Third Stage

Complications
Presented by Roll No.229,230,231,232

Supervised by AP Dr. Aye Aye Lwin

2.10.2019

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 Contents

1. Definition
2. Complications of Third Stage of Labour
• Post Partum Haemorrhage
• Retained Placenta
• Injury to Birth Canal
• Acute Inversion of Uterus
• Uterine Rupture
• Amniotic Fluid Embolism
• Post-Partum Collapse
3. Take Home Message
4. References

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 Third Stage of Labour

• The time from the delivery of fetus or fetuses to the delivery of

placenta and membranes
• A third stage lasting more than 30 minutes is defined as
abnormal.

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 Complications of Third Stage of Labour

• Post Partum Haemorrhage

• Retained Placenta
• Injury to Birth Canal
• Acute Inversion of Uterus
• Uterine Rupture
• Amniotic Fluid Embolism
• Post-Partum Collapse

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 Post Partum Haemorrhage

• Definition:
Loss of 500 ml of blood or more from the genital tract after delivery of
the fetus
• Types
Primary PPH
- Within 24 hours of delivery
Secondary PPH
- Between 24 hours and 6 weeks after delivery

Major – Blood loss > 1000 ml

Minor – Blood loss 500- 1000 ml
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 Causes

4 T’s
• Tone – Uterine Atony
• Tissue – Retained Placenta and/or Membrane
• Trauma – Injury to Genital Tract
• Thrombin – Clotting Disorders

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 1. Uterine Atony (80%)

• After the placenta is delivered, these contractions help compress the

bleeding vessels in the area where the placenta was attached.
• If the uterus does not contract strongly enough, called uterine atony, these
blood vessels bleed freely and hemorrhage occurs.
• This is the most common cause of postpartum hemorrhage.

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 Causes of uterine atony

• Retained pieces of placenta tissues

• Full bladder
• Primigravida, Grandmultiparity
• Antepartum Haemorrhage
• Prolonged Labour
• Overdistension of uterus (Multiple Pregnancy, Polyhydraminios, Big Baby)
• Myoma and uterine malformation
• Instrumental deliveries

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 2. Tissue Pieces

• Retained products of conception

• Retained placenta
• Morbid adhesion of placenta
 Placenta accreta
 Placenta increta
 Placenta percreta

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 3. Trauma to birth canal

Laceration of vagina, cervix and uterus

• Instrumental delivery
• Big baby
• Episiotomy

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 4. Thrombin (1%)

• Pregnancy related DIC

 Abruptio placenta
 IUFD
 Amniotic fluid embolism
• Non pregnancy related bleeding disorder
e.g VW disease, ITP

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 Clinical Features of PPH

• Signs and symptoms of hypovolemic shock such as

Pallor & fainting Attack
Tachycardia, Tachypnoea
Fall in BP
Slow capillary refill (>2 sec)

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 Management

• Call for help

• Multi-disciplinary approach
Senior involvement of anaesthetist, obstetricians, haematologists, AS, HS,
Nurses, workers

• Resuscitations
Access vital signs
IV lines using 2 wide bore cannulas (14-16G)
Withdraw blood for FBC, grouping & matching, coagulation screen , reserve 4-6 units of blood
Blood transfusion if necessary
Give IV fluid (crystalloid or colloid)
Oxygen inhalation
Monitor vital signs

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• Check the uterine atony
Empty the bladder
Perform uterine fundal massage
Syntocinon infusion (20-40 units in 500 ml 0.9% NS)
Slow IV ergometrine 0.5 mg (Contraindicated in hypertension, heart
disease)
IV oxytocin 5 units
Carboprost 0.25 mg by IM injection (15 mins interval, max 8 doses)
Contraindicated in asthma
Misoprostol 800 µg sublingually
Tranexamic acid

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• Check tear in genital tract
• Check the placenta for missing cotyledons and membrane
• Check clotting profile if DIC is suspected
APTT,OSPT,BT,CT, PC, Fibrinogen level should be done.

