Abnormalities of third stage of labour

Post partum hemorrhage:

Postpartum hemorrhage (PPH) is excessive bleeding after delivery of the fetus and may occur before or after delivery of the placenta, Postpartum hemorrhage (PPH) is traditionally defined as the loss of more than 500 milliliters of blood following vaginal delivery or more than 1000 milliliters following cesarean delivery.PPH is considered severe when blood loss exceeds 1000 milliliters after vaginal delivery or results in signs or symptoms of hemodynamic instability,Postpartum hemorrhage can be classified as primary, which occurs within 24 hours of deliv-ery, or secondary, which occurs 24 hours to 12 weeks postpartum. Primary PPH is more common than secondary PPHEven with appropriate management, approximately five percent of obstetric patients will experience PPH, and one percent of vaginal deliveries will result in severe PPH

Potential sequel of PPH include orthostatic hypotension, anemia and fatigue which can make breastfeeding and maternal care of the newborn more difficult. Postpartum hemorrhage may increase the risk of postpartum depression and acute stress reactions. Transfusion may be necessary and carries associated risks including infection and transfusion reaction. In the most severe cases, dilutional coagulopathy

should be anticipated. Hemorrhagic shock may lead to Sheehan’s Syndrome (posterior pituitary ischemia with delay or failure of lactation), occult myocardial ischemia, or death.

Risk Factors for Postpartum Hemorrhage:Antepartum Risk Factors

History of PPH (estimated 10 percent recurrence with subsequent deliveries)

•Nulliparity •Grand multiparity (> five deliveries)

•Coagulopathy (congenital or acquired including use of medications such as aspirin or heparin)

•Abnormal placentation •Age > 30 years

•Anemia •Overdistension of the uterus

Labor Risk Factors Prolonged labor (first, second, and/or third stage)

•Preeclampsia and related disorders •Fetal demise

•Induction or augmentation •Use of magnesium sulfate

•Chorioamnionitis Surgical Interventions

Operative vaginal delivery • Cesarean section ,episiotomy

Mnemonic for the Specific Causes of PPH

Tone Atonic uterus 70 percentTrauma Lacerations, hematomas, inversion, rupture 20 percent Tissue Retained tissue or membranes, invasive placenta 10 percent Thrombin Coagulopathies 1 percent

Diagnoses and managementPregnant women have increased plasma volume and red blood cell mass. In addition, they are typically healthy and can accommodate mild to moderate blood loss without having signs or symptoms such as orthostasis, hypotension, tachycardia, nausea pallor, slow cap refilling, dyspnea, oliguria, or chest pain .Appreciation of risk factors,accurate estimation of blood loss and recognition of women developing symptoms of cardiovascular compromise are imp steps in mgx. Once excessive blood loss is suspected, treatment must be initiated quickly by progressing through the Four T’s mnemonic (Tone,

Trauma, Tissue, and Thrombin).Management

Summon help from senior obstetrician , anesthetist, 2 midwives haematologist blood bank

Resuscitation Two large bore IVs bladder catheter

Oxygen by mask

Fluid Resuscitation intravenously, fluid balance chart central venus pressure and

arterial linesMonitor BP, HR, urine output CBC clotting factors LFT , RFT, type and cross match at

least 6 units of bloodTransfuse blood as soon as possible ,may

need cryo FFP plateletes

In practice dx and mgx should occur simultaneously. Rapid fluid resuscitation , bladder catheterization, should occur at the same time as assessing and treating the cause. Since uterine atony is the most common cause , the uterus should be massaged and oxytocics given 40 IU in 500 ml saline over 4 hours. Bimanual uterine compression and more potent drugs can also be used like ergometrine 0.5 mg i.m misopristol 800 micrograms rectally. A vaginal exam should be done to expel clots of uterus which prevent its contraction ,the placenta should be delivered if retained and inspected for missing cotyledons, and assess genital tract trauma. Any tear should be repaired .if bleeding continues referral to theater is indicated for further exam under anasthesea. Under GA we can do uterine tamponade with balloons ,radiological occlusion of uterine vessels, laparotomy for bilateral iliac artery ligation uterine compression sutures(B-lynch), and finally hysterectomy. Massive PPH require correction of clotting

factors using FFP platelets and cryo precipitate.

