1. COMPLICATIONS OF
THIRD STAGE OF LABOUR

2. 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

3. Types:
Primary
⚫Third stage hemorrhage - Bleeding occurs before
expulsionof placenta.
⚫True PPH - Bleeding occurssubsequenttoexpulsion
of placenta (majority).
Secondary PPH/ delayed/late

4. ⚫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

5. Primary post partum
haemorrhage
Causes
⚫4 T’s
⚫Tone –Uterineatony
⚫Tissue-Productsof conception, Placenta
⚫Trauma: Planned-Cesarean section,episiotomy
⚫ Unplannned-Vaginal/cervicxal tear,surgical
trauma
⚫Thrombin: Congenital-Von Willebrand’s disease
⚫ Acquired-DIC,dilutional coagulopathy

6. Uterine atony(80%)
⚫High parity
⚫Overdistended uterus
⚫General anesthesia
⚫Poorly perfused myometrium
⚫Prolonged labour

7. ⚫Following augmented labour
⚫Uterineatony in previous labour
⚫Chorioamnionitis
⚫Malformationof uterus
⚫Uterine fibroid
⚫Very rapid labour
⚫Mismanaged third stageof labour

8. ⚫Constriction ring:
⚫Incompleteseparation of placenta
⚫Retained placenta
⚫Abnormallyadherent
⚫Avulsed cotyledon, succenturiate lobe
⚫Placentaprevia
⚫Placental abruption
⚫A full bladder

9. ⚫Traumatic( 20%):
⚫Combinationof atonicand traumaticcauses
⚫Blood coagulationdisorders, acquired orcongenital:

10. Otherrisk factorsare;
⚫Antepartum hemorrhage
⚫Historyof PPH orretained placenta
⚫Anaemia
⚫Ketoacidosis
⚫HIV/AIDS

11. Clinical Features
May beobvioussuch as,
⚫Visible bleeding
⚫Maternal collapse
Subtlesigns as,
⚫Pallor
⚫Rising pulserate
⚫Falling BP
⚫Altered level of consciousness
⚫Mayrestless/drowsy
⚫Enlarged uterus, boggy on palpation

12. Diagnosis
⚫Directobservation in open hemorrhage.
⚫In concealed case, diagnosis is based on clinical
effects.
⚫In traumatic hemorrhage- uterus is contracted.
⚫In atonic hemorrhage-uterus is relaxed.

13. Investigations
⚫Thorough examinationof the lowergenital tract.
⚫CBC, clotting screen, cross match, Coagulation studies
⚫Hourly urine output
⚫Continuouspulse/blood pressureorcentral venous
pressure monitoring
⚫ECG, pulseoximetry

14. 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
theabove agents.

15. ⚫Intranatal
⚫In theeventof a womancoming todeliverywhile
receiving therapeutic heparin, the infusion should be
stopped. Heparin activity will fall to safe levels within
an hour. Protaminesulphatewill reverseactivity more
rapidly, if required.
⚫Slowdeliveryof baby.
⚫Expertobstetricanesthetist.
⚫Active managementof 3rd stageof labour.

16. ⚫Following delivery, administering a uterotonic
⚫Avoiding pulling thecord, avoid fiddling and kneading
the uterus, avoid Crede’sexpression
⚫Examine placentaand membranes for intactness.
⚫Continueoxytocin foratleast 1 hrafter
⚫Check forgenital tract trauma.
⚫Observe the patient forabout 2hrs after thedelivery

17. Immediate care in PPH
⚫COMMUNICATE.
⚫RESUSCITATE.
⚫MONITOR / INVESTIGATE.
⚫STOPTHE BLEEDING.

18. Management of 3rd stage
hemorrhage
The principles in the managementare:
⚫Toempty the uterusof its contentand to make it
contract.
⚫Toreplace the blood. If in shock, then manage shock.
⚫Toensureeffective hemostasis in traumatic bleeding.

19. Placental site bleeding
⚫Palpate the fundusand massage the uterus to make it
hard.
⚫Ergometrine 0.25mg or methergine 0.2mg is given
intravenously.
⚫Startadextrosesalinedripand arrange for blood
transfusion, if necessary.
⚫Catheterise the bladder, if it is found to be full.
⚫Sedation may begiven with morphine 15mg
intramuscularly.

20. Manual Removal of Placenta
⚫Step 1
⚫Step 2
⚫Step 3
⚫Step 4
⚫Step 5
⚫Step 6
⚫Step 7

21. Difficulties:
⚫Hour– glasscontraction
⚫Morbid adherentplacenta

22. ⚫Complications :
⚫ Haemorrhage due to incomplete removal
⚫ Shock
⚫ injury to the uterus (rare)
⚫ infection
⚫ inversion
⚫ Subinvolution
⚫ Thrombophlebitis
⚫ Embolism.

23. Management of true post partum
haemorrhage
Principles
⚫To diagnose thecauseof bleeding.
⚫To take promptand effective measures tocontrol
bleeding.
⚫To correct hypovolemia.

