4. Placental Separation
• Duncan
– As the placenta
separates, blood from
the implantation site
may escape into the
vagina immediately
• Schultze
– As the placenta
separates, blood from
the implantation site
is concealed behind
the placenta and
membranes and will
egress as the
placenta is delivered
5. Manual Extraction of Placenta
IVF with 20 unit oxytocin at 10mL/min or 200mU of per minute
30. Degree of Laceration
• First degree
– fourchette, perineal skin of vaginal mucosa
• Second degree
– fascia and muscle of the perineal body but not
the anal sphincter
• Third degree
– vaginal mucosa, perineal skin, fascia up to the
anal sphincter but not the rectal mucosa
• Fourth degree
– encompasses extension up the rectal mucosa
31. Genital Tract Lacerations
• Vaginal Lacerations (colphorexxis)
– middle or upper third of the vagina +
perineum/cervix
– forceps, vacuum or spontaneous vaginal
delivery
– bright red bleeding with contracted uterus
without retained placental fragments
32. Injuries to Levator Ani Muscles
• Overdistension of birth canal
• Injury to pubococcygeus
– urinary incontinence
33. Injuries to the Cervix
• <0.5cm
• >2cm - repair
• rotation by forceps, forceps delvery, and delivery
with incomplete cervical dilatation
• Annular or Circular Detachment of the Cervix
– entire vaginal portion is avulsed
• Diagnosis
– visualization
• Management
– surgical repair with interrupted or continuous absorbable
sutures
37. Vulvo-vaginal Hematoma
Superficial
•
•
•
•
Unilateral swelling
Overlying edema
Ecchymosis
Treatment
– evacuation with ligation of
vessels
– elimination of dead space
by suturing in layers
– vaginal packing
Retroperitoneal
• Less obvious
• More difficult to diagnose
– UTZ, IV pyelography, CT
scan
• Treatment
– exploratory laparotomy
• identify bleeders
• ligation of vessels
38. Placenta Previa
•
Total
– Internal os completely covered by
placenta
•
Partial
– Internal os partially covered by
placenta
•
Marginal
– Edge of placenta is at the margin
of internal os
•
Low lying
– Placenta is implanted in the lower
uterine segment such that the
placental edge does not reach the
internal os but in close proximity
•
Vasa Previa
– Fetal vessels courses throgh
membranes and presents at the
cervical os
40. Placental Migration
• Placenta has no actual circumferential
villi invasion that reached the internal
cervical os.
• Repeat scanning at 32 weeks or so
showed no previa
41. Placenta Previa
• Management
– fetus is preterm and no other indication for
delivery
• tocolysis & control of bleeding (close observation)
– fetusCESAREANmature
is reasonably DELIVERY is
necessary in practically all women
• stabilize mother then deliver
– labor withensued
has PLACENTA PREVIA.
• delivery
– hemorrhage is severe regardless of gestational
age
• delivery
42. Placental Abruption
- Effusion of blood behind the placenta but the
• Premature remains adherent
placental marginsseparation of the normally
implanted placenta
- Placenta is completely separated yet the
membranes retained their attachment to the uterine
wall
- Blood gains access to the amniotic fluid after
breaking through membranes
- Fetal head is closely applied to the lower uterine
segment that blood cannot make its way
43. Placental Abrubtion
• Cause
– Unknown
• Risk Factors
–
–
–
–
–
–
–
–
–
–
–
–
Increase Age and Parity
Bleeding is almost always
Preeclampsia
MATERNAL.
