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Complications of the third stage of labour



Third stage labour complication

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Third stage labour complication

  2. 2. THIRD STAGE OF LABOUR Begins after expulsion of fetus and ends with expulsion of placenta and membranes It is the most crucial stage of labour Average duration is 15 minutes in both primi and multigravida. With active management, it is reduced to 5 minutes. 2
  3. 3. IT HAS 3 PHASESI. Phase of Placental seperationII. Descent of placenta to the lower segmentIII. Expulsion of placenta with membranes 3
  4. 4.  PHASE OF PLACENTAL SEPERATION :-For some time after delivery of the foetus, patientexperiences no pain. Intermittent discomfort coincidingwith uterine contractions occurs. After the birth of babyuterus measures 20 cm vertically and 10cm anteroposteriorialy, discoid in shape .Surface area of placental site is reduced due to retraction.Placenta is inelastic cannot contract simultaneously,hence buckling occurs.Plane of seperation is through the deep spongy layer ofdecudia basalis . 4
  5. 5. THERE ARE TWO WAYS OF seperation1. Central (SCHULTZE) :-detachment starts from centre, uterine sinuses are opened, retro placental collection of blood occurs resulting in further seperation.3. Marginal (Mathew duncan):- Here seperation starts at margin, more area get separated with progressive uterine contractions. This occurs more frequently 5
  6. 6. SIGNSBefore seperation- uterus is discoid, firm, non- ballotable. height of uterus is a litle below umblicus. Length of cord remains static. 6
  7. 7. After seperation –•uterus becomes globular, firm, ballotable.• Fundal height is raised•Sudden gush of blood•Permanent lengthening of cord occurs. 7
  8. 8. EXPULSION OF PLACENTAPlacenta lies in lower uterine segmentor upper vagina by contractions andretractions of uterus. It is furtherexpelled out by either voluntarycontractions of abdominal muscles orby manual procedure 8
  9. 9. MECHANISM OF CONTROL OF BLEEDING• Arterioles passing tortuously through the interlacing intermediate layer of myometrium are clamped by retraction. This is called ‘living ligature’ or ‘physiological sutures of uterus’.• Thrombosis occurs to occlude the torn sinuses which is facilitated by hypercoagubable state of pregnancy.• Myotamponade due to apposition of walls of uterus also contribute. 9
  10. 10. EXAMINATION OF PLACENTAPlacenta is placed on the pronated hands and examined:- Maternal surface is first examined for any missing cotyledons. Completeness of membranes should be assessed. Placental foetal surface should be inspected for any blood vessels that radiate beyond placental edge into membranes with no corresponding placental tissue. Position of insertion of cord is noted. Cut end of cord is examined for number of vessels. Cord length is seen. Placental weight is recorded. Any calcification, clots. In twins, chorionicity can be determined. 10
  11. 11. MANAGEMENT OF THIRD STAGE OF LABOURTwo methods of management Expectant or traditional Active 11
  12. 12. EXPECTANT In this , placental seperation and its descent into vagina are allowed to occur spontaneously. Normally, placenta is expelled within 15-20 miniutes. With the aid of gravity. One hand is kept on fundus to o Recognise signs of seperation of placenta o To note uterine contraction and relaxations o To note cupping of fundus 12
  13. 13. EXPECTANT MANAGEMENT Delivery of the baby clamp, divide ligate cord wait & watch •Guard Fundus •Empty Bladder Placenta separated wait for spontaneous expulsion with aid of gravity 13
  14. 14. fails Assisted Expulsion Examine placenta & membranesInspection of vulva, vagina, perineumuterus should not be massaged 14
  15. 15. ASSISTED EXPULSIONI. Controlled cord traction- Also known as modified Brandt-Andrew’s method  Palmar surface of fingers of left hand are placed above the symphysis pubis. Body of uterus is pushed upwards & backwards towards umbilicus  Right hand gives a steady traction in downward & backward direction until the placenta comes outside introitus.  It is done only when uterus is hard & contracted 15
  16. 16. Placenta is graspedwith hand &twisted round &round with gentleextraction so thatmembranes arestripped intact 16
  17. 17. II. Fundal Pressure Is preferred in case of premature or macerated baby Four fingers are placed behind the fundus & thumb in front. fundus is pushed downwards & backwards. Pressure is applied when uterus becomes hard and released as soon as placenta passes through introitus 17
  18. 18. ACTIVE MANAGEMENT OF THIRD STAGE Preferred method Powerful uterine contraction are initiated within 1 minute of delivery of a baby by giving parenteral oxytocin Controlled cord traction is done Fundal massage throughthe abdomen until ut is well contracted It favours early seperation of placenta & produces effective uterine contractions after seperation 18
