Apr 12, 2023 1

Complications ofComplications of33rdrd Stage of labour Stage of labour

Dr Khin Saw Nwe

Consultant, CWH, Mandalay.

Apr 12, 2023 2

1. Retained placenta2. Post partum haemorrhage

PPH-with placenta retained -without retained placenta

3. Tear and lacerations in genital tract4. Uterine inversion5. Amniotic fluid embolism6. Uterine rupture7. Post partum collapse8. Coagulation disorder (DIC)Retained placenta Placenta is not expelled 30 min after the delivery of

foetus

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Causes of retained placenta(1) Uterine atony

-fully bladder-grandmultip -prolonged labour-precipitate labour-prolonged Anaesthesia -over distension of Ut –Twins

(2) Constriction ring-hourglass constriction of Ut-localized constriction just above LUS due to

– intrauterine manipulation -prolonged labour

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(3) Morbid adhesion of placentatypes acreta

increta percreta

Sign and symptom -bleeding PV slight/heavy or no bleeding -shock-Ut. Flabby-usually

Management1. I/V line2. Bld G&M –reserve bld

--if necessary – give bld3. Resuscitation of shock4. Catheterization-aseptic

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5. Look for signs of pla: seperation

If (+) controlled cord traction & deliver the placenta

If (-) –I/V Ergometrine /synto CCT

If still (-) Manual Removal under anesthesia in OT

-follow the cord

-find the edge

-abd. hand guard the Ut

-remove the pla:

-give oxytocis

-check the Pla:

-antibiotics

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Postpartum Haemorrhage Def: -loss of 500ml or more of blood from genital tract after

delivery1) PPH with retained placenta2) PPH without retained placenta

Incidence 2% of all deliveries Types P• PPH –bleeding within 24hr after delivery

S• PPH –bleeding 24hr after the deliveryCauses of Primary PPH(1) Ut atony -full bladder

-prolonged labour-GM-over distension of Ut-APH -Abruptio -placenta praevia-fibroid

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(2) Trauma in the genital tracta) spontaneousb) interferences -forceps

-vacuum-Op-LSCS

-perinetal tears -vg -Cx -Ut. rupture

(3) Coagulation disordersDIC – Abruptio

(4) Ut inversionComplications—

1) shock if anaemia >worse2) mat. death3) post partum anaemia4) renal failure5) post partum pituitary necrosis Sheehan’s syndrome

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Prevention (1) Antenatal Care

-correct anaemia-prevent anaemia-high risk patient

-past H/O PPH-Twins, hydramnios-G.M Myoma

Delivery in hospital(2) During labour -prevent prolong labour

-partogram -Active M of 3rd stage

Management - two principles-Bleeding must be arrested -Blood vol. must be restored

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P’ PPH ē retained placenta

(M) – same as retained placenta

It placenta is already delivered ē PPH

Check BP, pulse, Color

-consciousness

-Ut. Contraction

-free fluid in abdomen

-Ut height –hard or soft

-placenta –complete or not to check

Put up I/V line-drip

-reserve blood G&M

-give blood if necessary CVP line

-if shock –(T) the shock

-empty bladder-catheterization

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If Ut is soft –I/V Ergometrine 0.5mg -I/V syntocinon 5-10unit -PG

-Continue synto 40 unit in drip-rub the ut per abd-ut fundus-If still bleeds -Bimanual compression

-Fist in ant fornix vaginally -Abd hand in post fornix- compress the Ut between 2 hands

Aortic Compression Bleeding(+) Laparotomy

-TAH-Internal Iliac artery ligation

-antibioticsintake out put chart for renal failure

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2’ PPH >24hr after delivery incidence 5-10%

Causes-retained pieces of placenta

-seperation of infected slough in Cx or

Vg tear, LSCS wd.

-infected fibroid

(T) Evacuation

-antibiotics

Blood transfusion

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Uterine inversionUt is turned inside out partially or totallyTypes -1st degree Fundus inside the Ut

-2nd degree fundus in vag.-3rd degree whole Ut outside the introitus

Clinical features –profound shock-painshock-PPH-appearance of fundus at vulva -pain-Ut fundus not felt per abd

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(T) Immediate replacement

-(T) of shock

-I/V line

-Bld transfusion

-manual reposition

-O sullivain’s hydrostatic pressure method

-3 feet above the patient- put N/S into the vaginal

Genital tract injury

1st perineal tear –skin + small area of P. body

2nd perineal tear-P. body + Vg

3rd perineal tear –anal sphincter & mucosa

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1st + 2nd –Immediate repair –LA

3rd tear –OT-under Anaesthesia

-anal mucosal 1st

-sphincter

-vg., P. body + skin

Post OP-wound care –keep clean & dry

-oral liquid followed by semisolid + solid

-catheter

-antibiotics

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Postpartum obstetric shockCauses - 1)Amniotic fluid embolism

2)pulmonary embolism3)A/C ht failure-cardio myopathy

-vulvular heart disease4)pneumonitis-Mendelson’s syndrome5)pneumothorax6)CVA7)Eclampsia8)hypoglycaemia9)septicaemia10)asso ē GA, prolonged labour, trauma,

electrolyte imbalance, Mat. Infection(T) – (T) the cause.

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Coagulation disorder

DIC

Abruptio placenta

Amniotic fluid embolism

Puerperal sepsis

Prolonged & massive haemorrhage

DVT

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The end