Philippine Obstetrical and Gynecological Society (Foundation), Inc.

CLINICAL PRACTICE AND GUIDELINES

ON
THIRD TRIMESTER BLEEDING AND
POSTPARTUM HEMORRHAGE

DRSC
Philippine Obstretical and Gynaecological Society (Foundation), Inc.

CLINICAL PRACTICE GUIDELINES

On
THIRD TRIMESTER BLEEDING
And POSTPARTUM HEMORRHAGE
November 2009

Task Force on Clinical Practice Guideline

In the Management of
Third Trimester Bleeding and Postpartum Hemorrhage

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 CPG ON THIRD TRIMESTER BLEEDING
AND POSTPARTUM HEMORRHAGE

TOPICS/ CONTENTS/ AUTHORS

A. THIRD TRIMESTER BLEEDING

Antepartum
Hemorrhage………………………………………………………………....…..………2
Blanca C. De Guia, MD, MSc

Abruptio
Placenta………………………………………………………..…..………….....………3
Ernesto S. Uichanco, MD

Placenta
Previa…………………………………………………………….……………………..11
Blanca C. De Guia, MD, MSc

Placenta
Accreta……………………………………………………………..………………..…19
Angelita R. Teotico, MD

B. POSTPARTUM HEMORRHAGE

Postpartum
Hemorrhage……………………………………..………………..…….……………29
Rafael S. Tomacruz, MD

Uterine
Atony………………………………………………………………..…………………29
Rafael S. Tomacruz, MD

Retained
Placenta…………………………………………………………….…………………31
Ryan B. Capitulo, MD

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 Uterine
Rupture................................................................................................................36
Ryan B. Capitulo, MD

Genital Tract Trauma

Lyla D. Reyes, MD
Uterine Inversion
Lyla D. Reyes, MD

C. Appendix
I. Level and Grade of Recommendation
II. Antenatal Perineal Massage
III. Method of Hydrostatic Reduction
IV. Johnson Maneuver
V. Huntington Maneuver
VI. Hultain Maneuver

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 ANTEPARTUM HEMORRHAGE
Blance C. De Guia, MD, MSc

Definition and Incidence

Antepartum Hemorrhage is defined as vaginal bleeding from 22 weeks of

gestation up to delivery. The most common causes include placenta previa, placenta
accrete and others, which include reproductive tract lesions.
It occurs in 2 to 5% of pregnancies.

Physiology
The uterus receives 1% of cardiac output in the nonpregnant state but receives
20% of the cardiac output in the third trimester of pregnancy.
When massive bleeding occurs during the third trimester the loss of blood greatly
alters the hemodynamics of blood distribution resulting in a very unstable pregnant
woman.

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 ABRUPTIO PLACENTA
Ernesto S. Uichangco, MD

Background

By definition, abruption placenta is the premature separation of a normally implanted

placenta. When there is placenta previa, it is not conventionally considered abruption in
the true sense. It is a convential source of vaginal bleeding in the second half of
pregnancy, complicating about 1% of births.

It may be a ―revealed‖ type of abruption, in which case blood tracts down ―revealed‖
between the membranes and the deciduas, and escapes through the cervix into the
vagina. Less commonly, it may be a ―concealed‖ type of abruption when blood
accumulates behind the placenta, with no obvious external bleeding.

Abruptio placenta may be ―total‖, involving the entire placenta, in which case it
typically leads to fetal death. Or it may be ―partial‖, with only a portion of the placenta
detached from the uterine wall.

In the past, expectant management has resulted in perinatal death rates as high
as 50% among infants alive at the time of admission. In an attempt to improve fetal
outcome, some authors have suggested immediate delivery, usually by caesarean
section (CS), in all but the mildest cases. More recently, in an effort to optimize fetal
survival and to attain a more acceptable CS rate, selective management of abruption
placenta has evolved.

The precise pathophysiology that leads to abruption placenta is still not fully
understood in many cases. It may result from hemorrhage at the decidual-placental
interface and it seems that acute vasospasm of small vessels may be the event that
immediately preceds the placental separation. There may be thrombosis of the decidual
vessels with associated decidual necrosis and venous hemorrhage.

In some cases, it may be due to acute processes resulting from one of the following:

1. Shearing forces resulting from trauma

2. Sudden uterine decompression resulting from membrane rupture with
hydramnios
3. Cocaine usage leading to acute vasoconstriction with resultant placental
separation

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 In the majority of cases it is thought involve chronic processes, abruption placenta
as the consequence of a long standing process that probably dates back to the first
trimester. Placental bed biopsies in women with abruption demonstrate a lack of
adequate trophoblastic invasion and in some, evidence of chronic pathologic lesions.
Uteroplacental insufficiency seems to play a role in the cause of abruptio, with bleeding
in the first two trimesters of pregnancy associated with an increased risk of subsequent
placental separation. Thrombin, found within the hemorrhage is a potent uterotonic
agent and uterine contractions are frequently present.

Acute separation of the placental deprives the fetus of oxygen and nourishment,
with the consequence that the fetus frequently dies if the abruption is severe,

On the maternal side, the coagulation cascade is activated with consumption of

coagulation factors and consequent disseminated intravascular coagulapathy (DIC).
This risk is highest when there is such a large placental detachment as to cause fetal
death. Hemorrhage associated with DIC leads to further consumption of coagulation
factors setting off a vicious cycle. The evolution and acceptance of the concept of a long
standing or ―chronic abruption‖ may have changed the old perception and management
of this hemorrhagic complication.

Recommendations:

1. When is abuptio placenta suspected?

The diagnosis of abruption placenta is a clinical one and it is suspected in

women who present with vaginal bleeding or abdominal pain or both, a
history of trauma, or those who present in otherwise unexplained preterm
labor. (Grade C)

Summary of evidence

The classically described symptoms of abruption placenta are vaginal bleeding

and abdominal pain but may occur with neither or just of one of these signs. It is
diagnosed clinically when 2 ot more of the following criteria are present:

1. Significant unexplained vaginal bleeding after 20 weeks of gestation

2. Uterine irritability manifested as high frequency uterine contractions or uterine
hypertonous.

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 3. Uterine tenderness or back pain – significant in the presence of sonographic
evidence of a posterior placent
4. Evidence of fetal distress on electronic fetal heart rate monitoring (EFM)

The severity of symptoms depends on the laceration of the abruption,

whether it is revealed or concealed, and the degree of separation. Admittedly, the
amount of bleeding may be a subjective estimate.

Typically there is uterine hypertonous with associated high-frequency, low-

amplitude uterine contractions occurring five or more times in ten minutes.
Likewise, it may manifest as baseline uterine tone that is excessive by palpation.

The uterus is frequently tender and may feel hard on palpation. The clinician,
though, must be careful to exclude local factors like costoverterbral angle
tenderness due to pyelonephritis or musculoskeletal pain. Backache may be the
only symptom, especially when the placental position is posterior.

There may be acute fetal distress, and in distress and in cases where more
than 50% of the placenta has separated, fetal demise. There is a correlation
between the extent of placental separation and the risk of stillbirth, with stillborn
still occurring in most cases in which there is greater than 50% placental
separation. Fetal distress may be manifested on heart rate monitoring as
repetitive late decelerations with loss of baseline variability, or sustained
bradycardia. (Level III)

2. Which clinical tests are useful in the evaluation of pregnant women

suspected of having abruption placenta?

The clinical tests most useful are the ultrasonographic examination of the
uterus and placenta and EFM. (Grade A)

Summary of evidence

Fetal heart rate patterns described in association with abruptio are recurrent
late or variable decelerations, reduced variability, bradycardia, or a sinusoidal
fetal heart pattern. (Level III)

The ultrasonographic appearance of abruptio depends to a large extent on

the size and location of the bleeding, as well as the duration between the
abruption and the time the ultrasonographic examination was performed.

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 In cases of acutely revealed abruption, the examiner may detect no abnormal
ultrasonographic findings. Nyberg and colleagues, in a retrospective cohort study
of images in 57 cases of abruption, found that the ultrasonographic appearance
of abruption in the acute phase was hyperechoic to isoechoic when compared
with placenta. Later on, as the hematomas resolved, they became hypoechoic
within 1 week and sonolucent within 2 weeks. In some cases, only a thickened
heterogenous placenta could be seen. Thus, it is important to realize that
abruption may have a variety of ultrasonographic appearance. (Level II-2)

Ultrasonography will fail to detect at least one half of cases of abruption.

However, when the ultrasonoram seems to show an abruption, the likelihood that
there is indeed an abruptio is extremely high. Importantly, a negative
ultrasonogram does not rule out an abruption. (Level II-2)

Yeo and colleagues, in prospective cohort study of 73 patients presenting

with vaginal bleeding in the second half of pregnancy, using 7 ultrasonographic
parameters, showed that the sensitivity of ultrasoubd for abruption placenta was
80% whereas specificity was 92%. Positive and negative predictive values were
95% and 69%, respectively.

These are the Ultrasonographic Criteria for Diagnosis of Abruptio

Placenta used:

1. Preplacental collection under the chorionic plate (between the placenta

and amniotic fluid)
2. Jello-like movement of the chorionic plate with fetal activity
3. Retroplacental collection
4. Marginal hematoma
5. Subchorionic hematoma
6. Increased heterogenous placental thickness (more than 5cm in a
perpendicular plane)
7. Intra-amniotic hematoma (Level II-2)

Ulrasonography may also predict prognosis in abruption. Nyberg and

colleagues in a retrospective review of 69 cases of abruptio, found that fetal
mortality correlated with the ultrasonographically estimated percentage of
abruption and with the location, with the worst prognosis occurring in
retroplacental abruptios. An important role of ultrasonography in evaluation of
bleeding in the second half of pregnancy is placental location; if there is a

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 placenta previa, it makes it less likely that abruption is the cause of the
bleeding. (Level II-2)

3. What other pregnancy conditions should be considered in patients

suspected of abruptio?

All other pregnancy conditions that can cause abdominal pain and
bleeding should also be considered. These include placenta previa,
appendicitis, urinary tract infections, preterm labor, fibroid degeneration,
ovarian pathology and muscular pain. The above mentioned and clinical
tests, correlated with good history and thorough physical examination, will
help make a proper diagnosis. (Grade C)

4. What is the optimal method of initial management of a patient with

abruption placenta?

It consists of stabilizing the pregnant patient, detecting any coagulation

derangement, and instituting monitoring methods to detect maternal as
well as fetal compromise. (Grade C)

Summary of Evidence

The following measures are intituted as recommended by the University of

Cincinnati Medical Center.

1. Nasal Oxygen
2. Intravenous hydration using large bore catheter
3. Type and crossmatch for 4 units of packed red blood cells
4. Evaluation of hematologic and clotting studies (complete blood clount,
prothrombin time, partial thromboplastin time, fibrinogen, platelet count)
5. Monitoring of urinary output with indwelling bladder catheter
6. Continuous electronic fetal heart rate and uterine activity monitoring
(Level III)

It is important to stabilize the patient and to correct any coagulation

derangement before and during delivery or surgery. It is prudent to involve an
anaesthesiologist in the early care.

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 At present, opinion on the management of abruptio range from a conservative
approach to a more aggressive approach of immediate delivery by CS in all but
the mildest cases. Some authors have suggested that ―intensive fetal monitoring
and a readiness to do a CS for the sake of the fetus alone‖ may result in
improvement of fetal survival. (Level III)

5. When is immediate CS indicated in patients with abruptio placenta?

At term or near term with a live fetus, prompt delivery is indicated once
there is evidence of fetal compromise, severe uterine hypertonous, life-
threatening vaginal bleeding or DIC when vaginal delivery is not imminent.
CS should be performed promptly because of total placental detachement
could occur without warning. (Grade B)

Summary of Evidence

In a case control study examining the relationship between decision-to-

delivery and perinatal outcome in 33 patients with clinically overt abruption and
fetal bradycardia, Kayani and colleagues found that longer decision-to-delivery
interval of 20 minutes or less was associated with substantially reduced neonatal
morbidity and mortality. (Level II-2)

6. Is there room for expectant management in abruptio placenta?

Expectant management is an option when both maternal and fetal status

are reassuring or when there is fetal demise as long as the mother is
stable. (Grade B)
Summary of Evidence

It is important to individualize management on a case-by-case basis. More

aggressive management, desirable in cases of severe abruptio, may not be
appropriate in milder cases. The proper choice depends on the presentation, the
gestational age, and the degree of maternal and fetal compromise.

When both maternal and fetal status is reassuring, conservative

management, with the goal of vaginal delivery, is reasonable. Near term, labor, is
established, should be allowed to progress; otherwise induction of labor should
be considered. Both mother and fetus should be monitored closely during labor.
(Level III)

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 In severe abruption with fetal death, regardless of gestational age, expectant
management is acceptable as long as the mother is stable. When the fetus is
dead or previable, there is no evidence that establishing an arbitrary time limit for
delivery is necessary. Experiences at both the University of Virginia and Parkland
Hospitals indicate that maternal outcome depends on the diligence with which
adequate fluid and blood replacement therapy is pursued rather than the interval
to deliver. At the University of Virginia Hospital, women with severe abruptio
placenta who were transfused for 18 hours or more before delivery experienced
complications that were neither more numerous nor greater in severity than the
group in which delivery was accomplished sooner. (Level II-2)

7. Is there room for a conservative approach when there is abruption

placenta in very preterm pregnancies (20-34 weeks gestation)?

When there is only partial abruption placenta and the maternal and fetal
status are reassuring, the patient may be managed conservatively. (Grade
B)

Summary of Evidence

Preterm birth is the leading cause of perinatal death in women with abruptio,
and to optimize perinatal outcomes, it is desirable, if possible to prolong
gestation. Extremely close fetal monitoring is necessary because there is a
significant risk of fetal death. Steroids should be administered to promote fetal
lung maturation. Serial ultrasonography is recommended to evaluate progression
or regression of the abruptio.

Initial hospitalization for further evaluation and assessment of fetal well-being

is reasonable. Prolonged hospiatalization and monitoring may be necessary. It
may be possible to discharge these patients for outpatient management of the
fetal status is reassuring once they have remained stable for several days.
Patient should, however, be delivered in a center with adequate neonatal
facilities and the parents should be counselled by a neonatologist regarding
potential treatments and outcomes for the neonate. (Level III)
8. Are tocolytic agents a safe option in the management of abruptio
placenta in pregnancies very far from term?

It seems reasonable to use tocolytics with caution in stable women who

have partial abruptio placenta but are remote from term. (Grade B)

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 Summary of Evidence

It has been generally taught that tocolytics, specially α-sympathomimetics

such as terbutaline are contraindicated in the presence of vaginal bleeding,
because side effects such as tachycardia could mask the clinical signs of blood
loss.

Sholl in a retrospective cohort and case- control study, evaluated the safety of
tocolytics (including intravenous magnesium sulfate and α-sympathomimetics) in
the presence of bleeding in the second half of pregnancy, including patients with
suspected stable abruptio placenta. They concluded that tocolysis for the preterm
patients appeared to be beneficial in prolonged gestation and did not increase
the likelihood of caesarean delivery, hemorrhage, or fetal demise. (Level II-2)

Bond and colleagues expectantly managed 43 women with clinical evidence

of abruptio placenta before 35 weeks of gestation, using tocolysis in cases of
where there were contractions. There were no intrauterine deaths. They
achieved a mean latency period to delivery of 12.4 days (Level II-2)

Towers and colleagues reviewed 236 cases if third trimester bleeding, which
included 131 cases of abruptio placenta, with a mean gestational age of 28.9
weeks at the time of first bleeding. In 95 (73%) of these women, tocolysis had
been used. The mean time for bleeding until delivery was 18.9 days. Fetal
mortality was related prematurity and no adverse maternal or fetal effects of
tocolysis occurred. (Level II-2)

9. Are the patients with abruptio placenta at increased risk for adverse
pregnancy outcomes in future pregnancies?

There is a ten-fold increased risk of abruptio in a subsequent pregnancy

and likewise an increased risk of other adverse pregnancy outcomes,
including preterm birth and preeclampsia. Patients will also have an
increased risk of uteroplacental perfusion. (Grade A)

Summary of Evidence

In a records review of births in Norway from 1967 through 1992, Rasmussen

and co-workers studied deliveries occurring immediately after an index case of
abruptio placenta and were able to identify 3074 non-abruptio births and 139

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 cases of recurrent abortions. They also found an increased risk of small for
gestational age babies, preterm birth, pregnancy induced hypertension (PIH),
and perinatal death in immediate subsequent deliveries.

Results were interpreted as epidemiological evidence for the hypothesis

that PIH, intrauterine growth restriction, preterm delivery and abruption placenta
all share an etiolgicval factor or represent clinical expressions of recurring
placental dysfunction. Histopathologic studies demonstrated lesions that
indicated placental dysfunction (such as acute atherosis in uteroplacental arteries
and excess of decidual vascular lesions) and it was suggested that these can
recur in subsequent pregnancies.

Although no interventions have been demonstrated to reuce this risk some

recommendations are possible. Hypertension should be controlled before and
during the subsequent pregnancy. Women who smoke tobacco or use cocaine
should be counselled on the adverse effects of exposure to these pregnancies, it
will be reasonable to consider serial growth scans every 4 weeks in the second
half of pregnancy.

Where the mother has had two or more prior abruptions, amniocentesis
for lung maturity and delivery at about 37 weeks gestation should be seriously
considered

Summary

There are no randomized controlled trials (RCT) that have specifically examined
abruption and the overwhelming majority of studies are observational (cohort, case
control or case series). Studies that have examined management strategies are
typically limited by small numbers. Levels of available evidence for the diagnosis and
management of abruption are mainly II-1, II-2 and III.

Abruption placenta remains an important cause of perinatal mortality and

morbidity. Perinatal mortality is determined by the severity of the abruptio and the
gestational age at which it occurs. Unfortunately neither accurate prediction nor
prevention of abruption is possible at the present timer. Despite advances in medical
technology, the diagnosis of abruptio is still a clinical one. When abruption does occur,
there are some strategies that may help minimize the risk of morbidity and mortality
associated with this condition.

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 These include early recognition and prompt delivery in cases in which the fetus is
mature and, in stable cases remote from term, conservative management to enable
steroid administration, allow transfer to a center with facilities for care of the preterm
infant, and in some cases, permit fetal maturation before delivery. Finally, close
attention to maternal condition, with replacement of blood and blood products as
indicated, may improve outcomes for the mother.
With assurance of fetal wellbeing and in the absence of other obstetric indications for
CS, studies suggest that more than 50% of patients diagnose to with abruptio may
deliver vaginally with good neonatal outcome. Performing immediate CS on all patients
with diagnosis would result in an unnecessary high CS rate and may not improve
neonatal outcome.

The following are algorithms fro management of abruption placenta from Oyelese
which may be useful in the Philippine Setting.

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*Algorithm for the management of placental abruption in term or near term and preterm
births. In all case, complete blood count and coagulation indices should be checked;
blood or blood volume should be replaced; coagulopathy should be corrected; and
intake, output and renal function should be monitored.

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 PLACENTA PREVIA
Blanca C. De Guia, MD, MSc

Background

Placenta Previa is defined as a placenta implanted in the lower segement of the uterus,
presenting ahead of the leading pole of the fetus. Maternal and fetal morbidity and
mortality from this are considerable.

It involves implantation of the placenta over the internal cervical os. Variants include:
1. Complete implantation over the os (complete placenta previa)
2. A placental edge partially covering the os (partial placenta previa)
3. Placenta approaching the border of the os (marginal placenta previa)
4. A low lying placenta implants within 2-3 cm from the os

Pathophysiology
Placental implantation is initiated by the embryo (embryonic plate) implanting into the
lower uterus. A defective decidual vascularization occurs causing adherence over the
cervix., possible secondary to inflammatory or atrophic change. When the lower
segment develops in the third trimester, bleeding occurs with disruption of placental
attachment in this area. Thrombin release from the bleeding sites promotes uterine
contractions and a vicious cycle of bleeding – contrations – placental separation –
bleeding occurs.

Frequency
Placenta previa occurs in 0.3%-0.5% of all pregnancies. The perinatal moratality
associated with it ranges from 2-3% and the maternal mortality (US) is 0.03%.
The maternal morbidities include anterpartum bleeding, need for hysterectomy, blood
transfusion, septicemia and thrombophlebitis.

Risk Factors
These include advancing age, multiparity, infertility treatment, multiple gestation,
erythroblastosis, prior uterine surgery, recurrent abortions, nonwhite ethnicity, low
socioeconomic status, short interpregnancey interval, smoking, cocaine use and others
(digital exam, abruption, and trauma).

Diagnosis
Clinical history

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 The classic presentation of placenta previa is pailess vaginal bleeding. Nearly
two-thirds of symptomatic patients present before 36 weeks, with half presenting before
30 weeks.
This hemorrhage stops spontaneously and recurs with labor.

Physical examination
Any pregnant patient beyond the first trimester who presents with vaginal
bleeding requires a speculum examnination followed by diagnostic ultrasound.
A digital examination is absolutely contraindicated until placenta previa is
excluded. Concurrent uterine contractions have to be monitored as 20% developed
these with bleeding

Laboratory Work-up
Complete blood count with platelets blood typing are important.

Recommendations :
1. What is the best way to diagnose placenta previa?

Transvaginal ultrasound is safe in the presence of placenta previa, and is

more accurate than transabdominal ultrasound (TAS) in locating the
placenta. (Grade A)

Summary of Evidence
The only randomized controlled trial (RCT) to date comparing TVS and
TAS confirmed that TVS is more beneficial. TVS has also been shown to be safe
in the presence of placenta previa even in the presence of vaginal bleediong.
TAS is associated with false positive rate of up to 25%. Accuracy rates for
TVS are high (sensitivity 87.5%, specificity 98,8%, positive predictive values
93.3%, negative predictive value 97.6%), establishibng TVS as the gold standard
for the diagnosis of placenta previa (Level I)

2. What are the conditions that can lead to false positive diagnosis of
placenta previa sonographically?
These are:
- Overdistended bladder
- Myometrial contractions (Grade C)

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 Summary of Evidence

Overdistention of maternal urinary bladder places pressure on the anterior

aspect of the lower uterine segment, compressing it agains the posterior wall and
causing the cervix to appear elongated. Thus the normal placent a may appear to
overlie the internal os. If the cervical length further exceeds 3-5 cm length,
imaging should be done after the patient emptied her bladder.

During myometrial contractions, two situations that assume placenta

previa may occur. First, the wall of the uterus may thicken and imitate placental
tissue, Second, the lower uterine segment may shortren and bring the inferior
edge of the placenta into contact with uterine cervical os. A contractionjn should
be suspected if the myometrium is thicker than 1.5 cm. Repeat ultrasound after
30 minutes may exclude this conditions (Level III)

3. What is the value of Magnetic Resonance Imaging (MRI)?

In most situations, MRI is no more sensitive than ultrasonography on

diagnosing placenta accrete, which is usually associated with placenta
previa. For women at high risk for placenta accrete, a 2 step-protocol that
uses ultrasonography first and then MRI for cases with inconclusive
ultrasonographic features may optimize diagnostic accuracy. (Grade C)

Summary of Evidence
MRI may be used for planning the dfelivery as it helps identify placenta
accrete, increate or percreta. MRI may be superior for the posterior placenta
accrea or the more invasive increta and percreta as thes abnormally adherent
placentas are closely associated with placenta previa. (Level III)

4. How should sonographic findings for placental location be

interpreted/reported?

Sonographers at TVS are encouraged to report the actual distance from the
placenta edge to the internal os, using standard terminology starting at 18
weeks of gestation.