  19. 19. Delivery of BabyInj-oxytocin 10 units i/ m within 1 minute Cord clamped, cut & ligated Placenta delivered bycontrolled cord traction fails wait for 10 minutes, repeat procedure 19
  20. 20. fails manual removalExamine placenta & membranesInspection of vulva, vagina, perineum 20
  21. 21.  It minimizes blood loss to about 1/5 Shorten the duration of 3rd stage to about half 1-2% increased chances of retained placenta If accidentally given during twin delivery, after birth of 1st twin can cause asphyxia of second baby Maternal pulse and BP should be monitored immediately after delivery and every fifteen minutes for the first hour. 21
  22. 22. DRUGS USE IN ACTIVE MANAGEMENT• Oxytocin• Carboprost (15-Methyl PGF2 alpha)• Ergot alkaloids (Ergometrine/Methylergometrine)• Misoprostol 22
  23. 23. DRUG DOSE ROUTE DOSE SIDE CONTRAIN FREQUEN EFFECTS DICATIONS CYOxytocin 10 units IM (10 units) stat •Nausea •Not as IV •Water bolus,otherwise intoxication none.Methergin 0.2mg First line IM/IV Every 2-4 hours •Nausea •Hypertension. Second line •Vommiting •Pre eclampsia PO. •hypertinsion15-Methly 0.25mg First line IM Every 15-90 •Nausea •BronchialPGf-2alfa Second line min(8 doses •Vomiting asthma intra uterine max) •Diarrhoea •Active •chills cardiac,renal or hepatic diseaseMisoprostol(PG 400-600mcg First line PR Single dose •Fever NoneE-1 second line PO •Tachycardia 23
  24. 24. COMPLICATION OF THIRD STAGE OF LABOUR• PPH• Retained placenta• Uterine inversion• Amniotic fluid embolism• shock 24
  25. 25. RETAINED PLACENTA• When the placenta is not expelled out even after 30 minutes of birth of the baby.• WHO criteria-15 minutes• Longer intervals are associated with an increased risk of PPH with rates doubling after 10 minutes• Affects 1-2% of all deliveries• In general 90% of placentas deliver within 15 minutes, 96% within 30 minutes and 98% within 60 minutes 25
  26. 26. PREDISPOSING FACTORS• Retained placenta in previous pregnancy• Long acting oxytocic agents, such as ergometrine or synometrine.• Uterine fibroids• Uterine anomaly, such as bicornuate uterus.• Uterine scar-previous caesarean section, myomectomy curretage placenta accreta 26
  27. 27. COMPLICATIONSo Hemorrhageo Shocko Puerperal sepsiso Risk of recurrence in next pregnancy around 6% 27
  28. 28. IN CASE OF NON ADHERENT PLACENTA, THE FOLLOWING STEPS ARE TAKEN Uterine massage must be performed to expel the clots. Oxytocics are repeated. 10 units of Oxytocics are given i/v 500 ml in NS. Ergometrine should be avoided as it may cause tonic uterine contractions which may further delay expulsion. Bladder should be emptied Controlled cord traction should be repeated to delivery the placenta. 28
  29. 29.  If placenta appears to be trapped in lower uterine segment, a vaginal examination should be done to remove the placenta. Injection of the umbilical vein with 20 ml solution of 0.9% saline with 20 units of oxytocin can be tried. Alternatively, Pipingas technique can be used in which a size 10 nasogastric tube is passed along the umbilical vein till resistance is felt. The tube is then withdrawn by 5cm and then the solution is injected. It results in complete filing of the placental bed resulting in adequate delivery of oxytocin to retroplacental bed. 29
  30. 30.  Intra-umbilical injection of 20 mg of PG F2α in 20 ml saline has also been tried. If placenta does not deliver within 30mts by these techniques, patient should be taken to O.T. for manual exploration of placenta under GA. If a distinct clevage plane can be located between placenta and uterine wall MROP should be tried. If not located then morbidly adherent placenta should be considered. 30
  31. 31. MANUAL REMOVAL OF PLACENTA A written informed consent At least 2 units of blood should be arranged It is done under GA Patient is placed in lithotomy position and bladder catheterized Labia are separated by fingers of one hand and the other hand is introduced into uterus in a cone shaped manner, following the cord which is made taut by other hand. Margin of placenta is located. Counter pressure is applied on uterine fundus to steady the fundus and guide the movements of fingers inside the uterine cavity. 31
  32. 32. Fingers are insinuatedb/w the placenta anduterine wall with theback of hand in contactwith the uterine wall.Placenta is separatedwith slicing sidewaysmovement of fingers tillit is completelyseparated. 32
  33. 33.  It is extracted by traction of cord by other hand. If removal is difficult : ‘piecemeal removal’ of placenta should be done. i/v Methergin 0.2 mg is given Inspection of cervico-vaginal canal should be done. Placenta should be examined 10 units oxytonic in 500 ml NS is started to initiate & maintain contraction. A broad spectrum antibiotic is given for 12-24 hrs to prevent infection. 33
  34. 34. COMPLICATIONSo Hemorrhage :- due to incomplete removalo Shocko Injury to uteruso Infectiono Inversiono Sub- involutiono Thrombophlebitiso Embolism 34
