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August 14, 2017
Abnormalities of the Third Stage of Labor
Dr. Ilarde
Department of Obstetrics and Gynecology

TOPIC OUTLINE Risk Factors for PPH (4T’s)

I. Introduction  Tone
a. Post Partum Hemorrhage  Tissue
b. Late Post Partum Hemorrhage  Trauma
c. Risk Factors for PPH
 Thrombin
II. Tissue Related Products of Conception
a. Placenta Accrete Syndrome Tone
b. Retained Placental Membranes Abnormalities of uterine contraction
III. Trauma Etiologic category and process Clinical Risk Factors
a. Lacerations/Genital Tract Trauma
b. Vulvovaginal Overdistention of uterus Polyhdramnios
c. Cervical Multiple gestation
IV. Puerperal Hematoma Macrosomia
V. Uterine Rupture Uterine muscle exhaustion Rapid labor
VI. Uterine Inversion (fatigue) Prolonged labor
VII. Uterine Atony
High parity
Oxytocin use/ augmentation
INTRODUCTION Prior PPH
Postpartum Hemorrhage Intraamniotic infection/ Fever
chorioamnionitis Prolonged rupture of
 Blood loss of >500 ml in the first 24 hours after delivery
 10% decrease in hemoglobin and hematocrit level membranes (ROM)
 >500 ml blood loss in vaginal delivery and >1L for CS Functional/ anatomic Fibroids
delivery distortion of uterus Placenta previa
 There is a need for transfusion Uterine relaxing medication Beta mimetics
 Treacherous feature: Failure of the pulse rate and blood Bladder distention which may Halogenated anesthetics
pressure to undergo modified alterations until prevent uterine contraction nitroglycerin
large amounts of blood has been lost Tissue
Accreta Prior uterine surgery, placenta
Estimated % Heart Rate Systolic Signs and Increta previa, multiparity
Blood blood Blood symptoms
Percrata
Lost (mL) volum Pressure
e Retained placental membrane Manual placental removal
500 – 1000 10
lost– 15 < 100 Normal None Trauma
Slight Vasocon- of the genital tract
1000 – 1500 15 – 25 100 – 120 decrease striction
restlessness, Laceration of cervix, vagina or Precipitous labor
1500 – 2000 25 – 35 120 – 140 80 – 100 pallor, perineum Macrosomia
oliguria Shoulder dystocia Operative
Anuria delivery Episiotomy
2000 – 3000 35 – 45 > 140 60 – 80 altered Extensions, lacerations at Deep engagement
LOC cesarean section Malposition
Uterine Rupture Previous Uterine Surgery
Late Postpartum Hemorrhage Uterine Inversion High Parity
 Bleeding after 24 hours of delivery Fundal Placenta
 The following are predisposed to hemorrhage due to Excessive cord traction
low baseline blood volume: Thrombin
o Small women abnormalities of coagulation
o Severe preeclampsia/eclampsia (generalized
Preexisting clot ting History of hereditary
vasoconstriction in the body)
abnormalities coagulopathy or liver disease
o Chronic renal failure
Acquired during pregnancy Bruising, Elevated BP
 Idiopathic
thrombocytopenic
Purpura

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 Abnormalities of the Third Stage of Labor

 Disseminated
intravascular
coagulation
Gestational hypertensive Elevated blood pressure
disorder of pregnancy with
adverse conditions
 Dead fetus in  Fetal demise
utero  Fever + neutrophil
 Severe infection abn
 Abruption  Antepartum
 Amniotic Fluid Hemorrhage RISK FACTOR
Embolus  Sudden collapse  Associated previa
Therapeutic anticoagulants History of thrombotic disease  Prior cesarian delivery

