THIRD STAGE

COMPLICATION OF
LABOUR
 LEARNING OBJECTIVES

• Secondary PPH
• Third stage complication of labour
• Retained placenta
• Morbid adherent placenta
• Inversion of uterus
• Amniotic fluid embolism
SECONDARY PPH
 SECONDARY PPH

• Bleeding usually occurs between 8th-14th day of delivery

• Causes are :
• Retained bits of placenta or membranes
• Infection and separation of slough over a deep cervico-vaginal laceration
• Endometritis and subonvolution of the placental site
• Withdrawal bleeding following oestrogen therapy for suppression of lactation
• Rare : chorion epithelioma, carcinoma of cervix, infected fibroid or fibroid polyps
and puerperal
 DIAGNOSIS

• Bleeding usually bright red and varying amount

• Varying degree of anemia and evidence of sepsis
• Int. examination : subinvolution and often patulous cervical os
• USG : retained bits of placenta inside uterine cavity
 MANAGEMENT
• Supportive therapy
• Blood transfusion
• Inj. Methergine 0.2 mg IM
• Antibiotics as routine

• Conservative
• Admission and careful watch for period of 24 hrs

• Active
• Explore the uterus under general anaesthesia
• Products are removed by ovum forceps
• Gentle curretage is done by using flushing curretage
• Methergine 0.2 mg IM
• Material send for histological examination
• Bleeding from sloughing of wound of cervico-vaginal canal controlled by suture
RETAINED PLACENTA
 DEFINITION
• Placenta is not separated and expelled within 30 minutes after
delivery of baby.
• Normal expulsion of placenta :

• Separation through the spongy layer of the decidua

• Descent into lower segment and vagina

• Expulsion
INTERFERENCE IN PHYSIOLOGICAL PROCESS MAY CAUSE :

SEPARATED UNSEPARATED
• Placenta completely • Placenta unseparated from
separated but retained uterine wall but does not
invade myometrium
(simple adeherent)

• Placenta is unseparated
and invades the
myometrium (morbid
adherent placenta)
CAUSES
 RISK FACTOR

• Preterm birth
• Previous retained placenta
• Induced/ augmented labour.
• Iv ergometrine
• Mismanagement of third stage of labour.
• Uterine anomalies.
 COMPLICATION

• Hemorrhage
• Shock
• Peurperal sepsis
• Risk of recurrence.
 DIAGNOSIS MADE AFTER 15
MINUTES SPENT FOLLOWING
DELIVERY OF BABY, WHERE THERE
IS NO SIGN OF PLACENTAL
SEPARATION.
 DIAGNOSIS : SEPARATED
PLACENTA
UTERUS Well contracted, os closed

PELVIC EXAMINATION Lower pole of placenta may be felt through the

os

ULTRASONOGRAPHY - Myometrium is thick all along

- clear demarcation between placenta and
myometrium
 INITIAL MANAGEMENT
• Call for extra help – senior obstetrician
• IV access.
• FBC, group, cross matching, diagnostic test (RFT,LFT), coagulation profile and ask
for 2 unit of blood.
• Monitor vitals
• Bladder catheterization
• If it was a physiological management, revert to active management
- Give Oxytocin
- Try controlled cord traction
MANAGEMENT : SEPARATED
PLACENTA
Uterus is
contracted and
os is closed

give glyceryl trinitrate

( 400 μg sublingual or
Give oxyocin  50 μg iv). 
placental controlled cord
expulsion traction

IF FAILED

Manual removal of
placenta
 DIAGNOSIS : UNSEPARATED
PLACENTA (SIMPLE ADHERENT)
UTERUS - Relaxed on palpation

PELVIC EXAMINATION - Placenta cannot be felt through os

ULTRASONOGRAPHY - Myometrium thickened in all areas

except where placenta is attached
 MANAGEMENT : UNSEPARATED
PLACENTA (SIMPLE ADHERENT)

• Oxytocin IV infusion (20 units in 500 ml saline)

/ 10 unit IM

• Umbilical vein is catheterized with nasogastric tube

+ One of the following (Normal saline/PGF2a/
Oxytocin/Misoprostol)

• If failed : manual removal of placenta

MORBID ADHERENT
PLACENTA
• Grades of morbid adherent placenta
depends on : depth of attachment and
invasion into muscular layer of uterus.

