Complications of third stage of labor.pptx

this power point deals with complications of third stage of labour

1. Complications of third stage of labor Dr Ramesan CK MBBS, MS, MCH ASSISTANT PROFESSOR, OBG, GMCH, MANJERI

2. ‘The most important single issue of care in labour is diagnosis. When the initial diagnosis is wrong, all subsequent care is likely to be also wrong’. KIERAN O’DRISCOLL

3. Definition Third stage of labor : The part of labor from the birth of the baby until the placenta and fetal membranes are delivered.

4. Active management of third stage of labour Uterotonics for the prevention of postpartum haemorrhage (PPH) Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH.

5. AMTSL controlled cord traction (CCT) for removal of placenta Delayed umbilical cord clamping (not earlier than 1 minute after birth)

6. AMTSL Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin . Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. CCT is the recommended method for removal of the placenta in caesarean section

7. Third stage of labour complications Post partum haemorrhage Retained placenta Uterine inversion Uterine rupture Vaginal and perineal lacerations Vulvovaginal hematoma

8. Retained placenta A placenta is considered retained if not delivered (partly or completely) within 30 minutes after birth despite adequate attempts to deliver it in cases of active management of the third stage of labour in the third trimester In cases of expectant management (physiological management of third stage), a placenta is considered retained if not delivered after 60 minutes. In the second trimester, the risk of retained placenta is usually higher.

9. Risk factors Gestational age (<26 weeks) Previously retained placenta (commonest) (risk 2– 4- fold higher) BMI >35 kg/ m2 Pre- eclampsia Induction of labour, prolonged first, second, or third stage of labour precipitate labour

10. Risk factors Grand multiparity (≥4) Maternal age (≥35 years) Known placental abnormality e.g. succenturiate lobe/ double placenta Uterine abnormalities(congenital mullerian fusion defects) Placenta praevia Previous CS/ uterine trauma, e.g. multiple curretage Stillbirth, IUGR (abnormal placentation).

11. Complications Postpartum haemorrhage Intrauterine infection and sepsis Uterine inversion (if over- zealous traction applied) Hysterectomy Maternal death

12. Prevention By active management of the third stage of labour

13. Management Oxytocin injection into the umbilical vein with 20 IU of oxytocin in 20 ml of saline followed by proximal clamping of the cord.

14. The Pipingas technique A size 10 nasogastric tube is passed along the umbilical vein until resistance is felt, then retracted about 5 cm, and PGF2α (20 mg diluted in 20 mL of normal saline) or oxytocin (30 IU diluted in 20 mL of normal saline) is injected through the catheter.

15. Assess degree of bleeding and haemodynamic status If actively bleeding or haemodynamically compromised act quickly— Immediate treatment for PPH should include: Calling for appropriate help Uterine massage IV fluids, blood and blood products Uterotonics Catheterize the bladder

16. Management Judicious attempt at controlled cord traction, with a hand on the abdomen to secure uterine fundus. Avoid excessive traction. If undelivered after 30 minutes, manual removal under anaesthesia and antibiotic prophylaxis is recommended. Anticipate PPH at all stages

17. Manual removal of placenta (MROP) Perform in theatre with sterile technique Adequate anaesthesia (usually epidural/ spinal). Bladder should be emptied. Prophylactic broad- spectrum antibiotic cover Use hand to progressively dilate cervix. Tocolysis is rarely required

18. MROP

19. MROP Manually shear placenta off uterine wall along the plane of cleavage/ separation while guarding the uterine fundus abdominally with the non- dominant hand. Remove placenta wholemeal if possible and check whether it is complete Re- explore cavity to check if empty. Bimanual compression of uterus to reduce inevitable bleeding.

20. Management If manual removal fails, instrument extraction using ring forceps or other large- headed forceps. If extracted placenta is incomplete and excessive bleeding ensues, curettage with a large, blunt curette might be needed.

21. In the event of non- delivery of the placenta When the placenta is morbidly adherent (placenta accreta / increta / percreta ) and does not separate at manual removal or is very difficult, then no further attempts should be made to deliver it as there is an increased risk of heavy bleeding and the need for hysterectomy.

22. Options If bleeding is minimal and does not continue Leave the placenta undisturbed (antibiotic and oxytocic cover) Placenta tends to autolyse and separate and get extruded Methotrexate is of questionable benefit

23. Options If active bleeding Balloon tamponade Emergency arterial embolization Surgical haemostasis: over sewing of the placental bed, compression sutures, pelvic devascularisation hysterectomy — preferable if the family is complete and no desire for future fertility or the bleeding is causing hemodynamic disturbance.

24. Post partum haemorrhage Postpartum hemorrhage (PPH) is defined as blood loss in excess of 500 ml after a vaginal delivery and greater than 1000 ml following a cesarean delivery Postpartum decline in hematocrit concentration level of 10%.

25. PPH 35% of all maternal deaths A significant cause for maternal morbidity or near miss mortality including coagulopathy, shock and adult respiratory distress syndrome, and peripartum intensive care unit admission

26. Classification PPH is classified as immediate or primary if it occurs within 24 hours after the completion of the third stage Delayed or secondary if it occurs between 24 hours and within 6–12 weeks of the puerperium.

