Complications of 3 rd stage of the Labour

Complications of 3 rd stage of the Labour

1. Mrs. U SREEVIDYA Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. Time from the birth of the baby to the expulsion of the placenta and its membrane Events: Placental separation Descent to lower segment Expulsion with membrane. 3 rd STAGE OF LABOR

3. Important 3 rd stage complication Postpartum he morrha g e Retention of placenta Sho c k P u lmo n a r y embolism Uterine inversion

4. AVERAGE B L OOD Vaginal deli v e r y 500mL Ce s a r e an delivery 10 0mL Cesarean h y s t e r e c t o m y 1500mL

5. POST P A R TUM HE M ORR H AGE

6. DEFINITION Quantitative (WHO): A m ou n t o f blood lo s s in excess of 500mL following birth of baby.

7. DEFINITION Clinical : Any amount of bleeding , from or into genital tract , following birth of baby  the end of puerperium , which adversely affect the condition of patient , evidenced by rise in PR , and falling BP .

8. Any amount of bleeding from and into the genital tract following the birth of the baby up to the end of the pueperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling BP is called post partum haemorrhage ”. Incidence 4-6% of all deliveries.

9. CLASSIFICATION AMOUNT OF BLOOD LOSS TY P E S Minor (< 1L) Severe (> 2L) Major (> 1L) S E C ON D A R Y PRIM A R Y

10. beyond 24 hours and within p u erperium within 24 hours following the birth of baby Third stage hemorrhage: Bleeding occurs before expulsion of placenta True PPH: Bleeding occurs subsequent to expulsion of placenta

11. Primary Postpartum H emorrha g e

12. Primary post partum haemorrhage Causes 4 T’s Tone Tissue Trauma Thrombin( blood coagulopathy)

13. A t onic u t erus Blood c oagulop a t h y Combined (atonic uterus +trauma) CAUSES R e t ained tissues T r aum a tic D r ugs Tone Thrombus Trauma Tissues

14. COMMONEST CAUSE OF PPH 80% 1. A t onic u t erus

15. Separation of placenta Torn uterine sinuses Cannot be compressed effectively Imperfect contraction & retraction of uterine musculature Bleeding continues

16. C A U S E S GRAND M U L TI P ARA O V ER D I S T E NDED UTERUS MALNUTRITION & ANEMIA ANTEPARTUM H E M ORR H A GE PROLONGED OR RAPID LABOUR ANESTHESIA INDUCTION OR A UGM E N TA TION UTERUS M A L F OR M A TION MISMANAGED 3 RD STAGE OFLABOR

17. Uterine atony High parity Over-distension of the uterus Malnutrition and anemia Antepartum hemorrhage General anesthesia Poorly perfused myometrium Prolonged labour Following augmented labour

18. Uterine atony in previous labour Chorioamnionitis Malformation of uterus Uterine fibroid Very rapid labour Mismanaged third stage of labour

19. Constriction ring: Avulsed cotyledon, succenturiate lobe Placenta previa Placental abruption A full bladder

20. CONTRIBUTES OF ALL PPH 10- 20% 2. T r aum a tic Trauma to genital tract usually occurs following operative delivery and even after spontaneous delivery

21. Trauma involves usually the cervix, vagina, perineum, paraurethral region ( episiotomy wound or lacerations ) Rupture of uterus (rare) Broad ligament haematoma V ul v o - v agin a l haematoma Uterine inversion

22. Cause PPH due to imperfect uterine contraction Bits of placenta Blood clots 3. R e t ained tissues

23. Rare causes of PPH Blood coagulopathy may be due to diminished pro- coagulants or increased fibrinolytic activity Conditions : Abruptio placentae Jaundice in pregnancy Thrombocytopenic purpura HELLP syndrome IUD Specific therapy following coagulation screen including recombinant activated factor VII may be given 4. Blood c oagulop a t h y (THROMBUS)

24. Drugs Use of t o c olytic drugs Ritodrine Nifedipine Ma g ne s ium sulphate Combination of atonic and traumatic causes

25. Clinical Features Visible bleeding Maternal collapse Pallor Rising pulse rate Falling BP Altered level of consciousness May restless/drowsy Enlarged uterus, boggy on palpation

26. Diagnosis Direct observation in open hemorrhage. In concealed case, diagnosis is based on clinical effects. In traumatic hemorrhage- uterus is contracted. In atonic hemorrhage-uterus is flabby and becomes hard on massaging.

