓Vasodilation and increased permeability of the

capillaries↓

Reduced systemic vascular resistance↓

Vasodilation and hypotension continue


Management of Septic Shock

Goal: preventing further deterioration by restoring circulatory volume and eradication of the infection.

• Identify the source of infection and protect reinfection.

• Antibiotic treatment after blood cultures.• UTZ to detect retained products of conception.• Keep informed of progress.

Documents

Complications in Third and Fourth Stage of Labor