**Prompt recognition and treatment is critical MATERNAL COMPLICATIONS

A (Assessment)  Massive hemorrhage
 Hemodynamic Status  DIC
 Determine Cause of Bleeding  Visceral injury
B (Breathing)  ARDS
 Oxygen Supplementation  Renal failure
C (Circulation)  Infection
 Death
 IV access (double line large bore catheter), adequate
Fetal Complications
circulating blood volume thru crystalloids and blood
products  Adverse perinatal outcome from preterm delivery and
restricted fetal growth (IUGR)
Management
TISSUE-RETAINED PRODUCTS OF CONCEPTION  Adhered placenta during the third stage of labor =
hemorrhage
Placenta Accreta Syndrome
 Ideally should be diagnosed antepartum = Best outcome:
 Accret, ac + crescere; to grow from adhesion or coalescence, to
planned delivery in a tertiary hospital
adhere, to become attached to
 Percreta and Increta
 Abnormally firm adherence to myometrium due to
o Almost always mandates hysterectomy
partial/total absence of the decidua basalis, imperfect
 Conservative management: reserved from hemodynamically
development of Nitabuch layer
stable patients
 Leading cause of intractable PPH
o Leaving the placenta in situ
 Closely linked to prior uterine surgery ↑ incidence
 after the fetus has been delivered, it may
 Histological diagnosis cannot be made from the placenta
be possible to trim the umbilical cord and
alone, and the uterus or curettings with myometrium are
necessary for histopathological confirmation repair the hysterotomy incision but leave
the placenta in situ. This may be wise for
women in whom abnormal placentation
Variants of Placenta Accreta Syndrome
was not suspected before cesarean
villi are attached to the delivery and in whom uterine closure
Placenta accreta myometrium stops bleeding. After this, she can be
transferred to a higher level facility for
villi invade the definitive management.
Placenta increta myometrium  Iiwanan lang yung placenta sa loob then
use chemotherapy to “kill” it
villi penetrate through the o Methotrexate therapy
Placenta percreta myometrium and to or  Wedge resection – focal accrete
serosa
Retained Placental Membrane
 In all three varieties, abnormal adherence may involve;
 Retained placental fragments
o Total placenta accreta – involves all lobules o Inspect placenta after delivery for completeness
o Focal - if all or part of a single lobule is abnormally (routine) – cotyledon count
attached o Defect: Uterus is manually explored then fragment
o Partial – few to several cotyledons is removed
 Retained succenturiate lobe
o Accessory lobes – located at a distance from the
placenta

2 of x [OBeshies <3: Jayvee, Migs, Ekay, Janzy, Bien, Cams, Lyien]


o Presentation: bleeding
TRAUMA
Lacerations/Genital Tract Trauma
 Suspect if (+) bleeding despite contracted uterus
 Second most common of postpartum bleeding
 Lacerations of perineum, cervix, vagina, or uterus
Vulvovaginal
 Small, superficial anterior vaginal wall tears: no need for
repair
 Extensive tears: intrauterine exploration for possible uterine
tears
o Suture repair with effective analgesia
o Blood replacement
o Capable assistance
Cervical
 Superficial - occur in more than half of vaginal deliveries
(<0.5 cm)
 Seldom require repair unless extending to upper third of
vagina
 Diagnosed with visual inspection with adequate exposure
 Colporrhexis – total or partial avulsion of the cervix from
the vagina, usually from difficult deliveries
 Other cervical injuries:
o Anterior cervical lip ischemia
o Annular/ circular detachment of cervix
PUERPERAL HEMATOMA
 Most often associated with a laceration, episiotomy, or an
operative delivery
o Spontaneous rupture of blood vessels
o Excruciating pain
 Tense, fluctauant, tender, swelling of varying site even
covered by discolored skin
 Hallmark symptom: Pelvic pressure
 Supralevator extension  the hematoma extends upward in
the paravaginal space and between the leaves of the broad
ligament.
o The hematoma may escape detection until it can be
felt on abdominal palpation or until hypovolemia
develops
 Pain or inability to void
 Change in vital signs disproportionate to blood loss
Management
 Managed according to size, duration of delivery and
expansion
 Expectant: smaller vulvar hematoma (follow-up closely)
 Surgical exploration: severe pain or hematoma continues
to enlarge
 Embolization: primarily or secondarily if surgical attempts
for homeostasis have failed
UTERINE RUPTURE
 Primary  previously intact or unscarred uterus
 Secondary  preexisting myometrial incision, injury, or
anomaly
 Most often site: thinned out lower uterine segment
Classic Signs and Symptoms
 Fetal distress (during labor) – decelerated heart rate
 Diminished baseline uterine pressure
 Abdominal pain
3 of x [OBeshies <3: Jayvee, Migs, Ekay, Janzy, Bien, Cams, Lyien]
Abnormalities of the Third Stage of Labor
 Loss of uterine contractility
 Abnormal labor or failure to progress
 Hemorrhage and shock
 Recession of presenting part (from engaged to -2 or -3)
Fetal prognosis depends on degree of placental separation
and magnitude of placental bleeding and hypovolemia, should be
delivered within 18 mins
Management
 Definitive management: Fetal delivery (immediate
abdominal delivery)
 Conservative management: uterine repair (young, still
wants to give birth, not extensive and (-) extension of
rupture
 Rupture of previous scars: revise edges and primary
closure
 Hysterectomy: intractable uterine bleeding, multiple
rupture sites, longitudinal to artery
UTERINE INVERSION
 One of the classic hemorrhagic disasters encountered in
obstetrics.
 Risk Factors
I. Fundal placental implantation,
II. Delayed-onset or inadequate uterine
contractility after delivery of the fetus, that is,
uterine atony,
III. Cord traction applied before placental
separation, and
IV. Abnormally adhered placentation such as with
the accrete syndromes
V. Completely inverted, protrusion of bluish
mass
 Absence of uterine fundus in palpation
 Immediate recognition is needed for good outcome
Management
 Immediate recognition for quick resolution and good
outcome
 Once any degree of uterine inversion is recognized,
several steps must be implemented urgently and
simultaneously;
I. Immediate assistance
 Immediate assistance is summoned, including
obstetrical and anesthesia personnel.
II. Blood
 Blood is brought to the delivery suite in case it may
be needed.
III. Large bore intravenous system
 The woman is evaluated for emergency general
anesthesia. Large-bore intravenous infusion
systems are secured to begin rapid crystalloid
infusion to treat hypovolemia while awaiting
arrival of blood for transfusion.
IV. Prompt replacement of the uterus
 If the recently inverted uterus has not contracted
and retracted completely and if the placenta has
already separated, then the uterus may often be
replaced simply by pushing up on the inverted
fundus with the palm of the hand and fingers in the
direction of the long axis of the vagina.
V. Leave placenta
 Abnormalities of the Third Stage of Labor