27. A) GENERAL EXAMINATION The general examination of the patient correspond to the amount of blood loss In excessive blood loss, manifestation of shock appear as hypotension , rapid pulse , cold sweaty skin , pallor , restlessness , air hunger & syncope ABDOMINAL EXAMINATION In atonic PPH: Uterus is larger than expected, soft, & sque e zing it lead to gush of clotted blood PV . In traumatic PPH: Uterus is contracted

28. C) VAGINAL EXAMINATION In atony : Bleeding is usually started few minutes after delivery of t he fetus It is dark red in colour Placenta may not be delivered In trauma : Bleeding starts immediately after delivery of fetus It is bright red in colour Lacerations can be detected by local examination

29. I n ve s tigations Thorough examination of the lower genital tract. This may require theatre/anaesthesia. CBC, clotting screen, cross match, Coagulation studies Hourly urine output Continuous pulse/blood pressure or central venous pressure monitoring ECG, pulse oximetry

30. PREVEN T IO N - ANTENATAL Improvement of the health status of the women & to keep the haemoglobin level normal (>10g/dl). High risk patients who are likely to develop PPH ( such as twins, hydramnios etc.) are to be screened & delivered in a well equipped hospital Blood grouping should be done for all women so that no time is wasted during pregnancy. Placental localization must be done in all women with previous caesarean delivery by USG or MRI to detect placenta accreta or percreta Women with morbid adherent placenta are at high risk of PPH. Such a case should be delivered by senior obstetrician.

31. PREVENTIO N - INTRANATAL Active management of the third stage , for all women in labour should be routine as it reduces PPH by 60%. Cases with induced or augmented labour by oxytocin , the infusion should be continued for at least 1 hour after the delivery. Women delivered by caesarean section : Oxytocin 5 IU slow IV is to be given to reduce blood loss (Carbetocin 100mcg) Spontaneous separation & delivery of the placenta reduces blood loss (30%) Exploration of the utero- vaginal canal for evidence of trauma following difficult labour or instrumental delivery. Expert obstetric anaesthesist is needed when the delivery is conducted under general anaesthesia Examination of the placenta & the membranes should be a routine so as to detect at the earliest any missing part.

32. Immediate care in PPH COMMUNICATE. RESUSCITATE. MONITOR / INVESTIGATE. STOP THE BLEEDING.

33. Communicate to clinical team Call experienced midwife Call obstetric registrar & alert consultant Call anaesthetic registrar, alert consultant Alert haematologist Alert Blood Transfusion Service Call porters for delivery of specimens / blood

34. Resuscitate IV access with 14 G cannula X 2 Head down tilt Oxygen by mask, 8 litres / min Transfuse Crystalloid Colloid

35. Management of 3 rd stage hemorrhage The principles in the management are: To empty the uterus of its contents & to make it contract To replace the blood To ensure effective haemostasis in traumatic bleeding

36. Steps of management: Placental site bleeding Palpate the fundus and massage the uterus to make it hard. To start crystalloid solution (NS or RL) with oxytocin (1L with 20 units) at 60 drops per minute and to arrange for blood transfusion Oxytocin 10U IM or Ergometrine 0.25mg or methergine 0.2mg is given intravenously. Catheterise the bladder Sedation with morphine 15mg intramuscularly. To give antibiotics

37. MANAGEMENT OF THIRD STAGE BLEEDING Palpate the fundus & massage the uterus to make it hard To start normal saline drip with oxytocin & arrange for blood transfusion Oxytocin 10 units IM/ Methergin 0.2mg IV Catheterize the bladder Antibiotics (Ampicillin 2g & Metronidazole 500mg IV) Placenta separated Not separated Express the placenta out by fundal pressure or controlled cord traction method Manual removal under GA ** Traumatic haemorrhage should be tackled by sutures

38. Manual Removal of Placenta Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7

39. STEPS OF MANUAL REMOVAL OF PLACENTA PREPARATION- General anesthesia, Lithotomy position, Catheterization INTRODUCTION of one hand into the uterus after smearing with antiseptic solution in cone shaped manner fingers of the other hand separate the labia majora fingers of uterine hand should locate the placenta