• Accreta : chorionic villi attach to

myometrium, rathen than within
decidua basalis

• Increta : chorionic villi invade the

myometruim

• Percreta : chorionic villi invade through

perimetrium ( uterine serosa )
 PLACENTA ACCRETA -
DEFINITON
• Form in which placenta is anchored to the myometrium completely or partially
without intervening decidua
• Incidence increasing due to increase in caesarean section rates.
ETIOLOGY – absence of decidua basalis and poor development of
fibrinoid layer
RISK FACTORS
1. Prior uterine surgery (cesarean section, myomectomy, curettage,
manual removal of placenta)
2. Placenta previa
3. Multiparity
4. Uterine anomalies, submucous fibroids

Risk in unscarrred uterus : 3%

Placenta previa with one prior cesarean section : 11%
Placenta previa with two prior cesarean section : 40%
Placenta previa with two or more prior cesarean section : 67%
 DIAGNOSIS

ANTENATAL INTRANATAL
• Hematuria +/- • Profuse bleeding during
• Ultrasonography with color manual removal of placenta
Doppler • Shock features
• MRI - good sensitivity
ULTRASONOGRAPHY FINDINGS:
1. Myometrial thickness <1cm (from serosa to retroplacental
vessels)
2. Large intraplacental blood lakes
3. Loss/thinning of normal hypoechoic area behind the placenta
(clear areas)
4. Loss of normal continuous line at serosal-bladder interface
(bladder line)
5. Focal nodular projections into the bladder
COLOUR DOPPLER FINDINGS
:
1. Increase in vascular lakes
with turbulent flow
2. Hypervascularity of serosal
bladder interface
 MANAGEMENT :
ANTENATALLY
INITIAL MANAGEMENT:

1. Multidisciplinary team approach – SENIOR OBSTETRICIAN

2. Elective cesarean section is scheduled with given counselling to patients
and relatives
3. Kept blood products ready
4. Placenta should be localized, extent of penetration determined
5. Operative procedure, decision to conserve uterus, measures to reduce
bleeding must be planned
 OBSTETRIC MANAGEMENT

1. Focal placenta accreta

- Placental tissues are removed to the extent with a possibility of excessive
bleeding (may be controlled by oxytocics or intrauterine packing).
- If uterus fails to contract, early decision of hysterectomy is inidicated.

2. Total placenta accreta

- Hysterectomy is performed in parous women
- If future childbirth is desired and no bleeding, placenta is left in situ ligating
the umbilical cord at its attachment with placenta.
- Antibiotics and methotrexate is given and follow up.
- Uterine artery embolization can be done for conservation in case of massive
bleeding
 MANAGEMENT
INTRANATALLY
• Prompt resuscitation
• Most women require hysterectomy
• Pelvic arterial embolization may be a useful adjunct
UTERINE ARTERY EMBOLIZATION
UTERINE INVERSION
 DEFINITION
• Collapse of fundus into uterine cavity – uterus being
turned inside out partially completely.
• Rare but life- threatening, can cause severe
maternal morbidity and mortality.
• Incidence is about 1:2000-1:20,000 deliveries.
• Leads to shock, massive hemorrhage,
pulmonary embolism, infection and uterine
sloughing
 CLASSIFICATION

BASED ON EXTENT OF INVERSION

I DEGREE II DEGREE III DEGREE IV DEGREE

• Uterine fundus • Fundus • Fundus • Complete
descends into protrudes protrudes inversion of the
cavity through the os. through the uterus and
• Does not introitus vagina.
protrude through
the os

• May occur before or after expulsion of placenta

 ETIOLOGY

• SPONTANEOUS (40%)
• Due to localized atony on placental site over the fundus associated with
intraabdominal pressure (coughing, sneezing or bearing-down effort)

• IATROGENIC
• Pulling the cord when uterus is atony
• Fundal pressure when uterus is relaxed – faulty technique in manual
removal
 RISK FACTOR
• Injudicious attempts of removal of placenta
• Fundal attachment of the placenta
• Fetal macrosomia
• Short umbilical cord.
• Uterine overdistension.
• Prolonged labour
• Uterine malformations
• Invasive placentation
 DIAGNOSIS
• SYMPTOMS
• Acute lower abdominal pain with bearing down sensation.
• Profuse bleeding per vagina.
• Symptoms of shock.
• SIGNS :
• Features of shock ( hypotension, tachycardia )
• Pallor
• Per abdomen examination : cupping or dimpling of fundal surface
• Pear shaped mass protrudes outside vulva with broad end pointing downward,
reddish purple in colour ( complete )
• PER VAGINA :
• 1st degree : Only dimpling of the fundus
• 2nd degree : Cupping of the fundus and a mass can be felt
protruding through the cervix inside the vagina
• 3rd degree : Cupping of the fundus and a mass is felt outside the
vulva. Sometimes swelling remains covered with unseparated
placenta
 INITIAL MANAGEMENT

