1. Third stage of labour (Normal & abnormal) Dr. Abdalla H. Elsadig MD

2. Definition : Definition : 3 rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. 3 rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. Duration: Duration: - normally 5 to15 minutes. - 30 minutes have been suggested if there is no evidence of significant bleeding. The risk of complications continues for some period after delivery of the placenta. The risk of complications continues for some period after delivery of the placenta. Fourth stage of labor: begins with the delivery of the placenta and lasts for 1 hour. Fourth stage of labor: begins with the delivery of the placenta and lasts for 1 hour.

3. Significance  Postpartum haemorrhage (PPH) : - Maternal mortality.. The maternal mortality rate in the United States is approximately 7-10 women per 100,000 live births; 8% of these deaths are caused by PPH.. The maternal mortality rates in developing world exceeded 1000 women per 100,000 live births, 25% of these deaths are due to PPH. - Anemia: PPH causes anemia or poor iron. Anemia causes weakness and fatigue. prolonged hospitalization affects the establishment of breastfeeding. - Blood transfusion→ transfusion reaction and infection. - Emergency anesthetic intervention: due to severe PPH, retained placenta, and uterine inversion. - Sepsis: due to exploration or instrumentation of the uterus.

4. Mechanism of placental separation Uterine contractions and retraction reduce the uterine cavity → placental detachment and expulsion into the lower uterine segment. Uterine contractions and retraction reduce the uterine cavity → placental detachment and expulsion into the lower uterine segment. Retro-placental hematoma. Retro-placental hematoma. * Oxytocin, ergometrin and prostaglandins enhance placental separation and expulsion by causing uterine contraction. * Tocolytics/nitroglycerin and some inhalation anesthetics cause uterine relaxation and delay of placental separation causing dangerous bleeding following delivery.

5. What to do before delivery of the placenta?

6. 1. Look for signs of placental separation:  lengthening of the umbilical cord outside.  The uterus becomes firm and globular.  The uterus rises in the abdomen.  A gush of blood. 2. Assess the uterus : To exclude an undiagnosed twin To exclude an undiagnosed twin To determine a baseline fundal height To determine a baseline fundal height to detect the signs of placenta separation to detect the signs of placenta separation to detect an atonic uterus. to detect an atonic uterus.

7. Delivery of the placenta 1. Physiological or expectant management: - Wait for the signs of placental separation - Wait for the signs of placental separation - Make sure that the uterus is contracted. - Make sure that the uterus is contracted. - Controlled Cord traction: the body of the uterus is supported above the symphysis pubis by the left hand directed upward and backward. Then cord traction is applied continuously downward and forward with the right hand. - Controlled Cord traction: the body of the uterus is supported above the symphysis pubis by the left hand directed upward and backward. Then cord traction is applied continuously downward and forward with the right hand. 2. Active management: - By using one of the following: Ergometrine, Oxytocin, or Syntometrine (ergometrine + oxytocin ). - By using one of the following: Ergometrine, Oxytocin, or Syntometrine (ergometrine + oxytocin ). - Given at the delivery of anterior shoulder or after delivery of the baby. - Given at the delivery of anterior shoulder or after delivery of the baby. - Immediate delivery of the placenta with CCT. - Immediate delivery of the placenta with CCT.  Avoid uterine massage before placental delivery.

8. Mode of drugs administration Oxytocin: Oxytocin: - 10 IU, intramuscularly + with intravenous access in place, 10-20 IU is placed in 500-1000 mL of crystalloid and run quickly. - 10 IU, intramuscularly + with intravenous access in place, 10-20 IU is placed in 500-1000 mL of crystalloid and run quickly. - With cesarean deliveries: 5 IU is administered as an intravenous bolus, followed by a similar infusion. - With cesarean deliveries: 5 IU is administered as an intravenous bolus, followed by a similar infusion. Ergometrine: dose is 0.25- 0.5 mg IM or IV. Ergometrine: dose is 0.25- 0.5 mg IM or IV. Syntometrine (0.5 mg of ergometrine with 5 IU of oxytocin) : Syntometrine (0.5 mg of ergometrine with 5 IU of oxytocin) : The dose is 2 mg and given IM only. The dose is 2 mg and given IM only.