24. 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 forgrouping and cross matching and ask for 2
unitsof blood.
⚫ Infuserapidly 2 litres of NS (crystalloids) orplasmasubstitutes
⚫ Use awarming deviceand a pressurecuff.
⚫Monitor BP and pulseevery 25min, tem. every 4 hr.
⚫Monitor type and amount of fluids the patient has
received, urineoutput, drugs- type, dose and time, CVP.

25. Actual Management:
⚫ note the feel of the uterus.
Atonicuterus
⚫Step 1: Massage the uterus to make it hard.
⚫Step 2: Explore the uterusunder GA

26. ⚫Step 3: Uterine massageand bimanual compression.
⚫Step 4: Uterine tamponade
⚫Step 5: Surgical methods
⚫Step 6: hystrectomy

27. surgery
⚫Ligation of uterinearteries
⚫Ligation of theovarian and uterineartery anostomasis.
⚫Ligation of theanteriordivision of internal iliacartery
(unilateral or bilateral).
⚫B- Lynch brace sutureand haemostaticsuturing
⚫Angiographic arterial embolisation under fluoroscopy

28. Secondary PPH
Causes:
Thecausesare,
⚫Retained bitsof placenta or membranes.
⚫Infection and separation of slough overadeepcervico-
vaginal laceration.
⚫Endometritisand subinvolution of the placental site
⚫Withdrawal bleeding following oestrogen therapy for
suppressionof lactation.
⚫Otherrarecausesare—chorion epithelioma; carcinoma of
cervix, infected fibroid or fibroid polypand puerperal

29. Diagnosis:
⚫The bleeding site is usually brightred. 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
uterinecavity.

30. Managenent:
⚫Principles—
⚫(1) Toassess theamountof blood lossand toreplace
the lost blood.
⚫ (2) To find out thecauseand to takeappropriate steps
torectify it.

31. Supportivetherapy:
⚫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 fora period of 24hrsorso is
done in hospital.

32. Active treatment:
⚫As thecommonestcause is due to retained bitsof
placentaor membranes, it is preferable toexplore the
uterusurgently under GA. The productsare removed
byovum forceps. Gentlecurettage 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.

33. Complications
⚫Shock
⚫Collapse
⚫Disseminated intravascularcoagulation

34. Nursing Management
⚫Deficient fluid volume r/t excessive blood loss
secondary to uterine atony, lacerations, incisions,
coagulation defects, retained placental fragments,
hematomas
⚫Fearand anxiety r/t threat to physical being, deficient
knowledgeof treatment .
⚫Pain r/t uterinecontractions, distention from blood
between uterinewall and placenta.
⚫Risk forcomplication, shock related toexcessive
bleeding

35. ⚫Interrupted breast feeding r/t mother’s health state
during the PPH.
⚫Risk for impaired parent/ infant bonding r/t lack of
early parent/ infantcontact.
⚫Interrupted family process r/t change in family roles,
inability to assume usual role and prolonged recovery
period.

36. RETAINED PLACENTA
⚫placenta is said toretained when it is notexpelled out
even 30 minutesafter the birth of the baby.

37. Causes:
⚫Placentacompletelyseparated but retained is due to
poorvoluntaryexpulsiveefforts.
⚫Simpleadherent placenta is due touterineatonicity in
casesof grand multipara, overdistension of the uterus,
prolonged labour, uterine malformation or due to
bigger placental surfacearea. The commonestcauseof
retention of non-separated placenta is atonic uterus.
⚫Morbid adherentplacenta- partial orrarely
incomplete.
⚫Placenta incarcerated following partial orcomplete
separation due toconstriction ring, premature
attempts todeliverplacenta before it is separated

38. Diagnosis:
⚫It is made byan arbitrary timespent following delivery
of the baby.
⚫Featuresof placental separation is assessed.
⚫The hourglass contraction or the natureof adherent
placenta can only be diagnosed during manual
removal.

39. 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
evidenceof any bleeding, revealed orconcealed and to
note the signs of separation of placenta.
⚫The bladdershould beemptied using a rubber
catheter
⚫Any bleeding during the period should be managed as
outlined in third stage bleeding

40. Retained placenta:
⚫Separated
⚫Un-separated
⚫Complicated
Placenta is separated and retained:
⚫ Toexpress the placentaout bycontrolled cord
traction.

41. Unseparated retained placenta:
⚫ Manual removal of placenta is to bedone 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 forculture and sensitivitytest
and broad spectrum antibiotics is usuallygiven.
⚫Blood transfusion is helpful.
⚫ Manual removal of placenta.
⚫Retained placenta with an episiotomywound

42. Complications:
⚫Haemorrhage
⚫Shock is due to blood loss, at times unrelated blood
loss, specially when retained more than one hour,
Frequentattemptsof abdominal manipulation to
express the placentaout
⚫Puerperal sepsis
⚫Risk of recurrence in next pregnancy.

43. 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
onlya few toseveral lobules— partial placenta
accreta. All or part of a single lobule may be
attached— focal placenta accreta.

