3rd stage of labour and its complications

Dr.Mallika DattaAssistant Professor (G&O)Medical College, Kolkata

Objectives

• What is the 3rd stage of labour?• Enumerate its complications?• What is the ideal management of 3rd stage?

(Active management of 3rd stage of labour)• What is postpartum haemorrhage, its causes

and its management?• Management of other complications –

retained placenta, uterine inversion

What is 3rd stage of labour

• Begins with expulsion of the foetus and ends with expulsion of placenta and membranes

• Average duration – 15 min• Reduced to 5 min by Active management

Normal placental separation

• At beginning of labour, placental attachment corresponds to an area of 20 cm diameter

• From 2nd stage of labour, progressive diminution of the area due to uterine contraction and retraction, esp after the baby is delivered

• After birth of the baby, the whole uterus measures 20 cm by 10 cm

Normal placental separation

• So placental surface area is halved• Thus the inelastic placenta buckles and

separates• The plane of separation runs through the

deep spongy layer of decidua basalis• Innumerable torn sinuses with free circulation

from uterine and ovarian vessels now left

Control of bleeding

• Torn sinuses obliterated by complete retraction of the uterine muscles – arterioles passing through the interlacing fibres are clamped (living ligature)

• Also thrombosis• Apposition of the uterine walls (myotamponade)

Thus both placental separation and subsequent control of bleeding depend on uterine contraction and retraction

Complications of 3rd stage

• Postpartum haemorrhage• Retained placenta• Shock – haemorrhagic or non-haemorrhagic• Pulmonary embolism – amniotic fluid or air• Uterine inversion

Active management of 3rd stage of labour (AMTSL)

3 components• Administration of uterotonic drug within 1

min of delivery of baby• Delivery of placenta by controlled cord

traction (CCT)• Massaging the uterus to make it hard

AMTSL contd

• Reduces blood loss to 1/5th

• Reduces risk of PPH by 60%• Shortens duration of 3rd stage by half

• Only disadvantage – slight increase in risk of retained placenta

AMTSL – Uterotonic drug

• Within 1 min of delivery, PALPATE THE ABDOMEN to rule out the presence of an additional baby(s)

• Give Oxytocin 10U IM(Refrigeration needed, avoid large IV bolus)

• Alternative drugs – Ergometrine 0.2mg IMMisoprostol 600μg SL/oral/PR/PV

AMTSL - CCT

• One hand to hold cord (clamped close to perineum)

• Other suprapubic for counter-traction• Wait for next contraction (2-3min)

AMTSL -CCT

• When the uterus contracts, as will be evidenced by the uterus becoming hard and globular, or when the extra-vulval portion of the cord lengthens, gently pull downwards on the cord to deliver the placenta.

• If placenta does not descend during 30-40sec of CCT, stop pulling and wait for next contraction

AMTSL -CCT

• The signs of placental separation are:* The uterus becomes hard and globular

(uterine contraction).* The extra-vulval portion of the cord lengthens* There is a sudden gush of blood when the

placenta separates.* If the fundus of the uterus is gently pushed up

towards the umbilicus, the cord will not recede into the vagina.

AMTSL - contd

• Twist placenta while delivering so that membranes do not tear off

• EXAMINE the placenta and membranes after delivery for complete removal

AMTSL - Uterine massage

• Massage the uterine fundus until well contracted

• Repeat massage every 15 min for first 2 hrs• Ensure that uterus does not become flabby

when massage is stopped

Postpartum haemorrhage

• Blood loss in excess of 500 ml following birth of the baby

• Any amount of bleeding from or into the genital tract following birth of the baby up to the end of puerperium which adversely affects the general condition of the patient as evidenced by rise in pulse rate and falling blood pressure

Importance

• APH untreated leads to death in 12 hrs• Obstructed labour untreated leads to death in

2 days• Infection untreated leads to death in 6 days

• PPH untreated leads to death in 2 hrs

PPH – definition contd

• Primary PPH – within 24 hrs of delivery– 3rd stage haemorrhage : before expulsion of

placenta– True PPH : after expulsion of placenta

• Secondary PPH – Beyond 24 hrs and within puerperium ( 12 wks )