27. RCOG classification Minor (500–1000 ml) Moderate (1000–2000 ml) Severe (>2000 ml)

28. Risk factors

29. Causes of postpartum hemorrhage .

30. Prevention Active management of the third stage of labor (AMTSL).

31. Management Early recognition and prompt diagnosis [atonic/ truamatic ] Aggressive treatment of causative factors Maintenance of effective circulating intravascular volume by adequate replacement of blood and crystalloids Prompt recognition and correction of coagulopathy

32. Management

33. Pharmacological management Oxytocin 5– 10 IU IM bolus Oxytocin infusion 40 IU in 500 ml N/ saline at a rate of 125 ml/ hour Ergometrine 0.5mg IM or IV Misoprostol PR 800– 1000 mcg can be administered rectally Carboprost 250 mcg IM can be given every 15 minutes up to a maximum of 8 doses (2 mg). Contraindicated in asthma

34. Management If bleeding is persisting, approaching 1000– 1500 mL , or not settling with initial uterotonics , then transfer to theatre. The most senior obstetrician available should be present.

35. Surgical management Examination under anaesthesia (EUA) Direct uterine massage Uterine packing/ tamponade-condom If bleeding persists, then laparotomy would be the next step

36. Uterine massage

37. Management Compression sutures Pelvic devascularization Uterine artery catheterization Hysterectomy

38. Ligation of the uterine artery[o leary suture]

39. B-Lynch” suture.

40. Fluids and blood products Crystalloid: up to 2 L of Hartmann’s. Colloid: up to 1– 2 L of colloid until blood is available. Blood Fresh frozen plasma Platelet concentrate Cryoprecipitate

41. Blood components

42. Recombinant factor VIIa Effective in controlling severe, lifethreatening hemorrhage Recombinant factor viia acts on the extrinsic clotting pathway Given at a dosage of 50–100 μg /kg and repeated after 2 hours if haemostasis is not achieved Potentially prevent hysterectomy and the need for massive transfusion

43. Tranxemic acid Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.

44. Massive transfusion The three most common definitions of MT in adult patients are: Transfusion of ≥10 red blood cell (RBC) units within 24 h Transfusion of >4 RBC units in 1 h with anticipation of continued need for blood product support Replacement of >50% of the TBV by blood products within 3 h

45. From: Update on massive transfusion Br J Anaesth. 2013;111(suppl_1):i71-i82. doi:10.1093/bja/aet376 Br J Anaesth | © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected] Pathophysiological changes as a result of massive haemorrhage and transfusion

46. Massive transfusion protocols Administer blood products in a ratio of 1:1:1 (PRBC:FFP:PLT). In patients requiring massive transfusion of blood products, minimize crystalloid resuscitation to prevent dilutional coagulopathy . Platelet transfusions are indicated in the following situations: Surgical / obstetric patients with microvascular bleeding and PLT count <50,000. Any surgical patient with PLT count <20,000.

47. FFP (10-15 ml/kg) is indicated in the following situations: Hemorrhage with elevated PT or PTT (> 1.5 times normal). Urgent reversal of warfarin therapy Cryoprecipitate should be administered in the following situations: Hemorrhage with fibrinogen concentrations <100 mg/dL Bleeding patients with von Willebrand's disease. Tranexamic acid should be considered in patients with significant hemorrhage ▪ Initial dose: 1 gram IV over 10 minutes A second gram of TXA (either bolus or continuous infusion over 8 hours) may be considered in the presence of ongoing transfusions or hyperfibrinolysis

48. Consider the Massive Transfusion Protocol (MTP) in the presence of hemorrhage and Systolic blood pressure ≤ 90 mmHg Heart rate ≥ 120 beats per minute ( bpm ) pH ≤ 7.24

49. Consider MTP implementation if transfusing ≥ 4 units of PRBCs over 1 hour or expected transfusion of ≥ 10 units over 24 hours (more than one total blood volume) Maintain platelet counts above 100,000 during times of active hemorrhage Correct moderate and severe hypothermia (<34oC) using convective air blankets, humidified heated ventilator circuits, and warmed fluid infusions

50. Vaginal and perineal lacerations Perineal lacerations are classified as follows First degree : laceration of the vaginal epithelium or perineal skin only. Second degree : involvement of the perineal muscles but not the anal sphincter.

51. Vaginal and perineal lacerations Third degree : disruption of the anal sphincter muscles which should be further subdivided into: 3a: <50% thickness of external sphincter torn 3b: >50% thickness of external sphincter torn 3c: internal sphincter also torn. Fourth degree : a third- degree tear with disruption of the anal Epithelium. Isolated laceration of the rectal mucosa ( buttonhole ) without involvement of the anal sphincter

52. Etiology Normal vaginal delivery Instrumental delivery Shoulder dystocia Malpresentation and malposition Big baby

53. Management Manage bleeding Perform rectal examination to exclude anal sphincter involvement Ensure adequate analgesia

54. Management First- degree tears may not need suturing unless associated with bleeding. All second- degree tears should be sutured If multiple lacerations are present, each laceration should be repaired individually ensuring anatomical and cosmetic restoration.

