The document discusses complications that can occur during the third stage of labor. The third stage involves the period from birth of the baby to delivery of the placenta. Complications include postpartum hemorrhage, retained placenta, morbidly adherent placenta, inverted uterus, and amniotic fluid embolism. Postpartum hemorrhage is the leading cause of maternal mortality in India and is often due to uterine atony. Risk factors, prevention, and management of postpartum hemorrhage and other third stage complications are described.

2. COMPLICATIONS OF THIRD
STAGE OF LABOUR

3. EVENTS OF THIRD STAGE OF LABOUR
• Period between expulsion of fetus to expulsion of placenta &
membranes (afterbirths)
• Duration: 15 min.(primigravida multigravida)
• AMTSL: 5 minutes
• Placental separation
• Placental expulsion

4. MECHANISMS TO CONTROL BLEEDING
1. Effective retraction of
uterine muscles : Living
ligatures
2. Thrombosis of torn sinuses
3. Myotamponade: apposition
of walls of the uterus

6. COMPLICATIONS OF THIRD STAGE OF LABOUR
• Postpartum haemorrhage
• Retained Placenta
• Morbidly adherent placenta
• Inversion of uterus
• Amniotic Fluid Embolism

7. POSTPARTUM HAEMORRHAGE - PROBLEM
STATEMENT
• No. 1 cause of maternal mortality in India
• 5,29,000 maternal deaths per year
• Death due to PPH
• 88% within 4 hrs of delivery
• 70% due to atonic PPH

8. PPH - Definitions
• Quantitative
• Vaginal Delivery >500 ml
• Cesarean Delivery >1000 ml
• >10% fall in hematocrit
“Care givers consistently underestimate actual blood loss.”

9. PPH - Definitions
Any amount of blood loss that threatens the
hemodynamic stability of the woman

10. Types of PPH
• Primary PPH
• Haemorrhage <24 hrs of birth
• Secondary PPH
• Haemorrhage >24 hrs till 6 weeks of birth

11. Primary PPH - Causes

12. PPH - Risk Factors

13. ATONIC PPH
• Uterine atony/ failure of the uterus to contract and retrtact effectively
enough to occlude the spiral arterioles
• 80% of all PPH
• Clinical features
• Uterus is flabby and filled with blood
• Torrential bleeding
• Tacycardia, Tachypnea
• Hypotension

15. Rule of 30
• Increase in HR by >30 beats/min
• Fall in Systolic BP >30 mmHg
• RR >30/min
• Hct drops by >30%
• Urine output <30ml/min
Pt has most likely lost >30% of her blood volume and is in
moderate shock

16. Prevention of Atonic PPH
• Improvement of health status of mother (Hb>11gm%)
• Identify high risk women
• Plan for institutional delivery /SBA
• Strict vigilance of all women in 3rd stage labor
• Practice AMTSL in all
• Examination of afterbirths ,should be a routine
• Explore Uterovaginal canal following difficult/ instrumental,
destructive delivery

17. Management of Atonic PPH
• Evaluation, resuscitation, communication within the medical team and
with the patient’s relatives and procedures to arrest the bleeding should
proceed simultaneously
Steps in Management
• 2 large bore iv cannulae
• Obtain blood sample for haematocrit and cross match
• Start NS infusion with 20 units oxytocin
• Monitor Pulse, BP and RR

18. STEPS IN MANAGEMENT OF PPH
• Insert Foley catheter and monitor urine output
• Use uterotonics in 2nd iv line
• Place a hand on the uterus to check for contraction and provide
uterine massage
• Continue volume resuscitation while awaiting blood
• Inspect cervix and vagina and explore uterine cavity for retained
placental bits

19. UTEROTONICS USED IN THE MANAGEMENT OF
PPH
Drug Dose/ Route Frequency Comment
Oxytocin iv: 20- 40 units in 500ml
NS/RL
continuous Avoid undiluted rapid iv
infusion
Methyl Ergometrine iv: 0.25 mg Every 2-4 hours Avoid in HT
PG F2α im : 250 mcg Every 15- 90 mins
Max 8 doses
Avoid in asthma
Misoprostol (PG E1) 800- 1000 mcg Use if injectables are
not available

20. MECHANICAL INTERVENTIONS- Bimanual
Compression

21. MECHANICAL INTERVENTIONS- Aortic
Compression

22. Mechanical Interventions - Non Pneumatic
Anti-Shock Garments

23. Uterine Tamponade
• Intrauterine Balloon
Tamponade
• Balloon inflated with 500-
600ml of saline
• Adapts to shape of the uterine
cavity and occlused the venous
sinuses.
• Bakri Balloon
• Senstaken Blakemore tube

24. Condom Catheter

25. Surgical Interventions
• Arterial Ligation
• Uterine Artery ligation
• Stepwise
Devascularisation
• Internal Iliac Artery
Ligation

26. Uterine Compression Sutures- B Lynch

27. Surgical Interventions
• Selective Arterial Embolization
• Peripartum Hysterectomy

29. Traumatic PPH
• Bleeding from genital tract injuries
• Lower genital tract
• Perineal lacerations
• Vaginal lacerations
• Cervical tears
• Vulvar hematoma
• Upper Genital Tract
• Uterine rupture
• Broad ligament/ retroperitoneal heamtoma

30. Cervical Tear

31. Secondary PPH
• Excessive bleeding that occurs between 24 hours and 12
weeks postpartum
• Causes
• Retained placental tissue
• Endometritis
• AV malformation
• Choriocarcinoma

32. Complications of PPH
• Hypovolemic shock
• Renal failure
• Multiorgan failure
• Transfusion related complications
• ARDS
• Infections and Septicemia
• VTE
• Postpartum pituitary Necrosis- Sheehan’s syndrome
• Anemia
• Maternal death

33. RETAINED PLACENTA
• Failure of placenta to be expelled within 30 mins of delivery of
placenta
• Incidence: 1-2%
• 2 types
• Trapped Placenta
• Morbidly adherent placenta

34. Trapped Placenta
• Placenta is trapped in the uterus but is not adherent
• Causes
• Uterine atony and failure of the retroplacental myometrium to
contract, thereby preventing placental detachment
• Hour glass contraction of uterus

35. Management
• Tackle PPH
• Oxytocin Infusion
• Sublingual GTN
• Pipingas Technique
• 50u Oxytocin in 30ml NS injected in the umbilical vein

36. Manual Removal of Placenta
• Under GA, preferably Halothane
• Insert right hand with fingers kept close together (Accouchers hand)
along the umbilical cord
• Left hand on the uterine fundus
• Locate the margin of the placenta and insert the right hand between the
plane of cleavage between the placenta and the uterine myometrium
• Withdraw placenta carefully with left hand on the fundus to prevent
uterine inversion
• Start oxytocin infusion 20 u in 500 ml NS to promote uterine contractions
• Antibiotic Cover

37. UTERINE INVERSION

38. Clinical features
• Sudden profuse bleeding
• Signs of shock
• Unable to palpate the uterine
fundus per abdomen
• Vaginal examination reveals
the inverted uterine fundus
• Placenta maybe still attached
to the uterine walls

40. Management
• Hydrostatic O’ Sullivan method
• Surgical Methods
• Abdominal
• Huntington’s Procedure
• Haltain’s Procedure
• Vaginal
• Spinelli Procedure
• Cascarides Procedure

41. THANK YOU