• Call for help. A senior obstetrician, nurse, and anaesthetist must be

summoned. Involve multidisciplinary people.
• Stop oxytocin infusion
• Insert 2 large bore IV cannula, begins fluid resuscitation
• Draw blood for CBC, coagulation profile, cross matching
• Start blood transfusion as soon as possible
• Continuous monitoring of vital signs
• Transfer to theatre and arrange appropriate analgesia
SUBSEQUENT MANAGEMENT

OR

IF FAILED
 MANUAL REPLACEMENT
• Patient is under general anesthesia.
• A hand is placed in the vagina with fingers around the inverted fundus and pushing
the fundus toward umbilicus along the axis of vagina
• If cervix felt as a constricting ring, One of Uterine relaxants is administered
1. Glyceryl trinitrate 50-200mcg IV
2. Terbutaline 0.25 mg subcutaneous/IV
3. Magnesium sulfate 4-6 g IV
4. Inhalational anaesthetic (halothane, enflurane)
• After replacement, hand should remained inside until uterus become
contracted.
• Remove placenta after uterus become contracted or prior to replacement.
 HYDROSTATIC METHOD (
O’SULLIVAN’s METHOD
• Patient is under general anesthesia
• Patient is placed in Trendelenburg position
• A sterile douche system is prepared using warmed normal saline and an
ordinary IV administration set
• Posterior fornix is identified
• The nozzle of the douche is placed in the posterior fornix
• At the same time, labia is sealed over the nozzle with other hand
• An assistant is asked to start the douche with full pressure (the water
reservoir is raised for at least 2 metres)
• Water will distend the posterior fornix of the vagina gradually, so it
stretches.
• This causes the circumference of the orifice to increase, relieves
cervical constriction and results in correction of the inversion.
 SURGICAL METHOD

ABDOMINAL APPROACH
HUNTINGTON PROCEDURE HAULTAIN PROCEDURE
Traction on round ligaments Vertical incision made on posterior uterine surface,
constriction ring is cut

VAGINAL APPROACH
SPINELLI PROCEDURE CASCARIDES PROCEDURE
Incision of constriction cervical ring Incision of constricting cervical ring
anteriorly posteriorly.
AMNIOTIC FLUID
EMBOLISM
 AMNIOTIC FLUID EMBOLISM
SYNDROME (AFES)

• Sudden cardiovascular collapse, altered mental status and DIC

due to entry of amniotic fluid, fetal debris and fetal antigens into
the maternal circulation through maternal venous channels in the
uterus or cervix.
• Anaphylactoid reaction.
• Rare : 1-12 per 100,000 deliveries.
 CRITERIA
• Occur during labour, cesarian delivery, dilation and evacuation or within 4 hrs
postpartum.

Acute
hypotension

Coagulopathy
Acute
hypoxia
 RISK FACTORS

OPENING UP OF VENOUS SITUATIONS WHICH CAUSING

CHANNELS IN THE UTERUS UNDUE INCREASE IN
INTRAUTERINE PRESSURE
1. Placenta previa 1. Labor induction
2. Abruptio placenta 2. Eclampsia
3. Cervical lacerations
4. Uterine atony
5. Caesarian section
6. Instrumental delivery
 DIAGNOSIS
INVESTIGATIONS FINDINGS
Pulse Oximetry Severe hypoxia (<60% saturation)
SYMPTOMS
ABG SIGNS
Hypoxia, metabolic acidosis,
hypocapnea (pCO2 <30)
1. Tachypnea 1. Cold extremities
2.Chest Xray
Restlessness Pulmonary
2. infiltrates, loss of lung
Hypotension
volume
3. Nausea, Vomiting 3. Crepititations, rhonchi
4.Blood test
Paresthesia Low hematocrit, peripheral smear
4. Bleeding from venipuncture
shows thrombocytopenia and
5. Altered sensorium sites
schistocytes (if DIC +)
6. Convulsions, coma 5. Vaginal bleeding
Serum Creatinine Increase
Serum electrolyte Metabolic acidosis, anion gap >20
ECG Abnormal pattern
 INITIAL MANAGEMENT
• Call senior obstetrician, anaesthetist, haematology. Involve multidisciplinary people
• Admit patient to ICU
• Take blood samples for
- Hb, peripheral smear, electrolytes, serum creatinine, LFT, prothrombin time.
-grouping and cross match
-DIC investigations
• Place intra arterial line for ABG
 OBSTETRIC MANAGEMENT

• Non reassuring FHR

• Rapid progressive deterioration of mother’s clinical status

URGENT DELIVERY
• VAGINAL
• -cervix fully dilated
• Fetal head descend to at least +2/+3 station
• C-SEC
• Adequate blood products should be kept in operation room