complications of 3 rd stage of labour
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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