A placental edge may exactly reaching the internal os is

described asw 0mm.

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 Placental edge may extend from 0 mm and 20 mm away frpm
the os.
Placental edge may extend from 0 mm to 20 mm beyod the os
and maybe reported as mm overlap. (Grade A)

Summary of evidence

There are several studies that have examined various distance of overlap
(MM) at 18-23 weeks gestation and the persisitence of placenta previa.

The likelihood of persistent placenta previa was effectively zero at term

when the placental edge reached but did not overlap the os (0mm) at second
trimester scan.

It increased significantly beyod 15 mm overlap such that a distance of >25

mm overlap had a likelihood of placenta previa at delivery between 40% and
100% (Level II-2)

5. How should one proceed after placental localization at the second

trimester?

When the placental edge lies between 20 mm toward from the internal os
and 20 mm overlap at second trimester, ultrasound should be repeated at
regular interval depending on the gestational age, distance from the
internal os, and clinical features such as bleeding, because continued
change in placental location is likely.

Overlap of 20 mm or more at anytime in the third trimester is highly

predictive of the need for caesarean section (CS).

Summary of Evidence

The process of placenta ―migration‖ or relative upward shift of the placenta

due to differential growth of lower segment is continuous unto the late third
trimester.

In a study of 26 patient scanned at a n average of 29 weeks, with the

placenta lying between 20 mm toward from the os and 20 mm overlap, 3 (1.5%)
required CS at delivery.

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 At 35 weeks, when the palcenta lie between 20 mm toward from the os
and 20 mm overlap, CS ranged from 40-90%. This shows that persistence of
placenta previa at 35 weeks results in more CS> (Level III)

6. Is vaginal delivery possible with placenta previa?

The os-placental edge distance on TVS after 35 weeks is valuable in

planning route of delivery.

When the placental edge lies >20 mm away from the internal os, women
may go into labor with a high expectation of success.

A distance of 20 mm to 0 mm from the os is associated with a high CS rate,

although vaginal delivery is still possible depending on the clinical
circumstances (Grad A)

Summary of Evidence

Five studies have examined the likelihood of vaginal delcviery for placenta
previa on the basis of distance to the placenta edge on last ulatrasound prior to
delivery. At 35-36 weeks gestrational age, a distance of >20 mm aqway from the
os was associated with high likelihood of vaginal delivery (range 63-100%).
Between 20 mm and 0 mm from the os, CS varies from 40-90%. (Level II-2)

7. When is CS indicated?

In general, any degree of overlap (>0mm) after 35 weeks is an indication for

CS as a route of delivery. (Grade B)

Summary of Evidence

When the placenta overlaps the os by any amount on the last scan at 35 weeks,
CS is required in all cases.

8. What are the risk factors for massive haemorrhage during CS in patients
with placenta previa?

Advanced maternal age, previous CS, and presence of sponge-like

sonographic features in the cervix are risk factors for massive bleeding

20
 during CS in cases of placenta previa regardless of whether adherence is
present.
In addition, ultrasound findings of placent located on the scar of a previous
CS and lack of clear zone are risk factors for placental adherence.

When these findings are identified preoperatively, management should be

tailored to account for the risk of massive intraoperative bleeding and a
multidisciplinary team alerted and prepared for intensive treatment. (Grade
A)

Summary of Evidence

In a study of 127 singleton pregnancies who had CS for placenta previa,

logistic regression analysis revealed that advanced maternal age (OR 5.4; 95%
CI 1.8-16.4), previous CS (OR 20.4%; 95% ci 4.0-105.2), and spongelike findings
in the cervix (OR 5.6; 95% CI 1.8-17.0) were associated with massive bleeding
(>2500 ml),
Placental adherence occurred in 5 cases and was more frequent in cases
where the placenta was located at the area of the scar of a previous CS (OR
123.1; 95% CI 4.5-3395.2) and where there was lack of a clear zone (OR 480;
95% CI 38.0-604.7) (Level II-C)

9. Is placenta previa associated with placenta accrete, increta or percreta?

Placenta accrete, increta or percreta may co-exist with placenta previa.

Women who have placenta previa with or without a CS scar should be
considered at high risk of having a morbidly adherent placenta.

Attention then should be focused in confirming this diagnosis using

ultrasound and when present, senior anesthetic and obstetric input are
noted in planning the deliver. (Grade A)

Summary of Evidence

The association between placenta previa and placenta accreta is strong,

with RR of 2.065 compared to a normally-located placenta. Placenta previa is
also associated with scarring of the lower segment of the uterus, and the risk of
placenta previa rises relative to the number of previous uterine incisions. (Level
II-2)

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10. Is tocolysis indicated in the treatment of uterine contractions in the
presence of bleeding due to placenta previa?

Tocolysis for treatment of uterine contractions in the presence of bleeding

due to placenta previa may be useful. (Grade B)

Summary of Evidence

The etiology of bleeding in placent previa is thought to be due to the dynamics of

the development of the lower uterine segement, but may also be triggered by
uterine contractions. Besinger, et. al. conducted a prospective study on 112
women with acute vaginal bleeding and known placenta previa and gave
tocolysis to 72 who had significant uterine activity (88%). This group of patients
had a prolongation from admission to delivery interval (39.2 vs 26.9 days, p
>0.02) and an increase in birthweight (2520 vs 2124 g, p<0.03) compared to 40
women who were not given tocolysis. The largest series of cases where tocolysis
has been used for bleeding in the third trimester including 76 of 105 women with
placenta previa is reported in a retrospective review by Towers, et. al. and has
suggested no increased morbidity or mortality associated with such use in a
tertiary setting. (Level II-C)

11. Is out patient management of placenta previa possible?

Outpatient management of placenta previa maybe appropriate for stable
women with support, close proximity to a hospital, and readily available
transportation and communication. (Grade C)

Summary of Evidence

Twenty-seven women were randomized to bed rest with minimal

ambulation to hospital and 26 women were discharged home. Overall, there was
no difference in any major outcome. (Level II-C)

12. Is it better to give regional anesthesia?

Regional anesthesia maybe employed for CS in the presence of placenta

previa. (Grade C)

22
 Summary of Evidence

Two retrospective studies concluded that regional anesthesia is safe and

one small randomized trial suggests epidural anesthesia is superior to general
anesthesia with regards to maternal hemodynamics. (Level II-2)

13. What are some good practice recommedations in the management of

placenta previa?

Suggestions for good practice recommendation include:

o Prior to delivery, all women with palcenta previa and their
partners should have had antenatal discussions regarding
delivery and possible blood transfusion.
o Blood should be available in the peripartum period.
o In any case where a woman with placenta previa is being
delivered, the consultant can call or a senior resident should
be involved.
o Any woman going to the operating room with known placenta
previa should be attended by an experience obstetrician and
anesthesiologist. This is especially true for those women with
higher risk of complications namely previous uterine scars,
anterior placenta previa or associated placenta accrete. (Grade
C)

14. What are some related issues to provide total care to the patient?

To provide total care, the following are recommended:

o Screening for infection
o Use of antenatal corticosteroids in preterm labor
o Thromboprophylaxis for any woman at increased risk of
thromboembolism. (Grade C)

15. What are some auditable standards in the management of placenta previa?
All women with massive haemorrhage with or without placenta previa
should be subjecte4d to clinical audit.

o Anticipation of haemorrhage with adequate workshop

o Appropriated personnel involvement
o Quick and effective resuscitation including blood and blood
components

23
o Appropriate monitoring instituted
o Discharge hemglobin
o Careful documentation (Grade C)

24
 PLACENTA ACCRETA
Angelito r. Teotico, MD

Placenta accreta refers to abnormal adherence of the placenta top the uterus
with subsequent failure to separate after delivery of the fetus. It results when the
0placenta adheres to the uterine wall because of abnormal development of the decidua
basalis and imperfect development of the fibrinoid layer allowing the trophoblasts, which
have tissue-invasive c characteristics similar to malignant neoplastic cells, to break the
barrier and invade the myometrium, serosa and infiltrate event the neighbouring organs
such as urinary bladder and the bowels.

Placenta accrete is a potentially catastrophic obstetric complication. Its most

significant feature is a tremendous uteroplacental neovascularization whi9ch causes life
threatening haemorrhage. Careful assessment of pregnancies at risk is warranted
because maternal morbidity and mortality from this condition are considerable. Prenatal
diagnosis is important to establish an appropriate management plan to help reduce
serious complications.

It has emerged as one of the common indications for emergency peripartum

hysterectomy and therefore, all obstetric care providers must be ready to handle this
obstetric emergency.

There are 3 types depending on the depth of invasion:

Placenta Accreta Vera (75%) –chorionic villi penetrate the decidua but not the
myometrium
Placenta Increta (15%) – chorionic villi penetrate and invade deeper into the
myometrium but not the serosa
Placenta Percreta (5%) – chorionic villi penetrate through the myometrium, may
perforate the serosa and extend to adjacent structures like the bladder of the bowels

There are 3 types depending on the number of cotyledons involved:

Total Placenta accreta, adherence involve all of the cotyledons

Partial placenta accreta, adherence involve few to several cotyledons
Focal placenta accreta, adherence involve a single cotyledon

25
Recommendations

1. What is the current trend in the incidence of placenta accreta?

The incidence of placenta accrete has increased 10 fold in the past 50

years and this attributed to the rapidly rising numbers of primary and
repeat caesarean births. Placenta accrete is an obstetric complication
directly related to uterine surgery. This information must be included in the
informed consent particularly those caesarean delivery on maternal
request.

Summary of Evidence

Reports in the literature have shown an increasing trend over the years from
1/30,000 in 1930’s, to 1/20,000 in 1960s , to 1/7,000 in 1980s. Miller and
colleagues reported an incidence of histologically confirmed placenta accrete of 1
in 2510 for a 10 year period ending in 10994. (Level III)

In a case control study made by Wu, which is a twenty year analysis of

abnormal placentation from 1882 – 2002 involving 64,359 deliveries, the overall
incidence of placenta accrete was reported at 1 in 533. In this study, the rate of
placenta accreta inccre4ased in conjunction with caesarean deliveries.

In a review of our local statistics, the incidence of placenta accrete has

increased from 1/6000 in 2002 to 1/3500 in 2005 to 1/2000 in 2007. This is
concurrent with an increasing caesarean section (CS) rate of 16%,k 26% and
30% in the respective years.

The association of placenta accrete with caesarean delivery must be made

known to patients seeking CDMR as this condition poses a risk to future
pregnancy. (Level III)

2. How does placenta accrete affect the mother?

Placenta accreta has emerged as a significant indication for peripartum

hysterectomy alongside the rising CS rate. This condition can lead to
massive obstetric haemorrhage, disseminate4d intravascular coagulopathy
(DIC), visceral injury, acute respiratory distress syndrome (ARDS), renal
failure, infection and death. Whenever this condition is suspected, a

26
management plan should be carefully formulated to maximize outcome for
both the fetus and the mother.

Summary of Evidence

In a retrospective cohort study from 1966-2005 by Flood comparing

decades 1966 – 2005, it was reported that the indications for peripartum
hysterectomy have changed significantly with uterine rupture decreasing from
40.5 – 9.3% (P<.0001) and placenta accrete increasing significantly from 5.4 –
46.5% (P<.0001). During the 2 decades, the overall CS rate has increased from
6-19% and the percentage of peripartum hysterectomy that occurs in the setting
of a previous CS has also increased from 27-57 % (P<.0001) (Level 2)

Other authors have reported placenta accreta to comprise 30-50% of their

peripartum hysterectomy and previous CS was a common factor.

Significant haemorrhage and severe maternal morbidity at the time of delivery

are c common in cases of placenta accrete. The bleeding may become massive
in cases of placenta percreta. Todd reported 33 cases of placenta
accrete/percreta managed in his center between 2001-2006 all managed by
hysterectomy, Blood loss during surgery ranged between 2500-5000m:,
necessitation transfusion of 3-29 units of packed red blood cell( RBC). Admission
to intensive care unit (ICU) was required for 51.6% of cases and 29% had
intraoperative while 40% had postpartum complications.

The feared increase in maternal deaths because of placenta accrete was not
observed in a study done by Clark in his review of maternal deaths between
2000-2006. In a series of 1.5 million deliveries, the author saw only 1 death from
placenta accrete. This could be attributed to the improved diagnostic and
management technologies in his center. (Level III)

In a review of our local statistic covering the period between 2002 – 2007,
there were 41 maternal deaths due to placenta accreta out of 1.48 million
deliveries, although there was a noticeable decrease from 8 cases (5.41% of
direct maternal death) in 2002 to only 2 cases (0.56% of direct maternal death)
in 2007. This could be attributed to increased clinician’s awareness, improved
diagnosis and management.

27
 3. How does placenta accreta affect the fetus?

Pregnancies complicated by placenta accreta are at increased risk

for adverse perinatal outcome resulting from preterm deliveries and
restricted fetal growth. Therefore, whenever placenta asccreta is being
considered, close antenatal fetal surveillance must be conducted. Giving
corticosteroids to enhance pulmonary maturity should be considered in
anticipation of an iatrogenic preterm delivery. (Grade B)

Summary of Evidence

Because placenta accrete is characterized by an abnormal placental

implantation, it may be assumed that fetal development would also be affected.

In a case control analysis conducted by Gielchinsky involving 34,450

deliveries in which 310 cases of placenta accrete were diagnosed, they found a
significant increase in preterm deliveries and small for gestational age babies.

4. Why should we screen for placenta accreta antenatally?

Antenatal diagnosis of placenta accrete may result to better maternal

outcome as there will be enough time to establish an appropriate
management plan and prepare surgery. (Grade B)

Summary of Evidence

Antenatal diagnosis is the key to a successful management outcome in

placenta accrete. This allows enough time to make multidisciplinary management
plan that is most appropriate for the patient.

The effect of antenatal diagnosis and subsequent placental non separation at

delivery on maternal outcome was evaluated by Wong in 16 confirmed cases of
placenta accrete (15 histologically and 1 visually).

Antenatal diagnosis and placental nonseparation resulted lower mean blood

loss (1.4 L vs 3.6L, p= 0.003) and lesser amount of blood transfused (1.2 vs 5.1,
p = 0.005). When an antenatal diagnosis was not made, attempted placental
separation led to emergency hysterectomy. (Level III)

28
 5. Who should be screened for placenta accreta?

All women with placenta prevail and a previous uterine surgery should
be screened for placenta accrete. The major risk factor is a combination of
placenta accrete. The major risk factor is a combination of placenta prevail
and a previous CS and the risk for prevail-percreta increases
proportionately with the number of CS. Whenever placenta prevail and a
previous uterine surgery co-exist diagnosis of placenta accrete must be
established antenatally. When antenatal diagnosis is not conclusive or not
possible, these women should still be managed as if they have placenta
accrete.

Placenta prevail with or without uterine surgery and advance maternal

age are independent risk factor for placenta accrete. Other risk factors
include prior myomectomy or reconstructive surgery, Asherman’s
syndrome, submucous leiomyomata and multiparity (gravida 6 or more). All
women with these risk factors must also be screened for placenta accrete.
(Grade B)

Summary of Evidence

CS is a well-established risk factor for abnormal placentation, both for

placenta prevail and placenta accreta. The exact mechanism is unknown. It is
hypothesized that the early embryo implants preferentially into areas of uterine
scarring and deficient decidua because of relative deficiency of blood flow and
oxygen tension in this area with the trophoblasts invading deeply into the
myometrium resulting to placenta accrete. In a large prospective observational
study, the centers of Maternal and Fetal Medicine Units (MFMU) Network
evaluated the risk of placenta accrete with increasing number of CS. In 143
cases of abnormal placentation among 30,132 caesarean deliveries, the
investigators found that the risk of abnormal placentation increased dramatically
with e4ach caesarean delivery particularly after the third CS. The risk of
abnormal placentation increased even more dramatically with each previous CS
in the presence of placenta previa. (Table 1)

29
 Table 1 Risk of abnormal placentation by number of previous caesarean
deliveries

No. of prior caesarean Abnormal placentation Previa accrete %

deliveries (n-143) 9n=91)
0 0.2 3.3
1 0.3 11
2 0.6 40
3 2.3 61
4 2.3 67
5 or more 6.7

Table 2. Risk of placenta accrete relative to uterine scarring and presence of

placenta prevail
No. of prior caesarean Incidence of placenta Incidence of
deliveries prevail concurrent placenta
prevail
0 0.26 5
1 0.65 24
2 1.8 47
3 3.0 40
4 10 67

A deficienc6y of decidualization may contribute to the development of

abnormal placentation. Placenta prevail itself raises the risk of placenta accrete
due to implantation over a high vascular, poorly contractile lower uterine segment
and an existing scar in the same area compounds the risk. Clark and colleagues,
in a single center study showed the effect of previous CS on the incidence of
placenta previa and accreta. (Table 2)

In a twenty-year analysis of abnormal placentation, a retrospective case

control study by Wu, significant risk factors for placenta accrete identified
included advance maternal age >35 years old ( OR 1.13, 95% CI 1.089- 1.194,
P<.0001), 2 or more CS (OR 8.6, 95% CI .536- 21.078. P<.0001) and presence
of placenta prevail (OR 51.4, 95% CI 10.65-248.39, P<.0001) (Level III). Other
risk factors for placenta accreta include Asherman’s syndrome, submucous
myomas, uterine surgeries and multiparity. All of these factors distort the uterine
cavity and endometrial environment. Multiparity and advance maternal age in
some way alter the nature of the endometrium, thereby increasing the risk of
abnormal placentation.

30
 6. How do we screen and diagnose placenta accreta antenatally?

The main screening modality used to make an antenatal d8iagnosis of

placenta accrete is gray scale ultrasound imaging combined with clinical
risk factors. (Grade B)

Diagnosis can be established by gray scale ultrasound combined with

Colour and Power Doppler ultrasound to increase accuracy of diagnosis.
Magnetic resonance imaging (MRI) must also be considered when results
of gray scale and Color Doppler are equivocal and non-conclusive or when
the placenta is posteriorly implanted.

Summary of Evidence

Antenatal diagnosis of placenta accrete should begin with a high index of

suspicion in women having risk factors. All women with placenta prevail and
previous CS ( being the most frequent predisposing factors must have an
ultrasound exam to screen for placenta accrete.

Diagnosis of placenta accrete can be established using gray scale ultrasound

combined with Color and Power Doppler.

Gray-scale sonographic signs of placenta accrete are:

1. Loss of normally visible retroplacental hypoechoic zone, which

corresponds to the decidua basalis, myometrium and dilated venous
channels

2. Progressive thinning of the retroplacental hypoechoic zone to <2

mm on serial exams
3. Presence of multiple placental lakes that represent dilated vessels
extending from the placenta through the myometrium fiving the placenta the
so-called ―Swiss cheese‖ appearance

4. Thinning or focal disruption of the uterine serosa-bladder wall

complex ( placenta percreta)

5. Focal mass-like elevation of tissue with the same echogenicity as

the placenta beyond the uterine serosa (placenta percreta)

31
 Using the above criteria, Frinberg reported a sensitivity of 93% and a
specificity of 79% for the use of ultrasound in diagnosing placenta accrete in
high risk patients. Many studies have found at 15-20 weeks of gestation, that
the presence of lacunae in the placenta is the most predictive sonographic
sign of placenta accrete, with a sensitivity of 79% and a positive predictive
value of 92%. After 20 weeks of gestation, the sensitivity of these findings
increases with values of 93% and 80% for lacunae and obliteration of the
retroplacental clear space, respectively.

Abnormal placental invasion induces angiogenesis resulting to

uteroplacental hyper vascularity. Color Doppler ultrasound has been utilized
as an aid in diagnosing placenta accreta because it highlights abnormal
areas of increased turbulent flow that may extend from the placenta into the
surrounding uterine wall and cervix.

Color Doppler signs suggestive of placenta accrete are:

1. Dilated vascular channels with diffuse lacunar flow pattern

scattered throughout the whole placenta and the surrounding myometrium
and cervix

2. A focal lacunar flow pattern showing irregular sonoluscent

vascular lakes with turbulent lacunar flow distributed regionally or focally
within the intraparenchymal placental area

3. Interface hypervascularity with abnormal vessels linking the

placenta to the bladder

4. Markedly dilated peripheral subplacental vascular channels

and pulsatile venous type flow over the cervix

5. Poor vascularity at sites of loss of hypoechoic zone

Chou, et. al. prospectively followed 80 women with placenta prevail using
transabdominal B-mode and Color Doppler ultrasonography with 17 cases of
accreta identified at delivery. Sixteen cases were suspected by Color Doppler, 14
of which were correctly diagnosed and 2 were false positives, while 3 cases were
not diagnosed giving a sensitivity of 82.4%, specificity of 96.8%, positive
predictive value of 87.5% and negative predictive value of 95.3%. (level II-2)

32
 A two stage imaging protocol to evaluate women at high risk for placenta
accreta has been proposed, consisting of an initial ultrasonography followed by
MRI when ultrasound features are inconclusive to optimize diagnostic accuracy.
In a historical cohort study conducted by Warshak, et.al. on 453 women with
placenta prevail, previous CS and low lying anterior placenta, ultrasonography
accurately predicted placenta accrete in 30 of 39 women and correctly ruled out
placenta accrete in 398 of 414 without placenta accrete (sensitivity 77%,
specificity 96%). Of the 42 women who underwent MRI, 23 of 26 cases were
correctly identified and 14 of 14 were ruled out (sensitivity 88%, specificity
100%).

Power and Color Doppler are often used for the diagnosis of placenta
accrete, demonstrating turbulent flow through placental lacunae. However, in the
majority of cases this imaging modality does not significantly improve the
diagnosis over that achieved by gray scale sonography alone. Thus, in majority
of clinical situations, Doppler should not be the primary technique used to
diagnose placenta accrete. In his report, the finding of ―numerous cohesive
vessels‖ visualized using 3D power Doppler in basal view was the best single
criterion for the diagnosis of placenta accrete with a sensitivity of 97% and
specificity of 92%.

MRI is also useful as an adjunct in the diagnosis of placenta accrete.

Diagnosis with high level of confidence can be achieved with this modality since
high signals from the placenta makes it easier to be distinguished from the
myometrium. A placental MRI provides a morphological description, as well as
topographical information that optimized diagnosis and surgical management.
This is particularly helpful in cases of posterior placenta where ultrasonographic
evaluation is difficult or to confirm bladder invasion. However, it is the
combination of different imaging modalities that may prove most effective in
diagnosing this condition.

