COMPLICATIONS OF

THIRD STAGE OF LABOUR

POSTPARTUM HEMORRHAGE

Any amount of bleeding from and into the genital tract

following the birth of the baby up to the end of the
pueperium which adversely affects the general
condition of the patient evidenced by rise in pulse rate
and falling BP is called post partum haemorrhage
Types:
Primary
⚫ Third stage hemorrhage - Bleeding occurs before
expulsion of placenta.
⚫ True PPH - Bleeding occurs subsequent to
expulsion of placenta (majority).
Secondary PPH/ delayed/late
⚫ Calculation of maternal blood volume
⚫Non pregnancy TBV=
[Ht(Inches)x50]+[Wt(pounds)x25]
2
⚫ Pregnancy TBV=add 50% to non pregnancy
⚫ In serious PPH, acute return of pregnancy TBV to
non pregnancy TBV
 Primary post partum
haemorrhage
Causes
⚫ 4 T’s
⚫ Tone –Uterine atony
⚫ Tissue-Products of conception, Placenta
⚫ Trauma: Planned-Cesarean section,episiotomy
⚫ Unplannned-Vaginal/cervicxal tear,surgical
trauma
⚫ Thrombin: Congenital-Von Willebrand’s
⚫ disease Acquired-DIC,dilutional coagulopathy
Uterine atony(80%)

⚫ High parity
⚫ Overdistended uterus
⚫ General anesthesia
⚫ Poorly perfused
myometrium
⚫ Prolonged labour
⚫ Following augmented labour
⚫ Uterine atony in previous labour
⚫ Chorioamnionitis
⚫ Malformation of uterus
⚫ Uterine fibroid
⚫ Very rapid labour
⚫ Mismanaged third stage of labour
⚫ Constriction ring:
⚫ Incomplete separation of placenta
⚫ Retained placenta
⚫ Abnormally adherent
⚫ Avulsed cotyledon, succenturiate lobe
⚫ Placenta previa
⚫ Placental abruption
⚫ A full bladder
⚫ Traumatic( 20%):
⚫ Combination of atonic and traumatic causes
⚫ Blood coagulation disorders, acquired or congenital:
Other risk factors are;
⚫ Antepartum hemorrhage
⚫ History of PPH or retained
placenta
⚫ Anaemia
⚫ Ketoacidosis
⚫ HIV/AIDS
 Clinical Features

May be obvious such as,

⚫ Visible bleeding
⚫Maternal collapse
Subtle signs as,
⚫ Pallor
⚫ Rising pulse rate
⚫ Falling BP
⚫ Altered level of
consciousness
⚫ May
restless/drowsy
 Diagnosis

⚫ Direct observation in open hemorrhage.

⚫ In concealed case, diagnosis is based on
clinical effects.
⚫ In traumatic hemorrhage- uterus is contracted.
⚫ In atonic hemorrhage-uterus is relaxed.
 Investigations

⚫ Thorough examination of the lower genital tract.

⚫ CBC, clotting screen, cross match, Coagulation studies
⚫ Hourly urine output
⚫ Continuous pulse/blood pressure or central
venous pressure monitoring
⚫ ECG, pulse oximetry
 Prevention
Antenatal
⚫ Improvement in health status, keep Hb level >10gm/dl.
⚫ Screen high risk clients.
⚫ Blood grouping
⚫ Women considered at high risk of thromboembolism may
be receiving prophylaxis in the form of Unfractionated
Heparin (UH) or Low Molecular Weight Heparin (LMWH)
antenatally.
⚫ Women with a lower level of increased risk of
thromboembolism may be receiving aspirin (75mg daily)
antenatally and may begin intrapartum prophylaxis
with the above agents.
⚫ Intranatal
⚫ In the event of a woman coming to delivery while
receiving therapeutic heparin, the infusion should be
stopped. Heparin activity will fall to safe levels within
an hour. Protamine sulphate will reverse activity more
rapidly, if required.
⚫ Slow delivery of baby.
⚫ Expert obstetric anesthetist.
⚫ Active management of 3rd stage of labour.
⚫ Following delivery, administering a uterotonic
⚫ Avoiding pulling the cord, avoid fiddling and kneading
the uterus, avoid Crede’s expression
⚫ Examine placenta and membranes for intactness.
⚫ Continue oxytocin for atleast 1 hr after
⚫ Check for genital tract trauma.
⚫ Observe the patient for about 2hrs after the delivery
Immediate care in PPH