Secondary PPH is a rare cause and it is due to retained products of conception and \or uterine infection.

TRAUMA Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Sutures for hemostasis are placed if direct pressure does not stop the bleeding,and should be placed well above the apex of lacerations.Cervical lacerations should not be sutured unless actively bleed.Vaginal lacerations require good light and good exposure with running locked sutures.Uterine rupture requiring laparotomy for repair or subtotal hysterectomy.

TISSUE Retained tissue (placenta, placental fragments, membranes,and blood clots) prevents the uterus from contracting enough to achieve optimal tone. Retained Placenta . The mean time from delivery until placental expulsion is eight to nine minutes. A longer interval is associated with an increased risk of PPH. Retained placenta, defined as the failure of the placenta to deliver within 30 minutes after birth (and after one hr in the absence of AMTL). Active management of the third stage should be recommended to all women because high quality evidence shows that it reduces the incidence of postpartum haemorrhage from 15 to 5 per cent. AMSTL started with the delivery of anterior shoulder by injection of oxytocin intramuscular. After delivery of the baby and when the signs of placental separation are recognized, controlled cord traction is used to expedite delivery of the placenta. When a contraction is felt, the left hand should be moved suprapubically and the fundus elevated with the palm facing towards the mother. At the same time, the right hand should grasp the cord and exert steady traction so that the placenta separates and is delivered gently, care being taken to peel off all the membranes, usually with a twisting motion.In approximately 2 per cent of cases, the placenta will not be expelled by this method. If no bleeding

occurs, a further attempt at controlled cord traction should be made after 10 minutes. If this fails, the placenta is ‘retained’ and will require manual removal under general or regional anaesthesia in the operating theatre. Direct injection of oxytocin into the umbilical vein may bring about delivery of the placenta while preparations are being made for theatre.

Physiological management of the third stage iswhere the placenta is delivered by maternal effort, andno uterotonic drugs are given to assist this process. It is associated with heavier bleeding . In the event ofhaemorrhage or if the placenta does not deliver after 30 minutes, manual removal of the placenta should be consid-

ered

Invasive placenta can be life threatening

risk factors include prior C\S, prior invasive placenta, placenta previa (especially in combination with prior cesarean sections, increasing to 67 percent with placenta previa and four or more

prior cesareans), advanced maternal age, and high parity

Classification is based on the depth of invasion. Placenta accreta adheres to the myometrium, placenta increta invades the myometrium, and placenta percreta penetrates the myometrium to or beyond the serosa. The usual treatment for

invasive placenta is hysterectomy

THROMBIN Coagulation disorders, a rare cause of PPH, are unlikely to respond to the uterine massage, uterotonics, and repair of lacerations. Coagulation defects may be the cause and/or the result of a hemorrhage and should be suspected in those patients who have not responded to the usual measures to treat PPH, are not forming blood clots, or are oozing from puncture sites. Many patients taking medications such as heparin or aspirin or who have chronic coagulopathies such as idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, von Willebrand’s disease, and hemophilia are identified prior to delivery, allowing advanced planning to prevent PPH. Coagulopathic bleeding before or during labor can be the result of HELLP syndrome (Hemolys Elevated Liver enzymes and Low Platelets) or disseminated intravascular coagulation (DIC). Obstetric conditions that can cause DIC include severe preeclampsia, amniotic

fluid embolism, sepsis, placental abruption (often associated with cocaine use or hypertensive disorders), massive PPH and prolonged retention of fetal demise. Evaluation should include a platelet count, prothrombin time (INR), partial thromboplastin time, fibrinogen level, and fibrin split products (d-dimer). If rapid laboratory testing is not available, an empty whole blood tube (“red top”) can be filled with maternal blood and taped to the wall. It should form a clot within five to 10 minutes. Management of coagulopathy consists of treating the underlying disease process, serially evaluating the coagulation status, replacing appropriate blood components.