7. How should we manage placenta accreta?

The management approach often recommended in cases of placenta

accreta is extirpative surgery but conservative management approach can
be done in selected case. (Grade B)

33
 Antenatal management

Counsel all patients with placenta accreta about delivery risks and
complications and future infertility if hysterectomy is performed. (Grade C)

Prepare team approach for delivery including a plan for emergent

surgery prior to scheduled delivery. Planning should include primary
obstetric surgeon, blood bank, primatologist anesthesiologist, gynecologic
oncologist, urosurgeon, labor and delivery nursing, operating room,
personnel, nursery and pediatric teams. (Grade C)
Ensure availability of adequate blood products (at least 4-6 units of
packed RBC fresh frozen plasma (FFP) and platelet concentrate at the time
of delivery. (Grade C)

Summary of Evidence

Providers caring for patients with prenatally suspected placenta accreta

should extensively counsel patients about potential risks and complications well
in advance of their estimated due date. Patients with accrete are at increased
risk for haemorrhage, blood transfusion, bladder/ ureteral damage, infection,
need for intubation, prolonged hospitalization, ICY admission, need for
reoperation, thromboembolic events and death. Discussions should involve
relative likelihood for hysterectomy and subsequent infertility.
A scheduled delivery is ideal, as it is associated with less intraoperative blood
loss than emergent delivery. In patients with strong suspicion for placenta
accreta it is strongly advised to perform the delivery prior to haemorrhage or
labor. Considerations should be given to performing the caesarean birth
electively and prematurely either after corticosteroids for fetal lung maturation or
after documentation of fetal lung maturity. The optimal timing of delivery is
unclear, some tertiary referral centers recommended 35-36 weeks and others 32-
34 weeks. The timing of delivery should be individualized. Bauer and colleagues
advocates early delivery typically at 34 weeks gestation after a course of
corticosteroid in cases of placenta percreta or in cases complicated by recurrent
antenatal bleeding. Patients at high risk for emergent delivery are patients with
recurrent vaginal bleeding. In a study by Eller, it was reported that women who
underwent scheduled CS hysterectomy had lower occurrence of ICU admission,
ureteric admission, intraabdominal infection, hospital re-admission and vesico-
vaginal fistula, than women who underwent emergency CS hysterectomy. (Level
III)

34
 A team approach and preoperative preparation is essential in anticipation of
extensive surgery which may be difficult. Preoperative planning must discuss
location of delivery, choice of anesthesia, type of abdominal incision and
management of the placenta. Incisions made through the placenta and attempts
to deliver it will often incite significant haemorrhage. Discussion by the operating
team should also incorporate patient’s wishes regarding conservative
management and future fertility.
Adequate blood product should be secured prior to delivery. Bauer, in his
center, prepares 20 units of packed RBC, 20 units of FFP, 6 packs of platelets
and 10 units cryoprecipitate. Use 1:1 ratio of packed RBC to FFP in cases of
massive haemorrhage.

8. Surgery in the presence of placenta accrete

If risk factors and prenatal imaging together strongly suggest this

diagnosis, CS hysterectomy is generally planned, especially for patients
who do not wish continued fertility. Profuse haemorrhage can occur when
attempting to separate the placenta, thus if the clinician is confident in the
diagnosis, it is prudent to proceed with hysterectomy with the placenta
attached. (grade B)

Uterine incision must be done away from the placenta. For the placenta
prevail accrete, incision must be a fundal classical incision, cutting thru
the placenta must be avoided. Ancillary procedures to lessen
intraoperative haemorrhage may be employed when feasible and available
like bilateral hypogastric artery ligation, internal iliac artery embolization,
common iliac artery balloon occlusion. (Grade B)

Summary of Evidence

The American College of Obstetricians and Gynecologists (ACOG) has

issued the following committee opinion on surgical management of placenta
accrete.

If the diagnosis of placenta accrete before delivery is suspected:

1. The patient must be counselled about the likelihood of hysterectomy and
blood transfusion.
2. Blood products and clotting factors should be available.
3. The appropriate location and delivery should be considered to allow
access to adequate surgical personnel and equipment.

35
 4. A preoperative anesthesia assessment should be obtained
5. If the diagnosis is made after a vaginal delivery when the placenta fails to
separate or when profuse bleeding is encountered selective.

Pelvic vessel embolization (if this is available) may be an alternative to hysterectomy.

The Royal College of Obstetricians and Gynecologists (RCOG) 31 issued the following
guidelines:

1. When placenta accrete is thought to be likely, consultant anesthetic and obstetric

input are vital in planning and conducting the delivery.
Crossed matched blood should be available and colleagues from other
subspecialties may be alerted to be standby to attend as needed.

2. In case of placenta accrete, increta and percreta, the risk of hemorrhage,

transfusion and hysterectomy should be discussed with the patient as part of the
consent procedure.

3. All Cs performed in women with placenta previa who had a previous CS

should be conducted by a consultant-obstetrician because of the high risk of major
morbidity.

A restrospective cohort study done by Eller involving 2 tertiary centers from

1996-2008 wherein 76 cases of placenta accrete were identified, showed that
scheduled CS hysterectomy without attempting placental removal was
associated with reduced rate of early morbidity compared with cases in which
placental removal was attempted (67 vs 36%, P=0.038). Women with
preoperative bilateral ureteric stents had a lower incidence of morbidity
compared with women without stents (18 vs 55%, P=0.018). (Level II-2)

Ancillary Procedures

Chou32 also reported the use of internal iliac artery embolization before
hysterectomy for placenta accrete in 6 cases and found a mean blood loss of 300-
3000ml but concluded that there is a need for further investigation of its effectiveness.
(Level III)

Another approach to minimize blood loss during hysterectomy and facilitate

surgery is the use of balloon catheter for occlusion and/or embolization of the pelvic
vasculature. To date however, the literature regarding this morbidity is limited. The
successful use of preoperative occlusive balloon catheters for CS hysterectomy has
been described in few case reports 33.

36
 However, in a case control study by Shrivastava34 involving 69 cases of
placenta accrete wherein 19 cases had balloon catheter plus hysterectomy while 50
cases had hysterectomy alone, difference in outcome between the 2 groups in terms of
blood loss (P=.79), transfused blood (P=.6), operative time (p=.85) and postoperative
hospital days (P=.85) were not significant. In this study, prophylactic intravascular
balloon catheters did not benefitwomen with placenta accrete undergoing hysterectomy.
(Level II-2)

Conservative management of placental accreta

Conservative management of placenta previa accretaca can be successful

in selected cases. It should be considered when fertility is desired, the condition
for extensive surgery is not optimum or in severe invasion like placenta percreta.
However, his must b considered only when the women are hemodynamically
stable. Conservative approach may involve leaving the placenta in situ or giving
methotrexate (MTX) therapy. No standard dose for MTX has been recommended
and certain guidelines must be followed when this modality is chosen.
Management modalities should be individualized and patients should be carefully
selected. (Grade B)

For focal accrete, a wedge resection of the area can be performed followed
by repaired of myometrium. (Grade B)

Summary of Evidence

Conservative management of placenta accreta involves different management

strategies which include, the following: leaving the placenta in situ, uterine artery
embolization, internal iliac artery ligation as initial surgery, and MTX therapy to dissolve
the placenta. Conservative management approach preserves fertility and in selected
cases of severe invasion like placenta percreta, this approach may even reduce
maternal morbidity from massive hemorrhage and blood transfusion.

Leaving the placenta in situ

Kayem, et al. compared the impact of conservative and extirpative strategies for
placenta accrete on maternal morbidity and mortality in a retrospective review of 33
cases and found a reduction in the hysterectomy rate (from 11,84.6% to 3, 15%;
P<.001), blood transfusion (3.2 L vs 1.5 L (P<.01) and DIC (5, 38.5% vs 1, 5%, P=.02).
(Level III)

37
 Conservative management of leaving the placenta in situ involves the following
steps: 35

1. The precise position of the placenta determined by ultrasound.

2. CS planned, with the abdominal incision at the infraumbilical midline, enlarged
above the umbilicus.
3. A vertical uterine incision carried out at a distance from the placental edge.
4. After delivery of the infant, delivery of the placenta ttempepted prudently, with the
injection of 5IU oxytocin and moderate cord traction.
5. If the placenta failed to separate, this is considered placenta accrete and left in
situ.
6. The cord cut at the placental insertion and left in the uterine cavity and the
uterine incision closed.
7. Prophylactic antibiotic therapy (amoxicillin and clavulanic acid) administered
systemically for 0 days.
8. Postoperative follow up including weekly examination for 6 months with
ultrasonography, clinical examination and blood count.

There are several case reports on leaving the placenta in situ without giving MYX.
There are 36 reported a case of placenta previa-percreta with bladder invasion. Surgery
was done at 36 weeks, leaving the placenta in situ followed by embolozation.
Postpartum course was uneventful, HCG dropped to <2U/L at 13 weeks postpartum.
The placenta passed out partially and the rest involuted. Uterus retuned to normal on
the 5th month. Tong17 reported3 cases of placenta accrete managed conservatively in
different strategies: (1) placenta left in situ followed by uterine artery embolization, (2)
placenta left in situ followed by MTX therapy, (3) focal area of accrete managed by
under running sutures. One patient had sepsis managed with antibiotics. In all cases,
balloon occlusion catheters were inserted in the bilateral internal arteries. (Level III)

Medical management with MTX

Conservative approach can also be done by medical management using MTX, a

folic acid antagonist that inhibits DNA synthesis and cell reproduction, primarily in
actively proliferating cells. It is possible that MTX hastens placenta dissolution. Several
case reports have documented decreases placental size and vascularity to complete
dissolution. 38-40. Local literature also reports successful outcome on MTX therapy
given weekly at 50 mg IM for 4-6 doses. 4,41 (Level III)

38
 Guidelines for medical management include the following:

1. The cord and membrane should be ligated as high as possible.

2. Broad spectrum antibiotics, for prophylaxis, and oxytocin should be administered
during the initial 72 hours.
3. Ultrasound should be performed daily to monitor involution and placental
vascularity, which should decrease over time.
4. 4 if HCG plateaus, placental vascularity persists, or placental involution stalls
after the initial 72- hours period, MTX should be administered (1mg/kg) on
alternate days for a total of 4-6 doses.
5. Medical management should be stopped if liver function test are 2 or more times
the normal value or there is evidence of thrombocytopenia (platelet level below
100,00), neutropenia (WBC <2,000), or renal dysfunction (createnin level >
1.5mg/dL).
6. If the patient becomes clinically unstable or placenta tissue fails to resolve
following TMX theraphy, hysterectomy should be considered.
Opponents of medical management suggest it increased the risk of sudden
hemorrhage, infection and or emergency surgery. 43 Patient may develop
vaginal bleeding several weeks after delivery. In a local data, bleeding in some
cases was observed on the 5th-6th weeks postoperatively. 44. An elective
hysterectomy can be considered earlier (between 2-4 weeks postpartum) to
avoid further complication. But even in cases when the placental mass fails to
resoleve or vaginal bleeding occurs, an interval of even a few days after the
delivery may simply hysterectomy due to uterine involution and concurrent
decrease in vascularity. Mussali, et at 45 reported 3 cases of placenta accreta
managed with MTX which resulted to reservation of the uterus in 2 patient.
Delayed hemorrhage on day 46 which necessitated hysterectomy was
encourage in1 case but there was no catastrophic hemorrhage encountered as
reported in immediate surgical management. (level III) side effect of MTX include
nausea, vomiting, indigestion, stomatitis, sore throat, fatigue, dizziness,
lightheadedness, temporary hair loss, anemia, leukopenia, inflammation of the
lungs. These are observed with very high doses or prolong use. In a local series,
no adverse effects have been observed.

Ancillary Procedures

Uterine artery embolization is an option employ in conjunction with leaving

the placenta in situ or with MTX therapy, although in our setting this may still be
limited, but whenever possible, this modality may be used. Sherer reported a

39
case of placenta previa-percreta in a 35 years old multigravida successfully
managed with 3 courses of MTX nad 3 bilateral uterine artery embolization.
Placenta completely dissolved after 9 months.

Focal accreta

If the area of accreta is focal and majority of the placenta has been
removed, then a wedge resection of the are can be performed. The myometrium
is subsequently oversewn in two layers.

Failure of conservative management

Failure of MTX has also been reported in the literature. Lou reported a case of
placeta percreta managed conservatively with MXX and uterine embolization.
However, the patient had heavy bleeding on the 44 th postoperative day
necessitating hysterectomy in an unstable hemodynamic condition. Butt reported
a cases of placenta percreta in a 30 weeks gestation previously delivered by
classical CS managed by leaving the placenta in situ followed by MTX therapy.
Postpartum bleeding occurred 1 week later which was managed by internal iliac
balloon catheterization and manual transcervical removal of the placenta which
resulted to hysterectomy and required massive blood transfusion.

40
 POSTPARTUM HEMORRHAGE
Rafael S. Tomacruz, MD
Background

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality,

accounting for nearly one third of all maternal deaths worldwide. PPH causes up to 60%
of all maternal deaths in developing countries. The majority of these deaths occur within
4 hours of delivery, indication they are a consequence of events in the third stage of
labor.
Traditionally, PPH has been defined as blood loss in excess of 500 ml in vaginal
deliveries, 1000 ml in caesarean section deliveries, 1.4 L in elective CS hysterectomy,
and 3.0 L in an emergency CS hysterectomy. It has also been defined as a decrease in
postpartum hematocrit levels >10% of prenatal values. However, due to difficulty in
accurately estimating and the non-reproducibility of measuring blood loss in these
situations, these definitions of PPH have not gained wide acceptance. For clinical
purposes, any blood loss that results in signs and symptoms of hemodynamic instability
should be considered as PPH. Bonnar, et. Al in 2000 correlated the amount of blood
loss (with its subsequent percentage of total blood lost in the body) to blood pressure
and clinical signs and symptoms. The WHO subsequently proposed a classification of
PPH similar and based on Bonnar’s definition where clinicians are now guided in
managing this life threatening condition. as blood loss after delivery exceeds 500ml, an
ALERT signal is raised and clinicians should anticipate the possible consequences of
continued bleeding. Although the total blood volume loss is more than 10%, signs and
symptoms are minimal and blood pressure is generally maintained. Once blood loss
exceeds 1000ml (total blood volume loss >15%) and now with signs and symptoms of
hemodynamic instability (tachycardia, hypotension, oliguria), an ACTION sugnal is
raised and clinicians should begin aggressive resuscitative measures to prevent its
progression to hypovolemic shock and orevent irreversible damage to organs or death.

Blood loss % Blood Loss ml Systolic Blood Signs and Symptoms

Pressure (mmHg)
10-15 500-1000 Normal Palpitations, dizziness,
tachycardia
15-25 1000-1500 Slightly low Weakness, sweating,
tachycardia
25-35 1500-2000 70-80 Restlessness, pallor,
oliguria
35-45 2000-2500 50-70 Collapse, air hunger, anuria

41
Hemorrhage Estimated Blood Blood Volume Loss Clinical Signs and
Class Loss (ml) (%) symptoms
0 <500 <10 None
1 500-1000 15 Minimal
2 1000-1500 20-25 Oliguria, tachycardia,
tachypnea, postural
hypotension
3 1800-2100 30-35 Hypotension, tachycardia,
cold clammy
4 >2400 >40 Profound shock

The general management of PPH involves anticipation, prompt recognition and

appropriate treatment. Anticipation of PPH begins in the antenatal period, when
clinicians identify and recognize risk factors or situations that may increase the risk or
predispose the gravid to PPH. Some of these risk factors are parity, presence of
situations that would tend to overdistend the uterus (macrosomia, multiple gestation),
number and type of CS and even prenatal ultrasound findings suggestive of placental
abnormalities. During labor, prolonged use of oxytocics for induction or augmentations
may likewise predispose a woman to PPH secondary to uterine atony.

Once PPH is recognized, the three basic steps of management include: A-

Assessment, B-Breathing, C-Circulation. In ASSESSMENT, the oatient’s hemodynamic
status is rapidly evaluated while the underlying etiology of the bleeding is investigated
and ascertained. In BREATHING, patient’s airway has to be ensured and maintained
and oxygen supplementation is administered, in order to increase the oxygen carrying
capacity of blood. In CRCULATION, intravenous access is maximized by inserting
multiple large-bore intravenous lines with maintenance of adequate circulating blood
volume by infusing appropriate amounts of crystalloids and transfusing the adequate
proportions of blood components. Management of PPH requires a simultaneous and
coordinated multidisciplinary approach involving the obstetrician(s), anaesthesiologists,
critical care nurses, and other surgical disciplines suitable to a particular situation.

It would be helpful to remember the various etiologies of PPH based on the four
T’s: TONE, TISSUE, TRAUMA, and THROMBIN. In TONE, uterine atony is the primary
etiology. In TISSUE, retained placenta or its secundines are the considerations. In
TRAUMA, lower genital tract lacerations, pelvic/perineal hematomas, and uterine
inversion should be primary considerations. And in THROMBIN, a pre-existing or
acquired coagulopathy (DIC) should be primary causes.

42
 Pathophysiology Clinical Risk Factors
Abnormal uterine Overdistended Uterus Multiple gestation
contractility Polyhydramnios
(TONE) Macrosomia
Uterine muscle fatigue Prolonged labor
Prior PPH
Chorioamnionitis Prolonged PROM
Uterine Fibroids, Placenta previa
distortion/abnormality
Uterine relaxing drug Beta mimetics, Magnesium Sulfate,
anesthetic drugs
Retained products Accreta/Increta/Percreta Prior uterine surgery
of conception Placenta previa
(TISSUE) Multiparity
Genital tract Laceration of the cervix, Precipitous delivery
trauma vagina or perineum Macrosomia
Shoulder dystocia
Operative delivery
Extension/laceration at CS Deep engagement, malposition,
malpresentation
Uterine rupture Prior uterine surgery
Uterine inversion Fundal placenta
Grand multiparity
Excessive traction on umblilical cord
Abnormalities of Preexisting clotting History of coagulopathy or liver
coagulation abnormalities e.g. disease
(THROMBIN) haemophilia, von
willebrands disease,
hypofibrinogenemia
Acquired in pregnancy Sepsis
DIC Intrauterine disease
HELLP Syndrome Hemorrhage
Anticoagulation

43
 UTERINE ATONY
Rafael S. Tomacruz MD

Background

Uterine atony is the leading cause of postpartum hemorrhage (PPH), observed

alone 40-50% of all cases of PPH. It is defined as failure of the uterus to contract and
retract following childbirth. Uterine atony is a condition which, in spite of the presence of
effective medical interventions, still claims thousands of maternal lives. It is generally
associated with an overdistended uterus (secondary to multiple gestation, macrosomia,
or polyhydramnios), uterine muscle fatigue (secondary to labor induction/augmentation,
Couvelaire uterus), uterine distortion (like the presence of myoma), chorioamnionitis
(from prolonged rupture of membranes) and the administration of uterine relaxing drugs
(such as beta-mimetics and anesthetic drugs).

Management of uterine atony starts with its prevention and later follows a
stepwise algorithm (if these preventive measures fail) designed to guide the clinician in
maximizing all the possible options prior to the performance of hysterectomy.
Prevention of uterine atony begins with Active Management of the Third Stage of Labor
(AMTSL). At present, this includes: administration of uterotonics soon after the baby’s
birth, delayed cord clamping, and controlled cord traction followed by uterine massage.
This standard management may be supplemented with the therapeutic administration of
additional uterotonic drugs (methylgometrine, prostaglandins) and hemostatics
(tranexamic acid, recombinant activated factor VII).

If bleeding persists despite AMTSL and other standard measures, we should

attempt to perform conservative procedures to prevent continued hemorrhage and the
performance of a hysterectomy. Conservative measures include non-surgical and
surgical procedures. It is but proper to state that one may not go through all these
measure one by one in the management of persistent hemorrhage from uterine atony.
Each procedure has its pros and cons and many of these measures require skill,
experience and technology to perform. Thus, one should not hesitate to skip procedures
he/she is not experienced or skilled to perform. Bypassing the conservative approaches
and doing an outright hysterectomy is an acceptable option in various situations: when
the woman has completed her family and reproductive function is no longer an issue,
when the woman is hemodynamically unstable and the most prudent and rapid way to
alleviate the condition is to perform a hysterectomy, or when the obstetrician is not
adept or experienced in performing the more complex conservative measures.

Recommendations

1. Is AMTSL better in reducing PPH compared with expectant management?

44
AMTSL is associated with reduced maternal blood loss, postpartum anemia, need
for blood transfusion and additional oxytocics. (Grade A)

Summary of Evidence

AMTSL is associated with reduced PPH greater than 500 ml (OR 0.37, 95% CI
0.33-0.41), reduced PPH greater than 1000ml (OR 0.36, 95& CI 0.25-0.52), reduced
postpartum anemia (OR 0.40, 95% CI 0.30-0.54), reduced need for blood transfusion
(OR 0.36, 95%, CI 0.24-0.54), and reduced need for additional oxytocics (OR 0.22, 95%
CI 0.19-0.26). However, it is also associated with increased incidence of nausea (OR
1.95, 95% CI 1.52-2.42). (Level 1)

2. Should we routinely administer oxytocin soon after the baby’s birth to reduce
the incidence of PPH?

Administration of oxytocin soon after the baby’s birth is associated with reduced
maternal blood loss and decreased trend for therapeutic maternal oxytocin.
(Grade A)

Summary of Evidence
Routine administration of oxytocin after the baby’s birth reduced PPH greater
than 500ml (RR 0.5, 95% CI 0.43-0.59), reduced PPH greater than 500ml (RR 0.61,
95% CI 0.44-0.87), and reduced need for additional oxytocics (RR 0.5, 95% CI 0.39-
0.64). (Level I)

3. Does delayed cord clamping reduce the incidence of PPH better compared with
early clamping?

Delayed cord clamping does not reduce the incidence of PPH compared with
early cord clamping. (Grade B)
Delayed cord clamping is more beneficial to the baby in terms of improvement of
iron status and increase in haemoglobin. (Grade B)

Summary of Evidence
There is no significant difference between delayed and early cord clamping in
terms of PPH. (Level II-2)
Delayed cord clamping ismore beneficial to the baby in terms of significant
increases in haemoglobin, improvement in iron status and, among preterm infants, less
intraventricular hemorrhage (RR 0.28, 95% CI 0.09-0.9) and less late onset sepsis (RR
0.12, 95% CI 0.03-0.95). (Level II-2)

4. Should uterine massage be routinely performed after delivery of the placenta?

Uterine massage is associated with reduced mean blood loss at 30 and 60

minuted and a reduced need for additional oxytocics. (Grade A)

45
Summary of Evidence
The women who underwent uterine massage after delivery of the placenta had a
lower mean blood loss at 30 minutes (Mean difference -41.60 ml, 95% CO -75.16 to -
8.04), lower blood loss at 60 minutes (Mean difference -77.40ml 95% CI -118.71 to -
36.09), reduced need for additional uterotonics (RR 0.20, 95% CI 0.08-0.50). (Level I)

5. Should oral misoprostol (600micrograms) be given to prevent PPH instead of

oxytocin?

Oxytocin is betther than oral misoprostol in preventing PPH. (Grade A

Oral misoprostol is associated with more adverse effects compared with
oxytocin. (Grade A)

Summary of Evidence
Compared to oxytocin, oral intake of misoprostol is associated with increased
blood loss greater than 1000ml (RR 1.34, 95% CI 1.16-1.55), increased use of
additional uterotonics (RR 1.41, i95% CI 1.31-1.50). There was no significant
differences between misoprostol and oxytocin in the need for blood transfusion (RR 0.8,
95% CI 0.62-1.04). (Level I)
Compared to oxytocin, oral intake of misoprostol is associated with more adverse
effects, such as shivering (RR 3.29, 95% CI 3.03-3.56), diarrhea (RR 2.52, 95% CI
1.60-3.98), and pyrexia with a temperature >38C (RR6.62 95% CI 5.45-8.05). (Level I)

6. Should sublingual misoprostol (600micrograms) be given to prevent PPH

instead of oxytocin?