44. PLACENTA INCRETA
⚫placenta increta, villi actually invade into the
myometriumand anchored into the muscle bundles.

45. PLACENTA PERCRETA
⚫with placenta percreta, villi penetrate through the
myometrium upto the serosal layer.

47. Associated Conditions
⚫placentaprevia,
⚫priorcesarean delivery,
⚫previouslyundergonecurettage
⚫ gravida 6 or more.
⚫MSAFP levelsexceeded 2.5 MoM;

48. Diagnosis
⚫Thediagnosis is madeonlyduring attempted manual
removal when the plane of cleavage between the
placentaand the uterinewallscannot be madeout.
⚫USG and colourdoppler:
two factorswere highly predictiveof myometrial
invasion: (1) a distance less than 1 mm between the
uterineserosa-bladder interfaceand the retroplacental
vessels, and (2) identification of large intraplacental
lakes

49. ⚫MRI:
(1) uterine bulging, (2) heterogeneous signal
intensitywithin the placenta, and (3) presenceof dark
intraplacental bandson T2-weighted imaging.

50. Pathological confirmation includes:
⚫Absenceof decidua basalis
⚫Absenceof nitabuch’s fibrinoid layer
⚫Varying degree of penetrationof thevilli into muscle
bundlesand uptoserosal layers

51. Management
In the focal placentaaccrete
⚫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 multiparouswoman.

52. In the total placentaaccrete:
⚫Hysterectomy is indicated in the parouswomen, while
in patientsdesiring to haveachild 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
bysome.

53. ⚫In rarecases:
⚫Placentaaccrete may invade bladder. In thatcase try to
avoid placental removal. It may need hysterectomy
and partial cystectomy. Methotrexate therapy may be
tried.
⚫PreoperativeArterial CatheterPlacement.
⚫Deliveryof the Placenta.

54. Complications:
⚫Haemorrhage
⚫Shock
⚫Infection
⚫Inversion of uterus

55. 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
partiallyorcompletely.

56. Varieties:
⚫Firstdegree: there is dimpling of the funduswhich still
remains above the level of internal os
⚫Second degree: the fundus passes through thecervix
but lies inside thevagina.
⚫Third degree: the endometriumwith orwithout the
attached placenta is visible outside the vulva. The
cervix and partof vagina may be also involved in the
process.

58. Etiology:
⚫Spontaneous: 40%
⚫Iatrogenic:

59. Diagnosis:
Symptoms:
⚫Acute lowerabdominal 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 thevulvawith broad end pointing downwards
and looking reddish purple in colour

60. Prevention:
⚫Do notemployany method toexpel placentaoutwhen
the uterus is relaxed.
⚫Puling thecord simultaneouslywith fundal pressure
should beavoided.
⚫Manual removal in a safe manner

61. Management
⚫Immediateassistance is summoned to include
anesthesia personnel and otherphysicians
⚫The recently inverted uteruswith placentaalready
separated from it mayoften 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.

62. ⚫Other tocolytic drugs such as terbutaline, ritodrine,
magnesium sulfate, and nitroglycerin have been used
successfully foruterine relaxation and repositioning
⚫Afterremoving the placenta, steady pressurewith the
fist is applied to the inverted fundus in an attempt to
push it up into thedilated cervix.
⚫Care is taken not to apply so much pressure as to
perforate the uterus with the fingertips

63. ⚫Surgical Intervention
⚫the uterus cannot be reinverted by vaginal
manipulation becauseof adenseconstriction ring . In
thiscase, laparotomy is imperative

64. Beforeshock develops:
⚫To replace the part firstwhich is inverted last with the
placenta attached to the uterus by steady firm pressure
exerted by the fingers.
⚫To applycounter support by theother hand placed on the
abdomen.
⚫Afterreplacement 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
becamecontracted
⚫Usual treatmentof shock including blood transfusion
should bearranged.

65. Aftershock develops:
⚫urgentdextrosesaline dripand blood transfusion
⚫topush the uterus inside thevagina if possibleand
pack thevagina with antiseptic rollergauze.
⚫Footend of the bed is raised.
⚫Replacement of uterus either manually or hydrostatic
method (O Sullivan’s) under GA. Hydrostatic method
is less shock producing.

66. Subacutestage:
⚫Improvegeneral condition by blood transfusion
⚫Antibiotics tocontrol sepsis
⚫Reposition of uteruseither manuallyor hydrostatic
method
⚫If failsabdominal reposition byoperation- Haultain
operation

67. Complications:
⚫Shock
⚫Tension on the nerves due to stretching of the infundibulo-
pelvic ligament.
⚫Pressure on theovaries as theydragged with the fundus
through cervical ring.
⚫Peritoneal irritation
⚫Haemorrhage, speciallyafterdetachmentof placenta
⚫Pulmonary embolism
If left uncared it leads to:
⚫Infection
⚫Uterinesloughing
⚫A chronic one

68. AMNIOTIC FLUID EMBOLISM