OBSTETRICAL SHOCK

Hypotension without significant external bleeding may result from concealed hemorrhage uterine inversion and amniotic fluid embolism.

An improperly sutured episiotomy can lead to concealed PPH .A soft tissue haematoma usually of the vulva can lead to occult blood loss without any evidence of laceration or episiotomy.

Uterine Inversion• It is turning inside out of the uterus .Fundal,

adherent, or invasive implantation of the placenta may lead to inversion. The patient may show signs of shock (pallor,

hypotension) without excess blood loss. Upon inspection, the inverted uterus may be in the vaginal vault or may protrude from the vagina, appearing as a bluish-gray mass that may not be readily identifiable as an inverted uterus

• If the placenta is still attached ,it should be left in place until after reduction to limit hemorrhage. If oxytocin is running, it should be stopped, and an attempt should be made to replace the uterus. If initial attempts to replace the uterus have failed ,general anesthesia may allow sufficient uterine relaxation for manipulation. Rarely surgery is required. Once replacement is successful an oxytocin infusion should be started before intrauterine hand is removed.

Amniotic fluid embolism

It is a rare condition charecterised by fulminating consumption coagulopathy, bronchospasm and vasomotor collapse.it is fatal in 80% of cases.It is triggered by an intravascular infusion of significant amount of amniotic fluid during a rapid labour in the presence of ruptured membranes.the thromboplastin in the amniotic fluid may trigger a consumption coagulopathy .The treatment include immediate CPR with mechanical ventilation ,correct the shock with electrolyte solution and packed RBC transfusion ,and reversal of coagulopathy with platelets and fibrinogene.

Uterine Rupture

Uterine rupture implies complete separation of the uterine

musculature through all of its layers, ultimately with all or a part

of the fetus being extruded from the uterine cavity. The overall

incidence is 0.5%.

Uterine rupture may be spontaneous, traumatic, or associated

with a prior uterine scar, and it may occur during or before labor

or at the time of delivery. A prior uterine scar is associated with

40% of cases. With a prior lower-segment transverse incision,

the risk for rupture is less than 1%, whereas the risk with a high

vertical (classical) scar is 4% to 7%. Sixty percent of uterine

ruptures occur in previously unscarred uteri.

DIAGNOSIS AND MANAGEMENT

The signs and symptoms of uterine rupture are highly

variable. Typically, rupture is characterized by the sudden onset

of intense abdominal pain and some vaginal bleeding.

Impending rupture may be heralded by hyperventilation,

restlessness, agitation, and tachycardia. After the rupture has

occurred, the patient may be free of pain momentarily and then

complain of diffuse pain thereafter. The most consistent clinical

finding is an abnormal fetal heart rate pattern. The patient may

or may not have vaginal bleeding, and if it occurs, it can range

from spotting to severe hemorrhage. The presenting part may be

found to have retracted on pelvic examination, and fetal parts

may be more easily palpated abdominally. Abnormal contouring

of the abdomen may be seen. Fetal distress develops commonly,

and fetal death or long-term neurologic sequelae may occur in

10% of cases.

A high index of suspicion is required, and immediate

laparotomy is essential. In most cases, total abdominal

hysterectomy is the treatment of choice, although debridement

of the rupture site and primary closure may be considered in

women of low parity who desire more children.

MATERNAL-FETAL RISK

Delay in management places both mother and child at

significant risk. The major risk to the mother is hemorrhage and

shock. Although the associated maternal mortality rate is now

less than 1%, if the mother is left untreated, she will almost

certainly die. For the fetus, rapid intervention will minimize

morbidity and mortality. The associated fetal mortality rate is

still about 30%.

Episiotomy

Definition

An episiotomy is an incision through the perineum made to

enlarge the diameter of the vulval outlet and assist childbirth.