• Minor <1L; Major >1L; Severe >2L

Causes of Primary PPH

• Atonic (70-80%)

• Traumatic (20%)

• Retained placenta (10%) and retained bits

• Blood coagulopathy

Atonic PPH - causes• Grand multipara• Over-distension of uterus – hydramnios, twin• Anaemia and malnutrition• Antepartum haemorrhage• Prolonged labour• Precipitate labour• Anaesthesia and drugs (tocolytics, magsulph, nifedipine)• Labour induction/augmentation with Oxytocin• Uterine malformation• Uterine fibroid• Mismanaged 3rd stage of labour• Morbidly adherent placenta

Management of PPH

• Shout for help• Rapid evaluation of general condition – look

for shock• Massage the uterus to make it hard• Give Oxytocin 10 U IM

Management of PPH

• 2 large bore (14 gauge) IV cannulas• Draw blood for Group and Cross-match, other

tests, requisition 4 units blood• Rapidly infuse 2L of NS or RL – initial 1L over

20 min. May subsequently give 1.5L colloid (Haemaccel) while waiting for blood

• Start Oxytocin infusion 20 U in 500 mL at 60 drops/min

Management of PPH

• Catheterise the bladder – Foley’s• Check if placenta has been expelled• Examine the placenta and membranes to see

if it is complete• Examine the cervix, vagina and perineum for

tears

Management of PPH

• Oxygen by mask 10-15 L/min• Keep the patient warm• Non-pneumatic anti-shock garment esp during

transfer• Commence monitoring and recording – pulse,

bp, respiratory rate, oximeter, type and amount of fluids infused, urine output, drugs- type,dose,time, CVP if sited

Transfusion

• Main therapeutic goals is to maintainHb > 8g/dlPlatelet count > 75,000/cummProthrombin time < 1.5 times mean controlAPTT < 1.5 times mean controlFibrinogen > 1.0 g/L• Nowadays recommendation is to infuse PRBC

and FFP in 1:1 ratio

Evaluation

• Immediate PPH• Uterus soft and not

contracted• Placenta examined -

complete• May be shock

• Atonic uterus

• Immediate PPH• Placenta examined –

complete• Uterus contracted

• Tears of cervix, vagina or perineum

Evaluation

• Placenta not delivered within 30min of delivery

• Immediate PPH

• Retained placenta

• Immediate PPH• Uterus contracted• Portion of maternal

surface of placenta missing or torn membranes with vessels

• Retained placental fragments

Evaluation

• Immediate PPH• Uterine fundus not felt

on abdominal palpation• Slight or intense pain

• Inverted uterus (may appear at vulva)

• Immediate PPH (bleeding is intraabdominal or vaginal)

• Severe abdominal pain• Tachycardia, Shock• Tender abdomen

• Ruptured uterus

Evaluation

• Bleeding occurs more than 24 hrs after delivery

• Uterus softer and larger than expected for elapsed time since delivery

• Bleeding is variable, may be foul smelling• Anaemia

• Delayed/Secondary PPH

Atonic uterus – Oxytocic drugsDrug Dose and route Continuing

doseMaximum dose

Precautions & contraindications

Oxytocin(Syntocinon)

IV infusion:20-40 units in 1L60 drops/min

IV infusion:20U in 1L40 drops/min

Not more than 3L IV fluids containing Oxytocin

Do not give as large IV bolus

Methyl ergometrine(Methergin)

IM or IV slowly0.2mg

Repeat 0.2mg after 15min.If required, 0.2mg repeated 4hrly

Five doses(Total 1mg)

High blood pressure, pre-eclampsia, heart disease

15-methyl Prostaglandin F2α = Carboprost(Prostodin)

IM250μg

IM 250μgRepeated every 15min

Eight doses(Total 2mg)

Asthma

Oxytocic drugs contd

• Prostaglandins should not be given intravenously – the may be fatal.

