LESSEN PLAN

ON

COMPLICATIONS OF THE

THIRD STAGE OF LABOUR

MRS, PRABHA.R
ASSO, PROF
OBG DEPARTMENT
ESCON

LESSON PLAN ON COMPLICATION OF THE THIRD STAGE OF LABOUR

  TOPIC: Complications of the third stage of labour.
 NAME OF THE SUPERVISOR:
 NAME OF THE STUDENT TEACHER:
 SUBJECT: OBSTETRIC AND GYNECOLOGICAL NURSING
 UNIT: UNIT II
 NAME OF THE CLASS: II YEAR M.Sc (N)
 NUMBER OF THE STUDENTS:
 VENUE AND DATE:
 A.V.AIDS: Black board, chart, OHP, Hand out, Leaflets, Pamphlets.
 PREVIOUS KNOWLEDGE: Students has the previous knowledge regarding normal third stage and its management in III YEAR, B.Sc (N).

GENERAL OBJECTIVES:
At the end of the class the students will be get adequate knowledge regarding the complication of the third stage of labour and its management during the
time of labour.

SPECFIC OBJECTIVES: At the end of the class the students will be

1. define occipito pph.
2. list out the incidence of the post partum haemorrhage.
3. explain the types of PPH.
4. describe the causes of PPH.
5. list the diagnostic and clinical effects of primary PPH.
6. explain the prevention of primary PPH.
7. explain the management of third stage bleeding.
8. explain the causes of secondary PPH.
9. discuss the diagnosis of secondary PPH.
10. describe the management of secondary PPH.
11. explain about the retained placenta.
12. discuss the placenta accrete.
13. explain about the inversion of the uterus.

Sl.No Specific objective Time Content Teaching Learnin A.V.aids Evaluation

aids g aids
 At the end of the  Introduction:-
class the
students will be
Of all the stages of labour, third stage is the most crucial one for the mother. Fatal
able to complications may appear unexpectedly in an otherwise uneventful first or second
stage. The following are the important complication: 1) Postpartum haemorrhage 2)
Retention of placenta 3) Shock – hemorrhagic or non hemorrhagic 4) Pulmonary
embolism either by amniotic fluid or by air 5) Uterine inversion.
Postpartum haemorrhage
Definition:- Taking Explain
1. define occipito Quantitative definition is arbitrary and is related to the amount of blood loss in Lecture notes with the Define post
pph. cum and help of partumhaem
excess of 500ml following birth of the baby. It may be useful for statistical discussi asking Black orrhage?
on doubts board
purposes. As the effect of the blood loss is important rather than the amount of
blood lost, the clinical definition which is more practical states, “any amount of
bleeding from or into the genital tract following birth of the baby upto the end of the
puerperium which adversely affects the general condition of the patient evidenced
by rise in pulse rate and falling blood pressure is called postpartum haemorrhage”.
2 list out the Incidence:-
incidence of the
post partum The incidence widely varies mainly because of lack of uniformity in the criteria used
haemorrhage. in definition and the extend of the use of prophylactic ergometrine. The incidence is
about 1% among hospital deliveries.
3. explain the types Types:-
of PPH. Explain What are all
Primary: Haemorrhage occurs within 24 hours following the birth of the baby. In the with the the types of
majority haemorrhage occurs within two hours following delivery. There are two help of PPH?
black
types: board.
 Third stage haemorrhage: Bleeding occurs before expulsion of
placenta.
  True postpartum haemorrhage: Bleeding occurs subsequently to
expulsion of placenta (majority).
Secondary: Haemorrhage occurs beyond 24 hours and within puerperium also called
delayed or late puerperal haemorrhage.