Oxytocin is preferred uterotonic compared with sublingual misoprostol on

oreventing PPH. (Grade A)

Summary of Evidence
One systematic review (covering 2 clinical trials) with less than 200 women
revealed that there was no difference in blood loss over 1liter or in any other outcome
related to PPH. Further research is needed to define the role of sublingual misoprostol
administration for the prevention of PPH. (Level II-I)

7. Should rectal misoprostol be administered to prevent PPH instead of oxytocin?

Oxytocin is the preferred uterotonic compared with rectal misoprostilin

preventing PPH. (Grade A)
Rectal misoprostol is associated with more adverse effects compared with
oxytocin. (Grade A)

Summary of Evidence

46
 There was only 1 study in the systematic review that compared misoprostol 600
micrograms administered rectally with oxytocin 10 IU IM in 803 women. There were no
differences in the blood loss of >1L and the use of blood transfusion.
Compared to oxytocin, rectal misoprostol is associated with more adverse
effects, such as shivering (RR 3.02, 95% CI 1.74-5.23) and pyrexia with a temperature
>38C (RR 2.74, 95% 1.08-6.93). (Level II-I)

8. Should hemostatic agents be routinely given in the management of uterine

atony?

Hemostatics are adjunctive forms of management for uterine atony. (Grade C)

Summary of Evidence
An antifibrinolytic agent, trranexamic acid, may be useful in emergencies. A dose
of 1 gm is given intravenously and can be repeated every 4-6 hours. Recombinant
Activated Factor VII, on the other hand, is used for the porevention and treatment of
hemorrhage in patients with hematologic disorders. Although not generally used in
obstetrics, there are numerous reports of its successful use in cases of intractable
hemorrhage from uterine atony. It is given in a dose of 60-120 micrograms/kg BW. Both
tranexamic acid and recombinant activated factor VII can be used in conjunction with or
after primary measures. (Level III)

9. What is/are the procedures to be performed if AMTSL and other standard

measures to prevent uterine atony fail to control the bleeding?

Conservative, non-surgical measures in the management of uterine atony may be

performed if bleeding persists after standard treatments. (Grade C)

Summary of Evidence
If bleeding persists despite AMTSL and other standard forms of treatment and
the patient is desirous of maintaining her reproductive potential, conservative measures
may be utilized. Among the non-surgical aspects of this form of treatment are bimanual
uterine compression and the internal uterine tamponade procedures. These are
numerous case reports and descriptive analyses of various devices used in internal
uterine tamponade. These include the Sengstaken-Blakemore tube (more popularly
used for bleeding esophageal ulcers), Rusch hydrostatic urological balloon, SOS Bakri
balloon, foley glove catheter. There have been no case controls, cohort or randomized
trials comparing any of these devices with other established forms to control PPH from
uterine atony. (Level II-3)

10. What is/are the procedures to be performed if AMTSL, other standard

measures, and non surgical procedures to prevent uterine atony fail to control
the bleeding>

Brace compression suture procedures may be performed for uterine atony if

bleeding persists after standard and non surgical procedures. (Grade C)

47
Summary of Evidence

If bleeding persists despite AMTSL, other standard forms of treatment, and other
non surgical interventions, and the patient is still desirous of maintaining her
reproductive potential, surgical measures may be utilized. These are the Brace
Compression Suture Procedures (more popularly known as the B-Lynch procedure),
vaso-occlusive measures (uterine and/or internal iliac artery ligation) and the
angiographic arterial embolization.

Because of its relative ease in performance, the brace compression suture

should be the initial conservative, surgical means of arresting PPH from uterine atony. It
should be attempted prior to the vaso-occlusive procedures. Its objectives are to
prevent or minimize uterine bleeding, maintain a tonically contracted uterus, and
promote normal uterine involution.

Prior to performing this procedure, a test for potential efficacy has to be done.
The patient is placed in a semi-lithotomy position (frog leg position) with an assistant
standing between the patient’s legs. The uterus is exteriorized by the
surgeon/obstetrician and bimanual compression is performed. The assistant
intermittently swabs the vagina to determine the presence of bleeding. If the bleeding
stops on applying such compression, there is a good probability that the B Lynch
procedure will work. If bleeding persists, B Lynch procedure may not be efficacious
since a possible coagulation disorder exists.

There have been over 1,827 cases reported on the use of this procedure in the
management of PPH secondary to uterine atony with only 31 cases reported failures.
These failures are usually secondary to wrong surgical technique leading to uterine
necrosis, no preoperative testing done, brace sutures not correctly applied, and
uncontrolled DIC.

Modifications of the B Lynch compression suture are the Hayman comoression

suture and the Cho Multiple Squares Suture. The former is used when atony ensues
after a vaginal delivery and opening the uterus (akin to performing a low transverse CS)
to guide the sutures is not performed. The latter, on the otherhand, is the alternative to
B Lynch when the uterine incision has already been sutured prior to determining uterine
atony. It is not necessary to re-open the uterine incision in this method.(Level II-3)

1. First stitch relative to low transverse CS: With the bladder displaced inferiorly,
the first stitch os placed 3cm below the CS incision on the patient’s left side and
threaded through the uterine cavity to emerge 3cm above the upper incision
margin approximately 4cm from the lateral borcder of the uterus.

48
2. The fundus: The suture is now carried over the top of the uterus and to the
posterior side. Once situated over the fundus, the suture should be more or less
vertical and lie about 4cm from the cornu.
3. The posterior wall: The location on the posterior uterus where the suture is
placed through the uterine wall is on the horizontal plane at the level of the
uterine incision at the insertion of the uterosacral ligament.

4. Role of the assistant: As the operation proceeds, the assistant continues to

compress the uterus as the suture is fed through the posterior wall into the cavity.
This will enable progressive tension to be maintained as the suture begins to
surround the uterus. Assistant compression will also help to pull the suture
material through to achieve maximum compression, without breaking it, at the
end of the procedure. Furthermore, it will prevent suture slipping and uterine
trauma. The suture now lies horizontally on the cavity side of theposterior uterine
wall.

5. The fundus: As the needle pierces the uterine cavity side of the posterior wall, it
is placed over the posterior wall, bringing the suture over the top of the fundus
and onto the anterior right side of the uterus. The needle re-enters the cavity
exactly in the same way as it did on the left side, that is 3 cm above the upper
incision and 4cm from the lateral sides of the uterus through the upper incision
margin, into the uterine cavity and then out again through 3 cm below the lower
incision margin.

6. Later role of the aassistant: The assistamt maintains the compression as the
suture material is milked through from its different portals to ensure uniform
tension and slipping. The two ends of the suture are put under tension after the
lower segment incision has been closed by either a one- or two- layer method.

7. Relation to the hysterometry incision: The tension on the two ends of the
suture material can be maintained while the lower segment incision is closed, or
the knot can be tied first, followed by closure of the lower segment.

8. Post application and hysterotomy closure: It is probable that the maximum

effect of suture tension lasts for only abut 24-48 hours. Because the uterus
undergoes its primary involution process in the first week after vaginal or
ceasarian delivery, the suture may have lost some tensile strength, but
hemostasis would have been achieved by that time. There is no delay in closing
the abdomen after the application of the suture. The assistant standing between
the patient’s legs swabs the vagina again and confirms that the bleeding has
been controlled.

49
 RETAINED PLACENTA
Ryan B. Capitulo MD

Background
Retained placenta is defined in various ways, the mos t common definition is retention
of the placenta in utero for more than 30 minutes. This is an arbitrary definition, and
management is greatly influenced by the clinical assessment of whether significant
bleeding is occurring. This bleeding may be visible or may manifest only by the
increasing size of the uterus. In the absence of any evidence of placental detachment,
consider the diagnosis of complete placent accrete or a variant. This condition may be
present with bleeding if only a portion of the placenta is abnormally implanted.

Recommendations

1. What is the role of umbilical vein injection in the management of retained

placenta?

Umbilical vein injection may reduce the need for manual removal of a retained
palcwenta (Grade B)

Summary of Evidence
A number of trials have evaluated the role of injection into the umbilical cord in
the management of retained placenta in women not experiencing significant
bleeding. The definitions of retained placenta range from 15-60 minutes without
placental delivery but are most commonly 20-30 minutes. Injections into the cord
vein have used isotonic sodium chloride solution (normal saline), oxytocin and
saline, prostaglandin and saline, and dextran 70.
The studies comparing injection of oxytocin (commonly 10 IU) and saline
(commonly 20 ml) with expectant management (OR, 0.7; 95% CI 0.48-1.02) or
saline injection alone (OR, 0.59; 95% CI 0.43-0.82 and NNT, 8; 95% CI 5-20)
suggest that this practice indeed reduces the need for manual removal of the
placenta. This intervention seems reasonable in stable women with minimal bleeding
while preparations for a manual removal are being made.

2. What is the definitive management of retained placenta?

Manual removal of the placent is warranted if the other maneuvers have failed
to deliver the placenta and significant bleeding occurs. This followed by
administration of antibiotics (Grade B)

50
Summary of Evidence

The retained or partially detached placenta interferes with uterine contraction and
retraction and leads to bleeding. Perform manual removal with a level of analgesia
that matches the clinical urgency of the situation. The cessation of an oxytocin
infusion or the administration of uterine relaxants to promote uterine exploration and
manual removal is of questionable value and may lead to increased bleeding.
Ultrasound may be useful in select cases.
When possible, an elbow-length glove is worn and attention is paid to asepsis.
The perineum and vagina must be prepared. The vaginal hand may be immersed in
provide-iodine solution to facilitate easier entry. The hand is passed into the vagina
through the cervix into the lower segment following the umbilical cord. Care is taken
to minimize the profile of the hand as it enters, keeping the thumb and fingers
together in the shape of a cone to avoid damage.
Control of the uterine fundus with the nonvaginal hand is essential. If the
placenta is encountered in the lower segment, it is removed. If the placenta is not
encountered, the placental edge is sought. Once found, the fingers gently develop
the space between the placenta and uterus and shear off the placenta. The placenta
is pushed to the palmar aspect of the hand and wrist; when it is entirely separated,
the hand is withdrawn in order to encourage strong uterine contraction, and then
perform uterine massage. Care must be taken to ease out the membranes. Once
uterine contraction is established, examine the placenta and membranes to
determine further exploration of curettage is necessary. The administration of
antibiotics following manual removal is sometimes advocated. Evidence is very
limited, but a single, randomized trial supports the practice (Level II-3)

51
 UTERINE RUPTURE
Ryan B. Capitulo, MD

Background

Uterine rupture in pregnancy is a rare and often catastrophic complication with a

high incidence of fetal and maternal morbidity. Several factors are known to increase
the risk of uterine rupture, but even in high-risk subgroups, the overall incidence of
uterine rupture is low. From 1976-2005, 19 peer-reviewed publications that described
the incidence of uterine rupture reported 1654 cases of uterine rupture among 2, 504,
456 women, yielding an overall rupture rate of 1 in 1514 pregnancies (0.07%). The
initial signs and symptoms of uterine rupture are typically nonspecific, a condition that
makes diagnosis difficult, which sometimes delays definitive therapy. From the time of
diagnosis to delivery, only 10-37 minutes are available before clinically significant fetal
morbidity becomes inevitable. Fetal morbidity invariably occurs because of catastrophic
hemorrhage, fetal anoxia, or bot. the inconsistent premonitory signs and the short time
for instituting therapeutic action make uterine rupture a fearful event.

Uterine rupture during pregnancy is a rare occurrence that frequently results in

life-threatening maternal and fetal compromise, whereas uterine scar dehiscence is a
more common event that seldom results in major maternal or fetal complications. By
definition, uterine scar dehiscence constitutes separation of a pre-existing scar that
does not disrupt the overlying visceral peritoneum (uterine serosa) and that does not
significantly bleed from its edges. In addition, the fetus, placenta, and umbilical cord
must be contained within the uterine cavity without a need for cesarean sections (CS)
because of fetal distress. By contrast, uterine rupture is defined as a full-thickness
separation of the uterine wall and the overlying serosa. Uterine rupture is associated
with clinically significant uterine bleeding; fetal distress; expulsion or protrusion of the
fetus, placenta, or both into the abdominal cavity; and the need for prompt CS, uterine
repair, or hysterectomy. Although a scar from CS is a well-known risk factor for uterine
rupture, most events that involve disruption of the uterine scar result in uterine-scar
dehiscence rather than frank uterine rupture. These 2 entities must be clearly
distinguished because their options for clinical management and outcomes analyses
differ.

The peer-reviewed literature was searched using the PubMed-Medline and

Cochrane databases for articles published in the English language. The search terms
were uterine rupture, pregnancy and prior CS, vaginal birth after caesarean (VBAC),
ttrial of labor (TOL), uterine scar dehiscence, and pregnancy and myomectomy.
Standard reference tracing was also used. Articles published in 1976-2009 that
described the incidence of uterine rupture and that included sufficient information
regarding the authors’ definitions of uterine ruptue and of uterine scar dehiscence were
incorporated for review. All studies were observational or reviews. A total of 73
published articles were included for data extraction and analysis.

52
Recommendations

1. What are the risk factors that predispose to rupture of the unscarred uterus?

The normal unscarred uterus is least susceptible to rupture. Grand multiparity,

neglected labor, malpresentation, breech exctraction, uterine instrumentation and
congenital uterine anomalies are all predisposing factors for uterine rupture. The
increased risk of uterine rupture attributable for the use of oxytocin in gravidas
with unscared uteri is uncertain.(Grade B)

Summary of Evidence

Many authors have considered multiparity a risk factor for uterine rupture. Golan,
et. al. noted that in 19 (31%( of 61 cases, uterine rupture occurred in women with a
parity of more than 5. Schrinsky and Benson found that 7 of 22 women (32%) who had
unscarred uterine rupture had a parity of greater than 4. In a study by Mokgokong and
Marivate, the mean parity for women who had pregnancy-related uterine rupture
associated with high parity, Gardeil, et. al. found only 2 (0.005%) women with uterine
rupture among 39, 529 multigravidas who had no previous uterine scar.

Schrinksy and Benson reported 22 cases of uterine rupture in gravidas with

unscarred uteri. Nineteen (86%) ruptures occurred during labor, and 3 (14%) that
involved unscarred uterine rupture. Golan, et. al. noted that, among 126,713 deliveries,
oxytocin was used in 26 of 61 cases (43%) that involved unscarred uterine rupture.
However, Plauche, et. al. attributed only 1 of 23 unscarred uterine ruptures (4%) to the
use of oxytocin. Therefore, the increased risk of uterine rupture attributable to the use of
oxytocin in gravidas with unscarred uteri is uncertain. In a review article by Nahum,
congenital uterine anomalies affected approximately 1 in 200 women. The walls of the
abnormal uteri in such cases tend to become abnormally thin as pregnancies advance,
and they can be inconsistent over different aspects of the myometrium. Ravasia, et. al.
reported an 8% incidence of uterine rupture (2 of 25) in those with normal uteri (P=
.013). Both cases of uterine rupture involved labor induction with prostaglandin E2.
Pregnancies implanted in the rudimentary horn of the uterus pose special risk for
uterine rupture up to 81% (387 of 475) in those women attempting induction of labor.
Importantly, 80% of ruptures occurred before the third trimester, with 67% occurring
during the second trimester. Although the uterine rupture rate in anomalous, unscarred
uteri during pregnancy appears t be increased relative to that for normal uteri, the
precise risk for diffrerent uterine malformations remains uncertain. (Level II-2)

2. What are the risk factors that predispose to rupture the unscarred uterus?

For women with a single previous CS scar (whether vertical of transverse) at the
lower uterine segment, the risk for uterine rupture during spontaneous labor is
increased compared to those with unscarred uteri. The risk for rupture increases

53
with oxytocin induction or augmentation, cervical ripening with prostaglandins,
shorter inter-delivery interval, one layer closure of uterine incision, lower uterine
wall thickness of less than 2-3.5 millimeter, fetal macrosomia and increasing
maternal age. The risk for uterine rupture is highest with multiple CS scars,
previous classical CS and previous myomectomies. (Grade B)

Summary of Evidence

The effect of previous CS on the risk of uterine rupture had been studied
extensively. In a meta-analysis, Mozurkewich and Hutton used pooled data from 11
studies and showed that the uterine rupture rate for women undergoing TOL after
previous CS was 0.39% compared with 0.16% for patiens undergoing elective repeat
CS (OR 2.10; 95% CI 1.45-3.05). Restricting the meta-analysis to 5 prospective cohort
trils generated similar results (OR, 2.06; 95% CI, 1.40-3.04). Hibbard, et. al. examined
the risk of uterine rupture after previous CS in 1324 women who underwent a
subsequent TOL. They reported a significant difference in the risk of uterine rupture
between women who achieved successful vaginal birth compared with women in whom
attempted vaginal delivery failed (0.22% vs 1.9%; OR, 8.9%; 95% CI 1.9-42). The effect
of previous CS on the rate of subsequent pregnancy-related uterine rupture can be
further examined according to additional subcategories.

Classical CS is infrequently performed in the moderm era and currently account

for 0.5% of all birthday in the United States. In a meta-analysis, Rosen, et. al. reported
an 11.5% absolute risk of uterine rupture (3 of 26 cases) in women with classic vertical
caesarean scars who underwent an unplanned TOL. Chauhan, et. al. reported that the
uterine rupture rate for 157 women with classic uterine caesarean scar was 0.64% (95%
CI 0.1-3.5%). All patient underwent repeat CS, but a high rate of preterm labor resulted
in 49% of the patients being in labor at the time of their CS. Landon, et. al. reported a
1.9% absolute uterine rupture rate (2 of 105 cases) in women with a previous classic,
inverted T, or J incision who either presented in advanced labor or refused repeat CS.
However, Chauhan, et. al. observed a 9% rate of asymptomatic uterine scar dehiscence
(95% CI 5-15%).

A meta-analysis of pooled data from 5 studies demonstrated a 1.1% absolute risk

(12 o 1112 cases) of symptomatic uterine rupture in women undergoing a TOL with a
low vertical caesarean scar. Compared with women with low transverse caesarean
scars, these ata suggest no significantly increase risk of uterine rupture or adverse
maternal and perinatal outcomes.

The risk of uterine rupture after a low transverse CS varies depending on

whether labor is induced or spontaneous, as well as other factors. The vast majority of
CS in the United States are of the low transverse type. For women who have had 1
previous CS, examining the various risks of uterine rupture is instructive. These
absolute risks for uterine rupture are discussed below.

54
 In a study of 20, 095 women by Lydon-Rochelle, et. al., The spontaneous uterine
rupture rate among 6980 women with a single CS scar who underwent scheduled
repeat CS without a TOL was 0.16%. This finding indicates that uteri with caesarean
scars have a intrinsic propensity for rupture that exceeds that of the unscarred organ
during pregnancy, which is 0.013% (OR increased by approximately 12-fold). Therefore,
all other uterine rupture rates must be reference to this expected baseline rate.

Lydon-Rochelle, et. al. showed that the uterine rupture rate among 10, 789
women with a single previous CS who labored spontaneously during a subsequent
singleton pregnancy was 0.52%. This rate of uterine rupture implies an increased
relative risk (RR) of 3.3 (95% CI 1.8-6.0) for women who labor spontaneously compared
with women who undergo elective repeat CS. In a study by Ravasia, et. al. of 1544
patients with a previous CS who later labored spontaneously, the uterine rupture rate
was 0.45%. Zelop, et. al. found that among 2214 women with 1 previous CS who
labored spontaneously, the uterine rupture rate was 0.72%.. The authors of this article
performed a meta-analysis of 29, 263 pregnancies from 9 studies from 198-2004 and
showed that the overall risk of uterine rupture was 0.44% for women who labor
spontaneously after a previous CS.

Zelop, et. al. found that the rate of uterine rupture in 560 women who underwent
labor induction after a single prevous CS was 2.3% compared with 0.72% for 2214
women who had labored spontaneously (P=0.001). In a study by Ravasea, et. al. of 575
patients who underwent labor induction, the uterine rupture rate was 1.4% compared
with 0.45% for women who labored spontaneously (P=0.004). Blanchette, et. al. found
that the uterine rupture rate after prvious CS when labor was induced was 4.0%
compared with 0.34% for women who labored spontaneously. This last finding suggests
a 12-fold increased risk of uterine rupture for women who undergo labor induction after
previous CS.

Lyndon-Rochelle, et. al. reported a 15.6-fold increased risk for uterine rupture
(95% CI 8.1-30) when prostaglandins E2 (PGE2) were used in gravidas who underwent
a TOL after previous CS who underwent labor induction with PGE2, the uterine rupture
rate was 2.45% compared with 0.77% without PGE2 use. Taylor, et. al. identified 3
uterine ruptures among 58 patients with 1 previous CS who received PGE2 alone for
labor induction. The uterine rupture rate was 5.2% compared with 8 (1.1%) ruptures
among 732 patients not treated with PGE2. Ravasia, et. al. found that 2 ruptures
occurred among 172 patients who underwent labor induction with PGE2 alone (1.7%),
which was significantly higher than 0.45%, of 7 of 1544 women who labored
spontaneously. In contrast, Flamm, et. al. found a uterine rupture rate of 6 (1.3%) of 453
patients with a previous CS who were treated with PGE2 in combination with oxytocin.
This result was not significantly different from the rate of 33 (.0.7%) of 4569 women who
were not treated with PGE2. In a small study, Delaney and Young also did not find a
significant difference in uterine rupture rates between patiens with scars from a previous
CS who underwent labor induction with PGE2 and patients with previous CS who
labored spontaneously (1.1 vs 0.3%; P=.15). Landon, et. al. reported no uterine ruptures
among 227 patients who underwent induction with PGE2 alone. Although the study was

55
underpowered to detect small differences, the
underpowered to detect small difference, the
administered did not appear to significantly affect
patients received misoprostol; 111, dinoprostone;
prostaglandins).
particular type of prostaglandin
particular type of prostaglandin
the uterine rupture rate. (Fifty-two
60, PGE2 gel; and 4, combined

In a study by Blanchette, et. al., the rate of uterine rupture for 288 women who
underwent oxytocin augmentation of labor after a previous CS was 1.4% compared with
0.34% for 292 women who underwent a trial of spontaneous labor. This finding suggest
a 4-fold increased risk of uterine rupture in women who undergo labor augmentation
with oxytocin compared with spontaneous labor after previous CS.

Several studies have shown a protective association of previous vaginal birth on

uterine rupture risk in subsequent attempts at vaginal birth after previous CS. Zelop, et.
al. compared 1021 women who underwent a TOL after a single CS with 1 previous
vaginal delivery with 2762 women who underwent a TOl with no previous vaginal
delivery. The uterine rupture rate was 0.2% versus 1.1% (P=.01).

In a study by Esposito, et. al., an interpregnancy interval between CS and a

subsequent pregnancy of <6 months was nearly 4 times as common among patients
who had uterine rupture than in control subjects (17.4 vs 4.7%; OR 3.92; 95% CI 1.09-
14.3). Among 23 patients who had uterine rupture after a previous CS, the mean
interpregnancy interval was 20.4 ±4 15.4 months compared with 36.5 ±4 30.3 months
for control subjects (P=.01). Shipp, et. al. similarly found that the risk of symptomatic
uterine rupture was increase 3-fold in women with interdelivery intervals for less than 18
months when they underwent a TOL, after 1 previous CS (OR 3.0; 95% CI 1.2-7.2). In
support of this observation, Bujold and Gauthier reported 1527 women who underwent
a TOL after a single previous low transverse CS, finding that 2.8% of patients who had
an interdelivery interval of less than 24 motnhs had a uterine rupture compared with
0.9% for those with an interdelivery interval of greter than 24 months (P< 0.01). The OR
for a uterine rupture during a subsequent TOL (after adjustment for confounding
variables) was 2.65 for women who had an interdelivery interval of less than 24 months
compared with women who had an interdelivery interval of less than 24 months
compared with women who had a interdelivery interval longer than this (95% CI, 1.08-
5.46). The authors speculated that a prolonged interpregnancy interval may allow time
for the previous CS scar to reach its maximal tensile strength before the scar undergoes
the mechanical stress and strain with a subsequent intrauterine pregnancy.

