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COMPLICATIONS OF THE THIRD STAGE OF THE LABOUR. Third stage of the labour Fatal complications occur even after uneventful first&second stage of the labour.

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Presentation on theme: "COMPLICATIONS OF THE THIRD STAGE OF THE LABOUR. Third stage of the labour Fatal complications occur even after uneventful first&second stage of the labour."— Presentation transcript:

1 COMPLICATIONS OF THE THIRD STAGE OF THE LABOUR

2 Third stage of the labour Fatal complications occur even after uneventful first&second stage of the labour

3 THIRD STAGE Delivery of the placenta Signs of placental separation * Descent / Lengthening of umbilical cord * Uterus rises up * Gush of blood (small quantity) * Placenta in vagina Active management: Brant - Andrews Method * Ergometrine mg (a) I:V / I:M / after delivery of baby at MOH * Methergin mg (b) * Syntometrine / Syntocinon (c) Avoid (a), (b), (c) if BP  in labour

4 THIRD STAGE: A. Mechanism of Placental Separation Shultze Mechanism of Placental Separation * Retroplacental clot * Placenta / membranes dragged downwards * Membranes peel from periphery * Placenta delivered by inversion Duncan Mechanism of Placental Separation * Separation at periphery of placenta * Placenta descends to vagina sideways * Maternal surface of placenta appears first at vulva

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6 Caution *Side effects *Hypertension *Hypertensive cases *Cardiac cases Are the placenta and membranes complete? Careful examination of placenta / membranes Problems *Primary PPH *Secondary PPH Repair of Episiotomy / perineal lacerations Care of Perineum

7 SPECIAL PROBLEMS / COMPLICATIONS DETECTED IN THIRD STAGE - {ANTICIPATE} *Vaginal lacerations *Cervical lacerations *Extension of episiotomy *Retained placenta / Parts / Membranes *Primary postpartum haemorrhage (Look out for) Ruptured uterus Shock Vulval haematoma

8 MAJOR COMPLICATIONS MAJOR COMPLICATIONS 1.postpartum hemorrhage 2.retained placenta 3.puerperal inversion of the uterus

9 Post partum hemorrhage Definition:any amount of bleeding from/into genital tract following birth of the baby up to puerperium which adversely affects the general condition of patient Incidence:1% among the institutional deliveries

10 PPH Hemorrhage within 24hrs following birth of the baby Hemorrhage beyond 24 hrs & within puerperium primary secondary Third stage bleeding True PPH Bleeding prior To placental expulsion Bleeding subsequent To expulsion

11 Primary PPH ETIOLOGY 1.Atonic(common):80% 2.Traumatic:20% 3.Mixed 4.Blood coagulopathy

12 ATONIC UTERUS Any factor which prevents contraction &retraction of uterus predisposes to it Causes: GENERAL 1.Malnutrition 2.Anemia 3.Grand multipara PLACENTAL: APH UTERINE 1.Malformation 2.overdistenton(twins Polyamnios) 3.Persistent over Distension(retained Bits) 4.Fibroid DURING LABOUR 1.Prolonged labour 2.Precipitate labour 3.Mismanaged 3 rd stage (rapid delivery,pulling the cord,kneading/ Fiddling uterus) 4.Constriction ring 5.Augmentation by Oxytocics 6.Deepened anesthesia

13 Primary PPH TRAUMATIC: Trauma to the cervix,vagina,perineum,para urethral tears,episiptomy wound,rarelyrupture uterus MIXED: both atonic & traumatic BLOOD COAGULOPATHY:blood dyscrasias, Diminished procoagulants(WASH OUT PHENOMENON) seen in abruptio placenta,IUD,HELLP syndrome,TTP

14 Diagnosis ATONIC: uterus is flabby,becomes hard on massaging TRAUMATIC: uterus is contracted & firm Clinical effects: alteration in pulse,BP,pulse pressure occur when blood loss is 20-25% blood volume which leads to unexpected mortality

15 PROGNOSIS DEATH in 10% cases Shock Puerperal sepsis Failing lactation Pulm embolism Thrombophlebitis Rarely Sheehans Syndrome Diabetes insipidus

16 MANAGEMENT PRINCIPLES: 1.Empty the uterus of its contents &make it contract 2.Blood transfusion 3.Effective hemostasis Third stage bleeding Placenta separated Expel the cord by Controlled traction Not separated Manual removal of placenta