⚫ COMMUNICATE.
⚫ RESUSCITATE.
⚫ MONITOR / INVESTIGATE.
⚫ STOP THE BLEEDING.
 Management of 3rd stage
hemorrhage
The principles in the management are:
⚫ To empty the uterus of its content and to make
it contract.
⚫ To replace the blood. If in shock, then manage
shock.
⚫ To ensure effective hemostasis in traumatic
bleeding.
Placental site bleeding
⚫ Palpate the fundus and massage the uterus to make
it hard.
⚫ Ergometrine 0.25mg or methergine 0.2mg is given
intravenously.
⚫ Start a dextrose saline drip and arrange for
blood transfusion, if necessary.
⚫ Catheterise the bladder, if it is found to be full.
⚫ Sedation may be given with morphine
15mg intramuscularly.
 Manual Removal of Placenta

⚫ Step 1
⚫ Step 2
⚫ Step 3
⚫ Step 4
⚫ Step 5
⚫ Step
6
⚫ Step 7
Difficulties:
⚫ Hour – glass contraction
⚫ Morbid adherent placenta
⚫Complications :
⚫ Haemorrhage due to incomplete removal
⚫ Shock

⚫ injury to the uterus (rare)

⚫ infection

⚫ inversion

⚫ Subinvolution

⚫ Thrombophlebitis

⚫ Embolism.
Management of true post partum
haemorrhage
Principles
⚫ To diagnose the cause of bleeding.
⚫ To take prompt and effective measures to
control bleeding.
⚫ To correct hypovolemia.
 Management
Immediate measures:
⚫ Call for help.
⚫ Head down tilt
⚫ Oxygen by mask, 8 litres / min
⚫ Put in two large bore,14 gauge, cannula.
⚫ Send blood for grouping and cross matching and ask for
2 units of blood.
⚫ Infuse rapidly 2 litres of NS (crystalloids) or plasma substitutes
⚫ Use a warming device and a pressure cuff.
⚫ Monitor BP and pulse every 25min, tem. every 4 hr.
⚫ Monitor type and amount of fluids the patient has
received, urine output, drugs- type, dose and time, CVP.
Actual Management:
⚫ note the feel of the uterus.
Atonic uterus
⚫ Step 1: Massage the uterus to make it
hard.
⚫ Step 2: Explore the uterus under GA
⚫ Step 3: Uterine massage and bimanual compression.
⚫ Step 4: Uterine tamponade
⚫ Step 5: Surgical methods
⚫ Step 6: hystrectomy
surgery
⚫ Ligation of uterine arteries
⚫ Ligation of the ovarian and uterine artery
anostomasis.
⚫ Ligation of the anterior division of internal iliac
artery (unilateral or bilateral).
⚫ B- Lynch brace suture and haemostatic suturing
⚫ Angiographic arterial embolisation under fluoroscopy
 Secondary PPH
Causes:
The causes are,
⚫ Retained bits of placenta or membranes.
⚫ Infection and separation of slough over a deep
cervico- vaginal laceration.
⚫ Endometritis and subinvolution of the placental site
⚫ Withdrawal bleeding following oestrogen therapy for
suppression of lactation.
⚫ Other rare causes are—chorion epithelioma; carcinoma
of cervix, infected fibroid or fibroid polyp and puerperal
 Diagnosis:

⚫ The bleeding site is usually bright red. Varying

degree of anaemia and evidences of sepsis are
present. Internal examination reveals evidences of
sepsis, subinvolution and often a patulous cervical
os. USG helps in detecting retained bits of placenta
inside the uterine cavity.
 Managenent:

⚫ Principles—
⚫ (1) To assess the amount of blood loss and to
replace the lost blood.
⚫ (2) To find out the cause and to take appropriate
steps to rectify it.
Supportive therapy:
⚫ Blood transfusion, if necessary; Inj Ergometrine 0.5mg
IM, if the bleeding is uterine in origin, antibiotics as
routine.
Conservative:
⚫ If the bleeding is slight and no apparent cause is
detected, a careful watch for a period of 24hrs or so
is done in hospital.
Active treatment:
⚫ As the commonest cause is due to retained bits of
placenta or membranes, it is preferable to explore
the uterus urgently under GA. The products are
removed by ovum forceps. Gentle curettage is done
by using
flushing curette. Ergometrine 0.5mg is given IM.If
bleed is from sloughing of wound of cervico-
vaginal canal, control it by suturing.
 Complications

