Third stage of labourThird stage of labour(Normal & abnormal)(Normal & abnormal)

Fahad zakwanFahad zakwan

•DefinitionDefinition : :• 33rdrd stage of labor: commences with the stage of labor: commences with the delivery of the fetus and ends with delivery of delivery of the fetus and ends with delivery of the placenta and its attached membranes.the placenta and its attached membranes.•DurationDuration::- normally 5 to15 minutes. - normally 5 to15 minutes. - 30 minutes have been suggested if there is - 30 minutes have been suggested if there is no evidence of significant bleeding.no evidence of significant bleeding.• The risk of complications continues for some The risk of complications continues for some period after delivery of the placenta. period after delivery of the placenta. •Fourth stage of laborFourth stage of labor: : begins with the begins with the delivery of the placenta and lasts for 1 hour.delivery of the placenta and lasts for 1 hour.

SignificanceSignificancePostpartum haemorrhage (PPH) : Postpartum haemorrhage (PPH) : - Maternal mortality.- Maternal mortality.- - AnemiaAnemia: PPH causes anemia or poor iron. Anemia causes : PPH causes anemia or poor iron. Anemia causes

weakness and fatigue. prolonged hospitalization affects the weakness and fatigue. prolonged hospitalization affects the establishment of breastfeeding. establishment of breastfeeding.

- Blood transfusion- Blood transfusion→ transfusion reaction and infection. → transfusion reaction and infection. - Emergency anesthetic intervention: due to severe PPH, - Emergency anesthetic intervention: due to severe PPH,

retained placenta, and uterine inversion. retained placenta, and uterine inversion. - - SepsisSepsis: due to exploration or instrumentation of the : due to exploration or instrumentation of the

uterus.uterus.

Mechanism of placental Mechanism of placental separationseparation

• Uterine contractions and retractionUterine contractions and retraction reduce the reduce the uterine cavity uterine cavity →→ placental detachment and placental detachment and expulsion into the lower uterine segment.expulsion into the lower uterine segment.• Retro-placental hematoma. Retro-placental hematoma. * * OxytocinOxytocin, , ergometrineergometrine and and prostaglandinsprostaglandins enhance placental separation and expulsion by enhance placental separation and expulsion by causing uterine contraction .causing uterine contraction .

* * Tocolytics/nTocolytics/nitroglycerinitroglycerin and some inhalation and some inhalation anesthetics cause uterine relaxation and delay of anesthetics cause uterine relaxation and delay of placental separation causing dangerous bleeding placental separation causing dangerous bleeding following deliveryfollowing delivery..

What to do before delivery of the What to do before delivery of the placenta?placenta?1. 1. Look for signs of placental separation:Look for signs of placental separation: lengthening of the umbilical cord outside.lengthening of the umbilical cord outside. The uterus becomes firm and globular. The uterus becomes firm and globular. The uterus rises in the abdomen. The uterus rises in the abdomen. A gush of blood. A gush of blood.

2. 2. Assess the uterusAssess the uterus::

• To exclude an undiagnosed twinTo exclude an undiagnosed twin• To determine a baseline fundal heightTo 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.

Delivery of the placentaDelivery of the placenta

11. . Physiological or expectant Physiological or expectant management: management:

- - Wait for the signs of placental separationWait for the signs of placental separation - Make sure that the uterus is contracted.- Make sure that the uterus is contracted. - - Controlled Cord tractionControlled Cord traction: the body of the : the body of the uterus is supported above the symphysis uterus is supported above the symphysis pubis by the left hand directed upward and pubis by the left hand directed upward and backward. Then cord traction is applied backward. Then cord traction is applied continuously downward and forward with the continuously downward and forward with the right hand. right hand.

2. 2. Active management: Active management: - By using one of the following: - By using one of the following: ErgometrineErgometrine, , OxytocinOxytocin, or , or SyntometrineSyntometrine (ergometrine + oxytocin ).(ergometrine + oxytocin ).

- Given at the- Given at the delivery of anterior shoulder delivery of anterior shoulder or after delivery of the baby.or after delivery of the baby.

- Immediate delivery of the placenta with - Immediate delivery of the placenta with CCT.CCT.

