complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism

1. COMPLICATIONS OF
THIRD STAGE OF LABOUR

2. 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

3. 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

4.  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

5. 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,surgical
trauma
 Thrombin: Congenital-Von Willebrand’s disease
 Acquired-DIC,dilutional coagulopathy

6. Uterine atony(80%)
 High parity
 Overdistended uterus
 General anesthesia
 Poorly perfused myometrium
 Prolonged labour

7.  Following augmented labour
 Uterine atony in previous labour
 Chorioamnionitis
 Malformation of uterus
 Uterine fibroid
 Very rapid labour
 Mismanaged third stage of labour

8.  Constriction ring:
 Incomplete separation of placenta
 Retained placenta
 Abnormally adherent
 Avulsed cotyledon, succenturiate lobe
 Placenta previa
 Placental abruption
 A full bladder

9.  Traumatic( 20%):
 Combination of atonic and traumatic causes
 Blood coagulation disorders, acquired or congenital:

10. Other risk factors are;
 Antepartum hemorrhage
 History of PPH or retained placenta
 Anaemia
 Ketoacidosis
 HIV/AIDS

11. 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

12. 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.

13. 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

14. 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 Unfractionated
Heparin (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.

15.  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.

16.  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

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

18. 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.

19. 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.

20. Manual Removal of Placenta
 Step 1
 Step 2
 Step 3
 Step 4
 Step 5
 Step 6
 Step 7

21. Difficulties:
 Hour – glass contraction
 Morbid adherent placenta

22.  Complications :
 Haemorrhage due to incomplete removal
 Shock
 injury to the uterus (rare)
 infection
 inversion
 Subinvolution
 Thrombophlebitis
 Embolism.

23. 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.

24. 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.

25. 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

26.  Step 3: Uterine massage and bimanual compression.
 Step 4: Uterine tamponade
 Step 5: Surgical methods
 Step 6: hystrectomy

27. 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

28. 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

29. 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.

30. 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.

31. 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.

32. 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.If
bleed is from sloughing of wound of cervico- vaginal
canal, control it by suturing.

33. Complications
 Shock
 Collapse
 Disseminated intravascular coagulation

34. 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

35.  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.

36. RETAINED PLACENTA
 placenta is said to retained when it is not expelled out
even 30 minutes after the birth of the baby.

37. 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

38. 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.

39. 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

40. Retained placenta:
 Separated
 Un-separated
 Complicated
Placenta is separated and retained:
 To express the placenta out by controlled cord
traction.

41. 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

42. 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.

43. PLACENTA ACCRETA
 It is defined as an extreme rare form in which the
placenta is directly anchored to the myometrium
partially 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.

44. PLACENTA INCRETA
 placenta increta, villi actually invade into the
myometrium and anchored into the muscle bundles.

45. PLACENTA PERCRETA
 with placenta percreta, villi penetrate through the
myometrium upto the serosal layer.

47. Associated Conditions
 placenta previa,
 prior cesarean delivery,
 previously undergone curettage
 gravida 6 or more.
 MSAFP levels exceeded 2.5 MoM;

48. 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 myometrial
invasion: (1) a distance less than 1 mm between the
uterine serosa-bladder interface and the retroplacental
vessels, and (2) identification of large intraplacental
lakes

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

50. 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

51. 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.

52. 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.

53.  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.

54. Complications:
 Haemorrhage
 Shock
 Infection
 Inversion of uterus

55. 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.

56. 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.

58. Etiology:
 Spontaneous: 40%
 Iatrogenic:

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.
 Puling the cord simultaneously with fundal pressure
should be avoided.
 Manual removal in a safe manner

61. 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.

62.  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

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

64. 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.

65. 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.

66. 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- Haultain
operation

67. Complications:
 Shock
 Tension on the nerves due to stretching of the infundibulo-
pelvic ligament.
 Pressure on the ovaries as they dragged with the fundus
through cervical ring.
 Peritoneal irritation
 Haemorrhage, specially after detachment of placenta
 Pulmonary embolism
If left uncared it leads to:
 Infection
 Uterine sloughing
 A chronic one

68. AMNIOTIC FLUID EMBOLISM