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1. Complications Of third stage of labor

2. The impo r tant compli c ation o f thi r d stage of labor:- Post partum hemorrhage Retention of placenta Inversion of the uterus Amniotic fluid emb olis m / Pulmonary embolism Obstetric Shock Injuri e s t o bi r t h canal

3. “ Any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium which adversely affect the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called post partum hemorrhage”.

4. The i n cide nce i s ab out 4 – 6 % of all deliveries.

5. Minor (< 1 liter) Major (> 1 liter) S e v e r e ( > 2 l i ter)

6. Hemorrhage occurs within 24 hours following the birth of the baby. Thi r d Stag e Ble e di n g T rue P ostpa r tu m Haemo r rha g e Hemorrhage occurs beyond 24 hours and within puerperium also called delayed or late puerperal hemorrhage.

7. Atonic uterus Traumatic Retained Tissue Blood Coagulopathy

8. Retained b i ts o f cotyled o n o r membrane In f e c tion and se p a ra t io n o f slough o v e r a deep ce r vio – vag i n a l lace r ation . End o me t ri t i s a nd sub i n v o l uti o n o f t he p l acenatl si t e . Second a r y hemo r rh a ge f r o m c a es a r ean section wound.

9. Hemoglobin l e vel In t er n al exam i nat i on t o r e v eal se p sis sub involution Ultrasonography

10. T o empty th e uter u s of it s c o nte n t and to ma k e i t c o nt r ac t . T o r ep l ace th e b l o o d th r ough b l o o d transfusion. To ensure effective haemostasis through stop pi n g th e bleed i ng f r om tra u mat i c si t e .

11. T r u e P o s tpa r tu m Haemo r rhage Same as t h ird st a ge b le e di n g pl u s Inj. Misop r ostol 1m g p er r ectum Bim a nua l comp r es s ion o f ute r us Tight ute r ine pa c king Ba l loo n tamponade Lig a tion o f ute r ine a r te r y Hysterectomy

12. Supportive therapy:- met h argin . 2 mg I/M an ti b iot i c th e r a p y , IV Fl u ids Active t reatment ge n tle cu r at t age t o r em o v e p l acenta u n der gene r al an ae s t h es i a

13. Complications of PPH Shock M a te r na l de a th Acut e r enal f ailu r e Pue r pera l sepsis

14. “ The placenta is said to be retained when it is not expelled out even 30 minutes after the b i r th o f the ba b y . ”

15. There are three phases involved in the normal expulsion of placenta Separation th r ough the spon g y l a y er of t he decidua Descent into the lower segment and vagina Finally its expulsion to outside

16. Placenta complete l y separated but r etai n ed is due t o poor v olu n t a r y ex p u l si v e ef f o r ts. Simp l e adhe r ent p l acenta or non separated p l acenta i s d u e t o atonic ute r us. P r ematu r e attempts t o deli v er th e p l acenta be f o r e i t i s sepa r ated. Interference in any of these physiological processes, results in its retention .

17. R E TE N TIO N O F P L A CEN T A Causes 1. Retained separated placenta Atony of uterus Contraction ring Premature attempts to deliver placenta before it is separated 2. Retained non-separated placenta Simple adherance- Due to uterine atony Morbid adherance- Placenta accreta, increta or percreta

18. Diagnosis of r etained p l acenta i s made whe n p l acenta does not del i v e r ed after th e 30 mi n utes of ba b y del i v e r y Adhe r ent p l acenta can o n l y be diag n osed dur i ng ma n ual r em o val.

19. Hemorrhage Puerp eral se p sis Risk of its recurrence in next pregnancy Shoc k i s d ue t o : - Blood loss F r eq u ent attem p t s of abdomi n al man i pulat i on t o ex p r ess th e place nt a out.

20. During the period of arbitrary time limit of half an hour, the patient is to be watched careful for evidence of any bleeding, revealed or concealed and to note the signs o f se p arat i on o f p l acent a . The b l a d der shou l d be emp t ie d us i ng a r u b b er catheter.

21. The r e a r e th r ee types of r etained p l acenta : - a. Separated placenta but retained a. Unseparated retained placenta a. Complicated retained placenta

22. Placenta is separated and retained :- ex p r ess th e p l acenta out b y co n troll e d co r d traction.

23. Uns e pra ted ret a ined pl a ce n t a : - ma n ual r em o val of th e p l acenta i s t o be done u n der gene r al ane s the s ia.