• Alternative drug – Misoprostol 1000μg per rectum

• Carboprost 500μg may be given intramyometrially

• Assess clotting status with bedside clotting test – failure of clot to form after 7 min or soft clot that breaks down easily = coagulopathy

Atonic uterus – bleeding continues

• Bimanual compression of uterus

• Aortic compression

Atonic uterus – bleeding continues

• Balloon tamponade

Has superseded uterine packingFoley’s catheter, Bakri balloon, Sengstaken-

Blakemore oesophageal catheter, condom catheter, urological Rusch balloon

Averts hysterectomy in 78% cases

Balloon Tamponade contd.

Balloon Tamponade contd.

200-500 mL normal salineKept 4-6 hrsIn daytime, with senior staff present, deflate

balloon and see

• Tamponade test: A +ve test (=control of PPH following inflation of balloon) indicates that laparotomy is not required.

Atonic uterus – bleeding continues

• Take to OT• Under anaesthesia, explore uterus for

placental fragments and remove clots• Repeat uterine massage – if still atonic,

proceed to laparotomy

Atonic uterus - laparotomy

• B-Lynch suture or multiple square

sutures

Work by compression/tamponade

Avert hysterectomy in 80% of cases

Stepwise uterine devascularization1. Ligation of uterine

arteries – at lateral border of uterus, junction of upper and lower uterine segments, 2cm inside myometrium

2. Ligation of utero-ovarian anastomoses – Just below ovarian ligament

Ligation of internal iliac arteries

• 2-3cm distal to bifurcation of common iliac. • Reduces pelvic blood flow by 50%. • Drop in arterial pulsation, with pressure reduced

to that of venous system. • Average decrease in pulse pressure is 77% with

one side and 85% with both sides ligated. • Venous bleeding is easily controlled by

temporary pressure and clot formed remains there.

Atonic uterus – Hysterectomy

• If all else fails, hysterectomy.• Second consultant to be involved in decision• May be subtotal – rapidly done, less duration

of exposure to anaesthesia• Must be total if placenta praevia, uterine

rupture involving lower segment, etc

Angiographic arterial embolization

• Angiographic arterial embolization usually with gelatin sponge

• Either internal iliac or more usually uterine arteries embolized

• Only in haemodynamically stable patients• Takes time, usually 60min• Must be done in radiology department• Requires experienced radiologist, fluoroscopy,

correct arterial catheters

Angiographic arterial embolization

• Temporary distal occlusion for 4 wks• Some materials may provide permanent

occlusion• 90-95% success rate• Best to perform prophylactically• Or put angiographic catheters in place pre-

operatively/predelivery for high risk cases like suspected placenta accreta

Traumatic PPH

Traumatic PPH contd.

• Tears of birth canal are the 2nd most frequent cause of PPH

• May coexist with atonic uterus• Examine and carefully repair• If bleeding continues assess clotting status

with bedside clotting test

Repair of cervical tear

Retained placenta• When placenta is not expelled even 30 min after

delivery of the baby• Causes:Placenta completely separated but retained due

to poor expulsive effortsSimple adherent placenta due to uterine

atonicity – commonest causeMorbidly adherent placentaPlacenta incarcerated following separation due

to constriction ring

Retained placenta

• Accounts for 10% of PPH cases and occurs in 0.5 to 3% of all deliveries

• Risks:HaemorrhageShock – due to blood loss, when prolonged,

frequent attempts to express the placentaPuerperal sepsisRecurrence in subsequent pregnancy

Retained placenta• Check for signs of placental separation – if

present, remove placenta by controlled cord traction

• Avoid forceful traction or fundal pressure – may cause uterine inversion

• Give Oxytocin 10U IM if not already given for AMTSL

• Empty the bladder• DO NOT give ergometrine for retained placenta

as it causes tonic uterine contractions which may delay expulsion

Retained placenta – Manual removal under GA

• Catheterization, prophylactic antibiotic

• Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor.

• Insert the other hand (long gloves) into the vagina and up into the uterus

Manual removal under GA

• Let go of the cord and move the other hand to abdomen in order to support the fundus and to provide counter-traction during removal to prevent inversion of the uterus

• Move the fingers of the hand in the uterus laterally until the edge of the placenta is located.

Manual removal under GA

• Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall (slicing movements)

Manual removal under GA

• Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall.