Primary postpartum haemorrhage:-

describe the
4. causes of PPH. Causes:-
Atonic uterus (80%):-
Atonic of the uterus is the commonest cause of postpartum haemorrhage. As long as
the placenta remains unseparated, bleeding is unlikely. With the separation of the Taking Explain What are all
Lecture notes with the the causes of
placenta, the uterine sinuses which are torn cannot be compressed effectively due to cum and help of the PPH?
imperfect contraction and retraction of the uterus and bleeding continues. The discussi asking flannel
on doubts board.
following are the conditions which often interfere with the retraction of the uterus as
a whole and of the placental sites in particular.
1) Grand multipara— inadequate retraction and frequent adherent placenta
contribute to it. Associated anemia may also probably play a role.
2) Over distension of the uterus—as in multiple pregnancies, hydramnios and
large baby. Imperfect retraction and a large placental site are responsible for
excessive bleeding.
3) Malnutrition and anemia – even slight amount of blood loss may develop
clinical manifestations of postpartum haemorrhage.
4) Ante partum haemorrhage
5) Prolonged labor—Poor retraction, infection (amnionitis) dehydration and
analgesic drugs used during labour are the responsible factors.
6) Anaesthesia—It is the depth of anaesthesia and also the anaesthetic agents
(ether, halothane of cyclopropane) which cause atonicity.
7) Initiation or augmentation of delivery by oxytocin—Post delivery uterine
atonicity is likely unless the oxytocin is continued for at least one hour
following delivery.
8) Persistent uterine distension-- Retention of partially separated placenta of bits
of placenta or blood clots interferes with effective retraction.
9) Malformation of the uterus – Implantation of the placenta in the uterine
septum of a septate uterus or in the corneal region of a bicornuate uterus may Lecture Taking Explain
cum notes with the
cause excessive bleeding. discussi and help of
on asking hand
10) Uterine fibroid cause imperfect retraction mechanically.
doubts out
11) Mismanaged third stage of labour—this include 1) Too rapid delivery of the
baby preventing the uterine wall to adapt to diminishing contents. 2)
Premature attempt to deliver the placenta before it is separated 3) kneading
and fiddling the uterus 4) pulling the cord. All these produce irregular uterine
contractions leading to partial separation of placenta and haemorrhage. 5)
Manual separation of the placenta increase blood loss during caesarean
delivery.
12) Constriction ring—Hour glass contraction formed in the upper segment across
the partially separated placenta or at the junction of the upper and lower
segment with the fully separated placenta trapped in the upper segment may
produce excessive bleeding.
13) Precipitate labour— in rapid delivery separation of the placenta occurs
following the birth of the baby. Bleeding may be due to genital tract trauma
also.
 Traumatic (20%):-
Taking Explain
Trauma to the genital tract usually occurs following operative delivery; even after Lecture notes with the
spontaneous delivery. Blood loss from the episiotomy wound is often cum and help of
discussi asking OHP
underestimated. Similarly blood loss in caesarean section amounting to 800—1000 on doubts
ml is often ignored. Trauma involves usually the cervix, vagina, perineum
(episiotomy wound and lacerations) Para-urethral region and rarely, rupture of the
uterus occurs. The bleeding is usually revealed but can rarely be concealed (vulvo-
vaginal of broad ligament haematoma).
Combination of atonic and traumatic causes:
Blood coagulation disorders, acquired or congenital:-
Blood dyscrasias or blood coagulation disorders are less common causes of
postpartum haemorrhage. The blood coagulopathy may be due to diminished
procoagulation (washout phenomenon) or increased fibrinolytic activity. The firmly
retracted uterus can usually prevent bleeding even if serious disorders clotting
mechanism are present. The conditions where such disorders may occur are
abruption placentae, jaundice in pregnancy thrombocytopenic purpura, HELLP
syndrome or in IUD.

5. List the Diagnosis and clinical effects: What are

diagnostic and In the majority the vaginal bleeding is visible outside as a slow trickle. Rarely diagnostic
clinical effects of and clinical
primary PPH. the bleeding is totally concealed either as vulvo vaginal or broad ligament effects?
hematoma. The effect of blood loss depends on—1) Pre delivery hemoglobin level,
2) degree of pregnancy induced hypervolaemia and 3) speed at which blood loss
occurs. Alteration of pulse blood pressure and pulse pressure appears only after class
2 haemorrhage (20-25% loss of blood volume) On occasion blood loss is so rapid an
 brisk that death may occur within a few minutes.
State of uterus as felt per abdomen gives a reliable clue as regards the cause of Lecture Taking Explain
bleeding. In traumatic haemorrhage, the uterus is found well contracted. In atonic cum notes with the
demons and help of
haemorrhage the uterus is found flabby and becomes hard on massaging. However tration asking demons
both the atonic and traumatic cause may co-exist. Even following massive blood doubts -tration
and re-
loss from the injured area, a state of low general condition can make the uterus demon
atonic. strate