24. C o mplica ted ret a ined pl a ce n ta : - the following form u lated to guide l ines are m a n a ge the case of retained placenta comp li c ate d b y h e m o rrhage shock or sepsis.

25. Retained placenta with shock but no hemorrhage :- t o t r eat th e shock and whe n th e c o nd i tion im p r o v es ma n ual r em o val of th e place nt a is t o be don e . Retained placenta with hemorrhage:- Cont r ol th e fund u s massage and ma k e it hard In j . Metherg i n . 2 mg IV T o sta r t normal sal i ne drip wit h o xytoc i n and a r range f or b l ood tra n sf u sio n . Cathet e rized th e bla d der

26. Place n t a se p arated not se p arated E x p r ess th e place n ta out by cont r olled co r d tract i on ma n ual r em o val u n der ge n er a l anesthesia Traumatic suture should be tracked by sutures

27. Retained placenta with sepsis:- In t rauterine s wab s a r e ta k en f or cu l tu r e and sens i tiv i t y tes t and b r oad spectr u m ant i biotics i s gi v en. Blo o d trans f us i on i s help f u l . As soon as the general conditions permits, a r rangement i s ma d e f or ma n ual r em o val.

28. R e tai n e d p l a ce n t a wit h a n ep i si o tomy wound:- The bleeding points of the episiotomy wound are to be secured by artery forceps. An ear l y decis i on f or ma n ual r em o val shou l d be ta k en f oll o w ed b y r epair of the ep i sioto m y w ound.

29. margins of the placenta.

30. The placenta is gradually separated with sideways slicing movements of the fingers, until whole of the placenta is separated.

31. “It is an extremely rare but a life threatening complication in third stage in which the uterus is turned inside out pa r tial l y o r comp l ete l y ” .

32. Iatrogenic this is due to mismanagement of th e thi r d stage of la b o r . Pu l l i ng th e c o r d whe n th e uter u s i s atonic sp e cia l l y whe n comb i ned wit h fu n dal pressure. Funda l p r ess u r e whe n th e uter u s i s r ela x ed. Fault y techn i que i s ma n ual r em o val

33. Sh o ck i s ext r e me l y p r o f o u nd ma i n l y of ne u r ogenic origin due t o : - Tension on the nerves due to stretching of i n fu n dibulo pe l vic l igament . P r essu r e o n t he o v a ries as a r e dra g g ed with the fundus through the cervical ring H a emor r hage sp e c ial l y after de t achme nt o f p l acent a . I f lef t u n care d i t ma y le a d to : - Infection Uteri n e sloug h ing

34. Do not emp l o y a n y method t o expel the p l acenta out whe n th e ute r us i s r ela x ed. Pul li n g th e co r d si m u l tane o us l y wit h fu n dal p r ess u r e sho u l d be a v oided. Ma n ual r em o val shou l d be done i n p r oper manner

35. Call f or extra he l p Be f o r e t he sho c k d ev elops urgent man ual r ep l acement e v en wit h out anaes t he s i a . Principle steps are:- To replace the part first which is inverted last wit h the p l acenta attach e d . To apply counter support by the other hand p l aced o n the abdome n .

36. After replacement, the hand should remain inside the uterus until the uterus become contracted b y pa r entral o xytoc i n . The placenta is to be removed manually only after the uterus becomes contracted. The placenta may however be removed prior to replacement:- blood los s i f pa r tia l l y T o r educe the bulk T o minimiz e the separated Blood tr a n s f u s i on f or shock

37. Management Repla ce m ent of u te r us - Manual r eplacement - Hyd r ost a tic r epla c ement - Sur g ical r eplacement An t ibio t ics to c o n t r ol se p sis

38. The condition of amniotic fluid embolism occurs when amniotic fluid ente r s t he mat e rnal ci r culation th r ough a tear in the membrane or placenta Onset:- Amniot i c fluid emboli s m can occur at a n y stage o f gestation .

39. causing hypoxia, hypotension The i n it i al phase i s one t h e vas o spasm of and car di o vasc u la r coll a ps e . The second phase is the development of left ventricular failure with hemorrhage and coagulation disorder followed by pulmonary edema.

