3rd Stage of Labour

Third stage of labour (Normal & abnormal) Dr. Abdalla H. Elsadig MD  Definition : 3rd stage of labor: commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. Duration: - normally 5 to15 minutes. - 30 minutes have been suggested if there is no evidence of significant bleeding.  The risk of complications continues for some period after delivery of the placenta.  Fourth stage of labor: begins with the delivery of the placenta and lasts for 1 hour.  Significance Postpartum haemorrhage (PPH) : . and uterine inversion.000 live births. .  . . prolonged hospitalization affects the establishment of breastfeeding. . .Anemia: PPH causes anemia or poor iron. .Emergency anesthetic intervention: due to severe PPH. Anemia causes weakness and fatigue.Maternal mortality. retained placenta.000 live births. The maternal mortality rate in the United States is approximately 7-10 women per 100. 25% of these deaths are due to PPH. . The maternal mortality rates in developing world exceeded 1000 women per 100.Sepsis: due to exploration or instrumentation of the uterus. 8% of these deaths are caused by PPH.Blood transfusion→ transfusion reaction and infection. ergometrin and prostaglandins enhance placental separation and expulsion by causing uterine contraction .  Retro-placental hematoma. . * Tocolytics/nitroglycerin and some inhalation anesthetics cause uterine relaxation and delay of placental separation causing dangerous bleeding following delivery. * Oxytocin.Mechanism of placental separation  Uterine contractions and retraction reduce the uterine cavity → placental detachment and expulsion into the lower uterine segment. What to do before delivery of the placenta? . .What to do before delivery of the placenta? 1.     Look for signs of placental separation: lengthening of the umbilical cord outside. The uterus rises in the abdomen. The uterus becomes firm and globular.     2. A gush of blood. Assess the uterus: To exclude an undiagnosed twin To determine a baseline fundal height to detect the signs of placenta separation to detect an atonic uterus. Given at the delivery of anterior shoulder or after delivery of the baby. 2. .Controlled Cord traction: the body of the uterus is supported above the symphysis pubis by the left hand directed upward and backward.Wait for the signs of placental separation . or Syntometrine (ergometrine + oxytocin ).  Avoid uterine massage before placental delivery.Delivery of the placenta 1.Make sure that the uterus is contracted. . Active management: . Then cord traction is applied continuously downward and forward with the right hand. Oxytocin. Physiological or expectant management: . . .By using one of the following: Ergometrine.Immediate delivery of the placenta with CCT. .Mode of drugs administration  Oxytocin: .25. 10-20 IU is placed in 500-1000 mL of crystalloid and run quickly. followed by a similar infusion.   Ergometrine: dose is 0.With cesarean deliveries: 5 IU is administered as an intravenous bolus.10 IU. intramuscularly + with intravenous access in place.0. Syntometrine (0.5 mg of ergometrine with 5 IU of oxytocin) : The dose is 2 mg and given IM only.5 mg IM or IV. . .Delivery of membrane By rotating the placenta about the insertion site as it descends or grasping the membranes with a clamp or artery forceps and drawn down. ↑iron stores in the newborn and ↓levels of early childhood anemia. Method of cord clamp:  . usually 2-4 minutes. →↑Hb.Umbilical cord management  cord clamping: Delayed until the cord is pulseless. Physiological Versus Active Management Physiological Management Uterotonic agent Active management None or after placenta With delivery of delivered anterior shoulder or baby Assessment of size Assessment of size and tone after delivery and tone after delivery None controlled cord traction when uterus contracted Early Uterus Cord traction Cord clamping Variable . What to do after delivery of the placenta? . .  Uterine exploration: .No longer recommended for normal deliveries or those following previous cesarean delivery.The cervix should be visualized after all forceps deliveries . Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine massage). Examine the placenta for completeness and detection of abnormalities. Suturing of lacerations.Is justified in patients with bleeding originating high in the genital tract. .Immediately after delivery of the placenta     Determine the fundal position and size of the uterus. Ensure continuous infusion of oxytocin. Do uterine massage.Fourth stage  Observe the vital signs. Encourage early breastfeeding to promote endogenous oxytocin release. assess the lower genital tract for bleeding. Close observation every 15 minute for the next hour. . repair of an episiotomy or any lacerations.        palpate the abdomen to assess and monitor uterine tone and size. . COMPLICATIONS Postpartum hemorrhage Uterine atony.  .  Retained placenta.  Trauma.  Uterine inversion. Primary PPH: blood loss of 500 ml or more in the first 24 hours after delivery. It is divided into primary and secondary PPH.Retained dead fetus.Postpartum hemorrhage ( PPH)   Def: is an excessive blood loss from the genital tract after delivery of the baby.  Genital tract trauma. . .   Causes: Uterine atony.Inherited coagulopathy. .  retained placental tissue.  Uterine inversion.  