Prognosis:
Postpartum haemorrhage is one of the life threatening emergencies. It is responsible
for maternal death in about 10% especially in the third world countries. Prevalence
of malnutrition and anemia, inadequate antenatal and intra natal care and lack of
blood transfusion facilities are some of the important contributing factors. There is
also increased morbidity. These include shock transfusion reaction, puerperal sepsis,
failing lactation, pulmonary embolism, thrombosis and thrombophlebitis.
What are all
6. Explain the
Prevention:- the steps of
prevention of Postpartum haemorrhage cannot always be prevented. However the incidence and primary PPH?
primary
PPH. specially its magnitude can be reduced substantially if the following guidelines are
followed.
1) Antenatal
-Improvement of the health status of the patient and to keep the hemoglobin
Taking Explain
level normal (>10gm /dl) so that the patient can withstand some amount of the Lecture notes with the
blood loss. cue m and help of
discussi asking demons
-High risk patients who are likely to develop postpartum haemorrhage (such as on doubts tration
and
twins, hydramnios, grand multipara, APH, history of previous third stage
redem
complication, severe anemia) are to be screened and delivered in a well equipped onstra
 hospital. tion
-Blood grouping should be done for all women so that no time is wasted during
emergency.
2) Intra natal:
-Slow delivery of the baby is done. Baby should be pushed out by the retracted
uterus and not to be pulled out.
-Expert obstetric anesthetists are needed when the delivery is conducted under
general anaesthesia. Local or epidural anaesthesia is preferable to general
anaesthesia, in forceps, ventouse or breech delivery.
-During caesarean section spontaneous separation and delivery of the placenta
reduces blood loss.
-Active management of the third stage, especially of the “at risk “patients should
be a routine.
-Temptation of fiddling of kneading with the uterus or pulling the cord should be
avoided so also the crede’s expression.
-Examination of the placenta and membranes should be a routine so as to detect
at the earlier any missing part. Taking Explain
-In all cases of the induced or accelerated labour by oxytocin the infusion should Lecture notes with the
cum and help of
be continued for at least one hour after the delivery. discussi asking demons
-Exploration of the utero vaginal canal for evidence of trauma following difficult on doubts tration

labour or instrumental delivery.

-To observe the patient for about two hours after the delivery and if the uterus
remains hard and contracted only then she should be sent to the ward.
All said and done it is the intelligent anticipant skilled supervision, prompt detection
What is
and effective institution of therapy that can prevent an otherwise normal case from management
 undergoing a disastrous consequence. of third stage
bleeding?
7. explain the
Management of third stage bleeding:-
management of The principle in the management are:
third stage
bleeding. - To empty the uterus of its contents and to make it contrast.
- To replace the blood. On occasion patient may be in shock. In that case
patient is managed for shock first.
- To ensure effective haemorrhage in traumatic bleeding
Stages of management:
1) Placental site bleeding: The following procedure are to be followed;
- To palpate the fundus and massage the uterus to make it hard. The massage
is to be done by placing four fingers behind the uterus and thumb in front.
However if bleeding continues even after the uterus becomes hard suggests
the presence of genital tract injury.
- Ergometrine 0.25 mg or methergin 0.2mg is given intravenously. Taking Explain
Lecture notes with the
- To start a dextrose saline drip and arrange for blood transfusion if necessary. cum and help of
- To catheterize the bladder if it is found to be full. discussi asking leaflet
on doubts
- Sedation may be given with morphine 15mg intramuscularly.
During this procedure, if features of placental separation are evident expression of
the placenta is to be done either by fundal pressure or controlled cord traction
method. If the placental is not separated manual removal of placental under general
anaesthesia is to be done. However if the patient is in shock she resuscitated first
before undertaking manual removal. If the patient is delivered under general
anaesthesia quick manual removal of the placenta solves the problem. In cases
where methergin is given I.V with the delivery of the anterior shoulder, manual
removal is done promptly when two attempts of controlled cord traction fall.
Crede’s expression of the placenta is abandoned as it is not only ineffective, but
produces shock and rarely inversion.
2) Management of traumatic bleeding:
The utero vaginal canal is to be explored under general anaesthesia after the
placenta is expelled and haemostatic sutures are placed on the offending
sites. Explain about
Steps of manual removal of placenta:- the steps of
manual
1) Steps I: The operation is done under general anaesthesia. In extreme urgency removal of
where anaesthetist is not available the operation may have to be done under placenta?

