COMPLICATIONS OF THIRD STAGE OF LABOUR

POSTPARTUM HEMORRHAGE

Any amount of bleeding from and into the genital tractfollowing the birth of the baby up to the end of thepueperium which adversely affects the generalcondition of the patient evidenced by rise in pulse rateand falling BP is called post partum haemorrhage

Types:

Primary

Third stage hemorrhage - Bleeding occurs before expulsion of placenta.

True PPH - Bleeding occurs subsequent to expulsion of placenta (majority).

Secondary PPH/ delayed/late

Calculation of maternal blood volume

Non pregnancy TBV=

[Ht(Inches)x50]+[Wt(pounds)x25]

2

Pregnancy TBV=add 50% to non pregnancy

In serious PPH, acute return of pregnancy TBV to non

pregnancy TBV

Primary post partum

haemorrhage

Causes

4 T’s

Tone –Uterine atony

Tissue-Products of conception, Placenta

Trauma: Planned-Cesarean section,episiotomy

Unplannned-Vaginal/cervicxal tear,surgicaltrauma

Thrombin: Congenital-Von Willebrand’s disease

Acquired-DIC,dilutional coagulopathy

Uterine atony(80%)

High parity

Overdistended uterus

General anesthesia

Poorly perfused myometrium

Prolonged labour

Following augmented labour

Uterine atony in previous labour

Chorioamnionitis

Malformation of uterus

Uterine fibroid

Very rapid labour

Mismanaged third stage of labour

Constriction ring:

Incomplete separation of placenta

Retained placenta

Abnormally adherent

Avulsed cotyledon, succenturiate lobe

Placenta previa

Placental abruption

A full bladder

Traumatic( 20%):

Combination of atonic and traumatic causes

Blood coagulation disorders, acquired or congenital:

Other risk factors are;

Antepartum hemorrhage

History of PPH or retained placenta

Anaemia

Ketoacidosis

HIV/AIDS

Clinical Features

May be obvious such as,

Visible bleeding

Maternal collapse

Subtle signs as,

Pallor

Rising pulse rate

Falling BP

Altered level of consciousness

May restless/drowsy

Enlarged uterus, boggy on palpation

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 relaxed.

Investigations

Thorough examination of the lower genital tract.

CBC, clotting screen, cross match, Coagulation studies

Hourly urine output

Continuous pulse/blood pressure or central venous pressure monitoring

ECG, pulse oximetry

Prevention

Antenatal Improvement in health status, keep Hb level >10gm/dl.

Screen high risk clients.

Blood grouping

Women considered at high risk of thromboembolism may be receiving prophylaxis in the form of UnfractionatedHeparin (UH) or Low Molecular Weight Heparin (LMWH) antenatally.

Women with a lower level of increased risk of thromboembolism may be receiving aspirin (75mg daily) antenatally and may begin intrapartum prophylaxis with the above agents.

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.

Following delivery, administering a uterotonic

Avoiding pulling the cord, avoid fiddling and kneading the uterus, avoid Crede’s expression

Examine placenta and membranes for intactness.

Continue oxytocin for atleast 1 hr after

Check for genital tract trauma.

Observe the patient for about 2hrs after the delivery

Immediate care in PPH

COMMUNICATE.

RESUSCITATE.

MONITOR / INVESTIGATE.

STOP THE BLEEDING.

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.

Placental site bleeding

Palpate the fundus and massage the uterus to make it hard.

Ergometrine 0.25mg or methergine 0.2mg is given intravenously.

Start a dextrose saline drip and arrange for blood transfusion, if necessary.

Catheterise the bladder, if it is found to be full.

Sedation may be given with morphine 15mg intramuscularly.

Manual Removal of Placenta

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Difficulties:

Hour – glass contraction

Morbid adherent placenta

Complications :

Haemorrhage due to incomplete removal

Shock

injury to the uterus (rare)

infection

inversion

Subinvolution

Thrombophlebitis

Embolism.

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.

Management

Immediate measures:

Call for help.

Head down tilt

Oxygen by mask, 8 litres / min

Put in two large bore,14 gauge, cannula.

Send blood for grouping and cross matching and ask for 2 units of blood.