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If bleeding is uncontrolled by drugs, initiate mechanical
management
• Bimanual uterine compression

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• Aortic compression

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• Intrauterine balloon tamponade

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If above measures fail,
• Laparotomy
Uterine compression suture (B lynch suture)
Bilateral uterine artery ligation
Bilateral internal iliac artery ligation
• As the last resort, hysterectomy

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B Lynch Suture

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Bilateral uterine artery ligation

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Bilateral internal iliac artery ligation

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 Consequences of PPH

• Circulatory collapse & hypovolemic shock

• Puerperal anemia & morbidity
• Puerperal sepsis
• Sheehan’s syndrome
• Psychological trauma

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 Prevention

• Regular AN care
• Identify high risk pregnancy for PPH
• Women with predisposing risk factors should be delivered in a
well-equipped hospital.
• Active management of third stage
IM 10 IU oxytocin (immediately after delivery of the baby)
Early clamping and cutting of the umbilical cord
Controlled cord traciton

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Retained placenta

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 Retained placenta

• It is the placenta which is not delivered within 30 minutes after

delivery of the fetus

• Incidence: 2% of deliveries

• Risks
Retained placenta in previous birth
Premature labour

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 Causes

1. Uterine atony
2. Mismanagement of third stage of labour
3. Placenta abnormalities
Morbid adhesion of placenta
1. Placenta accreta (80%)
2. Placenta increta (15%)
3. Placenta percreta (5%)
4. Uterine abnormalities
Bicornuate uterus
Subseptate uterus
5. IV administration of uterotonic agents
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 Clinical Features

• Retaining of placenta
Placenta separated but undelivered
Placenta is wholly or partially attached
• Postpartum Haemorrhage may be present or not (persistent
heavy bleeding with clot)
• Fever
• Foul smelling discharge containing large tissue residue

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 Management

• Resuscitation if associated with postpartum haemorrhage

• Empty the bladder & massage the uterine fundus to stimulate
contraction
• IV oxytocin
• At the same time, check the sign of placenta separation
• If present, deliver with controlled cord traction.

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• Controlled Cord Traction

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• If controlled cord traction is failed, manual removal of placenta
under general anesthesia and antibiotics cover in operation
theatre

• Counselling & consent

• Inform OT, anaesthetist
• Blood for grouping & matching and reserve blood
• Prophylactic antibiotics given
• Use of solution I, III for cleaning the perineum and vulva
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• Manual removal of placenta

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• Right hand follows along the cord up to the placenta.
• The other hand guards and balances the uterus per abdomen.
• The fingers of the right hand separates the placenta from the
uterine wall.
• After the complete separation of the placenta, placenta is
delivered and checked.
• IV syntocinon 10 units is given.
• Follow up for proper family planning and hospital delivery
because of recurrent risk

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Injury to Birth Canal

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 Injury to birth canal

Common birth canal injury

• Cervical tear
• Perineal tear
• Vaginal tear

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 Causes

• Attempted forceps delivery or breech extraction through

incompletely dilated cervix
• String uterine contractions as in precipitate labour
• Rigidity of the cervix following scar from previous operations
• Big baby

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• Superficial lacerations of cervix can be seen on close inspection
in more than half of all vaginal deliveries and seldom require
repair.
• Deeper lacerations are less frequent but even these may be
unnoticed.
• Cervical lacerations are not usually problematic unless they
cause haemorrhage or extend to the upper third of the vagina.

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 Treatment

• In general, cervical lacerations of 1 and even 2 cm are not

repaired unless they are bleeding
• Deep cervical lacerations usually require surgical repair
• Repair should be done under general anaesthesia in lithotomy
position with the interrupted catgut suture.

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 Perineal Tears
First degree Injury to perineal skin only

Second degree Injury to perineum involving muscles but

not the anal sphincter

Third degree Injury to perineum involving the anal

sphincter complex

III a Less than 50% External anal sphincter

(EAS) torn

III b More than 50% of EAS torn

III c Both EAS and Internal anal sphincter

(IAS) torn

Fourth degree Injury to the perineum involving the anal

sphincter complex (EAS and IAS) and
rectal mucosa 39
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 Risk Factors for Perineal Tear

• Big baby (weight >= 3kg)

• Nulliparity
• Shoulder dystocia
• Forceps delivery
• Scar in the perineum
• Midline episiotomy
• Precipitate labour

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 Perineal Repair

• First-degree tears may not require surgical repair.