9. Delivery of membrane By rotating the placenta about the insertion site as it descends or grasping the membranes with a clamp or artery forceps and drawn down.

10. Umbilical cord management cord clamping: Delayed until the cord is pulseless, usually 2-4 minutes, →↑Hb, ↑iron stores in the newborn and ↓levels of early childhood anemia. cord clamping: Delayed until the cord is pulseless, usually 2-4 minutes, →↑Hb, ↑iron stores in the newborn and ↓levels of early childhood anemia. Method of cord clamp: Method of cord clamp:

11. Physiological Versus Active Management Physiological Versus Active Management Physiological Management Active management Uterotonic agent None or after placenta delivered With delivery of anterior shoulder or baby Uterus Assessment of size and tone after delivery Cord traction None controlled cord traction when uterus contracted Cord clamping VariableEarly

12. What to do after delivery of the placenta?

13. Immediately after delivery of the placenta Determine the fundal position and size of the uterus. Determine the fundal position and size of the uterus. Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine massage). Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine massage). Examine the placenta for completeness and detection of abnormalities. Examine the placenta for completeness and detection of abnormalities. Suturing of lacerations. Suturing of lacerations. Uterine exploration: - No longer recommended for normal deliveries or those following previous cesarean delivery. - Is justified in patients with bleeding originating high in the genital tract. - The cervix should be visualized after all forceps deliveries

14. Fourth stage Observe the vital signs. Observe the vital signs. palpate the abdomen to assess and monitor uterine tone and size. palpate the abdomen to assess and monitor uterine tone and size. Do uterine massage. Do uterine massage. Ensure continuous infusion of oxytocin. Ensure continuous infusion of oxytocin. Encourage early breastfeeding to promote endogenous oxytocin release. Encourage early breastfeeding to promote endogenous oxytocin release. assess the lower genital tract for bleeding. assess the lower genital tract for bleeding. repair of an episiotomy or any lacerations. repair of an episiotomy or any lacerations. Close observation every 15 minute for the next hour. Close observation every 15 minute for the next hour.

16. COMPLICATIONS Uterine atony. Uterine atony. Retained placenta. Retained placenta. Trauma. Trauma. Uterine inversion. Uterine inversion. Postpartum hemorrhage

17. Postpartum hemorrhage ( PPH)   Def: is an excessive blood loss from the genital tract after delivery of the baby. It is divided into primary and secondary PPH.  Primary PPH  Primary PPH: blood loss of 500 ml or more in the first 24 hours after delivery. Causes: Causes:   Uterine atony.   Genital tract trauma.   retained placental tissue.   Uterine inversion.   Coagulation disorders: - Inherited coagulopathy. - Abruptio placentae. - Retained dead fetus. - Amniotic fluid embolism.

18. Uterine Atony Inability of the uterus to contract and retract effectively. The uterus increases in size (retained products) and is felt soft and boggy. The patient has a rapid, thready pulse with a decrease in BP. The patient may also looks pale and apprehensive.

19. Uterine Atony Factors predisposing : Over-distension of the uterus: multiple pregnancy, poly- hydramnios or fetal macrosomia. Retained products of conception: the placenta, placental cotyledon or fragments or a large amount of membranes. large placental site: multiple pregnancy. Prolonged labor: weak or incoordinate uterine action or mechanical difficulty will leading to uterine exhaustion and atony. Placenta praevia: inability of the lower uterine segment to contract and retract. Abruptio placentae: interstitial uterine hemorrhage and later hypofibrinogenaemia. Grand-multiparity: (a parity of 5 or more) ↑ fibrous tissue of the uterus ↓ muscular tissue. Operative deliveries: C/S & general anaesthesia that relax the myometrium, such as Halothane and Cyclopropane. multiple fibromyomata (leiomyomata), especially of the interstitial type resulting in ineffective uterine contraction and retraction. full bladder.