Chronic Hypertension
PROM (infection)
Multifetal Gestation
Low Birthweight
Hydramnios
Cigarette Smoking
Thrombophilia
Coccaine Use
Prior Abruption
Uterine Leiomyoma
Ethnicity (African-American and Caucasian)
44. Placental Abruption
• No clinical symptoms
– circumscribed
depression on the
maternal surface
– few centimeters in
diameter
– dark, clotted blood
– normal looking placenta
if recent abruption
– age of retroplacental clot
cannot be determined
exactly
45. Placental Abruption
• Signs and symptoms vary
– profuse external bleeding
– no bleeding + dead fetus
– bloody amniotic fluid
• Amniotomy: diminished AF volume allow spiral artery
compression thus reduce entry of thromboplastin and
decrease bleeding
– uterine tenderness, back pain + fetal distress
– tachysystole
– painful uterine bleeding
47. Placental Abruption
• Clinical evident placental abruption is
CONTRAINDICATED to tocolysis
• Dead fetus can be delivered vaginally EXCEPT if
with massive bleeding or other complications
48. Placental Adherence
• Placenta Accreta
– placental implantation in which there is
abnormally firm adherence to the uterine
wall as a result of partial or total absence
of the decidua basalis and imperfect
development of Nitabuch layer
– Placental villa ATTACHED to the
myometrium
•
•
•
TOTAL – all lobules
PARTIAL – few or several lobules
FOCAL – single lobule
49. Placenta Accreta
• Placenta Accreta
– Placental villus
attached/adheres in the
myometrium
• Placenta Increta
– Placental villus invades the
myometrium
• Placenta Percreta
– Placental villus penetrates
the myometrium and
serosa
50. Placenta Accreta
• “double set up”
• sonographic placental localization
– simplest, safest and most accurate
•
•
•
•
transabdominal utz
transvaginal utz
transperineal utz
MRI
– MSAFP >2.5MoM
51. Placenta Accreta
• UTZ + Doppler
– distance <1mm between
uterine serosa & bladder
interface & retroplacental
vessels
– large intraplacental lakes
• MRI
– uterine bulging
– heterogenous signal
intensity within placenta
– dark intraplacental bands
on t2 weighted imaging
52. Placenta Accreta
• Risk factors
–
–
–
–
–
–
–
–
Age
High parity
Placenta previa
Previous CS
History of curettage
Prior manual extraction
Prior retained placenta
Infection
53. Placenta Accreta
• Management
– Preoperative Arterial Catheter Placement
• balloon tipped catheters placed into internal
iliac arteries prior to surgery
• inflated after delivery of fetus
• hysterectomy
• embolization
– Cesarean Section
• placenta left in situ
• Methotrexate
– infection, necrosis, bleeding hysterectomy
54. Retained Placental Fragments
• examine placenta routinely after
delivery
• uterine exploration
–
recognize and remove retained
cotyledon or succenturiate lobe
55. Uterine Inversion
• Turning inside out of
the uterus during or
after delivery of the
placenta
• Consequence of
strong traction on the
umbilical cord
attached to a placenta
implanted in the
fundus
56. Uterine Inversion
•
•
Life threatening
Consequence of mismanagement of 3rd stage of
labor
– Excessive traction on the cord and fundal pressure (Crede’s
maneuver)
– Relaxed uterus
– Adherent placenta
– Short cord
– Congenital predisposition
– Increase intraabdominal pressure
– Manual removal of placenta
– General anesthesia
60. Uterine Inversion
• If cannot reinvert
uterus vaginally
LAPAROTOMY
– due to the dense
constriction ring
– fundus is pushed
upward from below
– fundus is pulled from
above using a deep
traction suture
– oxytocin infusion
62. Uterine Rupture
• Uterine Injury or Anomaly Sustained before Current
Pregnancy
–
Surgery involving the myometrium:
•
•
•
•
•
–
Cesarean delivery or hysterotomy
Previously repaired uterine rupture
Myomectomy incision through or to the endometrium
Deep cornual resection of interstitial oviduct
Metroplasty
Coincidental uterine trauma:
• Abortion with instrumentation—curette, sounds
• Sharp or blunt trauma—accidents, bullets, knives
• Silent rupture in previous pregnancy
–
Congenital anomaly:
• Pregnancy in undeveloped uterine horn
63. Uterine Rupture
• Uterine Injury or Abnormality During Current Pregnancy
–
Before delivery:
•
•
•
•
•
•
•
–
During delivery:
•
•
•
•
•
•
•
–
Persistent, intense, spontaneous contractions
Labor stimulation—oxytocin or prostaglandins
Intra-amnionic instillation—saline or prostaglandins
Perforation by internal uterine pressure catheter
External trauma—sharp or blunt
External version
Uterine overdistension—hydramnios, multifetal pregnancy
Internal version
Difficult forceps delivery
Rapid tumultuous labor and delivery
Breech extraction
Fetal anomaly distending lower segment
Vigorous uterine pressure during delivery
Difficult manual removal of placenta
Acquired:
•
•
•
•
Placenta increta or percreta
Gestational trophoblastic neoplasia
Adenomyosis
Sacculation of entrapped retroverted uterus
65. Uterine Rupture
Traumatic
• abruptio placenta
• difficult forceps delivery
• unusual fetal enlargement
– hydrocephaly
• breech extraction
Spontaneous
• high parity
• oxytocin use
• prostaglandin e2 or e1
use
66. Uterine Rupture
• Symptoms
– non reassuring fetal heart rate pattern
with variable deceleration, late
deceleration, bradycardia, fetal death
(most common)
– pain or tenderness
– loss of station
• Management
– Hysterectomy vs Repair
67. Consumptive Coagulopathy
• Temporary Hemophilia
– Placenta abruption
– Long dead macerated fetus in utero
• Hypofibrinogenemia
• DIC
• Pregnancy is HYPERCOAGULABLE state
– Increase factors I, VII, VIII, IX, X, plasminogen,
fibrinopeptide A, Beta-thromboglobulin, platelet
factor 4, fibrin-fibrinogen degradatiob products
• Compensate the accelerated intravascular coagulation
to maintain uteroplacental interface
70. Amniotic Fluid Embolism
• Risk Factors
–
–
–
–
–
maternal age
minority race
placenta previa
preeclamosia
forceps or cs
delivery
– meconium
staining
– rapid labor
detection of fetal squames or other debris of
fetal origin in the central pulmonary
circulation
73. Post Test
1. signs of placental separation
2.