In a Canadian study of 1,980 women who underwent a TOL after a single

previous low transverse CS, Bujold and Gauthier found a 4 to 5-fold increase risk of
uterine rupture for women who had a previous single-later uterine closure compared
with a 2-layer closure. Uterine rupture occurred in 15 (3.1%) of 489 cases of single-layer
closure versus 8 (0.5%) of 1, 491 cases of double layer closure (P<0.001). Using
stepwise multivariate logistic regression, the authors concluded that the OR for uterine
rupture in women who had undergone a single previous 1-layer caesarean
hysterectomy closure was 3.95 (95% CI, 1.35-11.49) compared with those who had a 2-

56
layer closure. Durnwald and Mercer found that 182 patients with single-layer closure did
not have a increased rate of uterine rupture, but the rate of uterine windows at
subsequent delivery was increased (3.5 vs 0.7%; P=0.046). Gyamfi, et. al. reported an
8.6% (3 0f 35) rate of uterine rupture in patients with a single-layer closure compared
with 1.3% (12 of 913) in those with double-layer interdelivery interval, the uterine rupture
rate remained significantly elevated even when the time interval was controlled for using
logistic regression (OR 7.20, 95% CI, 1.81-28.62, P=0.005).

For women with a history of 2 or more CS, 9 studies published in 1993-2005

showed that the risk of uterine rupture in a subsequent pregnancy is 0.9-6.0% (1 per 17-
112 pregnancies). This risk is increased 2- to 16-fold for women with only a single
previous CS. IN a study of 17, 322 women with scars from caesarean delivery, Miller,
et. al. found that, when women underwent a TOL, uterine rupture was 3 times more
common with 2 or more scars (1.7%) thn with 1 scar (0.6%) [OR 3.06; P< 0.001; 95% CI
1.95-4.79]. In the largest analysis to date, Macones, et. al. reviewed data from 17
tertiary and community hospitals and found that, in 1082 women with 2 uterine scars
who underwent a TOL, the risk of uterine rupture was increased 2-fold compared with
women with only 1 uterine scar (absolute rupture risk 1.8 vs 0.9%; adjusted OR 2.3;
95% CI 1.37-3.85). In the only study to control for potential confounding variables,
Caughey, et. al. concluded that, in women who had 2 previous CS times the risk of
those with only 1 previous CS (3.7 vs 0.8%; P=.001). They also found that women with
a previous vaginal delivery were about one fourth as likely to have uterine rupture as
patients without a previous vaginal delivery (OR, 0.26; 95% CI, 0.08-0.88). A 2004
American College of Obstetrics and Gynecology (ACOG) Guidelines suggests that, in
women with 2 previous CS, only those with a previous vaginal delivery should be
considered candidates for a TOL.

Elkousy, et. al. found that, in 9960 women who underwent a TOL after 1 previous
CS, the risk of uterine rupture was significantly greater for fetuses that weighed more
than 4000g (2.8%) than in those weighing less than 4000g (1.2%; RR 2.3, P<0.001).
For women with 1 previous CS and no previous vaginal deliveries, the uterine rupture
rate was 3.6% for women with fetal weights of more than 4000 g compared with women
with fetal weights of less than 4000 g (RR 2.3, P<0.001).

Shipp, et. al. showed that increasing maternal age has a detrimental effect on the
rate of uterine rupture. In a multiple logistic regression analysis that was designed to
control for confounding factors, the overall rate of uterine rupture in 3015 women with 1
previous CS was 1.1%. The rate of uterine rupture in women older than 30 years (1.4%)
versus younger women (0.5%) differed significantly (OR, 3.2; 95% CI, 1.2-8.4).

Several reports have suggested that transabdominal (TAS), transperineal,

transvaginal (TVS), or sonohysterographic ultrasonography may be useful for detecting
uterine-scar defects after caesarean delivery. Rozenberg, et. al. prospectively examined
642 women and found that the risk of uterine rupture after previous CS was directly
related to the thickness of the lower uterine segment, as measured during TAS
ultrasonography at 36-38 weeks of gestation The risk of uterine rupture increased

57
significantly when the uterine wallwastinner than 3. 5 mm. Using a 3.5 mm cutoff, the
authors had a sensitivity of 88%, specificity of 73.2%, positive predictive value of 11.8%,
and a negative predictive value of 99.3% in predicting subsequent uterine rupture. In a
study of 722 women, Gotoh, et. al. reported that a uterine wall thinner than 2mm, as
determined with ultrasonography performed within 1 week of delivery, significantly
increased the risk of uterine rupture. Positive and negative predictive values were
73.9% and 100% respectively.

3. What are the signs and symptoms of uterine rupture during pregnancy?

The classic signs and symptoms of uterine rupture are as follows: pattern
of abnormalities in fetal heart rate, diminished baseline uterine pressure, loss of
uterine contractility or hyperstimulation, abnormal labor or failure to progress,
abdominal pain, recession of the presenting fetal part, hemorrhage, and shock.
However, modern studies show that some of these signs and symptoms are rare
and that many may not be reliably distinguished from their occurrences in other,
benign obstetric circumstances. (Grade B)

Summary of Evidence

The signs and symptoms of uterine rupture largely depend on the timing, site,
and extent of the uterine defect. Uterine rupture at the site of a previous uterine scar is
typically less violent and less dramatic than a spontaneous or traumatic rupture
because the scar is relatively avascular.

Prolonged, late, or recurrent variable decelerations or fetal bradycardias are

often the first and only signs of uterine rupture. Bujold and Gauthier showed that
abnormal patterns in fetal heart rate were the first manifestations of uterine rupture 87%
of patients. In a study by Leung, et. al. prolonged decelerations in fetal heart rate
occurred in 79% of cases and was the most common finding associated with uterine
rupture. Rodriguez, et. al. found that fetal distress was the most common finding
associated with uterine rupture, occurring in 78%. Overall, in 4 studies from 1983-2000,
prolonged decelerations of fetal heart rate or bradycardias occurred in 114 (80%) of 143
cases of uterine rupture. In cases that involved the extrusion of the placenta and fetus
into the abdominal cavity, prolonged decelerations in fetal heart rate occurred invariably.

Sudden or atypical maternal abdominal pain occurs more rarely than do

decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in
13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL,
only 22% of complete uterine ruptures presented with abdominal pain and 76%
presented with signs of fetal distress diagnosed by continuous electronic fetal
monitoring (EFM). Moreover, in a study by Bujold and Gauthier, abdominal pain was the
first sign of rupture in only 5% of patients and occurred in women who developed
uterine rupture without epidural analgesia but not in women who received an epidural
block. Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture.
Inital concerns that epidural anesthesia might mask the pain caused by uterine rupture

58
have not been verififed and there have been no reports of epidural anesthesia for a TOL
because epidural anesthesia rarely mask the signs and symptoms of uterine rupture.
Phelan, et. al. found that abnormal patterns of uterine activity, such as tetany and
hyperstimulation, are often not associated with uterine rupture. In their study, in which
monitoring of uterine activity was limited to external tocodynamometry, tetany was
defined as a contraction lasting longer than 90 seconds, and hyperstimulation was
defined as more than 5 contractions in 10 minutes. Rodriguez, et. al. found that the
usefulness of intrauterine pressure catheters (IUPCs) for diagnosing uterine rupture was
not supported. In 76 cases of uterine rupture, the classic description of decreased
uterine tone and diminished uterine activity was not observed in any patients, 39 of
whom had IUPCs in place. In addition, rates of fetal and maternal morbidity and
mortality associated with uterine rupture did not differ with the use of an IUPC compared
with external tocodynamometry.

In 8 reports published in 1980-2002 in which investigators examined the

frequency of vaginal bleeding in case of uterine rupture, vaginal bleeding occurred in
11-67% of cases. In 3 studies, maternal shock from hypovolemia was associated with
uterine rupture in 29-46% of cases. (Level II-2)

4. What are the fetal and neonatal consequences of uterine rupture?

The consequences of uterine rupture to the fetus or neonate include hypoxia or

anoxia, acidosis, depressed Apgar scores, admission to the neonatal intensive
care unit (NICU) and perinatal death. (Grade B)

Summary of Evidence

The consequences of uterine rupture during pregnancy depend on the time that
elapses from the rupture until the institution of definitive therapy. In this regard,
appropriate therapy for the fetus and the mother are fundamentally different. Definitive
therapy for the fetus is delivery and must generally be accomplished with alacrity to
avoid major fetal morbidity and mortality. In the converse, therapy for the mother can
generally be supportive and resuscitative until surgical intervention can arrest the often
life-threatening uterine hemorrhage. Several studies have shown that the delivery of the
fetus 10-37 minutes after uterine rupture is necessary to prevent serious fetal morbidity
and mortality. If proper supportive measures (including fluid resuscitation and blood
transfusion), are available to treat the mother, the time for definitive surgical intervention
before the onset of major maternal morbidity and mortality may often be substantially
longer than that for the fetus.

Leung, et. al. found that 5 of 99 neonates (5%) born to women who had uterine
ruptures developed neonatal asphyxia (defined as umbilical artery pH <7 with seizures
and multiorgan dysfunction). No neonate had clinically significant perinatal morbidity
when delivery was accomplished within 17 minutes of an isolated and prolonged
deceleration of fetal heart rate. If severe late decelerations preceded prolonged
deceleration, perinatal asphyxia was observed as soon as 10 minutes from the onset of

59
the prolonged deceleration to delivery. In a study by Menihan, 6 of 11 fetuses born after
uterine rupture had bradycardias occur between 18-37 minutes prior to delivery.
Although the rate of fetal acidosis was high (91%), no permanent neurologic injuries or
neonatal deaths occurred. In 23 cases of uterine rupture, Bujold and Gauthier found
that, even with rapid (<18 min) intervention between rolonged deceleration in fetal heart
rate and delivery, 2 neonates developed hypoxicischemic encephalopathies with
impaired motor development. They concluded that, though rapid intervention did not
always prevent severe metabolic acidosis and serious neonatal disease, it probably did
limit the occurrence of neonatal death.

In 99 cases of uterine rupture, Leung, et. al. found that 43 newborns (43%) had
an umbilical artery pH level of less than7, and 25 of these newborns had a pH level of
less than 6.8. in association with these pH levels, 39 newborns (39%) had 5-minute
Apgar scores of less than 7, 12 of whom had 5-minute Apgar scores of less than 3.
Menihan found that 10 of 11 fetuses (91%) who were born after uterine rupture had an
umbilical artery cord pH level of less than 7.0, and 5 (45%) had 5-minute Apgar scores
less than 7. The most important factor for the development of fetal acidosis was
complete extrusion of the fetus and placenta into the maternal abdomen.

Menihan found that 8 of 11 newborns (73%) delivered after uterine rupture

required admission to the NICU. Kieser and Baskett found an NICU admission rate for
newborns after urine rupture of 8 out of 18 (45%). Landon, et. al. found a similar NICU
admission rate of 46 out of 144 newborns (32%) after urine rupture.

In studies reported before 1978, the fetal mortality rate associated with uterine
rupture was high. In a review of 33 studies by Schrinsky and Benson, 960 cases if
uterine rupture resulted in 620 infant deaths, yielding a perinatal mortality rate of 65%.
Blanchette, et. al. reported that 2 neonates (17%) died among 12 women who had
uterine rupture and that 1 of these neonates died after decision-to-deliver time of only
26 minutes after the acute onset of fetal bradycardia, lower abdominal pain, and vaginal
bleeding, which signalled the acute uterine rupture. Leung, et. al. reported that 6
perinatal deaths (6%) occurred among 99 patients who had urine rupture. In a study by
Lydon-Rochelle, et. al., the perinatal death rate among foetuses in 91 cases of uterine
rupture was 5.5% compared with 0.5% in control subjects. Landon, et. al. reported a
perinatal death rate from uterine rupture of 2% (2 of 124) among incidence of perinatal
death associated with uterine rupture is decreasing in modern era. (Level II-2)

5. What are the maternal consequences of uterine rupture?

The consequences of uterine rupture to the mother include bladder injury, severe
blood loss or transfusion, hypovolemic schock, need for hysterectomy and death.
(Grade B)

Summary of Evidence

60
 Lydon-Rochelle, et. al. reported significant maternal bladder injuries in 7 of 91
women (8%) whose uteri ruptured compared with 240 of 20,004 control subjects (1.2%)
in whom rupture did not occur (P = .001). ship, et. al. found that bladder injuries
occurred in 5 of 28 women (18%) who had a uterine rupture after previous low
transverse CS. In a study by Kieser and Baskett, 3 of 18 patients (17%) who developed
uterine rupture had a cystotomy. Leung, et. al. found that 12 of 99 patients (12%) who
developed uterine rupture had incidental cystotomies at the time of surgery, and 7 more
(7%) had either a ruptured bladder or an accidental cystotomy; the combined total
urologic injury rate was 19%.

Cowans, et. al. found that, among 5 patients who developed uterine rupture,
mean blood loss was 1500 ml and great enough to be symptomatic in 3 patients (60%).
In a study by Shipp, et. al., 7 of 28 women (25%) who had uterine rupture during a TOL
after a previous CS received a blood transfusion. Kieser and Baskett found that 8 of 18
patients (44%) who had a complete uterine rupture required blood transfusion. Leung,
et. al., 29% of women who had uterine rupture developed signs and symptoms of
hypovolemic shock. Rahman, et. al. reported that, of 96 women who had uterine
rupture, 33 (34%) developed hypovolemic shock. These modern rates of maternal
shock after uterine rupture appear to be reduced compared with the early rates reported
in a 53-year review of the literature by Eden, et. al.; their observed incidence was 11 of
24 cases (46%).

In a study from South Africa, 261 of335 women (78%) who had uterine rupture
were treated with hysterectomy. Flamm, et. al. found that 3 of 39 patients (8%) who
developed uterine rupture required hysterectomy. Kieser and Baskett found that 1 of 18
patients (6%) who developed uterine rupture required hysterectomy. Blanchette, et. al.
reported that hysterectomy was necessary in 2 of 12 women (17%) who developed
uterine ruprture. Hibbard, et. al. found that 6 hysterectomies (60%) were necessary in
10 women who had uterine rupture. Leung, et. al. reported than 19 of 99 patients (19%)
with sustained uterine rupture required hysterectomy. Thirteen hysterectomies (68%)
were performed for irremediable uterine atony, and 1 (5%) was performed because of
placenta accreta.

Maternal death as a consequence of uterine rupture occurs at a rate of 0-1% in

modern developed nations, but the morality rates in developing countries are 5-10%.
The availability of modern medical facilities in developed nation is likely to account for
this difference in maternal outcomes. In a South African study (1976), 22 of 260 women
had pregnancy-related rupture of an unscarred uterus died (mortality rate 8.5%). These
deaths could be further subdivided into mortality for women with longitudinal uterine
tears (15 of 183 patients [8.2%]), transverse tears (2 of 49 patients [4%]), posterior-wall
tears (2 of 16 patients [13%]). and multiple uterine tears (3 of 12 patients [25%]). Golan,
et. al. reported no deaths among 32 mothers who developed rupture of a scarred uterus
compared with 9 deaths among 61 women with an intact uterus (15%). In a study from
Los Angeles, Leung, et. al. reported 99 patients with uterine rupture; 1 woman (1%)
died. Mokgokong and Marivate noted that the maternal mortality rate associated with

61
uterine rupture largely depends on whether the diagnosis is established before or after
delivery; rates were 4.5% and 10.4%, respectively. (Level II-2)

6. What are the management options for uterine rupture?

Conservative surgical management involving uterine repair should be reserved

for women who have the following findings:
Low transverse uterine rupture
No extension of the tear to the broad ligament, cervix, or paracolpos
Easily controllable uterine hemorrhage
Hemodynamic stability
Desire for future childbearing
No clinical or laboratory evidence of an evolving coagulopathy

Hysterectomy should be considered the treatment of choice when intractable

uterine bleeding occurs or when the uterine rupture sites are multiple,
longitudinal, or low lying. Rupture of a previous CS scar often can be managed by
revision of the edges of the prior incision followed by primary closure. (Grade C)

Summary of Evidence

The most critical aspects of treatment in the case of uterine rupture are
establishing a timely diagnosis and minimizing the time from the onset of signs and
symptoms until the start of definitive surgical therapy. Once a diagnosis of uterine
rupture is established, the immediate stabilization of the mother and the delivery of the
fetus are imperative. After the fetus is delivered, the type of surgical treatment for the
mother should depend on the following factors:
Type of uterine rupture
Extent of uterine rupture
Degree of hemorrhage
General condition of the mother
Mother’s desire for future childbearing
No clinical or laboratory evidence of an evolving coagulopathy

As a rule, the time available for successful intervention after frank uterine rupture
and before the onset of major fetal morbidity is only 10-37 minutes. Therefore, once the
diagnosis of uterine rupture is considered, all available resources must quickly and
effectively be mobilized to successfully institute timely surgical treatment that result in
favourable outcomes for both the newborn and mother. Because of the short time
available for successful intervention, the following 2 premises should always be kept
firmly in mind: (1) Maintain a suitably high level of suspicion regarding a potential
diagnosis of uterine rupture, especially in high-risk patients. (2) When in doubt, act
quickly and definitively. (Level III)

7. What are the preventive strategies for uterine rupture?

62
The most direct prevention strategy for minimizing the risk of pregnancy-related
uterine rupture is to minimize the number of patients who are at highest risk.
(Grade B)

Summary of Evidence

The absolute risk of uterine rupture in pregnancy is low, but it is highly variable
depending on the patient subgroup. Women with normal, intact uteri are at the lowest
risk for uterine rupture (1 in 7440 pregnancies [0.013%]).

The most direct prevention strategy for minimizing the risk of pregnancy-related
uterine rupture is to minimize the number of patients who are at highest risk. The salient
variable that must be defined in this regard is the threshold for what is considered a
tolerable risk. Although this choice is ultimately arbitrary, it should reflect the prevailing
risk tolerance of patients, physicians, and of society as a whole. If this threshold is
chosen as 1 in 200 women (0.5%), the categories f patients that exceed this critical
value are those with the following:

Several previous CS
Previous classic midline CS
Previous low vertical CS
Previous low transverse CS with a single-layer hysterectomy closure
Previous CS with an interdelivery interval of less than 2 years
Previous low transverse CS with a congenitally abnormal uterus
Previous CS without a previous history of successful vaginal birth
Previous CS with either labor induction or augmentation
Previous CS in a woman carrying a macrosomic fetus who weighs more than
4000 g
Previous uterine myomectomy accomplished by means of laparoscopy or
laparotomy

If a gravida falls into any 1 of these categories, her risk for uterine rupture is
increased to more than 1 in 200, and a clinical management plan should be specifically
designed with this increased risk in mind. (Level II-2)

Conclusion

Uterine rupture is a rare but often catastrophic obstetric complication with an

overall incidence of approximately 1 in 1514 pregnancies (0.07%). In modern
industrialized countries, the uterine rupture rate during pregnancy for a woman with a
normal, unscarred uterus is 1 in 7440 pregnancies (0.013%).

The vast majority of uterine ruptures occur in women who have uterine scars,
most of which are the result of previous CS. A single cesarean scar increases the

63
overall rupture rate to 0.51%, with the rate for women with 2 or more cesarean scars
increasing to 2%. Other subgroups of women who are at increased risk for uterine
rupture are those who have a previous single layer-hysterectomy closure, a short
interpregnancy interval after a previous CS, a congenital uterine anomaly, a
macrosomic fetus, a history of prostaglandin use, and a failed trial of vaginal delivery.

Surgical intervention after a uterine rupture in less than 10-37 minutes is

essential to minimize the risk of permanent perinatal injury to the fetus. However,
delivery within this time cannot always prevent severe hypoxia and metabolic acidosis in
the fetus or serious neonatal consequences.

The most consistent early indicator of uterine rupture is the onset of a prolnged,
persistnet, and profound fetal bradycardia. Other signs and symptoms of uterine
rupture, such as abdominal pain, abnormal progress in labor, and vaginal bleeding, are
less consistent and less valuable than bradycardia in establishing the appropriate
diagnosis.

The general guideline that labor-and –delivery suites should be able to start
cesarean delivery within 20-30 minutes of a diagnosis of fetal distress is of minimal
utility with respect to uterine rupture. In the case of fetal or placental extrusion through
the uterine wall, irreversible fetal damage can be expected before that time; therefore,
such a recommendation is of limited value in preventing major fetal and neonatal
complications. However, action within this time may aid in preventing maternal
exsanguination and maternal death, as long as proper supportive and resuscitation
methods are available before definitive surgical intervention can be successfully
initiated.

64
 GENITAL TRACT TRAUMA
Lyla D. Reyes, MD

Background

Genital trauma is the second most common cause of postpartum bleeding with
an approximate incidence of 20%. It involves lacerations to the perineum, vagina, or
cervix; large episiotomy including extensions; ruptured uterus; and uterine inversion.
Bleeding from genital injury is a major cause of morbidity and mortality in several
disorders involving the female reproductive tract. Such morbidity associated with
childbirth may have immediate and long term effects on the physical, psychological, and
social well-being of the woman after delivery. Hence, appropriate management of
genital tract trauma is an essential concern of obstetricians and gynecologists.

A. GENITAL TRACT LACERATIONS

Background

Lacerations can occur within the genital tract during childbirth (OR 2.4; 95% CI
2.0-2.8). This often occurs at the vaginal vault as the fetal head passes through.
Lacerations can involve the perineum, vagina, and the cervix.
Perineal trauma may occur spontaneously or arise from episiotomy during
vaginal delivery. There are several classifications of spontaneous perineal trauma. It
can be classified according to location or depth of the perineal tissue involved. The
classification based on location include anterior and posterior perineal trauma. Anterior
perineal trauma is described as an injury involving the labia, anterior vagina, urethra or
clitoris. Posterior perineal trauma involves injury to the posterior vaginal wall, perineal
muscles or anal sphincters and may extend through the rectum. Regarding the
classification of spontaneous tears according to the degree or depth of the laceration
this includes:

First Degree involves the fourchettes, perineal skin, and vaginal mucous
membrane but not the underlying fascia and muscle

Second Degree aside from the skin and mucous membrane, the fascia and
muscles of the perineal body are involved

Third Degree lacerations extend through skin, mucous membrane,

perineal body, and anal sphincter
3a: less than 50% of external anal sphincter thickness torn
3b: more than 50% of external anal sphincter thickness torn
3c: internal anal sphincter torn

65
 Fourth Degree there is extension of laceration through the rectal mucosal to
expose lumen of the rectum

The current classification based on depth was adopted from the guidelines
published by Royal College of Obstetricians and Gynecologists (RCOG). The guidelines
as shown above further classified third degree laceration according to the extent of anal
sphincter injury. This additional classification was included to allow the differentiation
between further incontinence related to internal anal sphincter injury rather than external
anal sphincter alone. According to the meta-analysis cited by RCOG conducted by
Gupta et. al., the incidence of anal incontinence is increased in women who had both
internal and external anal sphincter damage compared with those who had external
anal sphincter damage alone. However, in acute obstetric trauma, identification of the
internal anal sphincter may not be feasible but recognizing the degree of external anal
sphincter damage is possible in all cases. However, this classification system has not
been extensively validated yet. In a survey conducted among doctors repairing third and
fourth degree lacerations revealed that the physicians concur with the classification of
Obstetric Anal Sphincter Injuries (OASI), and that further definitive research is strongly
recommended.