Avoid uterine massage before placental Avoid uterine massage before placental deliverydelivery..

Mode of drugs administrationMode of drugs administration• Oxytocin:Oxytocin: - 10 IU, intramuscularly + with intravenous access in - 10 IU, intramuscularly + with intravenous access in

place, 10-20 IU is placed in 500-1000 mL of crystalloid place, 10-20 IU is placed in 500-1000 mL of crystalloid and run quickly. and run quickly.

- With cesarean deliveries: 5 IU is administered as an - With cesarean deliveries: 5 IU is administered as an intravenous bolus, followed by a similar infusion.intravenous bolus, followed by a similar infusion.

• ErgometrineErgometrine:: dose is 0.25- 0.5 mg dose is 0.25- 0.5 mg IM or IV. IM or IV.

• SyntometrineSyntometrine (0.5 mg of ergometrine with 5 IU of (0.5 mg of ergometrine with 5 IU of oxytocin) oxytocin)

The dose is 2 mg and given IM only.The dose is 2 mg and given IM only.

Delivery of membraneDelivery of membrane By By rotatingrotating the placenta about the placenta about the insertion site as it descends the insertion site as it descends

or or graspinggrasping the membranes the membranes with a clamp or artery forceps with a clamp or artery forceps

and drawn down.and drawn down.

Umbilical cord managementUmbilical cord management

Cord clampingCord clamping: : Delayed until the Delayed until the cord is pulseless, usually cord is pulseless, usually 2-4 2-4 minutesminutes,,•↑↑Hb, Hb, •↑↑iron stores in the newborn and iron stores in the newborn and •↓↓levels of early childhood anemia.levels of early childhood anemia.

Physiological Versus Active Physiological Versus Active

ManagementManagement Physiological Physiological ManagementManagement

Active Active managementmanagement

Uterotonic agentUterotonic agent None or after None or after placenta deliveredplacenta delivered

With delivery of With delivery of anterior shoulder or anterior shoulder or babybaby

UterusUterus Assessment of size Assessment of size and tone after and tone after deliverydelivery

Assessment of size Assessment of size and tone after and tone after deliverydelivery

Cord tractionCord traction NoneNone controlled cord controlled cord traction when uterus traction when uterus contractedcontracted

Cord clampingCord clamping VariableVariable EarlyEarly

Immediately after delivery of the Immediately after delivery of the placentaplacenta

1.1. Determine the fundal position and size of Determine the fundal position and size of the uterus. the uterus.

2.2. Ensure that the uterus is contracted (can Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine be enhanced with oxytocin and uterine massage).massage).

3.3. Examine the placenta for completeness Examine the placenta for completeness and detection of abnormalities.and detection of abnormalities.

4.4. Suturing of lacerations.Suturing of lacerations.

Fourth stageFourth stage • Observe the vital signs.Observe the vital signs.

• palpate the abdomen to assess and monitor uterine palpate the abdomen to assess and monitor uterine tone and size. tone and size. • Do uterine massage.Do uterine massage.• Ensure continuous infusion of oxytocin.Ensure continuous infusion of oxytocin.• Encourage early breastfeeding to promote Encourage early breastfeeding to promote

endogenous oxytocin release.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.

COMPLICATIONSCOMPLICATIONS

• Uterine atony.• Retained placenta.• Trauma.• Uterine inversion.

Postpartum hemorrhagePostpartum hemorrhage

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: blood loss of 500 ml or more in the first 24 hours

after delivery.

• Causes:Uterine atony. Genital tract trauma.retained placental tissue.Uterine inversion.Coagulation disorders:

- Inherited coagulopathy.

- Abruptio placentae.

- Retained dead fetus.

- Amniotic fluid embolism.

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.

Uterine Atony• Factors predisposing :

• Over-distension of the uterus: Over-distension of the uterus: multiple pregnancy, poly-hydramnios or fetal macrosomia.

• Retained products of conception: 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.

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.

Genital tract trauma is suspected when there is continuous bleeding and the uterus is well contracted, particularly after an oxytocic drug has been given

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 3rd 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.

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).

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.

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).

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.

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.

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.

Management of (PPPH)• 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 × 109/L.

4. Administer cryoprecipitate to keep the fibrinogen level > 1 gm/L.