Abnormalities of the Third Stage of Labor and of the Placenta and Cord

The third stage of labour, from the delivery of the child until the expulsion of the placenta, remains the most unpredictable and
dangerous stage of labor from the mother’s point of view.

A.Retained Placenta

When syntometrine has been given with the crowning of the head or the delivery of the anterior shoulder, separation of the placenta will
usually occur within a few minutes of the delivery of the baby. Certainly, if the placenta is undelivered at 20 minutes it should be
considered to be “retained”.

Causes
1.Placenta separated but undelivered.

In such cases there have usually been signs of placental separation- bleeding, alteration of the shape of the uterus, lengthening of
the cord. If the signs have been missed, bleeding into the uterine cavity will occur because the uterus cannot retract fully until it is
empty.In this situation the fundus should be rubbed up to make it contract and the placenta removed by the Brandt-Andrews method.
The cord is pulled gently, and the other hand presses the uterus upwards so as to prevent inversion.

2. Placenta partly or wholly attached

If the placenta fails to separate at all there will be no bleeding. A cornual implantation of the placenta may cause this. Partial separation
will cause bleeding but the fundus will remain broad because the placenta still occupies the upper segment. Needless handling of the
uterus during the third stage is thought to encourage partial separation.Where oxytocics have been given an hour glass constriction
may develop in the lower segment and the cervix begins to close down.

3. Placenta Accreta

is a rare case of retained placenta. There is abnormal adherence of the placenta to the uterine muscle due to defect of decidual
formation. It is usually partial, and presents by partial separation accompanied by bleeding. On rare occasions it is complete, and
bleeding is absent.

Treatment

Intervention becomes necessary either because of bleeding or when 20 minutes have elapsed. An attempt should be made to remove
placenta by rubbing up a contraction and applying cord traction as described previously. If the placenta remains adherent the cord may
break. If this occurs, or the attempt is unsuccessful, manual removal of the placenta under anesthesia should be performed.

The hand covered with antiseptic cream is introduced into the vagina, following the cord.

The fingers begins to separate the placenta from the uterine wall. Never grasp the placenta until it is separated.

Note that the abdominal hand presses the uterus into the placenta and prevents tearing of the lower segment.

The placenta is inspected at once to see that it is complete and, if there is any doubt, the uterus is re-explored. Ergometrine or
oxytocin is then given and the uterus rubbed upto make it contract.

B.Primary PostpartumHaemorrhage

Primary Postpartum hemorrhage is blood loss from the birth canal of 500 ml or more within 24 hours of delivery. Afterv24 hours,
abnormal bleeding is classed as Secondary Post partum Hemorrhage

Causes
1.Uterine Atony

The uterus, although empty, fails to contract and control bleeding from the placental site. This is the commonest and potentially most
dangerous cause.

Predisposing Causes

Excessive uterine distension, Multiparity, Prolonged labor, Labour augmented with Syntocinon, General anesthesia, Placenta previa.
2. Partial Separation of the Placenta - uterus is prevented from contracting.

3. Retention of Placental Fragments

4. Trauma (uterus, cervix, vagina, episiotomy)

Consequences of PPH

-Bleeding may be very rapid causing circulatory collapse leading to shock and death.

-Puerperal anaemia and morbidity.

-Damage to the pituitary blood supply leading to pituitary necrosis- Sheehan’s syndrome.

-Fear of further pregnancies. Haemorrhage is terrifying for the mother.

Treatment

1. Measurement of blood loss

Blood spilt on bed linen and dressings is often ignored and only blood actually collected in a bowl is measured. The estimated loss is
therefore invariably lower than the actual loss. The mother’s response will be governed by her hemoglobin level.

2. Use of oxytocic drugs

Two are used: ergometrine 0.5 mg and oxytocin 5 units. Syntometrine is a proprietary combination of both these drugs. Ergometrine
produces tonic contractions of the uterus and is also a vasoconstrictor. It may therefore cause elevation of the blood pressure
especially if given intravenously. Its actions effects the uterus for 2-3 hours.

3. Plan of treatment

The aim is to stop the patient bleeding. Give an oxytocic intravenously. Rub up a contraction of the uterus to control bleeding and if the
placenta is undelivered attempt removal by cord traction.

Rapid assessment of the mother’s condition; set up an I.V. line and send blood for cross-match.

Treat the cause

1.If the placenta has been delivered check for completeness. If in doubt exploration of the uterus must be carried out.

2. If the uterus appears well- contracted and bleeding continues, damage to the cervix or vagina should be suspected. Proper
assessment of this will require exploration under anesthesia.

3.If both these causes have been excluded uterine atony is diagnosed.

Treatment for Uterine Atony

A recent Report on Confidential Enquiries into Maternal Deaths IN THE United Kingdom (published 1994) contains guidelines for the
management of massive obstetric hemorrhage. These are great value and should be referred to by all departments in preparing their
local protocol.

1. Prostaglandins

If the uterus continues to fail to contract in spite of the above measures, the next step is to employ the prostaglandin Carboprost
(Hemabate). It is given by intramuscular injection in a dosage of 250 micrograms and this may be repeated.

2. Bi-manual compression of the uterus

Having excluded an incomplete placenta and trauma to the genital tract by thorough exploration, the uterus is compressed between
the hands to control bleeding and stimulate contraction.

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