COMPLICATION OF IIIrd STAGE OF LABOUR

 

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 3^rd 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