COMPLICATION OF IIIrd STAGE OF LABOUR - assignment
INTRODUCTION
Of all the
stages, third stage is the most crucial one for the mother.
Fetal
complication mag appear unexpectedly in an otherwise eventful first or second
stage.
The main
important complication are;
Ø Postpartum
Haemorrhage
Ø Retained
Placenta
Ø Placental
Accreta
Ø Inversion
of the Uterus
POSTPARTUM
HAEMORRHAGE
DEFINITION
Any amount
of bleeding promor in to the genital tract following the birth of the baby up
to end of the perium. Which adversely
affects the general condition of the patient evidenced by rise in pulse rate
and falling blood pressure is called post partum haemorrhage.
INCIDENCE
The
incidence is about 4-6% all deliveries.
TYPES
Ø Primary
post partum haemorrhage
Haemorrhage occur with in 24 hours
following birth of the baby these are two types
o
Third stage haemorrhage
Bleeding occur before expulsion of
placenta.
o
Secondary post partum haemorrhage
Haemorrhage occurs beyond 24 hours and
within puerperium.
Primary
Post Partum Haemmorrage
Causes
Ø Atonic
Ø Traumatic
Ø Retained
Tissue
Ø Blood
Coagalopathy
Atonic
Uterus
Atonicity
of the uterus is the commenest cause of PPH with the separation of placenta.
The uterine sinuses which are torn, cannot be compressed effectively due to
imperfect contraction and retraction of the uterine musculakne and bleeding
continue.
Ø Grand
Multipara
Inadequate retraction and frequent
adherent placenta contribute to it. Associated anemia may also probably play a
role.
Ø Over
distention of the Uterus
As in multiple pregnancy, hydraminos and
large body. Imperfect retraction and a large placental site are responsible for
excessive bleeding.
Ø Malnutrition
and Anemia
Even slight amount of blood loss may
develop clinical manifestation of PPH.
Ø Antipartum
haemorrhage
Ø Prolonged
labour
Ø Anaesthesia
Ø Malformation
of the uterus
Ø Uterine
Fibroid
Ø Mismanaged
third stage labour
Ø Placenta
Ø Precipitate
labour
Traumatic
Trauma
occurs usually cervix, vagina, perineum, paraurethral region, rarely rupture of
a uterus occur combination of atonic and traumatic causes.
Retained
Tissue
Bit of
placenta blood clots causes PPH due to imperfect uterine retraction.
Drugs
Use of
tocolytic drugs.
Blood
Coagulation Disorders
Blood
coagulation may be due to diminished procoagulants or increased fibrinolytic
activity. The condition where such disorder occur or abruption placenta, help
syndrome.
Signs
of Post Partum Haemmorrage
Ø Vaginal
bleeding either as slow trickle or capicus flow.
Ø Pallor
Ø Raising
pulse rate and falling blood pressure.
Ø Restlessness
drowsy
Ø Enlarged
uterus, feels bogg on palpation
Ø Maternal
collapse
Prevention
Antenatal
Ø Improvements
of health states
Ø High
risk mother are to be screened and delivered in a well equipped hospital.
Ø Blood
grouping should be done.
Intranatal
Ø Slow
delivery of the baby is done.
Ø Expert
obstretic anesthestist is needed
Ø Spontaneous
separation and delivery of placenta reduce blood loss.
Ø Temptation
of fidding or kneeling with the uterus or pulling cord should be avoided.
Ø Examination
of placenta and membrane
Ø In
case of accelerated labour by oxytoan, the infusion continued for a least one
hour.
Management
of Third Stage Bleeding
Placental Site Bleeding
Ø To
plapate the funelos and massage the uterus.
Ø Ergometric
25mg or methargin 2mg is given intravenously.
Ø To
start dextrose saline drip.
Ø Sedation
may be given morphin is mg 1m.
During this
procedure placental separation are evident express the placenta eathy
controlled traction method or either by fundal pressure. If the placenta not
separated manual removal of placenta under general anesthesia.
Management
of Traumatic Bleeding
The atero
vaginal to be explored under general anaesthesia after placenta is expelled and
haemostatic sutures are placed on the offending sites.
Management
of True Post Partum Haemorrhage
(Immediate
Measures)
Ø Call for
extra help
Ø Put
in two large IV canula
Ø Send
blood for cross matching
Ø Rapidly
infuse normal saline
Ø Midwife
is assigned to monitor pulse, blood pressure
Actual
Management
Step-I
Ø Inj.
Methargin 2mg IV
Ø To
add oxytocin 10 units in 500ml of Ns, at the rate 40 drops/minute.
Ø To
examine the expelled placenta.
Ø To
catherize the bladder
Step-II
Ø The
uterus is explored under general anesthesia.
Ø In
refractory cases Inj. 1S methyl PGT2 25mg 1M or misoprostal 1000kg/rectum.
Step
- III
Ø Uterine
massage and bimanual compression
Step
-IV
Ø Uterine
temponade
Ø Insertion
of a sengstaken black more tube.
Step
-V
Ø Ligation
of uterine arteries
Ø Ligation
of ovarian and uterine artery anastomosis
Ø B
linen base suture and haemostatic suturing
Ø Angiographic
arterial embolisation
Step
- VI
Ø Hysterectomy
Causes
Ø Retained
bits of cotyledon and membranes
Ø Infection
and separation of slough and the laccrations.
Ø Endometriosis
and subinvolation of placenta.