3.
4.
5. degrees of laceration and anatomical
6. structure it affects
7.
8.
74. Post Test
9. Causes of postpartum hemorrhage
10.
11.
12. What is late PPH?
13. What is 3rd Stage Hemorrhage
14. Mode of delivery for placenta previa
15. Why can’t we give oxytocin in bolus?
Notes de l'éditeur
Duncan – dirty
Schultze - shiny
There is still no definite answer to the question concerning the length of time that should elapse in the absence of bleeding before the placenta is removed manually. Obstetrical tradition has set somewhat arbitrary limits on third-stage duration in attempts to define abnormally retained placenta and thus, to reduce blood loss from prolonged placental separation.
Several measures of hemorrhage, including curettage or transfusion, increased when the third stage was approximately 30 minutes or longer
Adequate analgesia is mandatory, and aseptic surgical technique should be used. After grasping the fundus through the abdominal wall with one hand, the other hand is introduced into the vagina and passed into the uterus, along the umbilical cord. As soon as the placenta is reached, its margin is located, and the border of the hand is insinuated between it and the uterine wall (Fig. 35-16). Then with the back of the hand in contact with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that used in separating the leaves of a book. After its complete separation, the placenta should be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at the same time by carefully teasing them from the decidua, using ring forceps to grasp them as necessary. Another method is to wipe out the uterine cavity with a laparotomy sponge.
IVF with 20 unit oxytocin at 10mL/min or 200mU of oxytocin per inute
Antepartum – placenta previa or abruptio
Postpartum – uterine atony or genital tract laceration
Late PPH – vaginal bleeding beginning after the 1st 24 hours following delivery, generally within 7-9 days and rarely several months later
Associated with uterine subinvolution as a consequence of infection, retained placental fragments, abnormal healing of the thrombosed vascular sinuses at the placental site
Subinvolution: softened uterus larger than expected for the time during puerperium
Bleeding is not massive – conservative management
Normal ultrasound: antibiotics and oxytocin
3rd stage hemorrhage is a PPH before placental delivery caused by attempts to hasten delivery of the placenta thereby causing incomplete placental separation.
Manual extraction of the placenta is done immediately if there’s massive bleeding after delivery of the fetus
in the absence of bleeding, manual extraction is not indicated until after 30minutes have elapsed
oxytocin IV and IM
Anytime the postpartum hematocrit is lower than one obtained on admission for delivery, blood loss can be estimated as the sum of the calculated pregnancy hypervolemia plus 500mL for eack 3 volumes percent drop in hematocrit
Table 35-2
Unrecognized intrauterine, intravaginal or intraperitoneal accumulation of blood
Stabilize patient then determine the cause and institute specific treatment depending on the cause
Primary consideration is to control the bleeding. Paramount is knowing the cause
Exploration of the uterus – with the hand still inside the uterus, exploration to determine if there are retained placenta. Bimanual massage is done to promote contraction
If bleeding continues, bimanual uterine compression is employed, with the fist inside the vagina, the knuckles on the anterior aspect of the uterus and abdominal hand pressing on the posterior aspect of the anteverted uterus.
