complications of third stage of labour nisha

8/6/2019 Complications of Third Stage of Labour Nisha

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COMPLICATIONS OF THIRD

STAGE OF LABOUR

presented by-LT NISHA


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THIRD STAGE OF LABOUR

The third stage of labour comprises of phases

of placental separation, its descent to the

lower uterine segment and finally expulsion

with the membranes.


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IMPORTANT COMPLICATIONS

POST PARTUM HAEMORRHAGE

RETENTION OF PLACENTA

SHOCK PULMONARY EMBOLISM

UTERINE INVERSION


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DEFINITION

Any amount of blood bleeding from or 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 blood pressure is called pph

blood loss of more than 500 mL following

vaginal delivery or more than 1000 mL

following cesarean delivery


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TYPES

PRIMARY hemorrhage occurs within24 hours

following the birth of the baby(majority within

2hours)

Third stage hemorrhage-occurs before

expulsion of placenta

True post partum hemorrhage bleeding occurs

subsequent to expulsion of placenta

SECONDARY-bleeding occurs beyond 24 hrs

&within puerperium


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Major causes

Uterine atony (90%)

lacerations of the genital tract(6%)

retained placenta(3%-4%) coagulation defects (blood dyscrasia)

(4T: tone, tissue,trauma,thrombin)


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Clinical features

Majority of bleeding is visible outside

Rarely the bleeding is concelled either as vulvo-vaginal or brod ligament haematoma

The effect of blood loss depends on- Pre delivery hb, speed which blood loss occurs

alteration in pulse,BP,pulse pressure

UTERUS-UTERUS found well contracted in

traumatic haemorrhage ATONIC HAEMORRHAGE flabby uterus&becomes

hard on massage


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Clinical featuresAbdominal examination: Pain and tenderness (concerning for retained placentatissue, rupture, or endometritis), distension, boggy or grossly palpable uterus (at or

above the umbilicus) is suggestive of atony. Palpation of an overdistended bladder

may indicate a barrier to adequate uterine contraction.

Perineal examination: A brisk bleed should be visible at the introitus; identify any

perineal lacerations.

Speculum examination: Gently suction blood, clots, and tissue fragments as neededto maintain the view of the vagina and cervix. Careful inspection of the cervix and

vagina under good light may reveal the presence and extent of lacerations.

Bimanual examination: Bimanual palpation of the uterus may reveal bogginess, atony,

uterine enlargement, or a large amount of accumulated blood. Palpation may also

reveal hematomas in the vagina or pelvis. Assess if the cervical os is open or closed.

Placental examination: Examine the placenta for missing portions, which suggest thepossibility of retained placental tissue.


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Management of third stage

bleeding Principles

To empty the uterus

To replace the blood

To ensure effective haemostasis


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Management of third stage

bleeding Placental site bleeding

Palpate the fundus&massage the uterus to makeit hard

Inj. Ergometrine0.25mg iv

Iv fluids

Catherisation

If Featurs of placental seperation is evident

expression is done by controlled cord traction orfundal pressure or manual removal under GA


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Introducing one hand into the vagina

along cord


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Supporting the fundus while

detaching the placenta


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Withdrawing the hand from the

uterus


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Management of traumatic bleeding

The utero-vaginal canal is to be explored

under GA after the placenta is expelled

&haemostatic sutures are placed on the

offending sites


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MANAGEMENT OF TRUE POST

PARTUM HAEMORRHAGE

PRINCIPLES

To diagnose the cause of bleeding

To take prompt & effective measures tocontrol bleeding

To correct hypovolaemia


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nursing management

Immediate

Call for extra help

Iv cannula

Send blood for crossmatching &blood demand

Infuse 2 l of NS or colloids

Monitor vital signs, urine out put, cvp


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SECONDARY PPH

causes bleeding occurs between 8 to14 day

Retained bits of cotyledons or membranes

Infection

Endo metritis & subinvolutionsecondary

haemorrhage from caesarean section


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diagnosis

Bleeding is bright red

Varying degree of anaemia

Sub involution of uterus

USG is useful in detecting the bits of placenta


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Inversion of uterus

It is extremely rare but life threatening

complication of third stage of labour in which

the uterus is turned inside out partially or

completely

VARIETIES

First degree

Second degree

Third degree


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Inversion of uterus

ETIOLOGY

Spontaneous(40%)

Iatrogenic-mismanagement of third stage oflabour


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DIAGNOSIS

SYMPTOMS- acute lower abdominal pain with

bearing down sensation.

SIGNS- varying degree of shock, Abdominal examination-cupping or dimpling

of fundal surface

complications of third stage of labour nisha

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