Ø Haemorrhage
from caesarean section
Ø Withdrawal
bleeding flowing estrogen therapy
Clinical
Features
Ø Lochia
heasier than normal consist bright red loss.
Ø The
lochia may be offensic if infection
Ø Subinvolation
of uterus and partuless os
Ø Pyrexia
and tachycardia
Ø Varying
degree of anemia
Management
Supportive Therapy
Ø Resuscitation
including blood transfusion
Ø Erogometrin
5mg IV
Ø Antibiotic
therapy
Concretive
Therapy
Ø Bed
rest and observation for 24 hrs
Active
Management
Ø Exploration
of uterus under general anasthesia
Ø Gentle
curettage is done
Ø Ergometrine
5mg 1m
Nursing
Management
Ø The
mother must be encouraged to empty the bladder
Ø All
pads and linen must be assessed for blood loss
Ø Maintain
input output chart
Ø Vital
signs and general condition must be monitored
Ø Haemoglobin
estimation and iron treatment
Ø Help
for breast feeding
RETAINED
PLACENTA
Definition
The
placenta is said to be retained when it is not expelled out even 30 minute
after the birth of the baby.
Causes
There are
three phases involved in the normal expulsion of placenta.
Ø Separation
through the spongy layer of the decidua
Ø Descent
in to the lower segment and vagina
Ø Finally
its expulsion to outside.
Interference
in any of these physiological process result in its retention
Ø Placenta
completely separated but retained
Ø Simple
adherent placenta
Ø Morbid
adherent placenta
Diagnosis
The
diagnosis of retained placenta is made by an arbitrary time spending delivery
of baby. Features of placental separation are assed. The hoar glass contraction
of the nature of adherent placenta can only be diagnosed during manual remove.
Complication
Ø Haemorrhage
Ø Puerperal
sepsis
Ø Risk
of its recurrence is next pregnancy
Ø Shock
is due to
o
Blood loss
o
At times correlated to blood loss, specially
when retained more the one hour.
Management
Period
of coatenful expectancy
Ø During
the period of orbitrary time limit of half on hear the patient is to be watched
carefully for evidence of bleeding.
Ø The
bladder should be emptied using rubber catheter.
Ø Any
bleeding closing the period should be managed as outlined in third stage
beleeding.
Retained
Placenta
Ø Placenta
is separated and retained
Ø Unseparated
retained placenta
PLACENTA
ACCRETA
Definition
Placenta
accrete is an extremely rare from in when placenta is directly anchored to the
myometrium.
Risk
Factors
Ø Placenta
previa
Ø Caesarean
delivery
Ø Manual
removal of placenta
Ø Increased
maternal age and purity
Diagnosis
Ø Ultrasound
imaging
Ø Colour
Doppler and MRI
Ø USG
Management
Ø In
partial placenta accrete
Remove the placental tissue as much as
possible effective uterine contraction and haemostosis are achieved by
oxytocics and if necessary by intrauterine plugging.
Ø In
total placenta accrete
Hapersctomy is indicated in pareus women,
which in patient desiring to hauc a child, conservative attitude may be taken
Ø In
rare case
Placenta accreta may invade the bladder,
in that case try to avoid placental removal. It may need hysterectomy and
pential cystectomy.
INVERSION
OF THE UTERUS
It is extremely
rare but a life threatening complication in third stage in which the uterus is
turned inside out partially or completely.
Types
Ø First
degree – there is dimpling of the fundus which still remains above the level of
internal OS.
Ø Second
stage – the fundus passes through the cervix but lies inside the vagina.
Ø Third
stage – the endometrium with or without the attached placenta is visible
outside the vulva.
Etiology
Ø Spontaneous
This is brought about by localized atomy
on the placental site over the fundus associated with sharp rise of intra
abdominal pressure.
Ø Latrogenic
o
Pulling the cord
o
Fundal pressure
o
Faculty techniac in manual removal
Risk
Factors
Ø Prolonged
labour
Ø Fetal
macrosomia
Ø Uterine
malformation
Ø Short
omblical cord
Complications
Ø Shock
Ø Haemorrhage
Ø Pulmonary
embolism
Diagnosis
Ø Symptoms
: Acute lower abdominal pain with bearing down sensation.
Ø Signs:
Varying degree of shock is present
Ø Bimanual
examination
Ø Sonography
Prevention
Do not
employ any method to expect the placent out when the ateros is relaxed pulling
the cord simultaneous with fundal pressure should be avoided. Manual removal
should be done.
Management
Ø Call
for extra help
Ø To
replace that part first which inverted lost with the placenta attached to the
uterus.
Ø To
apply counter support by the other hand placenta on the abdomen.
Ø After
replacement the hand should remain inside the uterus until the uterus becomes
contracted by parenteral oxytain.
Ø Removal
of placenta by manually after the uterus becomes contracted.
Ø Usual
treatment of shock including blood transfusion should be arranged
simultaneously.
CONCLUSION
Postpartum
haemorrhage is the one of danger complication of 3rd stage of
labour. The incidence is the 4-6% in all deliveries.
The main
complications are;
Ø Postpartum
Haemorrhage
Ø Retained
placenta
Ø Placenta
accrete
Ø Inversion
of the a-bus
BIBLIOGRAPHY
Ø A
Textbook of Obstetrics and Gynacological by D.C.Dutta
Page No.408-415.
Ø A
Textbook of Obstetrics by B.T. Basvantappa
Ø A Textbook of Obstetrics by Annamma Jacobe
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