Infuse rapidly 2 litres of NS (crystalloids) or plasma substitutes

Use a warming device and a pressure cuff.

Monitor BP and pulse every 25min, tem. every 4 hr.

Monitor type and amount of fluids the patient has received, urine output, drugs- type, dose and time, CVP.

Actual Management:

note the feel of the uterus.

Atonic uterus

Step 1: Massage the uterus to make it hard.

Step 2: Explore the uterus under GA

Step 3: Uterine massage and bimanual compression.

Step 4: Uterine tamponade

Step 5: Surgical methods

Step 6: hystrectomy

surgery

Ligation of uterine arteries

Ligation of the ovarian and uterine artery anostomasis.

Ligation of the anterior division of internal iliac artery (unilateral or bilateral).

B- Lynch brace suture and haemostatic suturing

Angiographic arterial embolisation under fluoroscopy

Secondary PPH Causes:

The causes are,

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.

Other rare causes are—chorion epithelioma; carcinoma of cervix, infected fibroid or fibroid polyp and puerperal

Diagnosis:

The bleeding site is usually bright red. Varying degree of anaemia and evidences of sepsis are present. Internal examination reveals evidences of sepsis, subinvolution and often a patulous cervical os. USG helps in detecting retained bits of placenta inside the uterine cavity.

Managenent:

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.

Supportive therapy:

Blood transfusion, if necessary; Inj Ergometrine 0.5mg IM, if the bleeding is uterine in origin, antibiotics as routine.

Conservative:

If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24hrs or so is done in hospital.

Active treatment:

As the commonest cause is due to retained bits of placenta or membranes, it is preferable to explore the uterus urgently under GA. The products are removed by ovum forceps. Gentle curettage is done by using flushing curette. Ergometrine 0.5mg is given IM.Ifbleed is from sloughing of wound of cervico- vaginal canal, control it by suturing.

Complications

Shock

Collapse

Disseminated intravascular coagulation

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

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.

RETAINED PLACENTA placenta is said to retained when it is not expelled out

even 30 minutes after the birth of the baby.

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

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.

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

Retained placenta:

Separated

Un-separated

Complicated

Placenta is separated and retained:

To express the placenta out by controlled cord traction.

Unseparated retained placenta:

Manual removal of placenta is to be done under GA.

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

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.

PLACENTA ACCRETA It is defined as an extreme rare form in which the

placenta is directly anchored to the myometriumpartially 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.

PLACENTA INCRETA placenta increta, villi actually invade into the

myometrium and anchored into the muscle bundles.

PLACENTA PERCRETA with placenta percreta, villi penetrate through the

myometrium upto the serosal layer.

Associated Conditions

placenta previa,

prior cesarean delivery,

previously undergone curettage

gravida 6 or more.

MSAFP levels exceeded 2.5 MoM;

Diagnosis

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 myometrialinvasion: (1) a distance less than 1 mm between the uterine serosa-bladder interface and the retroplacentalvessels, and (2) identification of large intraplacentallakes

MRI:

(1) uterine bulging, (2) heterogeneous signal intensity within the placenta, and (3) presence of dark intraplacental bands on T2-weighted imaging.

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

Management

In the focal placenta accrete

Remove the placental tissue as much as possible. Effective uterine contraction and hemostasis 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 multiparous 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.

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

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.

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.

Etiology:

Spontaneous: 40%

Iatrogenic:

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

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

Management

Immediate assistance is summoned to include anesthesia 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 anesthetic such as a halogenated inhalation agent has been administered.

Other tocolytic drugs such as terbutaline, ritodrine, magnesium sulfate, and nitroglycerin 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

Surgical Intervention

the uterus cannot be reinverted by vaginal manipulation because of a dense constriction ring . In this case, laparotomy is imperative

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.

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) under GA. Hydrostatic method is less shock producing.

Subacute 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- Haultainoperation

Complications:

Shock

Tension on the nerves due to stretching of the infundibulo-pelvic ligament.

Pressure on the ovaries as they dragged with the fundusthrough cervical ring.

Peritoneal irritation

Haemorrhage, specially after detachment of placenta

Pulmonary embolism

If left uncared it leads to:

Infection

Uterine sloughing

A chronic one

AMNIOTIC FLUID EMBOLISM