deep sedation with 10mg diazepam given intravenously. The patient is

Explain
placed in lithotomy position. With all aseptic measures the bladder is
Lecture Taking with the
catheterized. cum notes help of
demons and demons
2) Step II: One hand is introduced into the uterus after smearing with the
tration asking tration
antiseptic solution in cone shaped manner following the cord, which is made doubts and
black
taut by the other hand. While introducing the hand, the labia are separated by board
the finger of the other hand. The finger of the uterine hand should locate the
margin of the placenta.
3) Step III: Counter pressure on the uterine fundus is applied by the other hand
placed over the abdomen. The abdominal hand should steady the fundus and
guide the movements of the fingers inside the uterine cavity till the placenta
is completely separated.
4) Step IV: As soon as the placental margin is reached, the fingers are
insinuated between the placenta and the uterine wall with the back of the
hand in contact with the uterine wall. The placenta is gradually separated
with a sideways slicing movement of the finger until whole of the placenta is
 separated.
5) Step V: When the placenta is completely separated, it is extracted by traction
of the cord by the other hand. The uterine hand is still inside the uterus for
exploration of the cavity to be sure that nothing is left behind.
6) Step VI: Intravenous ergometrine 0.25mg is given ad the uterine hand is Explain the
malrotation?
gradually removed while massaging the uterus y the external hand to make it
hard. After the completion of manual removal, inspection of the cervico-
vaginal canal is to be made to exclude any injury. Listeni Explain
7) Step VII: The placenta and membrane are to be inspected for completeness ng and with the
Lecture Taking help of
and be sure that the uterus remains hard and contracted. cum notes pamphl
discussi and ets
Difficulties:
on asking
- Hour-glass contraction leading to difficulty in introducing the hand. doubts
- Morbid adherent placenta which may cause difficulty in getting to the plane
of cleavage of placenta separation.
Complications:-
- Haemorrhage due to incomplete removal
Demonstrate
- Shock the
- Injury to the uterus mechanism
of face to
- Infection pubis
- Inversion delivery?

- Sub involution
- Thrombophlebitis
- Embolism
Management of true postpartum haemorrhage:-
Principles:
  To diagnosis the causes of bleeding: atonic or traumatic.
 To take prompt and effective measures to control bleeding
 To correct hypovolaemia
Explain
Management: Listeni with the
Immediate measures: The following immediate measures are to be taken by the Lecture ng and help of
cum Taking pamphl
attending house officer (when the amount of blood loss is more than a liters). discussi notes ets
 Call for extra help—involve the obstetric registrar (senior staff) on call. on and
asking
 Put in two large bore (14 gauges) intravenous cannula. doubts
 Send blood for group (if not done before) and cross matching and ask for 2 Explain about
the
units (at least) of blood. persistent
occipito
 Infuse rapidly 2 liters of normal saline (crystalloids) or plasma substitutes
posterior?
like haemaccel (colloids), and urea linked gelatin, to re-expand the vascular
bed. Haemaccel is rich in potassium and calcium. It does not interfere with
cross matching.
 One midwife/rotating houseman should be assigned to monitor the following
Pulse, blood pressure, type and amount of fluid the patient has received,
urine output, drugs type and time and dose ,central venous pressure.
Actual management:-
The first step is to control the fundus and to note the feel of the uterus. If the uterus
is flabby the bleeding is likely to be from the atonic uterus. If the uterus is firm and
contracted, bleeding is likely of traumatic origin.