40. 3. COUNTER PRESSURE on uterine fundus by the hand placed on abdomen (abdominal hand) it should steady the fundus & guide the movements of fingers inside the uterine cavity till the placenta is completely separated 4. INSINUATION of fingers between the placenta and the uterine wall - back of the hand in contact with the uterine wall

41. 5. EXTRACTION of placenta traction of the cord by the other hand uterine hand is still inside the uterus for exploration of the cavity (to be sure that nothing is left behind) 6. COMPLETION IV Methergin 0.2mg is given uterine hand is gradually removed while massaging the uterus by the external hand to make it hard

42. 7. INSPECTION inspection of cervicovaginal canal to exclude any injury placenta and membranes is checked for completeness be sure that uterus remains hard and contracted

43. Difficulties : Hour – glass contraction Morbid adherent placenta constriction of an organ at its centre as a result of abnormal muscular  contraction . ...  Hourglass contraction  is the complication of labour , tending to trap the placenta in the upper part of the constricted uterus and possibly leading to excessive blood loss after delivery.

44. Complications Haemorrhage due to incomplete removal Shock Injury to the uterus Infection Inversion Subinvolution Thrombophlebitis Embolism.

45. Management of true post partum haemorrhage Principles To diagnose the cause of bleeding. To take prompt and effective measures to control bleeding. To correct hypovolemia.

46. Management General measures Call for help. Put in two large bore, 14 gauge, cannulas. Keep patient flat and warm. Send blood for grouping and cross matching and ask for 2 units of blood. Oxygen by mask, 10-15 litres / min Start 20 units of oxytocin in 1 L of NS at the rate of 60 drops/mt. Monitor vital signs Monitor type and amount of fluids the patient has received, urine output, drugs- type, dose and time, CVP.

47. Actual Management : note the feel of the uterus. Atonic uterus Step 1: Massage the uterus to make it hard. Step 2: Explore the uterus under GA

48. Step 3: Uterine massage and bimanual compression. Step 4: Uterine tamponade Step 5: Surgical methods Step 6: hystrectomy

49. Actual Management : Atonic u terus Step 1: Massage the uterus to make it hard and express the blood clot. Inj. Methergin 0.2mg IV. Start Inj.oxytocin drip (10 units in 500ml of NS) at the rate of 40- 60 drops per min. Catheterise the bladder Examine the expelled placenta and membranes for completeness. If the uterus fails to contract , proceed to the next step.

50. Step 2: Explore the uterus under GA. Simultaneous inspection of the cervix, vagina specially the para- urethral region is to be done to exclude co- existent bleeding sites from the injured area. Blood transfusion Continue oxytocin drip.

51. In refractory cases: Inj. 15 methyl PGF 2 α 250micro gram IM in the deltoid muscle every 15 minutes ( upto maximum of 2 mg) or Misoprostol (PGE 1 ) 1000 microgram per rectum. When uterine atony is due to tocolytic drugs, calcium gluconate (1 gm IV slowly)

52. Step 3: Uterine massage and bimanual compression. Step 4: Uterine tamponade Tight intra uterine packing done uniformly under GA. Balloon tamponade

53. Step 5: Surgical methods Ligation of uterine arteries Ligation of the ovarian and uterine artery anastomosis Ligation of the anterior division of internal iliac artery (unilateral or bilateral).

54. Step 6: Hysterectomy

55. P r o t o c ol Stage : normal - treated with fundal massage and oxytocin. Stage 1 : more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red cells.

56. Stage 2 : bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.

57. Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy Following PPH keep the patient in labour room and observe for 24- 48 hrs. Traumatic PPH The trauma to the perineum, vagina and the cervix is to be searched under good light by speculum examination and haemostasis is achieved by appropriate catgut sutures. The repair is done under GA, if necessary.

58. Secondary PPH Causes: The causes are, Retained bits of placenta or membranes. Infection and separation of slough over a deep cervico- vaginal laceration. Endometritis and subinvolution of the placental site Withdrawal bleeding following oestrogen therapy for suppression of lactation. Other rare causes are—chorion epithelioma; carcinoma of cervix, infected fibroid s or fibroid polyp s and puerperal sepsis.