• Second-degree tears
Repair is done at the operation theatre under anesthesia
Place a pad high in the vagina to prevent blood from the uterus from obscuring the view
(Care should be exercised to remove this after repair)
First repair the vaginal mucosa using rapidly absorbable suture material in continuous
stitch
Interrupted sutures are then placed to close the muscle layer
Closure of the perineal skin follows with either interrupted suture or a continuous
subcuticular stitch
VE to check for any missed tear
Rectal Examination to confirm the sphincter is intact.

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• Third & fourth degree tear
Repair of the rectal mucosa is performed first
External anal sphincter is then repaired
The remainder – same as second-degree repair

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Perineal Repair

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Uterine Inversion

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 Definition

• It is the condition in which body of uterus becomes either

partially or completely turned inside out after delivery of fetus
• It is life threatening emergency
• Incidence is 1 in 2000 to 1 in 10,000 deliveries.

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 Causes of uterine inversion

• Mismanagement of third stage of labour

Pulling on the card before placenta separation & while uterus is tonic
Pushing uterus from the fundus
• Fundal placenta
• Short cord
• Morbidly adherent placenta
• Very rarely associated with fundal myoma, uterine atony

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 Degree of uterine inversion

• First degree – inverted fundus extends to but not through the

cervix
• Second degree – inverted uterus passes through the cervix and
into the vagina
• Third degree – inverted uterus extends outside the vagina
• Fourth degree – inversion of both the uterus and vagina or total
uterine and vaginal inversion

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 Clinical features

Symptoms
• Severe abdominal pain with bearing down sensation
• Something coming through the introitus
• Sudden collapse after delivery

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 Signs

General
• Features of shock

Abdominal examination
• Level of fundus is lower down in abdomen
• Feeling of dimpling in uterine fundus

Vaginal examination
• The inverted uterus may be seen
• Placenta may or may not be separated

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 Complications

• Pain shock
• Postpartum haemorrhage
• Complications of repositioning of the uterus
• Puerperal sepsis
• Chronic inversion of uterus

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 Management

• Resuscitation (Immediate measure)

Call for help and note vital signs
Insert 2 wide bored IV cannula
Give IV fluid (crystalloid or colloid)
Withdrawal of blood for grouping & matching
Reserve 4-6 units, blood transfusion if necessary
• Relieve the pain by analgesics Pethidine or morphine with anti-
emetics
• Do not give the oxytocic drugs until the inversion is corrected

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• Do not remove the placenta if adherent before reposition
• Inform operation theatre
• Counselling the patient and take the consent
• Explain the procedures and complications

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Manual reduction under anaesthesia

• By pushing up on the fundus with the palm of the hand and

fingers in the direction of the long axis of the vagina
• The part of the uterus that came out last goes in first
• Replace the fundus last of all

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• If the placenta is still attached, perform manual removal after
correction
• IV oxytocin after the above procedures
• The hand should be removed after firm contraction occurs

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If fail, reduction by hydrostatic pressure (O’ Sullivan method)
• 4-5 liters of warm saline is placed 2 meters above the ground level
• Nozzles of 2 rubber tubes are placed in the posterior fornix of the
vagina
• Labia are sealed by operator’s hand
• Warm saline is allowed to run out
• The reduction of the inverted uterus is usually achieved in 5-10
minutes
• After correction, fluid in the vagina is released
• Uterine contraction is maintained by oxytocin infusion
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• O’ Sullivan Method

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If failed, reduction by laparotomy and surgical reduction may be
necessary
• Haultain procedure
• Huntington procedure

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Uterine Rupture

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 Uterine Rupture

• It is defined as full-thickness tear through endometrium,

myometrium and serosa.
• It may occur in unscarred uterus and more common in scarred
uterus (traumatic or iatrogenic)
• Uterine dehiscence is defined as disruption of the uterine
muscle with intact uterine serosa.