Atonic uterus:-
Step I-
a) Massage the uterus to make it hard and express the blood clot.
 b) Methergin 0.2mg is given intravenously. Explain Explain about
Lecture Taking with the actual
c) Morphine 15mg may be given intra muscularly cum notes help of management
d) Inj oxytocin drip is started (10 unit in 500ml of normal saline) at the rate of discussi and pamphl of PPH?
on asking ets
30-40 drops per minute doubts
e) To empty the bladder if it is found full
f) To examine the expelled placenta and membranes, if available for evidence
of missing cotyledon or piece of membranes. If the uterus fails to contract,
proceed to the next step.
Step II-
The uterus is to be explored under general anaesthesia. Simultaneously
inspection of the cervix, vagina specially the para-urethral region is to be done to
exclude co-existent bleeding sited from the injured area. In refractory cases:
 Inj;15methyl PGF2 α 250µg I.M in the deltoid muscle every 1-2hours(upto
maximum five doses)
OR
 Misoprostol(PGE1)1000µg per rectum is effective.
Step III- Uterine massage and bimanual compression.
Procedure:
a) The whole hand is introduced into the vagina in cone shaped fashion after
separating the labia with the fingers of the other hand.
b) The vaginal hand is clenched into a fist with the back of the hand directed
posteriorly and the knuckles in the anterior fornix.
c) The other hand is placed over the abdomen behind the uterus to make it
anteverted.
d) The uterus is firmly squeezed between the two hands. It may be necessary to
. continue the compression for a prolonged period until the tone of the uterus
is regained. This is evidenced by absence of bleeding if the compression is
released.
During the period, the resuscitative measures are to be continued. If in spite of
therapy the uterus remains refractory and the bleeding continues, the possibility of
blood coagulation disorders should be kept in mind and massive fresh whole blood
transfusion should be given until specific measures can be employed. However with
oxytocics and blood transfusion almost all cases respond well. Uterine contraction
and retraction regain and bleeding stops. But in rare cases, when the uterus fails to Listeni
ng and
contract, the following may be tried desperately as an alternative to hysterectomy. Lecture Taking Explain
cum notes with the
Step IV-Uterine tamponade-
discussi and help of
a) Tight intrauterine packing done uniformly under general anesthesia. on asking OHP
doubts
Procedure: A 5 meters long strip of gauze, 8cm wide folded twice is required. The
gauze should be soaked in antiseptic cream before introduction. The gauze is placed
high up and packed into the fundal area while the uterus is steadied by the external
hand. Gradually the rest of the cavity is packed so that to empty space is left behind.
A separate pack is used to fill the vagina. An abdominal binder is placed.
Intrauterine plugging acts not only by stimulating uterine contraction but exerts
direct haemostatic pressure (tamponade effect) to the open uterine sinuses.
Antibiotics should be given and the plug should be removed after 24 hours.
Insertion of a sengstaken Blakemore tube into the uterine cavity and inflating the
balloon with 200ml of normal saline. Mechanism for control of haemorrhage is
same as that of intrauterine plugging.
Step V-
Surgical methods to control PPH are many. An outline of stepwise uterine de
vascularisation procedures are given below.
1) Ligation of uterine arteries: the ascending branch of the uterine artery is ligated
at the lateral border between upper and lower uterine segment. The suture (No 1
chromic) is passed into the myometrium 2cm medial to the artery. In atonic
haemorrhage bilateral ligation is effective in about 75% of cases.
2) Ligation of the ovarian and uterine artery anostomasis if bleeding continues is Lecture Taking Explain
done just below the ovarian ligament. Rarely temporary occlusion of the ovarian cum notes with the
discussi and help of
vessels at the infundibulopelvic ligament may be done by rubber sleeved on asking OHP
clamps. doubts

3) Ligation of anterior division of internal iliac artery (unilateral or bilateral)

reduces the distal blood flow. It helps stable clot formation by reducing the
pulse pressure up to 85%. Due to extensive collateral circulation there is no
pelvic tissue necrosis. Bilateral ligation can avoid hysterectomy in about 50% of
the cases.
4) B-Lynch brace suture and haemostatic suturing; both these surgical methods
work by tamponade of the uterus.
5) Angiographic arterial embolisation (bleeding vessel) under fluoroscopy can be
done using gel foam. Success rate is more than 90% and it avoids hysterectomy.
Step VI-
Hysterectomy- rarely uterus fails to contract and bleeding continues in spite of the
above measures. Hysterectomy has to be considered in such a situation. Decision of
hysterectomy should be taken earlier in a parous woman. Depending on the case it
may be subtotal or total.
Traumatic PPH: The trauma to the perineum vagina and cervix is to be searched
under good light by speculum examination and homeostasis is achieved by
 appropriate catgut sutures. The repair is done under general anesthesia if necessary.

Secondary postpartum haemorrhage:-

8. Explain the
Causes: The bleeding usually occurs between 8th to 14th day of delivery. The causes
causes of
secondary PPH. of late postpartum haemorrhage are:
 Retained bits of cotyledon or membranes
 Infection and separation of slough over a deep cervico vaginal laceration. What are all
the causes of
 Endometritis and sub involution of the placental site due to delayed healing Taking secondary
Lecture notes Explain PPH?
process.
cum and with the
 Secondary haemorrhage from caesarean section wound usually occurs discussi asking help of
on doubts OHP
between 10-14 days.
a)it’s probably due to separation of slough exposing a bleeding vessels
b)from granulation tissue
 Withdrawal bleeding following estrogens therapy for suppression of
lactation
 Other rare causes are: chorion epithelium—occurs usually beyond 4 weeks
of delivery, carcinoma cervix, placental polyps, infected fibroid or fibroid
polyp and puerperal inversion of uterus.