• Remove the placenta by traction on cord• Uterine hand remains inside to explore the cavity• Give Oxytocin infusion/ IV methergin• Assistant massages fundus• Examine the placenta• Examine for tears of cervix or vagina

Problems encountered during Manual removal

• Hour-glass contraction/constriction ring: Localized contraction of circular muscles Often at junction of upper and lower

segment Can be relaxed by deepening the plane of

anaesthesia- halothane is useful

• Morbidly adherent placenta - no plane of cleavage found

Morbid adherent placenta• The placenta is directly

anchored on to the myometrium either partially or completely without any intervening decidua

• Absence of decidua basalis and poor development of Nitabuch’s fibrinoid layer

• 1 in 550 deliveries

Morbid adherent placenta

• Accreta – No decidua or Nitabuch’s layer

• Increta – penetration of villi in to myometrium

• Perceta – penetration up to serous layer

Morbid adherent placenta• Risk factors: Prior Caesarean delivery Placenta praeviaRisk of placenta praevia being accreta in unscarred uterus:

3%With one prior CS, risk of pl praevia being accreta is 11%With two prior CS, 40%With 4 or more prior CS, 67% Prior uterine surgery like D&C, manual removal,

myomectomy, synechiolysis Increasing maternal age and parity

Morbid adherent placenta - management

• With prior CS and placenta praevia, try to diagnose accreta by imaging (USG and MRI) and prepare pre-delivery

• Partial/focal accreta – Remove placenta piecemeal and give oxytocics. If bleeding continues, hysterectomy

• Total placenta accreta – Hysterectomy in parous women. Otherwise clamp cord close to attachment and leave placenta to be autolyzed.

• Uterine artery embolization, methotrexate

Uterine inversion

• Rare and life-threatening

• Uterus is turned inside out, partially or completely

• 1 in 20,000 deliveries• Leads to shock,

haemorrhage, embolism, chronic-infection

Uterine inversion degrees

• First degree – dimpling of uterine fundus, remains above level of internal os

• Second degree – fundus passes through cervix but remains in vagina

• Third degree (complete) – endometrium visible outside vulva

Uterine inversion contd.

Spontaneous 40% - due to sudden cough, sneeze, bearing down when uterus still atonic

Iatrogenic – faulty management of 3rd stage sith pulling the cord or fundal pressure when uterus is atonic

Uterine inversion - management

• Call for help• Treat shock• Correction under deep sedation or GA• Thoroughly cleanse the inverted uterus using

antiseptic solution.• Apply compression to the inverted uterus with

a moist, warm sterile towel until ready for the procedure

Manual correction

• Wearing high-level disinfected or sterile gloves, grasp the inverted uterus and push it through the cervix in the direction of the umbilicus to its normal anatomic position, using the other hand to stabilize the uterus

Manual correction contd.

• The part of the uterus that came out last (the part close to the cervix) should go in first.

• After replacement, leave hand inside until the uterus becomes contracted by parenteral oxytocic

• If the placenta is still attached, manually remove it after correction of inversion and after uterus becomes contracted

Hydrostatic correction – O’Sullivan’s method

• Woman in deep Trendelenburg position

• Sterile douche system with large nozzle, long tubing, warm water reservoir 3-5L

• Nozzle in posterior fornix • Seal labia with other hand• Douche with pressure

raising reservoir to 2 m

Uterine inversion contd.• If fails, Laparotomy under

GA• Haultain’s operation• Incise the constricting

cervical ring vertically, posteriorly

• Apply traction while assistant also attempts correction vaginally

• After correction, close the posterior cervico-uterine incision

To summarize

• AMTSL is recommended for ALL deliveries, with 10 U Syntocinon IM, CCT and uterine massage

• PPH is a dire emergency. Management involves t/t of shock with IV fluids, other supportive t/t including blood transfusion, uterotonics, ensuring complete removal of placenta, detection and repair of injuries.

To summarize

• A placenta not separated within 30 min requires manual removal. Failure to find a cleavage during removal indicates morbid adherent placenta, which may need hysterectomy

• Uterine inversion is rare but produces shock. Manual or hydrostatic correction is needed.

• Any questions ?

THANK YOU