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 Causes

During pregnancy
• Previous caesarean section
• Previous myomectomies
• Concealed APH
• Direct trauma
• Congenital uterine anomaly (Bicornuate or Unicornuate uterus)

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 Causes

During labour
• Induction and augmentation of labour
• Obstructed labour due to CPD, fetal macrosomia, transverse lie
• Internal podalic version, ECV, breech extraction
• Manual removal of placenta
• Instrumental delivery

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 Clinical features

History
• History of Risk factors for uterine rupture may be present

Symptoms
• Lower abdominal pain (over the scar area) which persists between
contraction
• In complete rupture, sense if something giving away followed by generalized
abdominal pain and shoulder tip pain
• Bleeding per vagina
• Haematuria
• Fainting attack and collapse

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General examination
• Features of shock

Abdominal examination
• Marked tenderness over site of rupture
• In complete rupture, two separate swelling, one uterus and the other fetus
• Loss of uterine contraction
• Fetal bradycardia
• Free fluid may be detected if intra-peritoneal bleeding is present

Vaginal examination
• Upward displacement of presenting part
• Bleeding per vagina
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 Management

• Resuscitation
• Call for help. Inform to senior obstetrician.
• Keep the airway patent and give high flow oxygen
• Setup IV line with two wide bore cannula
• Take blood sample for grouping and matching and reserve 4-6 units of blood
• Start with IV crystalloid solution while waiting for the blood
• Indwelling catheter to know urine output
• Give blood transfusion
• Relieve the pain by analgesics pethidine or morphine with anti-emetics
• Monitor the vital signs – pulse rate, blood pressure, respiratory rate, urine output

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• After resuscitation, explanation and counselling about her
condition and plan for management
• Obtain informed consent for laparotomy

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Laparotomy
• Urgent laparotomy to deliver fetus and repair uterus
• Vaginal examination should be performed and the fetus delivered by the quickest
route possible

For ruptured uterus

Suture repair
• Consider
If future fertility is desirable and uterus appears to be repairable (straight- cut
scar, minimal extension of the tear)
However, there is an increased risk of recurrence, which may be fatal.

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Hysterectomy
• Consider if future fertility is not desirable or uterus appears to
be unrepairable (multiple rupture sites, severe damage to
uterine blood supply or bruised and ragged tissue)

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Amniotic Fluid Embolism

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 Amniotic Fluid Embolism

• Obstetric emergency
• It is classically characterized by the abrupt onset of hypotension,
hypoxia and severe consumptive coagulopathy

• It is believed to be caused by amniotic fluid entering the

maternal circulation
• Causing acute cardiopulmonary compromise and severe
disseminated intravascular coagulation

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 Risk factors

• 35% for induction of labour

• 13% for ethnic-minority women 35 years or older
• 7% for multiple pregnancy

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 Clinical features

• Maternal collapse
• Shortness of breath
• Chest pain
• Feeling cold
• Light-headedness
• Distress & panic
• Restlessness

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 Diagnosis

• It is difficult to diagnose in life and is typically diagnosed at

post-mortem, with the presence of fetal squamous cells in the
maternal pulmonary capillaries
• It is suspected when patients suddenly collapse either in labour
or shortly after delivery with signs of central cyanosis

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 Management

• Management is supportive. There are no specific therapies available.

In the case of sudden collapse, management should be ABC
approach.

• Requires Intensive care

• High-does of hydrocortisone has been suggested as an appropriate
treatment

• The prognosis is poor.

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 Supportive measures

• Maintenance of Oxygenation
Supplemental oxygen
Tracheal intubation
• Ventilation
• Circulatory support with crystalloid and blood product
• Inotropes
• Cardiopulmonary resuscitation if the patient arrests
• Correction of coagulopathy
Fresh Frozen Plasma
Packed RBC
Platelets
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 Post-partum collapse

• It is the onset of shock in the immediate period following delivery of

the fetus

Causes
• Obstetric causes
Post-partum haemorrhage
Uterine rupture
Uterine inversion
Amniotic fluid embolism
Eclampsia
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• Non-obstetric causes
Pulmonary embolism
Cardiomyopathy
Aortic dissection
Myocardial infarct
Sub-arachnoid haemorrhage
Cerebral venous thrombosis
Hepatic rupture

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 Treatment

• In the case of sudden collapse, management should be the ABC

approach
• And then treat the underlying cause

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 Take home message

• Use ABC approach for all maternal emergencies

• Do not delay fluid resuscitation & blood transfusion
• Identification of risk factors, counsel about place of delivery and
regular AN care
• Women with predisposing factors should deliver in a hospital
with adequate facilities
• Active management of third stage

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 References

• Obstetrics by Ten Teacher, 20th edition

• Obstetrics & Gynaecology; An Evidence Based Textbook for
MRCOG 2nd edition
• High Risk Pregnancy Management option 4th edition
• Williams obstetrics 25th edition

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Question Time

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Thank You

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