⚫ Shock
⚫ Collapse
⚫ Disseminated intravascular
coagulation
 Nursing Management
⚫ Deficient fluid volume r/t excessive blood loss
secondary to uterine atony, lacerations, incisions,
coagulation defects, retained placental fragments,
hematomas
⚫ Fear and anxiety r/t threat to physical being,
deficient knowledge of treatment .
⚫ Pain r/t uterine contractions, distention from
blood between uterine wall and placenta.
⚫ Risk for complication, shock related to
excessive bleeding
⚫ Interrupted breast feeding r/t mother’s health state
during the PPH.
⚫ Risk for impaired parent/ infant bonding r/t lack
of early parent/ infant contact.
⚫ Interrupted family process r/t change in family roles,
inability to assume usual role and prolonged
recovery period.
 RETAINED PLACENTA
⚫ placenta is said to retained when it is not expelled
out even 30 minutes after the birth of the baby.
 Causes:
⚫ Placenta completely separated but retained is due
to poor voluntary expulsive efforts.
⚫ Simple adherent placenta is due to uterine atonicity in
cases of grand multipara, over distension of the
uterus, prolonged labour, uterine malformation or due
to bigger placental surface area. The commonest
cause of retention of non-separated placenta is atonic
uterus.
⚫ Morbid adherent placenta- partial or rarely
incomplete.
⚫ Placenta incarcerated following partial or complete
separation due to constriction ring, premature
attempts to deliver placenta before it is separated
 Diagnosis:

⚫ It is made by an arbitrary time spent following

delivery of the baby.
⚫ Features of placental separation is assessed.
⚫ The hour glass contraction or the nature of
adherent placenta can only be diagnosed during
manual removal.
 Management:
Period of watchful expectancy:
⚫ During the period of arbitrary time limit of an half an
hour, the patient is to be watched carefully for the
evidence of any bleeding, revealed or concealed and to
note the signs of separation of placenta.
⚫ The bladder should be emptied using a
rubber catheter
⚫ Any bleeding during the period should be managed
as outlined in third stage bleeding
Retained placenta:
⚫ Separated
⚫ Un-separated
⚫ Complicated
Placenta is separated and retained:
⚫ To express the placenta out by controlled
cord traction.
Unseparated retained placenta:
⚫ Manual removal of placenta is to be done under GA.
Complicated retained placenta:
⚫ Retained placenta complicated with haemorrhage or shock.
⚫ Retained placenta with shock no haemorrhage.
⚫ Retained placenta with haemorrhage
⚫ Retained placenta with sepsis
⚫ Intrauterine swabs are taken for culture and sensitivity
test and broad spectrum antibiotics is usually given.
⚫ Blood transfusion is helpful.
⚫ Manual removal of placenta.
⚫ Retained placenta with an episiotomy wound
 Complications:

⚫ Haemorrhage
⚫ Shock is due to blood loss, at times unrelated
blood loss, specially when retained more than one
hour, Frequent attempts of abdominal
manipulation to express the placenta out
⚫ Puerperal sepsis
⚫ Risk of recurrence in next pregnancy.
 PLACENTA ACCRETA
⚫ It is defined as an extreme rare form in which the
placenta is directly anchored to the myometrium
partially or completely without any intervening
deciduas. The abnormal adherence may involve all
lobules—total placenta accreta. Or, it may involve
only a few to several lobules— partial placenta
accreta. All or part of a single lobule may be
attached— focal placenta accreta.
 PLACENTA INCRETA
⚫ placenta increta, villi actually invade into the
myometrium and anchored into the muscle
bundles.
 PLACENTA PERCRETA
⚫ with placenta percreta, villi penetrate through the
myometrium upto the serosal layer.
 Associated Conditions

⚫ placenta previa,
⚫ prior cesarean delivery,
⚫ previously undergone curettage
⚫ gravida 6 or more.
⚫ MSAFP levels exceeded 2.5
MoM;
 Diagnosis

⚫ The diagnosis is made only during attempted

manual removal when the plane of cleavage between
the placenta and the uterine walls cannot be made
out.
⚫ USG and colour doppler:
two factors were highly predictive of myometrial
invasion: (1) a distance less than 1 mm between the
uterine serosa-bladder interface and the retroplacental
vessels, and (2) identification of large intraplacental
lakes
⚫ MRI:
(1)uterine bulging, (2) heterogeneous signal
intensity within the placenta, and (3) presence of
dark intraplacental bands on T2-weighted imaging.
Pathological confirmation includes:
⚫ Absence of decidua basalis
⚫ Absence of nitabuch’s fibrinoid layer
⚫ Varying degree of penetration of the villi into muscle
bundles and upto serosal layers
 Management

