Complications of 3 rd stage of labour

1. COMPLICATIONS OF 3 RD STAGE OF LABOUR Prashiddha Dhakal MBBS(KUSMS)

2. COMPLICATIONS OF 3 RD STAGE OF LABOUR Postpartum haemorrhage Retention of placenta Uterine inversion Obstetric shock Pulmonary embolism

3. POSTPARTUM HAEMORRHAGE

4. Bleeding from genital tract more than 500cc after the delivery of fetus Types Primary - Haemorrhage occurs within 24hrs following the birth of the baby -Third Stage Bleeding -True Postpartum Haemorrhage Secondary - Haemorrhage occurs beyond 24hrs and within puerperium

5. Causes Uterine atony Grand multipara Overdistension due to multifetal pregnancy, hydramnios , macrosomic fetus Anaesthesia , Tocolytic drugs Antepartum haemorrhage Primary Postpartum Haemorrhage

6. 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 disorders Thrombocytopenic purpura , Hypofibrinogenemia

7. 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

8. - 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

9. Secondary Postpartum Haemorrhage Causes Retained placenta Infection Subinvolution of uterus & Endometritis Choriocarcinoma , CA Cervix Fibroid polyp

10. Management IV Fluids Blood transfusion Antibiotics Removal of retained parts

11. Complications of PPH Shock Maternal death Acute renal failure Sheehan’s syndrome Puerperal sepsis

12. RETENTION OF PLACENTA Causes Retained seperated placenta Atony of uterus Contraction ring Premature attempts to deliver placenta before it is seperated Retained non- seperated placenta Simple adherance - Due to uterine atony Morbid adherance - Placenta accreta , increta or percreta

13. Complications Haemorrhage Shock Puerperal sepsis Risk of recurrence in next pregnancy

14. INVERSION OF UTERUS

15. 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

16. Causes 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

17. Management Replacement of uterus -Manual replacement -Hydrostatic replacement -Surgical replacement Antibiotics to control sepsis

18. Complications Haemorrhage Shock Pulmonary embolism Infection and uterine sloughing

19. OBSTETRIC SHOCK Causes 1. Hypovolemic Shock Postpartum haemorrhage Haematoma - Broad ligament/ Paravaginal 2. Neurogenic Shock Uterine rupture Uterine inversion

20. 3. Obstructive Shock Air embolism 4. Anaphylactic Shock Amniotic fluid embolism 5. Septic Shock Prolonged Rupture Of Membranes Retained placental tissues Manipulation & instrumentation

21. Management Ensure patent airway & give 100% Oxygen Control active bleeding IV Fluids- Crystalloids, Colloids, Blood IV Sodium bicarbonate (For acidosis) Antibiotics (For sepsis) Others- Steroids, Morphine, Ranitidine Monitor BP, ECG, Pulse oximetry , Urine output, Serum electrolytes, CVP, ABG

22. PULMONARY EMBOLISM Emboli can be thrombus, amniotic fluid or air Clinical features Sudden chest discomfort Air hunger Hypotension Haemorrhage (due to DIC) Collapse Management Similar to shock