Coagulation disorders: .Amniotic fluid embolism.Abruptio placentae. . .Uterine Atony    Inability of the uterus to contract and retract effectively. thready pulse with a decrease in BP. The patient may also looks pale and apprehensive. The patient has a rapid. The uterus increases in size (retained products) and is felt soft and boggy. large placental site: multiple pregnancy. . especially of the interstitial type resulting in ineffective uterine contraction and retraction. Prolonged labor: weak or incoordinate uterine action or mechanical difficulty will leading to uterine exhaustion and atony. polyhydramnios or fetal macrosomia. Retained products of conception: the placenta . multiple fibromyomata (leiomyomata). Operative deliveries: C/S & general anaesthesia that relax the myometrium. full bladder. such as Halothane and Cyclopropane.          Abruptio placentae: interstitial uterine hemorrhage and later hypofibrinogenaemia. Placenta praevia: inability of the lower uterine segment to contract and retract.Uterine Atony   Factors predisposing : Over-distension of the uterus: multiple pregnancy. Grand-multiparity: (a parity of 5 or more) ↑ fibrous tissue of the uterus ↓ muscular tissue. placental cotyledon or fragments or a large amount of membranes. Vaginal or cervical lacerations or tears: tend to occur over the perineal body.       Predisposing factors: Difficult labor. periurethral area and over the ischial spines al. previous caesarean section. Ventouse or CS. Precipitate labor. Genital tract trauma is suspected when there is continuous bleeding and the uterus is well contracted. particularly after an oxytocic drug has been given . Instrumental delivery: forceps.Genital tract trauma:     Causes: perineal laceration or episiotomy: obvious bleeding. Lacerated or ruptured uterus. .Retained placental tissue Uterine atony  Morbidly adherent placenta: .Diagnosis: 1) antenatally: U/S & MRI 2) in 3rd stage: commonly  Caught of placenta by the retraction ring at the junction of the upper and lower segments: following an Ergometrine injection than Syntometrine or Oxytocin injections. . manual removal of placenta or uterine curettage.Causes: previous CS. placenta previa. 3) percreta. .Due to abnormal development of decidua basalis. 2) increta.  .Degrees: 1) accreta (80%). Cornual placenta ( cornual pockets). Previous history of inversion ( 33%).Inversion of the uterus       the fundus of the uterus descends through the uterine body and cervix into the vagina. Predisposing factors: mal-management of the third stage: inappropriate traction during CCT or too rapid removal during MRP. and sometimes protrudes through the vulva. ↑intra-abdominal pressure + relaxed uterus (fundal pressure). This → traction on peritoneal structures → vasovagal vasodilatation + neurogenic chock. . guidelines for PPH management: Call for help ( senior staff.Management of (PPPH)      Two important principles: The bleeding must be stopped. anesthetists and hematologists). Ensure at least two peripheral infusion lines with large-bore IV canulae. coagulation studies and blood group and cross-matching. Examination to determine the cause. midwives. Give blood when it is available. Blood sample should be taken for a full blood count.       . Start intravenous fluid ( Hartmann’s or saline). Give intravenous oxytocic drugs ( methergine or syntocinon). the blood volume must be restored. 0. IV Syntocinon (5 iu) or IM syntometrin ( 1ml) + 30-40 units of syntocinon in 40 ml of normal saline run at 10 ml/hr.g. infundibulo-pelvic vessels ligation internal iliac artery ligation. uterine massage and bimanual compression.Management of (PPPH) Uterine atony: the placenta has delivered:  Resuscitate the patient as mentioned above.  .  Packing of the uterine cavity (gauze/balloon insufflation). up to 8 doses given by deep IM or Gemeprost intramyometrial or misoprostol rectally.5 mg).  If still no response. compression sutures or hysterectomy).Uterotonics: IV ergometrine (0. Carboprost Hemabate.  Stimulate uterine contraction by: . then go for examination under anesthesia and surgery ( uterine arteries ligation.25 mg every 15-90 min.  If no response: give prostaglandin analogues e. if the placenta not delivered. Ensure uterine contraction.Management of (PPPH)  Uterine atony: the placenta not delivered:      Resuscitate the patient as mentioned above. Ergometrine should be given and syntocinon in a drip should be set. . try to deliver the placenta by controlled cord traction. then take the patient to the theatre for manual removal of the placenta under general anesthesia. the vagina.Management of (PPPH)      Trauma: Is suspected when the bleeding persists. cervix and uterus. . Ruptured uterus is treated by repair or subtotal hysterectomy. Vaginal and cervical lacerations should be sutured. with well contracted uterus. Full exploration under general anesthesia for the vulva. Acute complete inversion: absent uterus on abdominal examination. reverse the inversion.  The treatment includes:  Resuscitation + manual replacement prior to onset of shock. The introitus is blocked with assistant’s fist.Incomplete inversion: presence uterine dimpling on abdominal examination.  manual replacement under general anesthesia (shock) if fails  O’Sullivan’s hydrostatic method: the vagina is filled with warm saline which is gradually instilled into the vagina by means of a douche can and tubing. 4 to 5 L of saline will balloon the vagina.  Laparotomy (Haultain’s): incision in the muscular ring in the posterior uterine wall and correction. . distend the uterus and so.  .Management of (PPPH) Uterine inversion:  The condition is diagnosed in various ways: . Administer cryoprecipitate to keep the fibrinogen level > 1 gm/L.Management of (PPPH)  DIC: Maintain the intravascular volume. 2. Administer fresh frozen plasma(FFP) at a rate to keep the activated partial thromboplastin: control ratio < 1. 1. Administer packed platelet to maitain a platelet count > 50 × 109/L. 4. 3. .5.