Diagnosis:-
9. discuss the Tell the
diagnosis of The bleeding is bright red and of varying amount. Rarely may it be brisk. Varying diagnosis of
secondary PPH. secondary
degree of anemia and evidence of sepsis are present. Internal examination reveals PPH?
evidences of sepsis sub involution of the uterus and often a patulous cervical os.
Ultra sonography is useful in detecting the bits of placenta inside the uterine cavity.
 Management:-

10. Describe the

Principle:
management of 1) To assess the amount of blood loss and to replace the lost blood. Explain about
secondary PPH. the
2) To find out the cause and to take appropriate steps to rectify it. management
Supportive therapy:- of secondary
PPH?
1) Blood transfusion, if necessary.
2) To administer ergometrine 0.5mg intramuscularly, if bleeding is uterine in Lecture Taking Explain
cum notes with the
origin. discussi and help of
3) To administer antibiotics as a routine. on asking OHP
doubts
Conservative:-
If the bleeding is slight and no apparent cause is detected a careful watch for
a period of 24 hours so is done in the hospital.
Active treatment:-
As the commonest cause is due to retained bits of cotyledon or membranes,
it is preferable to explore the uterine urgently under general anesthesia. One should
not ignore the small amount of bleeding as unexpected alarming haemorrhage may
follow sooner or later. The products are removed by ovum forceps. Gentle curettage
is done by using flushing curette. Ergometrine 0.5mg is given intramuscularly. The
materials removed are to be sent for histological examination.
Presence of bleeding from the sloughing wound of cervico-vaginal canal
should be controlled by haemostatic suture. Secondary haemorrhage following
caesarean section may at times require laparotomy.
Retained placenta:-
11. Explain about the
Definition:-
retained Define
placenta. The placenta is said to be retained when it is not expelled out even 30minutes retained
after the birth of the baby. placenta?
Causes:-
There are three phases involved in the normal expulsion of placenta: Explain the
causes of
 Separation through the spongy layer of the deciduas retained
 Descent into the lower segment and vagina placenta?

 Finally is expulsion to outside

Interference in any of these physiological processes results in its retention.
 Placenta completely separated but retained is due to poor voluntary
expulsive efforts.
 Simple adherent placenta is due to uterine atonicity in cases of grand
multipara over distension of uterus, prolonged labour, uterine malformation Taking Explain
or due to bigger placental surface area. The commonest cause of retention of Lecture notes with the
cum and help of
non-separated placenta is atonics uterus. discussi asking OHP
on doubts
 Morbid adherent placenta- partial or rarely, complete.
 Placenta incarcerated following partial or complete separation due to
constriction ring (hour-glass contraction) premature attempts to deliver the
placenta before it is separated.
Diagnosis:-
The diagnosis of retained placenta is made by an arbitrary time spent following What are all
the diagnosis
delivery of the baby. Features of placental separation are assessed. The hour-glass of retained
placenta?
contraction or the nature of adherent placenta can only be diagnosed during manual
removal.
Danger:-
The risk involved in prolonged retention of placenta are:
  Haemorrhage
 Shock due to (blood loss, at times unrelated to blood loss specially when
retained more than one hour and , frequent attempts of abdominal
manipulation to express the placenta out
 Puerperal sepsis
 Risk of its recurrence in next pregnancy
Management:-
Period of watchful expectancy:
Taking Explain How to
 During the period of arbitrary time of half an hour, the patient is to be Lecture notes with the manage the
watched carefully for evidence of any bleeding revealed or concealed and to cum and help of retained?
discussi asking OHP
note the signs of separation of placenta. on doubts
 The bladder should be emptied using a rubber catheter.
 Any bleeding during the period should be managed as outlined in third stage
bleeding.
Management of unforeseen complication during manual removal:
1) Hour-glass contraction—the placenta either un separated or separated—partially
or completely may be trapped by a localized contraction of circular muscles of the
uterus. This may be situated at the junction of the lower and upper segment or may
be placed in one cornu. Administration of any oxytocic especially ergometrine in the
active management of third stage or undue irritability of the uterus by premature
attempts to express the placenta is the important cause. The diagnosis is only made
during attempted manual removal.
Management : the ring should be made to relax by:
a) Deepening the plane of anesthesia (halothane is useful in these cases) then the
cone shaped hand is introduced and the separation of the placenta is preferably done
from above downwards to minimize bleeding.
2) Morbid adherent placenta: in majority the diagnosis is made only during
attempted manual removal. On rare occasion however no cleavage between the
placenta and the uterine wall is made possible and the diagnosis of a total placenta
accrete is certain.
Complicated retained placenta:
The following guidelines are formulated to manage the cases of retained placenta
complicated by haemorrhage shock or sepsis.
 Retained placenta with shock but no haemorrhage: to treat shock and when
Taking
the condition improves manual removal of the placenta is to be done. Lecture notes Explain
cum and with the
 Retained placenta with haemorrhage: the management protocol is similar to discussi asking help of
that mentioned in third stage haemorrhage. on doubts OHP