Intrapartum cervical lacerations have an overall incidence of 25-90% and most

cases are asymptomatic. On the other hand, the clinically significant cervical lacerations
complicate 0.2 to 4.8% of all vaginal deliveries. Minor cervical lacerations are most often
undetected since most of these would be less than 0.5 cm. On the other hand, cervical
tears may extend to the upper third of the vagina. In certain instances the cervix may be
avulsed, partially or completely. Although rare, lacerations of the cervix may also extend
to the lower uterine segment, peritoneum, and even involve the uterine artery including
its major branches.

It has been reported that women who had episiotomies or spontaneous perineal
lacerations have greater perineal pain or discomfort, decreased sexual satisfaction
postnatally, and delayed return of sexual activity than those who had an intact perineum
after delivery. This may disrupt breastfeeding, family life and sexual relations. Such may
occur depending on the severity of perineal trauma and on the effectiveness of
treatment. The type of suturing material, the technique of repair and the skill of the
operator are considered as the three main factors that influence the outcome of the
perineal repair.

Recommendations

1. What factors will increase the suspicion for genital tract lacerations?

Genital tract laceration should be suspected if bleeding will persist despite a

well-contracted uterus. (Grade C)

Summary of Evidence

66
 Most of the risk factors identified cannot be promptly used to prevent or
predict the occurrence of genital tract lacerations. However, the presence of
bleeding despite a well-contracted uterus along with any of the risk factors
mentioned bellow will increase the possible occurrence of such injury.

It is essential for clinicians to be aware of the factors that increase the risk for
the development of genital tract laceration. The factors associated with such injury
include induction of labor with oxytocin (OR 11.9; 95% CI 4.7-30.4), operative
vaginal delivery (adjusted OR, 10.0; 95% CI 3.0-33.3), mediolateral episiotomy with
forceps delivery (OR 5.62, 95% CI 2.16-14.62), midline episiotomy (adjusted OR
2.5; 95% CI 1.0-6.0), and birth weight over 4 kg (adjusted OR 1.68, 95% CI 1.18-
2.41). The other factors include second stage longer than 1 hour (4%), shoulder
dystocia (4%), persistent occipitoposterior position (3%), epidural analgesia (2%),
and precipitous delivery.

Perineal lacerations may occur in women with no apparent risk factors but the
presence of any of these risk factors increase the possible occurrence of such
injury. (Level III)

2. How can the occurrence of genital tract lacerations prevented?

Restricting the use of episiotomy can reduce the incidence of severe perineal
trauma. (Grade A)

Summary of Evidence

The purpose of performing an episiotomy is to prevent perineal lacerations.

Although, the routine use of such procedure was found to increase the risk of blood
loss and anal sphincter tears. A Cochrane review which included 8 randomized
trials, involving 5541 women, compared the effects of restrictive and routine
episiotomy. The proportion of women who had episiotomies was 75.15%
(2035/2708), while the proportion of those with restrictive episiotomy was 28.40%
(776/2733). The review demonstrated that liberal use of episiotomy does not reduce
the incidence of anal sphincter lacerations and is associated with increased
perineal trauma. The result of the review showed that restricting the use of
episiotomy to specific fetal and maternal indications, compared with routine use
during vaginal birth, was associated with lower rates of posterior perineal trauma
(RR 0.67, 95% CI 0.49-0.91), less suturing (RR 0.71, 95% CI 0.61-0.81), and fewer
healing complications (RR 0.69, 95% CI 0.56-0.85). But restrictive episiotomy was
noted to be associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61-
2.10). For the other outcome measures such as severe vaginal or perineal trauma
(RR 0.92, 95% CI 0.72-1.18), dyspareunia (RR 1.02, 95% CI 0.90-1.61), and
urinary incontinence (RR 0.98, 95% CI 0.79-1.20), no significant difference between
the 2 groups was noted. (Level I)

67
 The American college of Obstetricians and Gynecologists (ACOG)
recommends restrictive use of episiotomy rather than routine. This is based on
evidence that median episiotomy is associated with higher rates of injury to the anal
sphincter and rectum as compared to mediolateral episiotomy. Thus, routine
episiotomy does not prevent pelvic floor damage that may lead to incontinence.

Minimizing the use of operative vaginal delivery can decrease the incidence
of severe perineal trauma. Vacuum extraction is more effective in reducing
the severity of perineal trauma compared with forceps. (Grade B)

Summary of Evidence

Vaginal sidewall laceration is also most commonly associated with operative

vaginal delivery, but it may occur spontaneously. Lacerations often occur in the
region overlying the ischial spines. Cervical laceration is most commonly associated
with forceps delivery, and the cervix should be inspected following such deliveries.
To further avoid trauma to the cervix, assisted vaginal delivery (forceps or vacuum)
should never be attempted without the cervix being fully dilated. The frequency of
sidewall and cervical lacerations has probably decreased in recent years since
there has been a reduction in the use of midpelvic forceps and, especially,
midpelvic rotational procedures. (Level III)

In multivariate regression models, high birth weight (OR 1.68, 95% CI 1.18-
2.41; P=0.004), and forceps delivery combined with mediolateral episiotomies (OR
5.62, 95% CI 2.16-14.62; P<0.001) were proven as independent risk factors for
severe perineal trauma during childbirth. (Level II-1)

In a meta-analysis published in 2001 there were 10 randomized controlled

trials (RCTs), involving 2885 women, which reviewed the occurrence if perineal
trauma with forceps delivery and vacuum forceps extraction. The review was able
to demonstrate that perineal injury and pain at 24 hours was significantly reduced
with vacuum forceps extraction as compared to forceps delivery (RR 0.46, 95% CI
0.38-0.56). The number needed to treat (NTT) is 10, which means that to prevent 1
woman having perineal injury 10 women should undergo vacuum forceps extraction
rather than forceps delivery. However, none of the trials attempted to ―blind‖ the
allocated intervention during the postnatal assessments. (Level I)

The subsequent RCTs conducted found that fewer women had severe
perineal trauma and third-degree tears with vacuum extraction compared with
forceps delivery. But the risk of perineal trauma between the 2 groups was not
significantly different (RR 0.50, 95% CI 0.10-2.64; RR 0.58, 95% CI 0.19-3.15; and
RR 0.44, 95% CI 0.16-1.22). (Level II-1)

In an observational study, vacuum extraction was found to be more effective

in decreasing the proportion of women with severe perineal injury, se3vere perineal

68
pain at 24 hours, and altered fecal continence at 3 months. However, due to the low
quality of evidence no definite conclusion can be drawn. (Level III)

Continuous support may be more effective in reducing perineal trauma.

(Grade A)

Summary of Evidence

Continuous support during labor may be more effective in decreasing the

proportion of women who would need assisted vaginal delivery, hence reducing the
risk of perineal trauma. We don’t know whether continuous support during labor
may be more effective in reducing perineal trauma or in reducing rates of
episiotomy.
One systematic review conducted in 2005, which included 15 RCTs, involving
12, 791 women, compared continuous one-to-one intrapartum support from a
professional nurse, midwife, or layperson versus usual care. The RCTs were of
reasonable quality. Although the experimental intervention was always described as
one-to-one support, but the experience, relationship to the laboring woman, timing,
and duration of support varied between trials. Despite of this no heterogeneity
between the trials was noted. The review found that continuous support significantly
reduced assisted vaginal birth compared with usual care (RR 0.89, 95% CI 0.83-
0.96). however, there was no significant difference in the overall rate of episiotomy
or perineal trauma with continuous support (RR 0.97, 95% CI 0.90-1.05); and
perineal trauma (episiotomy or laceration requiring suturing) with usual care (RR
0.99, 95% CI 0.95-1.03). Although, there is some evidence of benefit for continuous
support during labor compared with usual care, particularly in reducing the rate of
assisted vaginal birth. However, no reduction was noted with the overall rates of
perineal trauma. (Level I)

Antenatal perineal massage reduces perineal trauma. (Grade A)

A Cochrane Review documented that antenatal perineal massage during the

last trimester of pregnancy reduces the likelihood of perineal trauma and
postpartum pain. Four good quality trials were included in the review, which
involved 2497 women, comparing digital antenatal perineal massage with control.
Perineal massage done at least once or twice a week from 35 weeks of pregnancy
performed by the woman or her husband was associated with an overall reduction
in the incidence of trauma requiring suturing (RR 0.91, 95% CI 0.86-0.96). The NNT
is 15. Women practicing perineal massage were found to be less likely to have an
episiotomy (RR 0.84, 95% CI 0.74-0.95), with NNT of 21. These findings were
significant for women without previous vaginal birth only. For women who previously
had vaginal delivery, a statistically significant reduction in the incidence of pain at
three months postpartum (RR 0.45, 95% CI 0.24-0.87) was reported, with NNT of
13. Regarding the incidence of first- or second-degree perineal tears or third/fourth-
degree perineal trauma, no statistically significant differences were reported
between perineal massage and no massage. Similarly, no significant differences

69
 were observed in the incidence of instrumental deliveries, sexual satisfaction, or
incontinence of urine, feces or flatus for any of the women who practiced perineal
massage compared with those who did not massage. (Level I)
Antenatal perineal massage reduces the occurrence of perineal trauma,
particularly episiotomies, and the reporting of ongoing perineal pain. It is generally
found to be well accepted by women. Thus, women should be made aware of the
possible benefit of perineal massage and provided with information on the process
of massage. For further details regarding perineal massage please refer to
Appendix II.

3. What measures can be done to properly identify genital tract lacerations?

All women undergoing vaginal delivery suspected to have genital tract

lacerations should be assessed thoroughly by exploration of the lower genital
tract to properly evaluate the extent of the injury. Most especially when
uterine atony and retained placenta has been ruled out. (Grade C)

Summary of Evidence

In antenatal genital tract lacerations, careful visual inspection of the lower

genital tract should be done. The patient should be in dorsal lithotomy position
assessed with appropriate assistance and good lighting to adequately visualize the
presence and extent of the lacerations. During the process, adequate anesthesia is
often essential to allow ease if exploration. In some instances, it may be necessary
to move the patient to the operating room, as surgical assistance may be needed to
obtain appropriate exposure.
Inspection of the cervix should be aided with the use of ring or sponge
forceps and appropriate retractors to ensure adequate visualization. The anterior lip
is grasped, and the cervix is inspected by using a second ring forceps placed at the
2-o’clock position, followed progressively ―leap-frogging‖ the forceps ahead of one
another until the entire circumference has been inspected. (Level III)

4. Once the lacerations are identified, how should it be managed?

Nonsuturing of first- and second-degree tears may be associated with wound

gaping up to 48 hours to 14 days after birth. However, leaving perineal skin
unsutured reduces dyspareunia and pain up to 3 months. (Grade B)

Summary of Evidence

In women with first- and second-degree tears or episiotomies, nonsuturing

of the perineal skin but apposing it with the sutured vagina and perineal muscles
may be more effective than suturing all three layers in decreasing the incidence of
dyspareunia at 3 months but not at reducing pain. However, this method may be
less effective in decreasing the incidence of gaping wound at 48 hours and at 10
days, but not at 14 days postpartum. There were two RCTs that compared non-

70
suturing of but apposed skin of perineal tears versus repair or suturing all three
layers. However, these RCTs were found to be of low-quality evidence.
In one RCT conducted in a large center in UK, involving 1780 primiparous
and multiparous women with first- and second-degree tears or episiotomies after
spontaneous or assisted vaginal delivery, nonsuturing of the skin was compared
with the skin sutured. In this RCT, no significant difference was noted in the
proportion of women reporting perineal pain at 10 days after birth ((RR 0.91, 95%
CI 0.77-1.06). With regards to dyspareunia at 3 months postpartum, the unsutured
skin compared with sutured skin group was significanctly reduced (RR 0.80, 95% CI
0.64-0.99).

Another RCT was conducted in Nigeria, involving 823 women who sustained
a second-degree tear or episiotomy. The trial showed that leaving the perineal skin
unsutured significantly decreased the proportion of women with perineal pain at 48
hours, 14 days, 6 week s and 3 months after delivery. Forty-eight hours after
delivery the risk of developing perineal pain with the skin unsutured was
significantly reduced as compared when the skin is sutured (RR0.87, 95% CI 0.78-
0.97). At 14 days postpartum, the risk of perineal pain further decreased
significantly in women with unsutured skin had as compared to those with the skin
sutured (RR 0.77, 95% CI 0.61-0.98). On the 6th week postpartum, the risk of
perineal pain was reduced by 36% for the unsutured skin group compared with the
skin sutured (RR 0.64, 95% CI 0.44-0.93). By 3 moths postpartum, there is 81%
reduction on the risk of perineal pain among women with unsutured skin compared
with the skin sutured (RR 0.19, 95% CI 0.06-0.54). When dyspareunia as an
outcome was assessed, there was also a significant reduction after 3 months
postpartum with unsutured skin of perineal tears as compared to those sutured
(RR0.52, 95% CI 0.33-0.81).

However, the two RCTs found that leaving the perineal skin unsutured
increased the rates of wound gaping 48 hours postpartum as compared with
suturing the skin. In the study of Gordon, et. al., the reported RR is 5.10 (95% CI
3.68-7.0) a a RR of 4.96 (95% CI 3.17-7.76) was accounted form Obovo, et. al. In
the study of Gordon, et. al., the risk of wound gaping was also noted to increase at
10 days after delivery. However, with Obovo, et. al., no significant difference in
wound gaping was reported at 14 days postpartum (RR 1.25, 95% CI 0.94-1.67)
unlike with the study of Gordon, et. al., (RR 1.56, 95% 1.30-1.88). Regarding wound
breakdown at 14 days postpartum, no significant differences were noted between
the unsutured and sutured skin groups (RR 1.27, 95% CI 0.56-2.85). Level II-1)

Any cervical tear, which is actively bleeding and/or 2 centimeters in legth or

lnger should be sutured. (Grade C)

Summary of Evidence

Cervical lacerations up to 2 cm in length occur frequently and can be

expected during childbirth. They usually heal rapidly and are of little consequence. If

71
 the lacerations are actively bleeding or if alterations in the anatomical relationship of
the cervix occur, such lacerations should be repaired. (Level III)

In repairing genital tract lacerations an anchoring suture is placed 1 cm above

the apex of the vaginal tear or episiotomy incision, and just above the angle
for cervical lacerations. (Grade C)

Summary of Evidence

Applying the suture above the apex of the laceration ensures hemostasis
of any bleeding vessels that may have retracted above it. (Level III)

Obliteration of dead spaces and prevention of overtightened sutures should

be ensured when repairing genital tract lacerations. (Grade C)

Summary of Evidence

Presence of dead spaces cannot assure hemostasis. This predisposes the

woman to hematoma formation, pain, infection, and wound breakdown as well. If
dead spaces cannot be closed securely, then a vaginal pack should be inserted.
Avoid over tightened sutures since this can cause unnecessary pain when
reactionary edema and swelling occur, and also may cause tissue ischemia which
delays healing. (Level III)

5. What suture material should be used in the repair of genital tract lacerations?

The use of absorbable synthetic material (polyglycolic acid and polyglactin

910) for repair of perineal trauma is preferred. Such material is associated
with less perineal pain, analgesic use, dehiscence and resuturing, although
there is increased suture removal, when compared with catgut. (Grade A)

Summary of Evidence

A meta-analysis, which included eight trials, involving 3681 women, reviewed

the evidence on absorbable synthetic versus catgut suture material for perineal
repair. There were 5 RCTs, which examined the use of analgesics as the outcome,
while the other 3 trials assessed the outcome perineal pain. Three out of the 8
RCTs assessed the outcome perineal pain. Three out of the 8 RCTs assessed the
presence of dyspareunia. With all the RCTs, blinding of the outcome assessment
was not possible due to the noticeable difference between the sutures. The findings
were consistent among the RCTs. Compared with catgut, the polyglycolic acid and
polyglactin groups were significantly associated with less pain (RR 0.78, 95% CI
0.67-0.90) and analgesic use (RR 0.74, 95% CI 0.65-0.85) in first 10 days
postpartum. The NNT is 18, which means that using polyglycolic acid or
polyglaactin suture in 18 women with perineal tears will reduce 1 event of perineal

72
 pain. By 3 months postpartum, there was no significant difference in perineal pain
(RR 0.86, 95% CI 0.64-1.08) or dyspareunia (RR 0.95, 95% CI 0.79-1.15) between
absorbable synthetic sutures and catgut chromic catgut. But rates of dyspareunia
were lower after 3 months from delivery with absorbable anesthetic sutures than
with chromic catgut (RR 0.59, 95% CI 0.39-0.91) with NNT of 20. Therefore, you
need to use absorbable synthetic sutures in repairing perineal tears of 20 women to
prevent one event of dyspareunia.

However, in the same systematic review suture removal was significantly more
common in the absorbable synthetic group as compared to the catgut group up to 3
months after postpartum (RR 1.78, 95% CI 1.44-2.20). The number needed to harm
(NNH) is 13, wherein 13 women with perineal tears repaired with absorbable synthetic
sutures there will be 1 event of dehiscence. This was based on the findings of 2 RCTs,
involving 2129 women.

There were 3 RCTs which compared rapidly absorbed suture polyglactin 910
suture and standard polyglactin suture for surgical repair. There was no systematic
review found. One RCT did not report their data in a standard format, hence, it was not
included for appraisal. With the other 2 RCTs, rapidly absorbed sutures significantly
reduced pain on ambulation within 2 weeks postpartum compared with standard
absorbable sutures. This accounted for the RR of 0.69 (95% CI 0.51-0.92) in the trial of
Gemynthe, et. al. No significant difference between suture groups was found in terms of
the risk of developing perineal pain, pain of sitting, or dyspareunia. Outcome assessors
were blinded as to the type of suture material used since the manufacturers produced
identical suture materials. Only the trial of Kettle, et. al. reported on the adverse effect of
suture material, which is suture removal. In this trial rapidly absorbed sutures were
significantly removed less frequently during the 3 months postpartum than standard
absorbable sutures (RR 0.23, 95% CI 0.14-0.35). (Level I)

The standard polyglactin 910 takes time to be absorbed. About 60% of the suture
remains up to 21-28 days after repair and it is not totally absorbed from the wound until
60-90 days. But current evidence reported a more rapidly absorbed synthetic suture
material when compared to standard polyglactin 910 material is associated with less
perineal pain with ambulation or need for suture removal up to 6 months after repair.
According to the product information sheet of the suture material, the tensile strength is
reduced at 10-14 days and completely absorbed from the tissue by 42 days.

In repairing the external anal sphincter muscle use of either monofilament

sutures such as polydiaxanone or braided sutures such as polyglactin can be
used with equivalent outcome. (Grade A)

Summary of Evidence

73
 No systematic reviews to assess the best suture material for repair of the
external anal sphincter were found. Only one RCT reported on the use of 3-0 PDS and
2-0 polyglactin (Vicryl). Out of the 103 women who followed up on the 6 th week after
repair of perineal tears after childbirth, no difference in suture-related morbidity between
the 2 suture material groups was found. Seventy percent of these women were
asymptomatic. Up to 12 months of follow-up showed no significant difference in
morbidity from anal incontinence, perineal pain or suture migration.

Use of fine suture size as 3-0 PDS and 2-0 polyglactin (Vicryl) may cause less
irritation and discomfort. Use of theses sutures is preferable since these are delayed
absorbable monofilament suture with a longer half-life and is less likely to precipitate
infection than braided sutures. (Level I)

With the repair of the internal anal sphincter muscle, fine suture size such as 3-0
PDS and 2-0 Vicryl may produce less irritation and discomfort. (Grade C)

The use of and 2-0 Vicryl or 3-0 PDS absorbable sutures with tapered needle is
suitable to repair cervical lacerations. (Grade C)

Summary of Evidence

Similarly, there are no systematic reviews or randomized studies conducted to

evaluate the type of suture materials use for the repair of internal anal sphincter and
cervical lacerations. The use of fine suture size such as 3-0 PDS and 2-0 Vicryl may be
associated with less irritation and discomfort. (Level III)

5. What techniques should be used to accomplish the repair of genital tract

lacerations?

Continuous subcuticular suture for repair of perineal skin is more effective in

reducing the proportion of women with short-term pain as compared to
interrupted sutures. (Grade A)

Summary of Evidence

A Cochrane systematic review of four RCTs, involving 1864 primiparous and

multiparous women, found that a continuous subcuticular technique of perineal skin
closure, when compared with interrupted transcutaneous stitches, was associated with
less short-term pain. Three of the trials presented data on pain up to day 10 in a
suitable format for inclusion in the analysis and only one study actually demonstrated
any statistical significance between the two interventional groups. Continuous sutures
significantly reduced the risk for perineal pain up to 10 days compared with interrupted

74
sutures (RR 0.75, 95% CI 0.63-0.89) with NNT of 14. This means to prevent one event
of perineal pain the perineal tears of 14 women should be repaired by continuous
subcuticular suture. However, there was no significant difference in the risk of women
with pain at 3 months between the subcuticular and interrupted suture groups (RR 1.10,
95% CI 0.77-1.57).

But in 1 RCT identified by the systematic review of Kettle, et. al. suture removal
was significantly more common up to 3 months from perineal skin repair in the
interrupted-suture group than in the continuous group (RR 1.41, 95% CI 1.16-1.72).
(Level I)

A loose, continuous non-locking suturing technique used to appose the vaginal

(anterior and posterior perineum) tissue, perineal muscle and skin is associated
with less short-term pain compared with the traditional interrupted method.
(Grade A)

Summary of Evidence

Two RCTs compared loose continuous suture for all layers versus interrupted
sutures. In a large trial involving 1542 women with second-degree tears or episiotomy in
the UK continuous sutures significantly reduced the risk of developing pain among
women with perineal tears at 10 days with continuous as compared with interrupted
suture (OR 0.47, 95% CI 0.38-0.58). However, no significant difference in the risk of
perineal pain was noted among these women at 3 months postpartum with continuous
and interrupted sutures (OR 0.70, 95% CI 0.54-1.47) even up to 12 months (OR 0.64,
95% CI 0.35-1.16). The odds of developing dyspareunia is not significantly different
after 3 months with continuous and with interrupted suture groups (OR 0.98, 95% CI
0.72-1.33) as well as at 12 months (OR 1.05, 95% CI 0.77-1.43).

In a smaller RCT, 212 primiparous women in Italy with a second-degree tear or

episiotomy were assessed to compare the effects of continuous and interrupted sutures
on perineal pain and dyspareunia. The suture material used was fast-absorbing
polyglactin 910 sutture material for perineal repair in both comparison groups. The trial
reported that continuous sutures significantly reduced the risk of women having perineal
pain at 10 days compared with interrupted sutures (OR 0.32, 95% CI 0.19-0.57).
However, no significant difference between groups in the risk of developing dyspareunia
at 3 months (OR 0.87, 95% CI 0.42-1.82).