40. T ear i n th e membrane Hy p e r toni c ute r i n e activ i ty Place n ta l abr u pt i on Cesa r ean section T erm i nation of p r egnancy Rup t u r e ute r us T rau m a m a y occur dur i ng i n trau t erine manipulation

41. Maternal r esp i r a to r y dist r ess : - th e w oman becomes s e v e r e l y dyspn i c and cyanosed. Maternal h ypote n sion and ute r i n e hypotonia. F etal dist r ess i n r es p onse t o h yp o xia Ca r diop u l m o n a r y a r r est Ma n y mothers pr esent wit h co n vu l sion immediately

42. Resuscitate m ust be sta r ted a t once Hyd r oco r ti s on e , larg e dose i n tr a v enous l y . Amin o p h yllin , int r a v e n o u s l y f or r espir at o r y distress Co r r ection o f ac i d – base im b ala n ce Co r r e c tion o f the b l o od los s and coagula t io n de f ect i f i n dicated .

43. Dissem i nated i n tr a v ascu l ar coagulop a t h y Acute r enal fai l u r e Neu r ological im p ai r ement Death

44. P U L M ONA R Y E M B O LI S M E m boli c a n be th r o m b u s , a m ni o tic f l u id or air Clinical features Su d d e n c h e st dis c o m f o r t Ai r hu n ger Hypotension Hae m o r rhag e (due to D IC) Collapse Management Similar to sh o c k

45. O B S T ETRIC S H O CK Causes 1. Hyp o v olemic Sho c k P ostpa r tum h a emo r rh a ge Haem a tom a - B r oa d ligament / P ar a v a g inal 2. Neu r oge n ic Sh o c k Uterine rupture Uterine inversion

46. 3. O bst r ucti v e Sho c k Ai r embolism 4. An a p h ylactic Sho c k Amnioti c fl u id embolism 5. Septic Sho c k P r ol o nge d Ruptu r e Of Membranes Retaine d placenta l tissues Manipul a tion & inst r ume n t a tion

47. Management Ensu r e p a tent a ir w a y & g i v e 10 % Oxyg e n Cont r o l a cti v e b le e ding IV Fluids- Crystalloids, Colloids, Blood IV So d ium bica r bon a te ( F o r acidosis) Antibiotic s ( F o r se p sis) Othe r s - Ste r oids, Mo r phin e , R a niti d ine Monitor B P , EC G , Pul s e o xim e t r y , U r ine out p ut, Se r um el e ct r o l ytes, CV P , ABG

48. Maternal injuries following child birth process are quite common and contribute significantly to maternal morbidity and even to death. P r e v e nt i on, ea rl y detecti o n and p r o m pt a nd effective management not only minimize the morbidity but prevent many gynaecological problems from developing later in life.

49. Laceration of the vulval skin posteriorly and th e Para u r ethral tea r on th e in n er asp e ct of la b i a mi n ora a r e th e c o mmon si t es. Para u r ethral tea r m a y be associated with br isk hemo r rhage and sho u l d be r epa i r ed b y i n te rrupted catgut sut u r e , p r e f era b l e after i n t r oduct i on of a ru b ber catheter i n t o the b l a d der t o p r e v ent i n j u r y of th e u r eth r a .

50. Minor i n j u r y i s q u it e comm o n spec i al l y during first birth. Gross injury is invariably a result of mismanaged second stage of labor. O v era l l ri s k i s 1 % of all vagi n al del i v e r y .

51. The perineum may be term due to several factors:- Over stretching of the perineum due to large baby, face delivery outlet contraction with narrow pubic arch, shoulder dystocia and f o r cep del i v e r y . Rapid stretching of the perineum due to rapid delivery of the head during uterine contraction precipitate labor and delivery of the after comin g head i n b r ee c h .

52. Inelastic perineum as in rigid perineum in elderly primigravida,, scar in the perineum following perivious operation, such as episiotomies or perineorrhaphy and vulval edema. Unattended delivery and inability of the w oman to stop b ear i ng d o w n .

53. Spontaneous tears are usually classified in degree which are related to the anatomical str u ctu r es wh i ch h a v e been tra u m a tize d . First degree:- Involves laceration of the fourchette (lower end of the posterior vagina o r pe r i n eal sk i n) on l y . Second degree:- Injury to perineum involving perineal body (muscles) but not involving the anal sp h i n c t e r .

54. Third degree:- Injury to perineum involving the anal sp h i n c t er comple x . Fourth degree:- The tear extends to the rectal mucosa. Injury to perineum involving the anal sphincter complex and anal epithelium.

55. Conduct of second stage of delivery with due care in those with increase likelihood of laceration. Maintain flexion of the head until the occiput comes u n der th e symp h ysis p u b i s so that lesser sub occipito frontal (10 cm) diameter emerges out of th e i n t r oit u s.