 If the placenta is still attached, it is not removed - Ergot derviatives (methergine & ergonovine):
until infusion systems are operational and a not given in HTN patiens , cause SE include
uterine relaxant drug administered increase in blood pressure
VI. Once repositioned, give uterotonics - E & F series prostaglandin:
 Once the uterus is restored to its normal  F2 alpha Carboprost
configuration, tocolysis is stopped. Oxytocin is then  Pge2 Dinoprostone
infused, and other uterotonics may be given  Pge1 Misoprostol (yung mga binebenta sa
 Meanwhile, the operator maintains the fundus in its Quiapo para magpalaglag; illegal na sa
normal anatomical position while applying bimanual Philippines)
compression to control further hemorrhage until the
uterus is well. - If unresponsive:
Surgical Intervention I. Bimanual uterine compression
 When bimanual compressions fail: - Begin bimanual uterine compression, which is
a) Huntington procedure – Application of easily done and controls most cases of continuing
atraumatic clamps to each round ligament and hemorrhage. This technique is not simply fundal
upward traction. massage. The posterior uterine wall is massaged by
b) Haultian incision – If the constriction ring still one hand on the abdomen, while the other hand is
prohibits repositioning, a longitudinal surgical cut made into a fist and placed into the vagina. This fist
is made posteriorly through the ring to expose the kneads the anterior uterine wall through the
fundus and permit reinversion anterior vaginal wall. Concurrently, the uterus is
c) Hysterectomy – Last resort also compressed between the two hands.
II. Immediately mobilize the emergent-care
UTERINE ATONY obstetrical team to the delivery room and
 The most frequent cause of obstetrical hemorrhage call for whole blood or packed red cells
 Failure of the uterus to contract sufficiently after III. Request urgent help from the anesthesia
delivery and to arrest bleeding from vessels at the team.
placental implantation site. IV. IV large bore intravenous system
a) Duncan mechanism - Blood from the implantation - Secure at least two large-bore intravenous
site may escape into the vagina immediately catheters so that crystalloid with oxytocin is
continued simultaneously with blood products.
b) Schultze mechanism – blood remains concealed
Insert an indwelling Foley catheter for continuous
behind the placenta and membranes until the
urine output monitoring.
placenta is delivered
V. Begin volume resuscitation with rapid
RISK FACTORS
intravenous infusion of crystalloid.
 Uterine overdistention
VI. With sedation, analgesia, or anesthesia
- Large fetus
established and now with optimal
- Multiple fetuses
exposure, once again manually explore the
- Hydramnios
uterine cavity for retained placental
- Retained clots
fragments and for uterine abnormalities,
 Labor induction
including lacerations or rupture.
 Anesthesia or analgesia
- Halogenated agents
B. NON SURGICAL INTERVENTION
- Conduction analgesia with hypotension
- Uterine packing or balloon tamponade
 Labor abnormalities
 Gauze, foley catheter, sengstaken blakemoore,
- Rapid labor
rush balloons, bakri postpartum balloons
- Prolonged labor
- Augmented labor
C. SURGICAL PROCEDURES
- Chorioamnionitis - Uterine compression sutures/ brace compression
 Previous uterine atony sutures (parang suspenders)
PHYSICAL EXAMINATION  B-lynch, square suture, hayman & cho
 Identified as a soft and boggy uterus by bimanual exam
 Uterus is tested by the surgeon first before
(Uterus is usually stone-hard after delivery) application of sutures
 Expression of clots during uterine massage - Pelvic vessel ligation (uterus-sparing)
 Every after placental delivery, palpate for contracted  Uterine artery ligation
uterus, if not, do fundal massage and initiate uterotonics o Marami pang collaterals
MANAGEMENT  Internal iliac artery ligation
A. UTERONICS o Decreases BP by 80%; decreases
- Oxytocin (first line) should not be given as a bolus, peripheral pulse rate
may cause hypertension and cardiac arrhythmias - Angiographic embolization
o Pure oxytocin: Intramuscular - Hysterectomy
o Diluted oxytocin: Intravenous
*When the patient is old, management is usually aggressive.

