COMPLICATIONS OF THIRD STAGE OF LABOUR

1. 2. 3.

4.
5.

Post partum haemorrhage Retention of placenta Shock Pulmanary embolism Uterine inversion

POSTPARTUM HAEMORRHAGE
QUANTATIVE: ANY AMOUNT OF BLOOD LOSS IN EXCESS >500 ML FOLLOWING BIRTH OF BABY CLINICAL: ANY AMOUNT OF BLEEDING FROM OR INTO THE GENITAL TRACT FOLLOWING BIRTH OF THE BABY UPTO THE END OF PUERPERIUM WHICH ADVERSELY AFFECTS THE G C EVIDENCED BY ^ PULSE RATE& FALLING B.P.

TYPES
PRIMARY: with in 24 hrs, in majority with in 2 hrs Third stage haemorrhage bleeding before expulsion of placenta True pph- after expulsion of placenta SECONDARY: after 24 hrs & with in puerperium (delayed/ late PPH)

PRIMARY PPH
CAUSES

ATONIC TRAUMATIC MIXED BLOOD COAGULOPATHY

ATONIC UTERUS (80%)

Grand multipara Over-distended uterus Malnutrition & anemia Antepartum hemorrhage Prolonged labour Anaesthesia Oxytocin use

ATONIC UTERUS
Persistent uterine distension Malformation of uterus Uterine fibroid Mismanaged third stage of labour Constriction ring Precipitate labour

TRAUMATIC (20%)
Episiotomy Lscs Trauma to cx,vagina,perineum,paraurethral region Rupture of uterus Vulvo-vaginal/ broad ligament hematoma Mixed Coagulation disorders

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2. 3. 4. 5.

Mixed Coagulation disordersAbruptio Jaundice TTP HELLP syndrome IUD

DIAGNOSIS& CLINICAL EFFECTS

BLEEDING VISIBLE OUTSIDE,rarely concealed Effects depends on: A) predelivery hb% B)degree of hypervolemia C)speed of blood loss Tachycardia , hypotension Uterus 1) flabby- atonic pph 2)contracted- traumatic pph

PREVENTION
Antenatal Improvement in health status High risk patients Blood grouping and Rh typing Intranatal -Judicious use of sedatives & analgesics -hasty delivery of head avoided -Local anaesthesia

PREVENTION

Expert anaesthesist AMTSL Kneading& fiddling of uterus Examination of placenta Oxytocin infusion to be continued Exploration of UV canal Observation for 2 hrs

Intelligent anticipation, skilled supervision, prompt detection, effective institution of therapy

MGM OF THIRD STAGE BLEEDING

PRINCIPLES 1. Empty the uterus 2.Replace blood 3.Ensure effective hemostasis Steps: placental site bleeding traumatic bleeding

PLACENTAL SITE BLEEDING

To palpate fundus & massage Ergometrine Sedation I v line Catheterisation Signs of placental seperation +/ + deliver - MRP

MANUAL REMOVAL OF PLACENTA

STEP- I GA, painting,draping,cathetirisation STEP-II hand introduced into uterus STEP-III counter pressure with other hand STEP-IV seperation STEP- V extraction STEP- VI ergometrine STEP- VII examination

Difficulties : Hour glass contraction Morbid adherent placenta

COMPLICATIONS Hemorrhage Shock Injury to uterus Infection Inversion Subinvolution embolism

MGM OF TRUE PPH

PRINCIPLES: Diagnose cause Control bleeding Correct hypovolemia

Management Call for help 2 16g iv cannula Blood grouping cross matching Infuse 2 ltr NS colloids Monitoring pulse,BP,i/o,drugs CVP

ATONIC UTERUS

STEP-I massage, methergin, oxytocin,catheterisation,examine placenta STEP-II explore uterus under GA

STEP-III

BIMANUAL COMPRESSION

STEP-IV hot intrauterine douche STEP-V tight intra uterine packing

HYSTERECTOMY LIGATION OF UTERINE ,OVARIAN,INT ILIAC ARTERIES EMBOLISATION TRAUMATIC- REPAIR

SECONDARY PPH
CAUSES: 1.retained bits 2. Separation of slough 3.Subinvolution 4.Lscs > 14 days a) Separation of slough granulation tissue 5.Estrogen therapy 6.Chorion epithelioma, cacx,placental polyp,infected polyp,inversion

b)from

MANAGEMENT
Diagnosis: bright red bleeding Examination- sepsis,subinvolution MGM: principles: 1. assess blood loss& replace 2.Cause detect & rectify Supportive ;BT,methergin ,antibiotics Active treatment: exploration of uterus under GA , digital, curretage,methergin,HPE Bleeding due to seperation of slough- by sutures LSCS suturing,int iliac art ligation ,hysterectomy

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