56. Ass u r e th e woman not t o bear d o w n du r i n g contractions to avoid forcible delivery of the head. Del i v e r y of th e head i n bet w een contraction P er f orms tim e l y ep i sioto m y T a k e ca r e duri n g deli v e r y of th e shou l de r .

57. Recent tear sho u l d be r epai r ed immediate l y following the delivery of the placenta. This reduce the chance of infection and min i mizes the blood loss. In c ases of d el a y b ey ond 24 hours, t he r epair i s to be w ithheld. Antibiotics should be sta r ted to p r e v ent infection. The complete tea r , s hould be r epa i r ed after 3 m onths, i f del a y ed b ey ond 24 hours.

58. Vaginal lacerations Without involvement of the perineum or cervix sometimes occurs. These a r e usu a l l y seen f o l l o wing i n s tr u m e ntal or m a nip u lat i v e deli v e r y . In such cases the tears are extensive and often associated wit h acti v e b l eedi n g .

59. The most comm o n site i s th e l o w er th i r d of th e vagina. The l o w er end of th e vagina m a y be t o rn transversely from its junction with the pe r i n eum le a vi n g a deep c a vity be h i n d and i n tac t pe r i n eum.

60. A vaginal tea r i s sutu r ed b y i n te r rupted or conti n uous sut u r es us i ng ch r omic catgut n um b er ‘ ’. In c a se of extens i v e lacerat i o ns i n a d dition to sutures, hemostasis may be achieved by i n tr a v a g ina l p l ugging b y r oller gauze soaked with glycerin and acriflavine.The p l ug sho u l d be r em o v ed after 24 hou r s.

61. Minor deg r ees of ce r vical tear s often occur dur i ng fi r st del i v e r y . E x ten s i v e ce r vical tea r i s ra r e . It i s th e c o mmonest cause of traumat i c post pa r tu m hemo r rhag e .

62. Causes Iatrogenic:- attempted forceps delivery or b r eech ext r action th r ough i n complete l y di l ated ce r vi x . Rigid ce r vix : - th i s m a y be congen i t al or mo r e common l y f oll o win g scar f r om p r e vious operat i o ns on th e ce r vi x . St r ong uter i ne contraction:- as in p r eci p it a t e la b o r .

63. Minor tea r r eq u i r e no t r eat m ent. Deep cervical tears associated with b l eedi n g sho u l d be r epa i r ed soon after deli v e r y of th e p l acenta. The r epa i r sho u l d be d o ne u nder gene r al ane s the s i a i n l i thot o m y pos i tio n wit h a good light.

64. Collection of blood anywhere in the area between the pelvic peritoneum and the peritoneal skin are called pelvic hematom a .

65. Pain i n per i neal r egion. Retent i on of ur i n e . V aria b l e deg r ee of shock or coll a ps e . T ense s w el l i n g at th e vu l va which becomes dusky a n d p u rp l e i n color and tender to touch. Pallor, rapid pulse and low blood pressure. A tende r pelv i c l u mp on pa l pati o n.

66. A s m all hematoma (<5cm ) i s t r eated con s e r vati ve l y wit h co l d co m p r es s . If i t i s large r than 5cm or i n c r easi n g i n siz e , it n e ed to b e e va c uat e d. The hemato m a i s drained u n der general ane s th e s i a and ble e ding points a r e sec u r ed. The dead space is to be obliterated by deep mattress sutures. P r op h ylactic antibiot i cs i s to b e adm i niste r ed. Blood tr a n s fusion and na r cotic analgesi c s f or pai n .

67. 2 . Supral evato r Hem a toma : - i t is rare. Ex t ens i on of ce r vical lacerat i o n or pr i am a r y vau l t ru p tu re . L o w er ute r i n e segme n t ru p tu re .

68. Unex p laine d shock wit h f eatu r es of shock f oll o win g del i v e r y . Abdomi n al exam i na t io n r e v eals s w el l i n g ab o v e th e ing uin a l p u sh i ng th e uter u s t o the opposite site. V agi n al exam i nat i on r e v eals occlu s io n of the vagi n al canal b y a b u lg e or a bo g y s w el l i n g f elt th r ough th e f ornix . Ult r ason o gr a p h y m a y sh o w th e exact locat i on of th e hema t om a .

69. T r eatment of shock. Exploratory laporotomy and drainage of th e hematom a . Ligat i on of th e b l eeding poin t s. Bila t eral i n ter n a l i lia c a r te r y l i gation m a y be r eq u i r ed t o cont r ol b l eedi n g.

70. Thank You