20. Genital tract trauma :   Causes: perineal laceration or episiotomy: obvious bleeding. Vaginal or cervical lacerations or tears: tend to occur over the perineal body, periurethral area and over the ischial spines al. Lacerated or ruptured uterus.   Predisposing factors: Difficult labor. Precipitate labor. previous caesarean section. Instrumental delivery: forceps, Ventouse or CS.  given  Genital tract trauma is suspected when there is continuous bleeding and the uterus is well contracted, particularly after an oxytocic drug has been given

21. Retained placental tissue Uterine atony Morbidly adherent placenta: - Due to abnormal development of decidua basalis. - Causes: previous CS, placenta previa, manual removal of placenta or uterine curettage. - - Degrees: 1) accreta (80%). 2) increta. 3) percreta. - - Diagnosis: 1) antenatally: U/S & MRI 2) in 3 rd stage: commonly Caught of placenta by the retraction ring at the junction of the upper and lower segments: following an Ergometrine injection than Syntometrine or Oxytocin injections.

22. Inversion of the uterus   the fundus of the uterus descends through the uterine body and cervix into the vagina, and sometimes protrudes through the vulva. This → traction on peritoneal structures → vasovagal vasodilatation + neurogenic chock.   Predisposing factors: mal-management of the third stage: inappropriate traction during CCT or too rapid removal during MRP. ↑intra-abdominal pressure + relaxed uterus (fundal pressure). Previous history of inversion ( 33%). Cornual placenta ( cornual pockets).

23. Management of (PPPH)   Two important principles: The bleeding must be stopped. the blood volume must be restored.   guidelines for PPH management: Call for help ( senior staff, midwives, anesthetists and hematologists). Ensure at least two peripheral infusion lines with large-bore IV canulae. Blood sample should be taken for a full blood count, coagulation studies and blood group and cross-matching. Start intravenous fluid ( Hartmann’s or saline). Give blood when it is available. Give intravenous oxytocic drugs ( methergine or syntocinon). Examination to determine the cause.

24. Management of (PPPH)   Uterine atony: the placenta has delivered: Resuscitate the patient as mentioned above. Stimulate uterine contraction by: - Uterotonics: IV ergometrine (0.5 mg), IV Syntocinon (5 iu) or IM syntometrin ( 1ml) + 30-40 units of syntocinon in 40 ml of normal saline run at 10 ml/hr. - - uterine massage and bimanual compression. Packing of the uterine cavity (gauze/balloon insufflation). If no response: give prostaglandin analogues e.g. Carboprost Hemabate, 0.25 mg every 15-90 min. up to 8 doses given by deep IM or Gemeprost intramyometrial or misoprostol rectally. If still no response, then go for examination under anesthesia and surgery ( uterine arteries ligation, infundibulo-pelvic vessels ligation internal iliac artery ligation, compression sutures or hysterectomy).

25. Management of (PPPH)   Uterine atony: the placenta not delivered: Resuscitate the patient as mentioned above. Ensure uterine contraction. try to deliver the placenta by controlled cord traction. if the placenta not delivered, then take the patient to the theatre for manual removal of the placenta under general anesthesia. Ergometrine should be given and syntocinon in a drip should be set.

26. Management of (PPPH) Trauma: Is suspected when the bleeding persists, with well contracted uterus. Full exploration under general anesthesia for the vulva, the vagina, cervix and uterus. Vaginal and cervical lacerations should be sutured. Ruptured uterus is treated by repair or subtotal hysterectomy.

27. Management of (PPPH)   Uterine inversion:   The condition is diagnosed in various ways: - Acute complete inversion: absent uterus on abdominal examination. - Incomplete inversion: presence uterine dimpling on abdominal examination.   The treatment includes: Resuscitation + manual replacement prior to onset of shock. manual replacement under general anesthesia (shock) if fails O’Sullivan’s hydrostatic method: the vagina is filled with warm saline which is gradually instilled into the vagina by means of a douche can and tubing. The introitus is blocked with assistant’s fist. 4 to 5 L of saline will balloon the vagina, distend the uterus and so, reverse the inversion. Laparotomy (Haultain’s): incision in the muscular ring in the posterior uterine wall and correction.

28. Management of (PPPH) DIC: DIC: 1. Maintain the intravascular volume. 2. Administer fresh frozen plasma(FFP) at a rate to keep the activated partial thromboplastin: control ratio < 1.5. 3. Administer packed platelet to maitain a platelet count > 50 × 10 9 /L. 4. Administer cryoprecipitate to keep the fibrinogen level > 1 gm/L.