17 Manual separation of the placenta STEP 1: general ANESTHESIA is given,BLADDER catheterised STEP 2: hand is introduced in CONE shaped manner &COUNTER PRESSURE is applied on on uterine fndus by other hand STEP 3: as soon as placental margin is reached,fingers are insinuated with DORSUM of hand in contact with uterine wall&placenta separated by slicing movements STEP 4:EXTRACTION of the placenta by traction of cord by other hand,EXPLORATION of uterus for any bits,IV ERGOMETRINE is given COMPLICATIONS: hemorrhage due to incomplete removal,sub involution,injury to uterus,infection

18 TRUE PPH MANAGEMENT ATONIC Massage the uterus STILL ATONIC surgical methods TRAUMATIC Oxytocin 10 units in 500ml ns Methergin 0.2mg IV Examine the expelled placenta Catherise the bladder Blood transfusion 15 methyl PGF2 250ug intra myometrial Misoprostol 1000ug PR UTERINE TAMPONADE Suturing on tear sites

19 OxytocinErgometrineMisoprostol Acts in 2-3 minsActs in 6-7 mins SafeContraindication: hypertension Safe InexpensiveMore inexpensiveInexpensive Minimal side affectsNausea and vomiting possible Shivering and temp common Cold storageDemanding cold storageNo cold storage Drug of choice; Can be in Uniject or Soloshot Discourage! Can be introduced for home birth when no skilled birth attendant (oral)

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21 UTERINE TAMPONADE Tight intrauterine packing is done uniformly under general anesthesia PROCEDURE:a A 5 metres gauze,8cm wide folded twice is required.the guaze is soaked in antiseptic solution.the guaze is placed high up & packed into fundal area while the uterus is steadied with other hand.rest of the cavity is packed.a separate pack is used to fill the vagina. MODE OF ACTION: stimulates uterine contraction &exerts tamponade effect on opened uterine sinuses

22 UTERINE TAMPONADE INSERTION OF SENGSTAKEN BLAKEMORE TUBE It is inserted into the uterine cavity & balloon is inflated with 200 ml normal saline.it has a tamponade effect as that of packing the uterus

23 SURGICAL METHODS Ligation of uterine arteries: ascending branch of uterine artery is ligated at he lateral border b/n upper & lower uterine seg.in atonic hemorrhage b/l ligation is required Ligation of ovaian & uterine artery anastomosis if bleeding continues is done just below the ovarian ligament Ligation of anterior division of internal iliac artery :reduces distal blood flow,no pelvic necrosis occurs due to collaterls

24 SURGICAL METHODS ctd… B LYNCH brace suture :it acts by tamponade effect.it compresses the uterus bimanually Angiographic arterial embolisation:it is done under fluroscopy by using gel foam

25 HYSTERECTOMY: if all the above methods fail.depending on the case it can be total/subtotal Decision of hysterectomy should be taken early in parous women

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28 SECONDARY PPH Bleeding between 8-14 th day (common) Causes: 1.retained bits 2.infection 3.endometritis &subinvolution 4.secondary hemorrhage from c/s wound 5.rarely CHORION EPITHELIOMA occurs beyond 4 wks of delivery DIAGNOSIS: Bleeding is bright red &evidence of sepsis Rx: Exploration of uterus for any bits blood transfusion hemorrhage from c/s wound at times require laparotomy

29 RETAINED PLACENTA DEFINITION:the placenta is said to be Retained when it is not expelled out even 30min aftr birth of the baby PHASES OF NORMAL EXPULSION OF PLACENTA: 1.separation through spongy layer of decidua 2.descent into LUS 3.expulsion outside Interference in any of these physiological process results in retained placenta 1.placenta completely separated but retained due to poor voluntary expulsive efforts 2.simple ADHERENT PLACENTA:due to uterine ATONICITY(COMMONEST CAUSE) 3.morbid adherent placenta(PLACENTA ACCRETA)

30 PLACENTA ACCRETA(MORBID ADHERENT PLACENTA) It is an extremely rare condition where placenta is directly anchored to myometrium with out any intervening decidua due to defective decidual formation Usually associated with placenta praevia,prior D&C operation,manual removal of placenta/myomectomy Pathological conformation includes: Absence of NITABUCH’S membrane(layer of fibrinoid degeneration of outer synctiotrophoblast at the jn of cytotrophoblastic shell & decidua Varying degree of penetration of villi into muscle bundles:PLACENTA INCRETA Varying degrees of penetration of villi upto serosa:PLACENTA PERCRETA

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32 MANAGEMENT ARBITARY TIME LIMIT OF HALF AN HOUR IS TO BE WATCHED FOR ANY EVIDENCE OF BLEEDING RETAINED PLACENTA Unseparated & retained Separated & retained Complicated retained placenta Manual removal of placenta Express by Controlled Cord traction   RETAINED PLACENTA WITH SHOCK:treat the shock &remove placenta manually   RETAINED PLACENTA WITH SEPSIS:broad spectrum Antibiotics   RETAINED PLACENTA WITH AN EPISIOTOMY WOUND: Manual removal with repair of Episiotomy wound