Prevalence

Although episiotomies were first described almost 300

years ago, widespread use of the procedure increased during the

twentieth century. By the early 1970s, rates were as high as 90

per cent and it was often advocated that there were two reasons

for episiotomy; one was a primigravida and the other a previous

episiotomy. In other words, every vaginal delivery should be

accompanied by episiotomy. It was argued that this reduced the

risk of tears and subsequent problems from prolonged bearing

down, such as prolapse. The evidence for the latter was tenuous.

Perineal trauma 225

The uncritical liberal use of episiotomy was opposed by

consumer groups including the National Childbirth Trust and

these very high rates of episiotomy have been reversed. In the

UK, rates approximate to the World Heath Organization (WHO)

recommendation of 10 per cent of normal deliveries, however,

there is considerable international variation (rates are 50 per cent

in the United States and 99 per cent in Eastern Europe).

Technique

The question of informed consent needs to be addressed

during antenatal care; when the fetal head is crowning, it is not

possible to obtain true informed consent

An episiotomy is performed in the second stage, usually

when the perineum is being stretched and it is deemed

necessary.

If there is not a good epidural, the perineum should be

infiltrated with local anaesthetic.

If an effective epidural anaesthetic is in place it should be

topped up for delivery with the patient upright to get best

coverage of the perineal area.

The incision can be midline or at an angle from the

posterior end of the vulva (a mediolateral episiotomy).

A mediolateral episiotomy is usually recommended; a

midline episiotomy is an incision in a comparatively avascular

area and results in less bleeding, quicker healing and less pain,

however, there is an increased risk of extension to involve the

anal sphincter (third/ fourth-degree tear).

A mediolateral episiotomy should start at the posterior part

of the fourchette, move backwards and then turn medially well

before the border of the anal sphincter, so that any extension

will miss the sphincter (Figure 15.1).

Complications

Complications include haemorrhage, infection

(prophylactic antibiotics may be indicated if contamination is

suspected), extension to the anal sphincter (third/fourth-degree

tears) and dyspareunia.

Figure 15.1 A right mediolateral episiotomy

Perineal trauma

Definitions

1. First-degree trauma corresponds to lacerations of the

skin/vaginal epithelium alone.

2. Second-degree tears involve perineal muscles and

therefore include episotomies.

3. Third-degree extensions involve any part of the anal

sphincter complex (external and internal sphincters):

i Less than 50 per cent of the external anal sphincter is tom.

ii More than 50 per cent of the external anal sphincter is

torn.

iii Tear involves the internal anal sphincter (usually there is

complete disruption of the external sphincter).

4. Fourth-degree tears involve injury to the anal sphincter

complex extending into the rectal mucosa.

An increased risk of perineal trauma is associated with:

larger infants

prolonged labour

instrumental delivery.

Prevalence

Eighty-five per cent of women who have a vaginal

delivery will have some degree of perineal trauma and 60-70

per' cent will require suturing. Internal anal sphincter

incompetence results in insensible faecal incontinence, whereas

external anal sphincter incompetence causes faecal urgency.

Third-degree tears are reported in approximately 2.8 per cent of

primigravidae and 0.4 per cent of multigravidae.

Perineal repair

The following is recommended as a routine for perineal repair

Ensure adequate analgesia. This may be achieved by

topping up an epidural or by infiltration with local anaesthetic.

It is often useful to place a pad high in the vagina to

prevent blood from the uterus from obscuring the view.

Check the extent of cuts and lacerations. Sometimes, the

anatomy is not clear and it becomes more apparent as the wound

is repaired. If a tear is complex, a more experienced operator

may be required.

First repair the vaginal mucosa using rapidly absorbed

suture material on a large, round body needle. Start above the

apex of the cut or tear (as severed vessels retract slightly) and

use a continuous stitch to close the vaginal mucosa.

Interrupted sutures are then placed to close the muscle

layer.