59. Diagnosis The bleeding site is usually bright red. Varying degree of anaemia and evidences of sepsis are present. Internal examination reveals evidences of sepsis, subinvolution and often a patulous cervical os. USG helps in detecting retained bits of placenta inside the uterine cavity.

60. Manage m ent Principles— (1) To assess the amount of blood loss and to replace the lost blood. (2) To find out the cause and to take appropriate steps to rectify it.

61. Call doctor Reassure woman and support person Rub up contraction by massaging uterus if it is still palpable Express any clots Encourage to empty bladder Give an uterotonic drug Keep all pads and linen to assess blood loss If bleeding persists transfer women to the high facilitated hospital.

62. Supportive therapy: Blood transfusion, if necessary; Inj Ergometrine 0.5mg IM, if the bleeding is uterine in origin, antibiotics as routine. Conservative treatment : If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24hrs or so is done in hospital.

63. Active treatment : As the commonest cause is due to retained bits of placenta or membranes, it is preferable to explore the uterus urgently under GA. The products are removed by ovum forceps. Gentle curettage is done by using flushing curette. Ergometrine 0.5mg is given IM. If bleed is from sloughing of wound of cervico- vaginal canal, control it by suturing.

64. Com p li c ations Shock Collapse Disseminated intravascular coagulation

65. Nursing Management

66. Nursing Assessment Assess for hypotension, tachycardia, change in respiratory rate, decrease in urine output, and change in mental status—may indicate hypovolemic shock. Assess location and firmness of uterine fundus. Percuss and palpate for bladder distention, which may interfere with contracting of the uterus. Monitor amount and type of bleeding or lochia present and the presence of clots. Inspect for intactness of any perineal repair

67. Nursing Management Deficient fluid volume r/t excessive blood loss secondary to uterine atony, lacerations, incisions, coagulation defects, retained placental fragments , hematomas Fear and anxiety r/t threat to physical being, deficient knowledge of treatment . Pain r/t uterine contractions, distention from blood between uterine wall and placenta. Risk for complication, shock related to excessive bleeding

68. Interrupted breast feeding r/t mother’s health state during the PPH. Risk for impaired parent/ infant bonding r/t lack of early parent/ infant contact. Risk for Infection related to blood loss and vaginal examinations

69. Nursing Interventions A. Decreasing Anxiety Maintain a quiet and calm atmosphere. Provide information about the situation and explain everything as it is done; answer questions that the woman and her family ask. Encourage the presence of a support person.

70. B. Maintaining Fluid Volume Maintain or start a large-bore IV line if vaginal bleeding becomes heavy. Ensure that crossmatched blood is available. Infuse oxytocin, IV fluids, and blood products at prescribed rate. Monitor CBC for anemia.

71. C. Preventing Infection Maintain aseptic technique. Evaluate for symptoms of infection, chilling, and elevated temperature, changes in white blood cell count, uterine tenderness, and odor of lochia. Administer antibiotics as prescribed.

72. Patient Education/Health Maintenance Educate the woman about the cause of the hemorrhage. Teach the woman the importance of eating a balanced diet and taking vitamin supplements. Advise the woman that she may feel tired and fatigued and to schedule daily rest periods. Advise the woman to notify her health care provider of increased bleeding or other changes in her status.

73. Evaluation Verbalizes concerns about her well-being Vital signs stable, urine output adequate, hematocrit stable Remains afebrile, WBC count within normal limits

74. RETAINED PLACENTA The placenta is said to be retained when it is not expelled out even 30 minutes after the birth of the baby.(WHO 15mnts)

75. PLACENTA ACCRETA, INCRETA, AND PERCRETA

76. INVERSION OF THE UTERUS It is extremely rare but a life threatening complication in third stage in which the uterus is turned inside out partially or completely.

77. OBSTETRIC SHOCK  Shock is a critical condition and a life threatening medical emergency.  Shock results from acute, generalized, inadequate perfusion of tissues, below that needed to deliver the oxygen and nutrients for normal function

78. AMNIOTIC FLUID EMBOLISM Definition An amniotic fluid embolism is rare but serious condition that occur when amniotic fluid, fetal material, such as hair, enters the maternal bloodstream

79. Thank You 