The trial of Kettle, et. al. accounted for significant suture removal 3 months
postpartum in the interrupted suture group than in the continuous group (RR 4.01, 95%
CI 2.59-6.19). No information regarding adverse effects was reported by Morano, et. al.
(Level I)

75
The use of a two-layer procedure of perineal repair, where the skin is apposed but
not sutured, is associated with an increase in wound gaping up to 10 days
following birth but less dyspareunia at 3 months postpartum than a three-layer
technique involving skin closure. (Grade A)

Summary of Evidence

Two large RCTs compared leaving the perineal skin unsutured but apposed (the
vagina and perineal muscle were sutured) to the traditional repair whereby all three
layers (vagina, perineal muscles and skin) were each sutured. One of the RCTs carried
out in a single centre in the UK involving 1780 women found no difference in short- or
long-term pain between the two groups. However, the other RCT carried out in Nigeria
among 823 women found that leaving the skin unsutured was associated with a
reduction in perineal pain up to 3 months postpartum. Both trials reported lower rates of
dyspareunia at 3 months postpartum in the groups that had the perineal skin left
unsutured. Both studies found that leaving the perineal skin unsutured was associated
with a significant increase in wound gaping up to 10 days following birth. (Level I)

For repair of the external anal sphincter, either an overlapping or end-to-end

(approximation) method can be used, with equivalent outcome. Where the
internal anal sphincter can be identified, it is advisable to repair separately with
interrupted sutures. (Grade A)

Summary of Evidence

A systematic review on the method of repair for third-degree tears examined

three trials involving 279 women. This review showed that there was no significant
difference in perineal pain (RR 0.08, 95% CI 0.00-1.45), dyspareunia (RR 0.62, 95% CI
0.11-3.39), flatus incontinence (RR 0.93, 95% CI 0.26-3.31) and fecal incontinence (RR
0.07, 95% CI 0.00-1.21) between the two repair techniques at 12 months. But a
significantly lower incidence in fecal urgency (RR 0.12, 95% CI 0.02-0.86, one-trial, 52
women) and lower anal incontinence score (weighted mean difference-1.70, 95% CI -
3.03 to -0.37) in the overlap group was noted. Overlap technique was also associated
with a significant lower risk of deterioration of anal incontinence symptoms over 12
months (RR 0.26, 95% CI 0.09-0.79, one trial, 41 women). There was no significant
difference in quality of life. The reviewers concluded that the limited data available show
that compared with immediate primary end-to-end repair of obstetric anal sphincter
injuries, early primary overlap repair appears to be associated with lower risks for fecal
urgency and anal incontinence symptoms. As the experience of the surgeon is not
addressed in the three studies reviewed, it would be inappropriate to recommend one
type of repair over another. However, most of these conclusions were based on one
study.

76
 One of the RCTs included in the review assessed the presence of residual
defects of the external anal sphincter with ultrasound, and found no significant
difference between groups. Sixty six percent of women had a residual full-thickness
defect in the external anal sphincter ultrasound after 3 months from primary repair with
overlap 40/57 [70%] and end-to-end (RR 0.88, 95% CI 0.67-1.15).

There is weak evidence of benefit associated with the overlap technique for
primary repair of the external anal sphincter compared with the end-to-end method.
(Level I)

The external anal sphincter appears as a band of skeletal muscle with a fibrous
capsule. Traditionally, an end-to-end technique is used to bring the ends of the
sphincter together at each quadrant (12, 3, 6 and 9 o’clock) using interrupted sutures
placed through the capsule and muscle. Allis clamps are placed on each end of the
external anal sphincter. The use of 2-0 PDS, a delayed absorbable monofilament
suture, will allow the sphincter ends to have adequate time to scar together. Recent
evidence suggests that end-to-end repairs have poorer anatomic and functional
outcomes than was previously believed. (Level II-2)

The cervical laceration is repaired with interrupted or running sutures. (Grade C)

Summary of Evidence

No RCTs regarding repair of cervical laceration was found. But according to case
reports either running or interrupted absorbable sutures are suitable to repair such
lacerations. Although, overzealous suturing aimed to restore anatomical appearance of
the cervix may lead to stenosis as the uterus returns to its non-pregnant state. (Level III)

6. Who should repair obstetric anal sphincter injury?

An experienced health provider should repair difficult trauma under regional or

general anesthesia done in the operating room. (Grade C)

The practitioner must be able to demonstrate clinical competence in suturing an

episiotomy and/or genital laceration before undertaking the procedure without
supervision. (Grade C)

Summary of Evidence

Repair done in the operating room will allow ease in performing the procedure
under aseptic conditions with appropriate instruments, adequate light and an assistant.
In this set up the patient can be adequately given regional or general anesthesia. This
will permit access to deeper tears, and promote relaxation of the perineal muscles and

77
anal sphincter. Thus, there will be ease in retrieving the retracted severed ends of the
anal sphincter, and help affix the ends together without any tension.

Repair of the anal sphincter by an unexperienced health provider may contribute

to maternal morbidity, especially subsequent anal incontinence. A survey conducted
among consultant and training obstetricians in two regions in the UK stressed on the
deficiency and dissatisfaction of these practitioners with their training in the
management of third-degree tears.

Limited research has been carried out to assess the techniques of teaching and
evaluating surgical skills in obstetrics. However, training may be improved by
implementation of structured surgical skills courses with the use of models, perineal
repair simulators, case scenarios and audiovisual material. A report on the effect of
hands-on training workshops on repair of third- and fourth-degree perineal tears showed
such increased awareness on perineal anatomy and recognition of anal sphincter injury.
(Level III)

In our setting, the four-year residency-training program in Obstetrics and

Gynecology among Philippine Obstetrical and Gynecological Society, Inc. (POGS)
accredited institutions ensures to provide teaching methods and the means to evaluate
the skill regarding the different approaches for perineal repair. An accredited staff
member assesses the competency of such training. Training among midwives of local
health centers is also being improved through the implementation of surgical skills
workshops with the use of models and audiovisual material. Nevertheless, practitioners
appropriately trained on perineal repair are more likely to provide consistent and high
standard of surgical skill. Thereby, contributing in the effort to lower the maternal
morbidity and litigation associated with this procedure.

7. What measures would be appropriate for the postoperative care and follow-up
of women with puerperal genital tract lacerations?

Perform a vaginal and rectal examination postoperatively to check for bleeding,

hematoma, and ensure that suture material has not been accidentally inserted
through the rectal mucosa. (Grade C)

If there is any significant dead space or if the vagina is too friable to accept
suturing, then pressure or packing is indicated for at least 24 hours. (Grade C)

Summary of Evidence

The literature contains little information on patient care after the repair of perineal
lacerations. There are no data in the literature from controlled studies regarding the best
mode of subsequent delivery following repair of genital tract lacerations.

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 The laceration must be observed for bleeding after the torn edges of the
lacerations are approximated. Vaginal packing using gauze is the most common
method to achieve vaginal tamponade. Pressure or packing over the repair may achieve
hemostasis or allow for better placement of further hemostatic stitches. Generally,
packs are left in place for 24-36 hours before removal. A urinary foley catheter and
broad spectrum antibiotic cover should be given where packs are used. Balloon
tamponade using Rusch catheters of Blakemore-Sengstaken tubes, as described for
treatment of uterine bleeding, can also be used. Cervical and vaginal vault lacerations
that continue to ooze despite treatment as detailed above or those that are associated
with hematomas may be amenable to selective arterial embolization. (Level III)

The success rates of these forms of management were evaluated in a systematic

review, which included all cases causing postpartum hemorrhage. The cumulative
success rates reported was 90.7% (95% CI 85.7-94.0%) for arterial embolization, 84.0%
(95% CI 77.5-88.8%) for balloon tamponade, and 84.6% (95% CI 81.2-87.5%) for iliac
artery ligation or uterine devascularization (P=0.06). Currently, no evidence suggests
that any one the method is better than the other for the management of severe
postpartum hemorrhage. No RCTs on the various treatment options were found. (Level
II-3)

The use of broad-spectrum antibiotics is recommended following obstetric anal

sphincter repair to reduce the incidence of postoperative infections and wound
dehiscence. (Grade C)

Summary of Evidence

A systematic review regarding antibiotic prophylaxis for fourth-degree perineal

tear designed to compare prophylactic antibiotics with placebo or no antibiotics was not
able to find any RCTs. Hence, there is limited data to support a policy for routine
prophylactic antibiotics in fourth-degree perineal tear during vaginal birth. To carry out
this policy a well-designed RCT is needed. However, intra-operative and postoperative
broad-spectrum antibiotics are advised because the occurrence of infection will increase
the risk of anal incontinence and fistula formation if the repaired anal sphincter breaks
down. (Level III)

The use of postoperative laxatives is recommended to reduce the

incidence of postoperative wound dehiscence. (Grade C)

Summary of Evidence

Laxatives are recommended during the postoperative period to minimize the

potential for repair breakdown from straining during defecation. Use of lactulose, and
bulk laxatives and constipating agents are recommended for about 10 days after the

79
repair. An RCT compared laxatives and constipating agents given postoperatively after
primary obstetric anal sphincter repair. In this trial, women in the laxative are had
significantly earlier and less painful bowel movement. There was no significant
difference in the symptomatic or functional outcome of repair between the two groups.
However, no systematic reviews were reported to assess the use of postoperative
laxatives and stool softeners as part of the postoperative care for patients who had
episiotomies or perineal injury. (Level III)

All women who incurred such injury should be informed regarding the extent of
trauma and discuss pain relief, diet, hygiene, and the importance of pelvic floor
exercises. (Grade C)

Summary of Evidence

According to the RCOG guidelines women should be offered physiotherapy and

pelvic floor exercises for 6-12 weeks after obstetric anal sphincter repair. However, this
recommendation was regarded as best practice based on the clinical experience of the
guideline development group. For proper wound care and healing women should also
be advised on the importance of appropriate diet and perineal hygiene. (Level III)

All women who have had obstetric anal sphincter repair should be reassessed 6-
12 weeks postpartum by an obstetrician-gynecologist. If incontinence develops
referral to a colorectal surgeon should be considered. (Grade C)

Summary of Evidence

No systematic review or RCTs were found to recommend the best method for
follow-up of repaired puerperal genital tract lacerations. It is useful to discuss the injury
sustained during childbirth and evaluate for symptoms of its complication
postoperatively.

When such symptoms develop the woman should be advised to follow up. If a
woman is having incontinence or pain at follow-up, referral to a specialist gynecologist
or colorectal surgeon for endoanal ultrasonography and anorectal manometry should be
considered. Some women may require referral to a colorectal surgeon for consideration
of secondary sphincter repair. (Level III)

8. What is the prognosis after repair of the genital tract laceration?

Women should be informed regarding the complications that may arise after
repair of the genital tract laceration. (Grade C)

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Summary of Evidence

The complications of repaired genital tract lacerations postoperatively include

perineal pain and discomfort, dyspareunia, fecal and urinary incontinence, and
breakdown of the repaired perineal laceration. Perineal pain and discomfort as a
complication of the injury may last for 10-12 days or even up to 3-18 months after giving
birth. Women may also complain of dyspareunia up to three months postpartum. (Level
III)

Regarding breakdown of perineal laceration repair after vaginal delivery, a

retrospective, case-control study reviewed and identified the associated risk factors.
The significant risk factors identified were mainly mediolateral episiotomy (OR 6.9, 95%
CI 2.6-18.7), operative vaginal delivery (OR 3.6, 95% CI 1.8-7.3), third- and fourth-
degree lacerations (OR 3.1, 95% CI 1.5-6.4) and meconium-stained amniotic fluid (OR
3.0, 95% CI 1.1-7.9). Longer second stage of labor (142 vs 87 minutes; P = 0.001) was
found to have the least association. Previous vaginal delivery was found to be protective
(OR 0.38, 95% CI 0.18-0.84). But the most significant factor reported was mediolateral
episiotomy in concurrence with operative vaginal delivery (OR 6.36, 95% CI 2.18-
18.57). (Level II-2)

Women should be advised that the prognosis following external anal sphincter
repair is good, with 60-80% asymptomatic at 12 months. Women who remained
symptomatic mostly reported the occurrence of incontinence of flatus or fecal
urgency. (Grade A)

Summary of Evidence

The outcome of repaired genital tract lacerations based on reported symptoms

and consequences of anal sphincter investigations were accounted by 7 prospective
case-control and 7 retrospective studies. Most of these studies only described the
technique of suturing the external anal sphincter either by interrupted or figure-of-eight
sutures. Only a few studies reported on the method of suturing the internal anal
sphincter. (Level II-2)

Majority of these studies reported symptoms of anal incontinence in 20-67% of

women who had third-degree laceration repair. The types of incontinence accounted
were passage of flatus in 59%, leakage of fluid or solid stool in 11%, and fecal urgency
in 26% of these women. One study even reported that symptoms of anal incontinence
markedly increased in 17 to 42% of cases after four years. However, there was no
standard questionnaire utilized by these studies to assess for symptoms on anal
incontinence. Hence, it is difficult to compare their study outcomes. (Level II-3)

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 But recently, RCTs comparing the techniques of external anal sphincter repair,
reported that there is a decreasing incidence of anal incontinence symptoms with both
overlap and end-to-end suturing. Sixty to eighty percent of women who have undergone
such repair were noted to be asymptomatic after 12 months. But there were 3 studies,
which confirmed the presence of persistent defects in 54-88% women who had third-
degree laceration repair followed up by endoanal ultrasound. On the contrary, more
recent RCTs reported fewer residual defects, which accounted to 19-36% of cases.
(Level I)

9. When would it be comfortable for women to have sexual intercourse after

repair of the genital tract laceration?

Women may resume sexual intercourse at 3 to 6 months after repair of laceration.

(Grade C)

Summary of Evidence

Dyspareunia or sexual problems after childbirth is reported as 17 to 83% at 8 to

12 weeks postpartum declining to 8-64% at six months postpartum. It is not just due to
pain from the scar which resulted from perineal repair but to several factors as well such
as psychological reactions, decreased libido, and decreased vaginal lubrication
correlated to hormonal changes in the early puerperium. Postpartum dyspareunia has
been previously been associated with the extent of trauma. Such that in a German
observational study, involving 655 primipara, intact perineum after vaginal delivery
(3.5%) or CS (3.4%) was noted to be associated with the least dyspareunia at six
months postpartum as compared with 11% among women who had episiotomies and
14% after operative vaginal deliveries.

The first sexual intercourse after childbirth may be difficult for women due to
dyspareunia, especially if there were injuries incurred in the genital area. Hence, they
may opt to delay resumption of their first sexual intercourse. The data from British
randomized trials on suture techniques and suture materials, including 1780 and 1542
participants, showed that 76 to 83% had resumed intercourse at three months and 86 to
99% at six months postpartum.

A population-based cohort conducted in Sweden investigated on the effect of

lacerations in the vagina, perineum, anal sphincter or rectum on sexual intercourse
during the first year postpartum. In this cohort 2490 women were asked to fill up a
questionnaire to gather information about their first sexual intercourse 1 year after birth.
The results showed that risk of not having sexual intercourse within 3 months after
childbirth were 1.5 (95% CI 1.2-1.8) for tears in the vagina, 1.4 (95% CI 1.1-1.6) for
tears in the perineum and 2.1 (95% CI 1.4-3.1) for tears in the anal sphincter and
rectum. On the other hand the risk of abstaining from intercourse after 6 months were

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1.6 (95% CI 1.2-2.3) for vaginal tears, 1.5 (95% CI 1.1-2-1) for perineal lacerations and
2.2 (95% CI 1.1-4.6) due to anal sphincter and rectal lacerations. No statistically
significant differences were found at 1-year follow-up. There were no associations found
between episiotomy and delay in resuming intercourse after adjusting the relative risks.
Therefore, lacerations in the genital tract significantly delay the woman’s capacity to
resume sexual intercourse by 3 to 6 months from childbirth.

In the Ipswich Childbirth study, the occurrence of dyspareunia one year

postpartum was associated with the suture material used during repair. They
documented that 8% of women sutured with polyglactin 910, compared with 14%
sutured with chromic catgut, experienced dyspareunia. (Level II-2)

B. GENITAL TRACT INFECTIONS

Background

The pregnant uterus, vagina, and vulva have rich vascular supplies that are at
risk of trauma during the birth process, and trauma may result in formation of a
hematoma. Puerperal genital hematomas are relatively uncommon but can be a cause
of serious morbidity and even maternal death. Hematomas occur in 1:300 to 1:1500
deliveries and, rarely, are a potentially life-threatening complication of childbirth. In a
case series the estimated incidences are 1 in 500 to 1 in 12,500 deliveries, with surgical
intervention required in approximately 1 in 1,000 deliveries. However, there may be
difficulty in diagnosing such condition, as symptoms can be non specific and bleeding is
often concealed.

Genital tract hematomas are classified according to their anatomical location.

The most common locations for puerperal hematomas are the vulva,
vaginal/paravaginal area, and retroperitoneum/subperitoneal.

The vulvar hematomas tend to be limited to the vulvar tissues superficial to the
anterior urogenital diaphragm, while a vulvovaginal hematoma may extend to the
paravaginal area. These types of hematoma arise from injury to the branches of the
pudendal artery including the inferior rectal, transverse perineal, or posterior labial
branches, as a result of episiotomy or perineal lacerations. Bleeding is then directed
toward the skin and the loose subcutaneous tissues exert little resistance to hematoma
formation. The hematoma can extend from the posterior margin of the anterior triangle,
at the level of the transverse perineal muscle, anteriorly over the mons to the fusion of
the fascia at the inguinal ligament.

83
 On the other hand, paravaginal hematomas occur from the damage to the
descending branch of the uterine artery. It is confined to the space bounded inferiorly by
the pelvic diaphragm and superiorly by the cardinal ligament. This type of hematoma
may not be obvious externally but can be palpated through vaginal examination. Blood
vessels in the vagina are surrounded by soft tissue and are not found in the superficial
fascia, thus, injury to these vessels can result to the collection of blood in the
paravaginal space or ischiorectal fossa. Extension and dissection of the bleeding into
the retroperitoneum may occur and form a palpable tumor above Poupart’s ligament.
Dissection of blood may also extend cephalad and reach the lower margin of the pelvic
diaphragm. Most vaginal or paravaginal hematomas often block the vaginal canal. They
are commonly associated with operative vaginal deliveries but may also occur
spontaneously.

The supravaginal or subperitoneal hematomas are the result of damage to the

uterine artery branches in the broad ligament. The hematoma can dissect
retroperitoneally or develop within the broad ligament.

Recommendations

1. Can the occurrence of genital tract hematomas be predicted and prevented?

The practitioner should be aware of the risk factors for genital tract hematoma
but also acknowledge the these risk factors will not frequently permit its
prediction or prevention. (Grade C)

Good surgical technique, with attention to hemostasis in the repair of lacerations,

should limit the occurrence of puerperal hematoma. (Grade C)

Summary of Evidence

The risk factors for genital tract hematoma include nulliparity, prolonged second
stage of labor, instrumental delivery, having a baby greater than 4000 grams, genital
tract varicosities, maternal age more than 29 years, preeclampsia, multifetal pregnancy,
and clotting disorders. In several case series, 87% of puerperal hematomas were
reported to occur from bleeding lacerations related to operative deliveries, sutured
perineal tears, or episiotomies. Hence, a good surgical technique with appropriate
hemostasis may reduce the incidence of puerperal hematomas. Even without
lacerations or incisions of the surrounding tissue, hematomas can still occur as long as
there is injury to a blood vessel. Hematomas are not unavoidable. However, no
published information on the risk of recurrence of puerperal hematomas was found in
subsequent deliveries.

84
 These risk factors may help the practitioner to be attentive to the occurrence of
puerperal hematomas. But it should be recognized that these factors will not completely
prevent or predict hematoma formation. As this type of injury may occur in both
spontaneous and operative vaginal delivery even without lacerations.

2. What signs and symptoms will facilitate the recognition of genital tract
hematoma?

Excessive perineal pain is a hallmark symptom of puerperal hematomas.

But a change in vital signs disproportionate to the amount of blood loss should
also prompt a gentle pelvic examination. It may present with non-specific signs
and symptoms as well. (Grace C)

A high index of suspicion is required to diagnose and manage these

hematomas promptly before signs of cardiovascular collapse develop. (Grade C)

Summary of Evidence

Clinical awareness is the most important factor to arrive at a correct diagnosis.

Recognition of the hematoma will depend on the extent of the bleeding, its associated
consequences and the level of awareness of the practitioner. Thus, a woman with a
large hematoma may present with cardiovascular collapse within a few hours of
delivery, while a woman with a small hematoma in an episiotomy may present with
persisting pain over a few days. Puerperal hematomas, aside from pain, usually present
with pressure symptoms, swelling as well as urinary retention due to inability to void or,
rarely, unexplained pyrexia.

The typical symptoms of hematomas will depend on its location. Vulvar and
vulvovaginal hematomas usually presents with pain and swelling in the perineum.
These hematomas are easy to detect if the woman is examined thoroughly and gently
but can be confused with abscesses. Failure to examine the patient can lead to
incorrectly attributing the pain to be arising from the episiotomy site, a tear or
hemorrhoids.

Paravaginal hematomas typically present with rectal pain, vague lower

abdominal pain, and signs of hypovolemia, These non specific symptoms can be
ascribed to other causes, and may delay diagnosis. The degree of shock is often not
proportional to revealed blood loss.

In case of supravaginal hematomas, signs of hypovolemia frequently present first

but abdominal pain may also be noted. For broad ligament hematomas, approximately
50% of cases present early with symptoms of lower abdominal pain, hemorrhage and
shock. On abdominal examination the uterus is deviated upward and laterally, to the

85
opposite side from the broad ligament hematoma. Usually, there are no vaginal
symptoms. It may be mistaken as a pelvic mass such as abscess, orother sources of
intra0abdominal bleeding. It can be clinically occult despite significant blood loss;
hence, a high index of suspicion is required to recognize these hematomas. (Level III)

3. What diagnostic modalities can aid in the investigation of genital tract

hematoma?

Imaging may be helpful to confirm the diagnosis when there is a high

clinical suspicion for hematoma but the patient remains hemodynamically stable.
(Grade B)

Summary of Evidence

The clinical presentation of the patient is the key to diagnose genital tract
hematoma. However, in cases when the patient is hemodynamically stable and if the
hematomas are located supravaginally or subperitoneally, imaging modalities may
serve to be useful.

According descriptive studies, ultrasound, computed tomography (CT) scans,

and magnetic resonance imaging (MRI) scans are mainly useful for diagnosing
hematomas above the pelvic diaphragm. These modalities are also useful to assess
any extension into the pelvis, particularly as bimanual examination may not detect them
until they become quite large and palpable. Aside from location, information regarding
the size, extent and progress or resolution of these hematomas may be provided by
these modalities as well. The added advantage of MRI is that it can help differentiate
between other causes of a pelvic mass, such as an abscess or endometrioma. (Level
III)

A complete blood count and coagulation screen are mandatory to aid in

estimating blood loss and to monitor coagulation status. (Grade C)

Summary of Evidence

Blood tests are necessary to determine baseline values and should be repeated
as necessary. Blood should be drawn for crossmatching, based on the clinical picture of
the patient. Transfusion is usually necessary with paravaginal and subperitoneal than
with vulvar hematomas. With monitoring of the coagulation status, this will guide the
practitioner in giving the appropriate management. (Level III)

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4. How will genital tract hematomas be managed?

Initial treatment of puerperal hematomas includes early recognition

followed by prompt attention to resuscitation and simultaneous search for the
cause of the bleeding. (Grade C)

Management aims to prevent further blood loss, minimize tissure damdage,

ease pain and reduce the risk of infection. (Grade C)

Summary of Evidence

There are limited literatures on the management of paragenital hematomas and

no randomized studies on the efficacy of various treatments have been published.

The clinical presentation of pelvic hematomas can be useful in defining the

location of the bleeding vessel. Once identified, these vessels should be ligated, and
sutured to stop the bleeding. If with lower genital tract hematomas, these are usually
managed by incision and drainage, although expectant management is acceptable if the
lesion is not enlarging.