Rapid IV oxytocin bolus – not recommended because it will lead to hypotension or cardiac arrest
Vaginal suppository not given because bleeding will just wash it off
Packing – not advocated because it may lead to false sense of security and delay in management
Oxytocin and ergot preparation administered during 3rd stage of labor were more effective than misoprostol in preventing PPH
In step 1, beginning below the incision, the needle pierces the lower uterine segment to enter the uterine cavity. In step 2, the needle exits the cavity above the incision. The suture then loops up and around the fundus to the posterior uterine surface. Here, in step 3, the needle pierces the posterior uterine wall to reenter the uterine cavity. The suture then traverses from left to right within the cavity. In step 4, the needle exits the uterine cavity through the posterior uterine wall. From the back of the uterus, the suture loops up and around the fundus to the front of the uterus. In step 5, the needle pierces the myometrium above the incision to reenter the uterine cavity. In step 6, the needle exits below the incision. Finally, the sutures at points 1 and 6 are tied below the incision.
Complications: uterine necrosis and peritonitis
Usually bleeding occurs late second trimester or after
Hemorrhage is due to the fact that the placenta is at the internal os and the formation of the lower uterine segment and the dilatation of the intrenal os result inevitably in tearing placental attachments and bleeding is augmented by inherent inability of the lower uterine segment to contract and thereby to constrict the avulsed vessels
Bleeding continues even after delivery of the placenta since the LUS contracts poorly
External hemorrhage – the placenta has detached in the peripherally and the membranes between the placenta and cervical canal are detached from the underlying decidua allowing blood to egress through the vagina
Concealed hemorrhage – more dangerous because the blood remains within the uterus since the placenta is still adherent to the uterine wall.
Effusion of blood behid the placenta but the placental margins remains adherent
Placenta is completely separated yet the membranes retained their attachment to the uterine wall
Blood gains access to the amniotic fluid after breaking through membranes
Fetal head is closely applied to the lower uterine segment that blood cannot make its way
Significant fetal bleeding is much more likely a traumatic abruption which results from a tear or fracture in the placenta rather than from placental separation itself.
Shock – massive blood loss placental thromboplastin enters maternal circulation intravascular coagulation AFE symptoms
Consumptive coagulopathy – hypofibrinogenemia (plasma level <150mg/dL) elevated fibrinogen-fibrin degradation products or D dimers thromboplastin enters circulation intravascular coagulation shock death
Renal failure – delayed treatment of hypovolemia secondary to massive blood loss acute renal failure (ACUTE CORTICAL NECROSIS) monitor UO 30-60mL/hour without diuretics (giving diuretics reults to deranged cardiac output)
Sheehan Syndrome – severe intrapartum or postpartum hemorrhage rarely followed by pituitary failure or sheehan syndrome characterized as failure of lactation, amenorrhea, breast atrophy, loss of pubic and axillary hair, hypothyroidism and adrenal cortical insufficiency pituitary gland necrosis diagnosed by MRI
Couvelaire uterus – due to widespread extravasation of blood into the uterine musculature and beneath the uterine serosa or uteroplacental apoplexy REMEMBER COUVELAIRE UTERUS IS NOT AN INDICATION FOR HYSTERECTOMY
Blood + crystalloid + delivery
Delaying delivery if fetus is immature is beneficial stable mother tocolysis 12 days meantime to deliver CS
If fetus is dead vaginal delivery except if excessive bleeding and with another complication preventing vaginal delivery
CS hysterectomy without removing placenta reduced morbidity
The placenta must be routinely examined after delivery.
Delivery of the placenta by cord traction especially when the uterus is atonic may cause uterine inversion
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 (Hong and colleagues, 2006; You and Zahn, 2006). In the meantime, if the inverted uterus has prolapsed beyond the vagina, it is replaced within the vagina
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. Alternatively, two fingers are rigidly extended and are used to push the center of the fundus upward. Care is taken not to apply so much pressure as to perforate the uterus with the fingertips. As soon as the uterus is restored to its normal configuration, the tocolytic agent is stopped. An oxytocin infusion is begun while the operator maintains the fundus in its normal anatomical position.
Initially, bimanual compression as shown in Figure 35-17 aids in control of further hemorrhage until uterine tone is recovered. After the uterus is well contracted, the operator continues to monitor the uterus transvaginally for any evidence of subsequent inversion.
Fetal death – spontaneous labor within 2 weeks. Monitor coagulation factor
Pathophysio – prevention of blood flow from right to left side of the herat due to pulmonary vasoconstriction
Diagnosis: detection of fetal squames or other debris of fetal origin in the central pulmonary circulation