55. Management Repair of a second- degree tear (including episiotomy) is performed in layers approximating the vaginal epithelium and perineal muscles. Rectal examination should be performed after repair to check for inadvertent insertion of sutures through the anal epithelium.

56. Management All third- and fourth- degree tears must be repaired in the operating theatre under regional or general anaesthesia. Anal epithelium is repaired with interrupted 3- 0 vicryl sutures with the knots tied in the anal canal. The internal anal sphincter is approximated using mattress sutures with 3- 0 pds sutures. The external sphincter can be repaired by the end- to- end or overlap technique using 3- 0 pdsr sutures.

57. Management All women with third- and fourth- degree tears should be prescribed antibiotics as a single IV dose intraoperatively , followed by 7 days of oral antibiotics. Laxatives should be prescribed for 7– 14 days.

58. Uterine inversion After delivery of the fetus , the uterus is partially or completely inverted and protrudes through the cervix, in or outside the vagina.

59. Classification First- degree (incomplete) inversion involves extension of the inverted fundus to the cervical ring. Second- degree (incomplete) inversion - the fundus protrudes through the cervical ring but the inverted uterus remains within the vagina. In third- degree (complete) inversion- the inverted fundus extends to the introitus. Fourth- degree inversion is a total inversion where the vagina is also inverted.

60. Puerperal uterine inversion can occur after a vaginal delivery or CS. It can be acute (<24 hours postpartum), subacute (>24 hours postpartum), or chronic (> 1 month postpartum).

61. Aetiology Mismanagement of the third stage involving fundal pressure and/ or excessive cord traction performed before placental separation. Too rapid withdrawal of the placenta during manual removal or at cs. Sudden rise in intra- abdominal pressure when the uterus is relaxed- Coughing or vomiting A short umbilical cord, fundal implantation of the placenta, morbidly adherent placenta, and uterine anomalies

62. Diagnosis Placenta may or may not be in situ Shock out of proportion to blood loss due to increased vagal tone Haemorrhage Uterine fundus not palpable per abdomen (in incomplete cases there may be a dimple in the fundal area) A mass in the vagina or outside the introitus.

63. Management Call for Help Manage shock Attempt to reposition the uterus:Do not attempt to remove the placenta if still attached to the uterus

64. Techniques to replace the uterus Manual replacement (the johnson manoeuvre) Preferable under general anaesthesia as it requires the uterus to be relaxed. Tocolytic drugs

65. Hydrostatic repositioning (O’Sullivan technique) Surgical management Huntington’s technique Haultain’s technique

66. Prevention Avoid mismanagement of third stage. Cord traction should not be applied until signs of placental separation appear, i.e. trickle of blood at introitus , lengthening of the cord, and globular, hard contracted uterus on palpation.

67. Vulval / perineal haematoma Risks factors Nulliparity Macrosomia, Prolonged second stage Vulval varicosities Clotting disorders Pre- eclampsia

68. Diagnosis Pain in the perineal area. Swelling of the perineal area. Occasionally may present with shock in spite of no obvious swelling- in cases of paravaginal haematoma. The classical presentation is pain, restlessness, urinary retention, and rectal tenesmus a few hours after delivery.

69. Management Management of shock if present. Surgical evacuation by incision and drainage if the haematoma is large and expanding. Incision should preferably be made in the vagina to avoid scar formation. Achieve haemostasis.

70. A large vulval haematoma may require a drain or pack in situ. Angiographic embolization can be considered when primary surgical management has failed. If small ( i.E. <5 cm) and not expanding use ice- packs and pressure dressings. Appropriate analgesia.

71. Uterine Rupture A uterine rupture is a frank opening between the uterine cavity and the abdominal cavity. A uterine dehiscenceis a “window” covered by the visceral peritoneum.

72. Etiology Iatrogenically caused by the use of oxytocics in the presence of a uterine scar Obstructed labor [grand multiparous] Midcavity forceps delivery, or breech extraction with internal podalic version External trauma Previously scarred uterus in labor

73. Risk factors Interdelivery interval of less than 24 months’ Gynecologic uterine surgery including laparoscopic myomectomy Placenta accreta Congenital uterine anomalies Postpartum fever

74. Diagnosis Sudden onset of fetal decompensation Abdominal pain, abrupt arrest of contractions, and retraction of the fetal presenting part Hemorrhagic shock in whom the cause is not immediately apparent Vaginal bleeding in a case of obstructed labor Fresh arterial blood in urine

75. Examination of the abdomen will most commonly reveal generalized tenderness, easily palpable fetal parts, and absent fetal heart activity.

76. Management Options Surgical repair or hysterectomy. Subtotal hysterectomy may be performed if the rupture is confined to the uterine corpus. Repair may be considered when technically feasible and there is a desire for future fertility If repair is performed, elective cesarean section has been advocated as soon as evidence of fetal lung maturity is obtained in a future pregnancy