Resuscitative measures should be considered the first line of treatment followed

by close observation. The extent of the blood loss is often underestimated and a high
index of suspicion is required. Aggressive fluid replacement and assessment of
coagulation status is essential if there is heavy bleeding or signs of hypovolemia. Blood
should be available for transfusion. Vaginal packing or balloon/blood pressure cuff
tamponade and antibiotics are commenced as other appropriate measures. A foley
catheter is inserted to avoid possible urinary retention that can occur due to pain, tissue
distortion from edema, or pressure of a vaginal pack. It is also advocated to monitor
fluid balance.

Large (> 3 cm) hematomas are best managed with surgical evacuation, primary
closure and compression for 12-24 hours, while small, non-expanding
hematomas (< 3 cm in diameter) can be managed conservatively. (Grade C)

Summary of Evidence

Small hematomas, less than 5 cm, can be managed with close observation.
However, according to the South Australian Perinatal Practice Guidelines, conservative
management is confined to non-expanding hematomas less than 3 cm. The latter
recommendation was preferred by the stakeholders who attended the presentation of
this practice guideline. Conservative treatment entails the use of ice packs, pressure
dressing and analgesia.

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 Patients with persistent signs of volume loss despite fluid replacement, as well as
those with large (> 3 cm) or enlarging hematomas, are best managed with surgical
evacuation of the clot. The involved area should be irrigated and the bleeding vessels
ligated. In patients with diffuse oozing, a layered closure will help secure hemostasis
and eliminate dead space. The primary closure is done with deep mattress sutures and
the overlying skin re-approximated without tension. Care must be taken to avoid
damage to contiguous structures such as the ureters, bowel and bladder during repair
procedures. Adequate anesthesia is mandatory. The surgical procedure should be
conducted in the operating room.

Small, stable subperitoneal hematomas, broad ligament and retroperitoneal

hematomas can be also managed conservatively particularly if the patient is stable and
the lesions are not expanding. If it is not possible to maintain a stable hemodynamic
state, or if these hematomas are enlarging and expanding, surgical management is
indicated. The surgical management for these hematomas requires an abdominal
approach with identification and ligation of bleeding vessels. (Level III)

Vaginal packing/pressure or insertion of drains for 24 to 36 hours may be useful

following drainage and repair of a paravaginal hematoma. (Grade C)

Summary of Evidence

There is no evidence to support the best or optimal management for vaginal

hematomas, which include primary repair with or without drains., primary repair with
packing, and packing alone have all been advocated. Vaginal packing for 24-36 hours
aims to tamponade bleeding vessels. Some authors believe that drains defeat the
object of packing. Insertion of drains can be useful to highlight ongoing or recurrent
bleeding.

A case series described the successful use of the blood pressure cuff in two
patients to control intractable vaginal bleeding following evacuation of vaginal
hematoma that developed after spontaneous vaginal delivery. A blood pressure cuff
was inserted into a sterile glove, which in turn was inserted into the vagina and the
pressure then gradually increased to 120 mmHg, 10 mmHg above the systolic pressure,
to stop the bleeding. Eight hours later, the pressure of the cuff was reduced by 10
mmHg and then taken out after 32 hours. Both patients had an uneventful recovery.

If first line management fails, additional surgical intervention is indicated

such as ligation of the internal iliac artery, hysterectomy, or even selective
arterial embolization, may be necessary. Embolization of the bleeding vessel may
by a therapeutic option in centers where interventional radiologists are available
and the bleeding is not life threatening. (Grade C)

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Summary of Evidence

Where there is continuing expansion of a superlevator hematoma without

extension into the cervix or uterus, selective arterial embolization is seen as the
treatment of choice over internal iliac artery ligation, which in itself has an uncertain
chance of success. Selective arterial embolization may be useful in situations in which
preservation of fertility is desired, when surgical options for managing hematomas have
been exhausted. However, no RCTs regarding its effectiveness have been conducted.

The technique of selective arterial embolization investigates these vessels by

preliminary transfemoral arteriography, followed by embolization using Gelfoam (gelatin)
pledglets. A case report on 35 patients with unanticipated postpartum hemorrhage
underwent this procedure conducted by Pelage, et. Al. In the series, bleeding was
controlled in all but one, who required hysterectomy 5 days later for re-bleeding. All
women who had successful embolization resumed menstruation. Across published case
reports and series, the aggregate success rate in controlling bleeding from hematomas
is over 90%.

The procedure, however, is not without risk and deaths have been reported due
to sepsis and multiple organ failure. Complications are uncommon (<9%), which include
local hematoma formation at the insertion site, low-grade fever, pelvic infection,
ischemic phenomena, such as uterine necrosis in rare instances, temporary foot drop,
vessel perforation, and contrast-related adverse effects. Use of temporary embolic
agents reduces the risk of ischemic problems.

The major drawbacks of the procedure are the requirement for 24-hour
availability of radiological expertise and the time required to complete the procedure.
Patients must be stable to be candidates for this procedure. (Level III)

UTERINE INVERSION
Lyla D. Reyes, MD

Background

Puerperal uterine inversion is due to displacement of the fundus of the uterus,

usually occurring during the third stage of labor. It is a complication of childbirth that
occurs between 1 in 2148 and 1 in 6407 births. Other authors reported this as a rare
condition, occurring in 0.05% of deliveries.

Uterine inversion is classified not only by the degree of inversion but by the time
of onset as well. The first classification is according to the occurrence of uterine

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inversion after delivery. Acute inversions occur immediately or within 24 hours after
delivery. This is the most common type of uterine inversion with a prevalence of 83.4%.
The subacute inversion occurs after the first 24 hours and within four weeks after
delivery. This accounts for 2.62% of all types of inversion. Finally the chronic inversion
occurring after more than four weeks after the delivery has been reported to take place
in 13.9% of such cases.

The second classification of uterine inversion is based on the anatomical severity

of the inversion. This is the most widely used classification. It includes four stages. In
the first stage the uterine base is in the uterine cavity and does not cross the cervix of
the uterus. With the second stage the uterine base crossed the cervix and passed
through the vagina. The third stage involves the visualization of the uterine base at the
vulva. Lastly, in the fourth stage the vaginal walls participate with the inversion.

However, others report the classifications as partial or complete inversion. The

uterine fundus that has inverted and lies within the endometrial cavity without extending
beyond the external os is called an incomplete or partial inversion. In complete inversion
the fundus is inverted and extends beyond the external os. A prolapsed inversion is one
in which the inverted uterine fundus extends beyond the vaginal introitus. A total
inversion, usually nonpuereral and tumor related, results in inversion of the uterus and
vaginal wall as well.

Studies have yet to clearly demonstrate the mechanism for uterine inversion.
Hoever, clinical vigilance for inversion, secondary to these potential causes, is generally
practiced. Inversion prevents the myometrium from contracting and retracting, and it is
associated with life—threatening blood losses as well as profound hypotension from
vagal activation.

Therefore, uterine inversion during the third stage of labor although unusual, is
potentially life threatening. But when managed promptly and aggressively, uterine
inversion can result in minimal maternal morbidity and mortality.

Recommendations

1. What factors will predispose to the occurrence of uterine inversion?

The causes of inversion remain undefined, but overly aggressive management of

the third stage of labor is a commonly ascribed cause. (Grade C)

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Summary of Evidence

Inversion of the uterus is principally a complication of the third stage of labor, and
the most common cause is traction applied to the umbilical cord while the uterus is
relaxed. In case of adherent or accretic placenta, the thin and relaxed myometrium is
predisposed to inversion when traction is applied. Inversion may occur more likely if the
placenta is situated at the fundal aspect of the uterus, where a direct traction may be
applied on the central portion of the non-contracted muscle.

Aside from excessive umbilical cord traction the other extrinsic factor associated
with uterine inversion is antepartum use of magnesium sulfate or oxytocin. Intrinsic
factors were also accounted in several case reports such as primiparity, uterine
hypotonia secondary to twin pregnancy and betamimetics, placenta accrete, particularly
involving the uterine fundus, fundal myoma, short umbilical cord, rapid emptying of the
uterus after prolonged distention, and congenital weakness or anomalies of the uterus.
However, the role of fundal pressure with undue cord traction is uncertain. The
underlying causes are not completely understood.

2. How is uterine inversion diagnosed?

Clinical signs and symptoms such as hemorrhage, shock, and severe pelvic pain
mainly support the diagnosis of the uterine inversion. Bimanual examination will
confirm the diagnosis and also reveal the degree of inversion. (Grade C)

Summary of Evidence

The classical presentation of uterine inversion is an obviously displaced uterus

while delivering the placenta, usually in association with postpartum hemorrhage and
clinical shock. The chock is often out of proportion to the degree of blood loss, although
if the placenta remains attached following inversion shock is less likely to occur. Uterine
inversion is also often associated with acute lower abdominal pain. Hence, profound
shock may not only be hemorrhagic in origin but neurogenic as well.

According to case reports, when there is complete inversion, the diagnosis is not
difficult and easily made by palpating the inverted fundus at the cervical os or vaginal
introitus. The completely inverted uterus usually appears as a bluish-gray mass
protruding from the vagina. In incomplete inversion, palpating the fundal wall in the
lower uterine segment and cervix might be required for diagnosis. Profuse bleeding,
absence of uterine fundus, or an obvious defect of the fundus on abdominal
examination, as well as evidence of shock with severe hypotension, will further provide
the clinician diagnostic clues for uterine inversion.

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Imaging can help when the diagnosis is uncertain after examination, and the
patient is sufficiently stable clinically to undergo such evaluation. (Grade C)

Summary of Evidence

Although clinical symptoms will provide the diagnosis in most cases, radiographic
methods to diagnose inversion have also been reported. In one literature, uterine
inversion was discovered incidentally in an acute incident by ultrasound findings. The
inverted uterus in transverse images was described as a hyperechoic mass in the
vagina with a central hypoechoic H-shaped cavity. Longitudinal images showed a U-
shaped depressed logintudinal groove from the uterine fundus to the center of the
inverted part. Magnetic resonance imaging (MRI) for uterine inversion has also been
reported. The appearance of the uterus is similar to that found in sonographic imaging;
however, MRI findings are more prominent. Thus imaging can help when the diagnosis
is uncertain after examination, and the patient is sufficiently stable clinically to undergo
such evaluation. (Level III)

3. What are the management options for uterine inversion?

Successful management requires early recognition of the inversion and prompt

replacement of the uterus, with or without general anesthetic and/or tocolytics.
Provide adequate analgesia before attempting to reposition the uterus. (Grade C)

Summary of Evidence

Management of uterine inversion has two important components: the immediate

treatment of the hemorrhagic shock and replacement of the uterus. If puerperal
inversion of the uterus is recognized immediately, the uterine corpus can usually be
pushed back through the cervical ring, by pressure Directed toward the umbilicus, either
manually by Johnson maneuver’ or by hydrostatic pressure. 15 (Level III)

Hydrostatic pressure, cited commonly in the British literature, is another method

used to reposition the uterus when inversion has occurred. In this method, first
described by O’ Sullivan in the British Medical Journal in 1945, a bag of warmed fluid is
hung on a pole used for intravenous fluids above the level of the patient and allowed to
flow, via tubing, into the vagina. The pressure of the water, held in place by the
clinician’s hands, results in correction of the inversion. It has been reported that
successful correction in five cases of inversion within a 7-year period of using this
method.16 More recently, a new technique of hydrostatic pressure was described.15
Citing difficulty in maintaining an adequate water seal to generate the pressure required,
the authors suggest attaching the intravenous tubing to a silicone cup used in vacuum
extraction. By placing the cup within the vagina, an excellent seal is created, and
adequate hydrostatic pressure for inversion correction is thus produced. Although

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success with this technique is cited in the literature, there has been no discussion of the
theoretical risk of air or amniotic fluid embolus. For details regarding the hydrostatic
pressure procedure please refer to Appendix III, and Johnson maneuver at Appendix
IV. (Level II-3)

Occasionally, administration of a smooth muscle relaxant such as beta-

adrenergic agonist (terbatuline), nitroglycerin, or magnesium sulfate may facilitate
replacement of the uterus. As uterine inversion is uncommon, it is difficult to compare
these different therapies. According to Abouleish, et al., terbutline 0.25mg and general
anesthesia are used as last resort17. They recommended terbutaline as a drug of rapid
onset and short duration. It was used successfully in five out of eight patients. In the
study of Brar, et. Al, terbutaline, 0.25mg was used successfully in 16 out of 18 patients,
but they recommended that it should not be used in patients with significant hypotension
and shock.7 In these patients, magnesium was used successfully in seven of eight
patients. Catanzarite, et. Al 19 and wendel, et. Al. 24 recommend an intravenous dose
of 4 grams magnesium sulfate. However, in the study of Dayan, et. Al, the benefits for
the use of low-dose nitroglycerin include quicker onset of uterine relaxation, quick
dissipation of the effect, obviating the need for reversal, and less effect on
hemodynamics than magnesium sulfate.20 (Level II – 3)

Immediately, provide intravenous access and resuscitation. (Grade C)

Summary of Evidence

Resuscitation, should start immediately while attempts are made to replace the
uterus manually. If immediate replacement is not possible, aggressive support of
circulation by blood transfusion and intravenous fluid during rapid transport to the
nearest facility with operative obstetrics capability is urgently indicated. 1,3,18,22,23
(Level III)

The placenta, if still attached, should be left in place until after reduction. (Grade
C)

Summary of Evidence

Controversy exists about wether the placenta should be removed before

repositioning the uterus. It is commonly suggested that removal of the placenta before
correction will result in increased blood loss and worsening of hemodynamics. Hence,
most authors advise replacement before removing the placenta. 5,9,10,16,25-28 (Level
III)

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 If the above method is unsuccessful, resuscitate and anesthetize the
woman, either repeat the procedure or consider laparotomy to correct the defect
or transvaginal cervical incision and repair. (Grade C.)

Summary of Evidence

When reduction under tocolysis fails, general anesthesia with halothane may be
induced to provide uterine relaxation and reduction attempted again. If unsuccessful,
further attempts should wait until the patient is hemodynamically stable. If further
attempts fail, laparotomy will frequently be indicated. 5,18

At laparotomy, although several procedures have been described, the two most
commonly cited are the Huntington and Hultainn procedures.11 The Huntington
procedure requires a laparotomy which involves grasping the round ligaments and
sequentially locate the cup or depression of the uterus formed by the inversion. Clamps
are placed in the cup of the inversion below the cervical ring, and gentle upward traction
is applied. Repeated clamping and traction continues until the inversion is corrected. A
variant of this has been described using suction applied to the inverted uterus via a
vacuum instrument. If the Huntington method fails Hultain procedure is done. With this
procedure an incision is made in the posterior portion of the cervical ring, again through
the abdomen, to increase the size of the ring and allow repositioning of the uterus. For
further details and figures regarding these procedures please refer to appendices V and
VI. (Level III)

Uterotonic drugs should only be given immediately after repositioning of the

uterus. (Grade C)

Summary of Evidence

Uterotonics are not administered until the uterus has been repositioned.
Thereafter oxytocic intravenous infusion should be given to maintain uterine contraction
and to prevent reinversion. If the uterus does not contract ergometrine or prostaglandins
may be given. 5,18,29 (Level III)

Hysterectomy is regarded as the last resort of management after repositioning

the uterus and medical treatment failed. (Grade C)

Summary of Evidence

Hysterectomy is indicated for gangrenous or hemorrhagic uterus despite the reduction

and medical treatment. 3,5,18 (Level III)

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Antibiotic prophylaxis is advisable. (Grade C)

Summary of Evidence

No randomized controlled trials (RCTs) have been published with regards to the benefit
of antibiotic prophylaxis should be instituted in order to prevent any upward spread of
infection. The use of antibiotics is left to the discretion of the provider because data from
the literature do not mandate its use. 3,5

The recommendation of World Health Organization (WHO) is to give a single

dose of prophylactic antibiotics, Ampicillin 2 g IV or Cefazolin 1 g IV plus metronidazole
500mg IV, after repositioning the inverted uterus. If the woman shows sign of infection
or has fever , give a combination of antibiotics, ampicillin 2 g IV every 6 hours,
gentamicin 5mg/kg body weight IV every 24 hours, and metronidazole 500mg IV every
8 hours. Continue the IV antibiotics until she is afebrile for 48 hours. 29 (Level III)

4. Can uterine inversion be prevented?

The application of active management of the third stage of labor including
controlled cord traction decreases the incidence of acute uterine inversion
following vaginal delivery. (Grade C)

Summary of Evidence
As a measure to prevent post partum hemorrhage, active management has been
widely adopted. Active management generally involves all three of the following
interventions; administration of routine prophylactic uterotonic agent, early cord
clamping and controlled cord traction. It has been noted that faulty management of
the third stage of labor may increase the risk of inversion of the uterus. The use of
active management of the third stage of labor decreases the incidence of acute
uterine inversion by fourfold. However, no RCT has examined the third component
of active management, which is controlled cord traction, particularly in cases of
preventing uterine inversion. 10, 30 (Level III)

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 APPENDIX

I
LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION

LEVEL DEFINITION
I Evidence obtained from at least one properly randomized controlled trial
II – 1 Evidence obtained from well-designed controlled trials without
randomization
II – 2 Evidence obtained from well-designed controlled cohort or case-control
analytic studies, preferably from more than one center or research group
II – 3 Evidence obtained from multiple time series with or without the
intervention.
III Opinions of respected authorities, based on clinical experience;
descriptive studies and case report or reports of expert committees.

GRADE DEFINITION
A There is good evidence to support the recommendation of the practice in
third trimester bleeding.
B There is fair evidence to support the recommendation of the practice in
third trimester bleeding.
C There is insufficient evidence to recommend for or against the inclusion of
practice in third trimester bleeding.
D There is fair evidence to support the recommendation that the practice be
excluded in third trimester bleeding.
E There is good evidence to support the recommendation that the practice be
excluded in third trimester bleeding.
GPP A good practice point (GPP) is a recommendation for best practice based
on the experience of the Task Force.

II

ANTENATAL PERINEAL MASSAGE

Perineal massage is usually done 3 to 4 times a week 5 to 10 minutes starting 6 weeks

before their estimated due date.1 The pregnant woman is advised to acquire a
comfortable position for the massage: semi-sitting, squatting against a wall, or standing
with one foot raised and resting on tub toilet or chair. Some women prefer to have the
massage performed on them while lying in bed. Advise the pregnant woman to try
different positions and find what position will make her comfortable.

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Perineal massage entails the use of one or two fingers inserted 3 to 4 cm deep into the
vagina. These fingers apply and maintain pressure, first down wards and then to each
side of the vaginal entrance. To allow the fingers to move smoothly, the use of any of
these lubricants – vitamin E, wheat germ oil, mineral oil, virgin olive oil, almond oil, and
lubricating gel (such as KY). Avoid using baby oil, petroleum jelly, hand lotion, or
perfumed oil as these are less well absorbed by the body and are believed to be
associated with allergic reactions as compared to vegetable or water-based products.2

After lubricating the fingers, massage is initially applied diagonally on either side of the
top of the vestibule, just below the urethra. The muscles of the vagina should be
allowed to relax, and this helps prepare the pregnant woman to the sensations of
childbirth. This should be followed by insertion of the index finger of both hands into the
vagina approximately 3 to 4 cm deep while the thumb presses on the perineum. A
steady gentle pressure is maintained as the fingers press downward on the area
between the vagina and the rectum and upward along the sides of the vagina in a ―U‖
sling type motion. This pressure will stretch the vaginal tissue, the muscles surrounding
the vagina, and the outer rim of the perineum. Then, massage the fourchette edge of
the perineum and outer layer of the perineum, towards the anus. Once at the anus, the
massage pattern is complete.

Explain to the woman that she will feel some pressure and uncomfortable stretching or
burning sensation. As the purpose of perineal massage is to help the woman gets used
to the burning sensation that occurs when the fetal head presses against the perineum.
The vaginal ang perineal sensation will be of tightness at first, but as the weeks would
progress, daily massage will relax and stretch the tissue.

III

METHOD OF HYDROSTATIC REDUCTION

(O’ Sullivan’s Hydrostatic Maneuver)

The hydrostatic method does not always require anesthesia and may be done in the
labor and delivery room. However, it is preferable to perform the procedure in the
operating room. The woman should be placed in lithotomy position. Two bottles of 1 liter
of warm (40C) irrigation fluid (e.g. sodium chloride 0.9%) are attached to a wide bore
giving set or cystoscopy irrigation set. The intravenous bottle should be placed on an IV
stand and kept about 2m above the ground level. The labia should be held tightly
around the forearm, using the other hand, to prevent the water from leaking out. An
assistant may be required. The nozzles of the two long rubber tubes should be directed
to the posterior fornix of the vagina. Run the warmed fluid by gravity or by pressure on
the bag. The fluid must be allowed to flow quickly and prevented from escaping. Up to 4
liters of fluid may be required. As the vaginal walls distend, the fundus of the uterus will
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begin to rise. In most cases this will reduce the inversion, with rapid resolution of the
shock. The placenta can be removed under anesthesia.

After correction of the inversion, the fluid in the vagina should be allowed to flow out
slowly. The uterus must be checked for complete replacement. Thereafter contraction of
the uterus must be maintained by appropriate oxytocic treatment. An intravenous
infusion containing 1 liter 5% dextrose with 20 units of oxytocin should also be provided.
Ergometrine 0.5mg should be administered intravenously as well.

Reduction of the inverted uterus may be achieved in about 5 to 10 minutes after

commencement of the hydrostatic technique. It this method is unsuccessful, resuscitate
and anesthesize the woman, either repeat the procedure or consider laparotomy to
correct the defect or transvaginal cervical incision and repair.

IV

JOHNSON MANEUVER

The placenta is left in place. The operator’s hand grasps the inverted uterus with the
placenta (see figure A). The fundus is allowed to rest of the palmar surface of the
operator’s hand with the fingertips exerting equal pressure around the collar of the
uterus within the cervical opening. The fundus is then replaced with upward pressure.
(see figure B). After repositioning the uterus, the placenta is manually removed followed
by uterine exploration. The operator’s hand is kept inside the uterus until it begins to
contract around the hand. (see figure C). A tight uterovaginal pack may be inserted
before the hand is removed from the uterine cavity (see figure D). The pack can be
removed after 24 hours.

HUNTINGTON MANEUVER

This maneuver is done during laparotomy. The surgeon grasps the surface of the uterus
in the crater created by the inversion with an allis clamp or a babcock (see figure A).
The clamps are used to simultaneously pull the uterus upward out of the cervical ring
until it is restored back into the peritoneal cavity. As the clamp steadily hold the uterus,
the surgeon now inserts another allis clamp into the crater and the uterus us further
pulled upward (see figure B). through successive bites of the clamp on the surface of
the uterus with upward traction applied, the uterus id gradually restored to its normal
position in the abdominal cavity (see figure C).

VI

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 HULTAIN MANEUVER

The maneuver is done through an abdominal-vaginal approach. As such procedure

requires a malleable retractor to be inserted vaginally. The retractor is inserted at the
posterior aspect of the vagina, with its tip placed between the posterior lip of the cervix
and the inverted uterine wall at the point at which the muscle will be incised abdominally
(see figure A). The rectocigmoid is held aside while an incision is made entirely through
the uterine wall at the point of constriction, (see figure B). The length of the incision
should be sufficient to permit the passage of the uterine fundus. The purpose of the
previously placed malleable retractor is to ensure that only the uterus will be incised and
prevent possible injury to the vagina. The fundus is restored by combined traction of the
uterine wall from above by the surgeon and pressure from the vagina by an assistant
(see figure C). When the uterus is completely restored the incision is closed with
interrupted sutures.

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