 Retained placenta with sepsis: the patient is usually delivered outside and is
admitted in the referral hospital after few hours or even days after
confinement.
Intrauterine swabs are taken for culture and sensitivity test and broad
spectrum antibiotic is given. Blood transfusion is helpful. As soon as the
general condition permits, arrangement is made for manual removal. The
operation should be done by a senior person, as there is possibility of the
presence of an adherent placenta.
 Retained placenta with an episiotomy wound: the bleeding points of the
episiotomy wound are to be secured by artery forceps. An early decision for
manual removal should be taken followed by repair of the episiotomy
wound.
 Placenta accrete:
Placenta accreta is an extremely rare form in which the placenta is directly
12. disscuss the anchored to the myometrium partially or completely without any intervening
placenta accrete.
decidua. The probable cause is defective decidual formation. The condition is
usually associated when the placenta is implanted in lower segment or over the
previously injured sites as in caesarean section, dilatation and curettage operation, Taking
manual removal synaecolysis or myomectomy. Lecture notes Explain
cum and with the
The diagnosis is made only during attempted manual when the plane of discussi asking help of
cleavage between the placenta and the uterine wall cannot be made out. Ultrasound on doubts OHP

imaging, colour Doppler and MRI have all been valuable in the diagnosis of
placenta accreta, increta and percreta during pregnancy. Pathological confirmation
includes,1) absence of decidua basalis 2) absence of Nitabuch’s fibrinoid layer and
3) varying degree of penetration of the villi into the muscle bundles or up to the
serosal layer. The risk includes haemorrhage, shock, infection and rarely inversion
of the uterus.
Management:-
 In partial placenta accreta- Remove the placenta tissue as much as possible.
Effective uterine contraction and haemostatic are achieved by oxytocics and
if necessary by intra uterine plugging. If the uterus fails to contract an early Explain the
decision of hysterectomy may have to be taken and this is preferable in multi management
of placenta
parous women. accrete?
 In total placenta accreta hysterectomy is indicated in parous women, while in
patients desiring to have a child, conservative attitude may be taken. This
consists of cutting the umbilical cord as close to its base as possible and
leaving behind the placenta which is expected to be autolysed in due course
 of time. Appropriate antibiotics should be given. Methotrexate therapy may
be tried.

Inversion of the uterus:-

It is an extremely rare but a life threatening complication in third stage in which the
13. explain about the
inversion of the uterus is turned inside out partially or completely. The incidence is about in 20,000
uterus. deliveries. The obstetric inversion is almost always an acute one and usually
Taking Explain
complete. Lecture notes with the
Varieties:- cum and help of
discussi asking leaflets
 First degree: there is dimpling of the fundus which still remains above the on doubts List out the
level of internal os. varieties of
inversion of
 Second degree: the fundus passes through the cervix but lies inside the uterus?
vagina.
 Third degree: the endometrium with or without the attached placenta is
visible outside the vulva. The cervix and part of the vagina may also be
involved in the process.
Etiology:-
Spontaneous (40%): this is brought about by localized atony on the placental Tell the
etiology of
site over the fundus associated with sharp rise of intra abdominal pressure as in inversion of
coughing, sneezing or bearing down effort. Fundal attachment of the placenta short uterus?

cord and placenta accreta are often associated.