33 MANAGEMENT OF PLACENTA ACCRETA PLACENTA ACCRETA FOCALTOTAL RARE CASES REMOVE THE PLACENTAL TISSUE AS MUCH AS POSSIBLE EFFECTIVE UTERINE CONTRACTIONS ACHIEVED BY OXYOCICS EARLY DECISION OF HYSTERECTOMY PREFERABLY IN MULTIPARA TO CONSERVE UTERUS: CUTTING THE UMBLICAL CORD AS CLOSE AS POSSIBLE TO ITS BASE & LEAVING IT FOR AUTOLYSIS PLACENTA ACCRETA MAY INVADE BLADDER. AVOID PLACENTAL REMOVAL IT MAY NEED HYSTERECTOMY & PARTIAL CYSECTOMY METHOTREXATE THERAPY MAY BE NEEDED

34 PUERPERAL INVERSION OF UTERUS Extremely RARE but life threatening INCIDENCE: 1 in 20,000 deliveries Obstetric inversion is ALMOST ALWAYS ACUTE & usually complete VARIETIES: I degree: dimpling of fundus which still remains above the level of internal os II degree: fundus passes through cervix but lies inside the vagina III degree: endometrium visible outside the vulva

35 ETIOLOGY  SPONTANEOUS: Due to localised atony on the placental site over the fundus associated with sharp rise of intra abdominal pressure as in coughing,bearing down effort.fundal attachment of placenta,short cord & placenta accreta are often associated.  IATROGENIC:mismanagement of 3 stage labour  Pulling the cord when uterus is atonic  credes expression when uterus is relaxed  Faulty technique in manual removal

36 COMPLICATIONS SHOCK: Extremely profound mainly neurogenic due to tension on the nerves due to streching of the infundibulo pelvic ligaments,pressure on ovaries,peritoneal irritation Hemorrhage: specially after detachment of placenta PULMONARY EMBOLISM

37 DIAGNOSIS SYMPTOMS: Acute lower abd pain with bearing down sensation SIGNS: SHOCK, P/A: cupping/dimpling of fundus O/E:Bimanual examination confirms not only the diagnosis but also the degree In complete variety:a pear shaped mass protrudes outside the vulva.

38 PROGNOSIS Death may occur suddenly due to shock,haemorrhage or embolism.

39 Differential Diagnosis Prolapse of a uterine tumour Gestational trophoblastic disease Occult genital tract diseaseGestational trophoblastic disease Marked uterine atony Undiagnosed second twin

40 MANAGEMENT PREVENTION:DO NOT EMPLOY ANY METHODS TO EXPEL PLACENA OUT WHEN UTERUS IS RELAXED PULLING THE CORD SIMULTANEOUS WITH FUNDAL PRESSURE SHOULD BE AVOIDED BEFORE SHOC K DEVELOPS:   REPLACE THE PART FIRST WHICH IS INVERTED LAST   APPLY COUNTER SUPPORT BY OTHER HAND ON ABDOMEN   HAND SHOULD REMAIN INSIDE THE UTERUS UNTIL IT STARTS CONTRACTING AFTER SHOCK DEVELOPS:   BLOOD TRANSFUSION   HAEMACEL   RAISE FOOT END   REPLACEMENT OF UTERUS EITHER MANUALLY/ HYDROSTATIC METHOD

41 Mangement of puerperal inversion

42 HYDROSTATIC METHOD(O’SULLIVAN METHOD) The inverted uterus is replaced into vagina.warm sterile fluid(5 litres) is gradually instilled into the vagina through a douche nozzle.the vaginal orifice is blocked by operators palms supplemented by labial apposition around the palm by an assistant The water distends the vagina & the consequent increased intravaginal pressure leads to the replacement of te uterus

43 IF THE MANUAL METHODS FAIL: HAULTAIN’S OPERATION:INCISING THE CONSTRICTION RING OF CERVIX AND UTERUS IS REPLACED BY ABDOMINAL ROUTE SPINELLI’S OPERATION:IT IS THE SAME THING IS DONE BY VAGINAL ROUTE

44 TAKE HOME MESSAGE NEVER employ any method to expel placenta from a relaxed uterus Observe the patient for about 2hrs after delivery & if uterus remains hard & contracted then only she should be sent to the ward Slow delivery of the baby is to be adopted Baby should be pushed out by retracted utrerus & not to be pulled out


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