complications of 3 rd stage of labour

COMPLICATIONS OF 3RD STAGE OF LABOUR

Prashiddha Dhakal MBBS(KUSMS)

COMPLICATIONS OF 3RD STAGE OF

LABOUR

Postpartum haemorrhage Retention of placenta Uterine inversion Obstetric shockPulmonary embolism

POSTPARTUM HAEMORRHAGE

Bleeding from genital tract more than 500cc after the delivery of fetus

TypesPrimary-Haemorrhage occurs within

24hrs following the birth of the baby -Third Stage Bleeding -True Postpartum HaemorrhageSecondary-Haemorrhage occurs

beyond 24hrs and within puerperium

Causes

1. Uterine atony Grand multipara Overdistension due to multifetal

pregnancy, hydramnios, macrosomic fetus

Anaesthesia, Tocolytic drugs Antepartum haemorrhage

Primary Postpartum Haemorrhage

2. Trauma Vaginal lacerations, Cervical tear, Perineal tear,

Uterine rupture, Episiotomy extension, Genital tract trauma after instrumental delivery

3. Retained tissues Cotyledon, Succenturate lobe, Placenta accreta

4. Coagulation disordersThrombocytopenic purpura, Hypofibrinogenemia

Management -Third Stage Bleeding Massage the uterus Inj Methergin 0.2 mg IV Oxytocin drip with crystalloid

solution Bladder catheterization Antibiotics Express placenta by Controlled

cord traction or by Manual removal under general anaesthesia

-True Postpartum Haemorrhage

Same as third stage bleeding plus

Inj Misoprostol 1mg per rectum

Bimanual compression of uterus

Tight uterine packing Balloon tamponade Ligation of uterine artery Hysterectomy

Secondary Postpartum HaemorrhageCausesRetained placentaInfectionSubinvolution of uterus & EndometritisChoriocarcinoma, CA CervixFibroid polyp

ManagementIV FluidsBlood transfusionAntibioticsRemoval of retained parts

Complications of PPHShockMaternal deathAcute renal failureSheehan’s syndromePuerperal sepsis

RETENTION OF PLACENTA Causes

1. Retained seperated placenta Atony of uterus Contraction ring Premature attempts to deliver

placenta before it is seperated

2. Retained non-seperated placenta

Simple adherance- Due to uterine atony

Morbid adherance- Placenta accreta, increta or percreta

Complications

HaemorrhageShockPuerperal sepsisRisk of recurrence in next pregnancy

INVERSION OF UTERUS

The body of uterus is partially or completely turned inside out.

Types

First degree- Dimpling of fundus which still remains above the level of internal os

Second degree- Fundus passes through cervix but lies inside the vagina

Third degree(Complete)- Endometrium is visible outside the vulva

Causes

1. Iatrogenic Pulling the cord when the uterus

is atonic specially when combined with fundal pressure

2. Spontaneous Sharp rise of intra abdominal

pressure when the uterus is lax

Management

Replacement of uterus-Manual replacement-Hydrostatic replacement-Surgical replacement

Antibiotics to control sepsis

Complications

HaemorrhageShockPulmonary embolismInfection and uterine sloughing

OBSTETRIC SHOCKCauses

1. Hypovolemic ShockPostpartum haemorrhageHaematoma- Broad ligament/Paravaginal

2. Neurogenic ShockUterine ruptureUterine inversion

3. Obstructive ShockAir embolism

4. Anaphylactic ShockAmniotic fluid embolism

5. Septic ShockProlonged Rupture Of MembranesRetained placental tissuesManipulation & instrumentation

Management

Ensure patent airway & give 100% Oxygen

Control active bleedingIV Fluids- Crystalloids, Colloids, BloodIV Sodium bicarbonate (For acidosis)Antibiotics (For sepsis)Others- Steroids, Morphine, Ranitidine

Monitor BP, ECG, Pulse oximetry, Urine output,

Serum electrolytes, CVP, ABG

PULMONARY EMBOLISM

Emboli can be thrombus, amniotic fluid or air

Clinical featuresSudden chest discomfortAir hungerHypotensionHaemorrhage (due to DIC)Collapse

ManagementSimilar to shock