Closure of the skin follows. Interrupted sutures can be

used; however, a continuous subcuticular stitch produces more

comfortable results.

Perform a gentle vaginal examination to check for any

missed tears or inappropriate apposition of anatomy. Remove

the pad that was placed at the top of the vagina and check that

no swabs have been left in the vagina.

• Finally, put a finger in the rectum to check that no sutures have

passed through into the rectal mucosa and that the sphincter is

intact. If sutures are felt in the rectum they must be removed and

replaced.

Repair of third- and fourth-degree trauma should be

performed or direcdy supervised by a trained practitioner. There

must be adequate analgesia. In practice, this means either a

regional or general anaesthetic, as local infiltration does not

allow relaxation of the sphincter enough to allow a satisfactory

repair. The lighting must be adequate and an assistant is usually

needed.

Repair of the rectal mucosa should be performed first. The

tom external sphincter is then repaired. It is important to ensure

that the muscle is correctly approximated with long-acting

sutures so that the muscle is given adequate time to heal. Some

surgeons opt for an end-to-end repair, while others use an

overlap technique; current evidence suggests that the outcome is

similar with both methods. The remainder of the perineal repair

is as for second-degree trauma.

Lactulose and a bulk agent, such as Fybogel, are recommended

for 5—10 days. It is common sense to give a broad-spectrum

antibiotic that will cover possible anaerobic contamination, such

as metronidazole (this* * should be prescribed orally rather than

per rectum). Adequate oral analgesia should also be prescribed.

All women who have sustained a third- or fourth- degree tear

should be offered follow up by someone interested in this field.

A team approach is best; physiotherapy should include

augmented biofeedback as this has been shown to improve

continence.

At 6-12 months, a full evaluation of the degree of symptoms

should take place. This must include careful questioning with

regard to faecal and urinary symptoms. Symptomatic women

should be offered investigation including endoanal ultrasound

and manometry (see Chapter 17, The puerperium).

Uterine Rupture

Uterine rupture implies complete separation of the uterine

musculature through all of its layers, ultimately with all or a part

of the fetus being extruded from the uterine cavity. The overall

incidence is 0.5%.

Uterine rupture may be spontaneous, traumatic, or associated

with a prior uterine scar, and it may occur during or before labor

or at the time of delivery. A prior uterine scar is associated with

40% of cases. With a prior lower-segment transverse incision,

the risk for rupture is less than 1%, whereas the risk with a high

vertical (classical) scar is 4% to 7%. Sixty percent of uterine

ruptures occur in previously unscarred uteri.

DIAGNOSIS AND MANAGEMENT

The signs and symptoms of uterine rupture are highly

variable. Typically, rupture is characterized by the sudden onset

of intense abdominal pain and some vaginal bleeding.

Impending rupture may be heralded by hyperventilation,

restlessness, agitation, and tachycardia. After the rupture has

occurred, the patient may be free of pain momentarily and then

complain of diffuse pain thereafter. The most consistent clinical

finding is an abnormal fetal heart rate pattern. The patient may

or may not have vaginal bleeding, and if it occurs, it can range

from spotting to severe hemorrhage. The presenting part may be

found to have retracted on pelvic examination, and fetal parts

may be more easily palpated abdominally. Abnormal contouring

of the abdomen may be seen. Fetal distress develops commonly,

and fetal death or long-term neurologic sequelae may occur in

10% of cases.

A high index of suspicion is required, and immediate

laparotomy is essential. In most cases, total abdominal

hysterectomy is the treatment of choice, although debridement

of the rupture site and primary closure may be considered in

women of low parity who desire more children.

MATERNAL-FETAL RISK

Delay in management places both mother and child at

significant risk. The major risk to the mother is hemorrhage and

shock. Although the associated maternal mortality rate is now

less than 1%, if the mother is left untreated, she will almost

certainly die. For the fetus, rapid intervention will minimize

morbidity and mortality. The associated fetal mortality rate is

still about 30%.