Iatrogenic: This is due to the mismanagement of third stage of labour.
 Pulling the cord when the uterus is atonic specially when combined with
fundal pressure.
 Crede’s expression while the uterus is relaxed.
  Faulty technique in manual removal.
Dangers:-
Shock is extremely profound mainly of neurogenic origin due to
 Tension on the nerves due to stretching of the infundibulo pelvic ligament.
Taking Explain
 Pressure on the ovaries as they are dragged with the fundus through the
Lecture notes with the
cervical ring and. cum and help of
discussi asking leaflets
 Peritoneal irritation. on doubts
Haemorrhage, specially after detachment of placenta
Pulmonary embolism
If left uncared for it may lead to
 Infection
 Uterine sloughing and
 Chronic one.
Diagnosis:-
Symptoms:-Acute lower abdominal pain with bearing down sensation.
What are all
Signs:- the diagnosis
 Varying degree of shock is a constant features. of inversion
of uterus?
 Cupping or dimpling of the fundus surface.
 Bimanual examination not only helps to confirm the diagnosis but also
degree. In complete variety a pear shaped mass protrudes outside the vulva
with the broad end pointed downwards and looking reddish purple in colour.
Prognosis:-
As it is commonly met in unfavorable surroundings, the prognosis is extremely
gloomy. Death may occur quite suddenly due to shock haemorrhage or embolism.
Even if the patient survives infection sloughing of the uterus and chronic inversion
with ill health may occur.
Prevention:-
Do not employ to expel the placenta out when the uterus is relaxed. Pulling the cord
simultaneous with fundal pressure should be avoided. Manual removal should be
done in a manner as it should be.
Management:-
Before the shock develop:- Urgent manual replacement even without anesthesia if
not easily available is the essence of treatment for a skilled accoucheur.
Principles steps: Explain the
management
 To replace the part first this is inverted last with the placenta attached to the of the
inversion of
uterus by steady firm pressure exerted by the fingers.
uterus?
 To apply counter support by the other hand placed on the abdomen.
 After replacement the hand should remain inside the uterus until the uterus
becomes contracted by parenteral oxytocin or PGF2α.
 The placenta is to be removed manually only after the uterus becomes
contracted. The placenta may however be removed prior to replacement—a)
to reduce the bulk which facilitates replacement or b) if partially separated
to minimize the blood loss.
 Usual treatment of shock including blood transfusion should be arranged as
and when required.
After the shock develops:-
Principal steps;
 The treatment of shock should be instituted with an urgent dextrose saline
drip and blood transfusion
 To push the uterus inside the vagina if possible and pack the vagina with
 antiseptic roller gauze
 Foot end of the bed is raised
 Replacement of the uterus either manually or hydrostatics method under
general anesthesia is to be done along with resuscitative measures.
Hydrostatic method is quite effective and less shock producing.
Sub acute stage:-
 To improve the general condition by blood transfusion
 Antibiotic are given to control sepsis
 Reposition of the uterus manually or by hydrostatic method may be tried
 If fails reposition may be done by abdominal operation(Haultain’s operation)

Summary:-
So far we are discussed about the introduction about the complications of the third
stage of labour include post partum haemorrhage in primary and secondary post
partum haemorrhage definition, like the blood loss is excess of 500ml following
birth of the baby. Etiology like atonic, traumatic, mixed, and blood coagulation.
Prevention like antenatal intranatal. And management has given during various
stages of labour. And the other condition like retained placenta definition, the
placenta is said to be retained when it is not expelled out even 30 min after the birth
of the baby. And its management includes manual removal of placenta. And the next
condition is placenta accreta, placenta is directly anchored to the myometrium
partially or completely, and its management. The last condition is inversion of the
uterus; it’s a life threatening condition in third stage in which the uterus is turned
inside out partially or completely. And the varieties in the three degree management.
And its dangers and management before the shock develops and after the shock
develops.

Conclusion:-
I hope you that, all are understood about the complications of third stage of labour
and its cause incidence and how to diagnose the condition and how to treat the
condition, I hope you can apply this knowledge in clinical setting and get adequate
knowledge and help for the people for saving their life. Thank you.

Evaluation:-
Write an assignment regarding recent and advanced method of treatment for
complication of third stage of labour,and write a care plan for this condition. And
submit this assignment within two days.

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4. D.C.Dutta.Textbook of obstetrics;1983.6nd ed. Calcutta: New central book

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