4 of x [OBeshies <3: Jayvee, Migs, Ekay, Janzy, Bien, Cams, Lyien]

 Abnormalities of the Third Stage of Labor

*When the patient is young, management is usually conservative.

Answers:
ACTIVE MANAGEMENT 1. 10% decrease in hemoglobin and hematocrit level
 Routine administration of oxytocin after delivery of 2. 1500-2000ml
baby IM 10 u 1 amp 3-5. Small women, severe preeclampsia/eclampsia, chronic renal
 Delayed cord clamping (1 – 3 mins) or until pulsations failure
stop 6-7. associated previa & Prior caesarian delivery
 Controlled cord traction to deliver the placenta 8. Colporrhexis
(support is applied on top) 9. Pelvic Pressure
10. Any of the ff:
EXPECTANT/PHYSIOLOGIC MANAGEMENT  Fundal placental implantation,
 Wait for signs of placental separation  Delayed-onset or inadequate uterine contractility after
 Placenta delivered spontaneously or with aid of gravity delivery of the fetus, that is, uterine atony,
and maternal pushing  Cord traction applied before placental separation, and
 Uterotonics not routinely administered  Abnormally adhered placentation such as with the
accrete syndromes
SEQUELAE  Completely inverted, protrusion of bluish mass
 Hemorrhage 11-12. Huntington Procedure and Haultian Incision
 Risk for Infection
13. Any of the following:
 Risk for Recurrent PPH
- Uterine compression sutures/ brace compression
 Risk for Hysterectomy sutures
 Risk for Sheehan’s syndrome  B-lynch, square suture, hayman & cho
 Risk for multi organ failure
 Uterus is tested by the surgeon first before
application of sutures
- Pelvic vessel ligation
 Uterine artery ligation
 Internal iliac artery ligation
- Angiographic embolization
- Hysterectomy
14. Any of the following
 Routine administration of oxytocin after delivery of
baby IM 10 u 1 amp
 Delayed cord clamping (1 – 3 mins)
 Controlled cord traction to deliver the placenta
15. Ergot derviatives (methergine & ergonovine): not given in
HTN patiens , cause SE include increase in blood pressure

Quiz!!!!

1. PPH is defined as ___% decrease in Hemoglobin and Hematocrit

level
2. Estimated blood volume lost to produce the following
symptoms: restlessness, pallor, oliguria: _______
3-5. Give 3 risk factors that predispose women to hemorrhage
due to low baseline blood volume:
6-7. Risk Factors for placenta accrete syndrome
8. total or partial avulsion of the cervix from the vagina, usually
from difficult deliveries
9. Hallmark symptom of Puerperal Hematoma
10. Give one risk factor for Uterine Inversion
11-12. 2 Surgical Interventions for Uterine Inversion
13. Give 1 surgical intervention for Uterine Atony
14. Give an Active Management for Uterine Atony
15. Uterotonic that causes hypertension

5 of x [OBeshies <3: Jayvee, Migs, Ekay, Janzy, Bien, Cams, Lyien]

 Abnormalities of the Third Stage of Labor

6 of x [OBeshies <3: Jayvee, Migs, Ekay, Janzy, Bien, Cams, Lyien]