In the focal placenta accrete

⚫ Remove the placental tissue as much as possible.
Effective uterine contraction and hemostasis are
achieved by oxytocics and if necessary by intrauterine
plugging. In cases of caesarean section the bleeding
areas are over sewed. If the uterus fails to contract
hysterectomy may have to be taken and this preferable
in multiparous woman.
In the total placenta accrete:
⚫ Hysterectomy is indicated in the parous women, while
in patients desiring to have a child conservative
attitude may be taken. This consists of cutting the
umbilical cord as close to its base as possible and
leaving behind the placenta which is expected to be
autolysed during the course of time. Appropriate
antibiotics should be given. Methotrexate also is used
by some.
⚫ In rare cases:
⚫ Placenta accrete may invade bladder. In that case try
to avoid placental removal. It may need hysterectomy
and partial cystectomy. Methotrexate therapy may be
tried.
⚫ Preoperative Arterial Catheter Placement.
⚫ Delivery of the Placenta.
 Complications:

⚫ Haemorrhage
⚫ Shock
⚫ Infection
⚫ Inversion of
uterus
 INVERSION OF THE UTERUS

⚫ Definition:
⚫ It is extremely rare but a life threatening
complication in third stage in which the uterus is
turned inside out partially or completely.
 Varieties:

⚫ First degree: there is dimpling of the fundus which

still remains above the level of internal os
⚫ Second degree: the fundus passes through the
cervix but lies inside the vagina.
⚫ Third degree: the endometrium with or without the
attached placenta is visible outside the vulva. The
cervix and part of vagina may be also involved in
the process.
 Etiology:

⚫ Spontaneous: 40%
⚫ Iatrogenic:
 Diagnosis:
Symptoms:
⚫ Acute lower abdominal pain with bearing
down sensation
Signs:
⚫ Varying degree of shock is a constant feature
⚫ Abdominal examination
⚫ Bimanual examination
⚫ In complete variety pear shaped mass protrudes
outside the vulva with broad end pointing
downwards and looking reddish purple in colour
 Prevention:

⚫ Do not employ any method to expel placenta out

when the uterus is relaxed.
⚫ Puling the cord simultaneously with fundal
pressure should be avoided.
⚫ Manual removal in a safe manner
 Management

⚫ Immediate assistance is summoned to

include anesthesia personnel and other
physicians
⚫ The recently inverted uterus with placenta already
separated from it may often be replaced
⚫ Adequate large-bore intravenous infusion systems
⚫ If still attached, the placenta is not removed until
infusion systems are operational, fluids are being
given, and a uterine-relaxing anesthetic such as a
halogenated inhalation agent has been administered.
⚫ Other tocolytic drugs such as terbutaline, ritodrine,
magnesium sulfate, and nitroglycerin have been used
successfully for uterine relaxation and repositioning
⚫ After removing the placenta, steady pressure with
the fist is applied to the inverted fundus in an
attempt to push it up into the dilated cervix.
⚫ Care is taken not to apply so much pressure as to
perforate the uterus with the fingertips
⚫ Surgical Intervention
⚫ the uterus cannot be reinverted by vaginal
manipulation because of a dense constriction ring .
In this case, laparotomy is imperative
Before shock develops:
⚫ To replace the part first which is inverted last with
the placenta attached to the uterus by steady firm
pressure exerted by the fingers.
⚫ To apply counter support by the other hand placed on
the abdomen.
⚫ After replacement the hand should remain inside the
until the uterus become contracted by parentral oxytocin
or
PGF2α
⚫ The placenta is to be removed manually after the uterus
became contracted
⚫ Usual treatment of shock including blood transfusion
should be arranged.
After shock develops:
⚫ urgent dextrose saline drip and blood transfusion
⚫ to push the uterus inside the vagina if possible
and pack the vagina with antiseptic roller gauze.
⚫ Foot end of the bed is raised.
⚫ Replacement of uterus either manually or hydrostatic
method (O Sullivan’s) under GA. Hydrostatic
method is less shock producing.
Subacute stage:
⚫ Improve general condition by blood transfusion
⚫ Antibiotics to control sepsis
⚫ Reposition of uterus either manually or
hydrostatic method
⚫ If fails abdominal reposition by operation- Haultain
operation
 Complications:
⚫ Shock
⚫ Tension on the nerves due to stretching of the
infundibulo- pelvic ligament.
⚫ Pressure on the ovaries as they dragged with the
fundus through cervical ring.
⚫ Peritoneal irritation
⚫ Haemorrhage, specially after detachment of placenta
⚫Pulmonary embolism
If left uncared it leads to:
⚫ Infection
⚫ Uterine sloughing
⚫ A chronic one