  35. 35. DIFFICULTIES ENCOUNTEREDHour glass contraction- there is a localized contraction of circular muscles of uterus either at the junction of lower and upper segment or may be placed in 1 cornu. It occurs due to premature attempts in removing of placenta or due to administration of methergin. It is managed by deepning the plane of anesthesia. 35
  36. 36. •Morbid Adherent Placenta- Also K/A PlacentaAccreta•Placenta is directly anchored to myometriumwithout any intervening decidua.•due to absence of decidua basalis or imperfectdevelopment of fibrinoid or nitabuch’s layer.•It is an area of fibrinoid degeneration wheretrophoblasts cells meet the decidua. The layerinhibits further invasion of decidua bytrophoblast . 36
  37. 37. TYPESPlacenta accreta:- Placenta adheres to myometruim (Fig. A)Placenta increta:- Placenta invades myometruim (Fig. B)Placenta percreta:- placenta penetrates myomentruim to or beyond serosa (Fig. C)Incidence is 1 in 2500 deliveries 37
  38. 38. RISK FACTORS Placenta previa and prior caesarean delivery o Risk of placenta accreta with placenta previa in an unscarred uterus is 3% o Women with placenta previa with previous 1 caesarean section has 14% risk of accreta. o Women with 3 caesarean have 44% risk Prior myomectomy Manual removal of placenta D&C Increasing maternal age and parity . 38
  39. 39. DIAGNOSISDuring pregnancyUSG is only 33% sensitive. The findings suggestive are  Loss of normal hypoechoic retroplacental myometrial zone.  Thinning and abruption of uterine serosa:- Bladder interface and focal exophytic masses within the placenta.Colour Doppler has a sensitivity of 100%  A distance less than 1 mm between the uterine serosa- bladder interface and retro placental vessels  Identification of large intraplacental lakes 39
  40. 40. MRI findings suggestive of accreta are:-  Uterine bulging  Heterogeneous signal intensity within the placenta  Presence of dark intraplacental bands on T2 weighted imaging. There is an unexplained rise of MSAFP and B-HCG greater than 2.5 MOM. 40
  41. 41. HISTO PATHOLOGICAL EXAMINATION Absence of decidua basalis Absence of nitabuch’s fibrinoid layer Varying degree of peneteration of the villi into the muscle bundles or upto serosa. 41
  42. 42. MANAGEMENT1. CONSERVATIVEIN PARTIAL PLACENTA ACCRETA :-As much as possible of placental tissue is removed manually.Oxytocics are given for effective uterine contraction andhaemostasis, or by intrauterine plugging. Remaining trophoblast is usually reabsorbed spontaneously. Levels of B-HCG should be monitored. During caesarean bleeding areas can be undersewed. 42
  43. 43. IN TOTAL PLACENTA ACCRETA : - After explaining the risks of hemorrhage and failure o Cord is cut as near to placenta which is left as such o Patients vitals and bleeding is monitored o Antibiotics are given o B-HCG values are monitored o Methotrexate 50 mg i/v on alternate days can be given 43
  44. 44. SURGICAL MANAGEMENTIf bleeding remains uncontrollable then:- Uterine art embolisation Low and high b/l uterine vesseles ligation Ligation of internal iliac arteriesIf all these methods fail or patient in shock :- hysterectomy. 44
  45. 45. INVERSION OF UTERUS A rare complication of third stage with incidence being .05% of deliveries Uterus is turned inside out either completely or partially Acute - With in 24 hrs subacute - 24 hrs - 4wkChronic > 4 wkIncidence - 1 in 2000 to 1,20,000Maternal survival rate is 85% 45
  46. 46. DEGREE OF INVERSIONI. Dimpling of fundus which still remains above the level of internal os.II. Fundus passes through cervix but is inside vagina 46
  47. 47. • Also called complete:- Endometrium with or without the attached placenta is visible outside the vulva. The cervix and part of vagina may also be involved. 47
  48. 48. ETIOLOGYI. SPONTANEOUS – Occurs is about 40%  caused by local atony on placental site over the fundus associated with increase in intra abdominal pressure as in coughing, sneezing or bearing down effort.  Fundal attachment of placenta (75%), short cord, placenta accreta may be associated. 48
  49. 49. IATROGENIC  Fundal pressure on a relaxed uterus  Strong traction on cord  Faulty techniques in manual removal of placentaASSOCIATED RISK FACTORS ARE  Uterine over distention  prolonged labour > 24 hrs  Uterine malformations  Short cord  Collagen diseases  Use of magnesium sulphate during labour 49
  50. 50. DIAGNOSISSymptoms :- Acute lower abdominal pain withbearing down sensationSigns:- 1. Varying degree of shock 2. On P/A –cupping or dimpling of fundal surface.On bimanual examination :- Crater like depression on abdomenalong with vaginal palpation of fundal wall in lower segment ofcervixSound Test – Confirmatory absent uterine cavity 50
  51. 51. In completevariety, a pearshaped bluish greymass protudesoutside vulva withthe broad endpointingdownwards 51
  52. 52. COMPLICATIONS• Shock:- is mainly neurogenic  Tension on nerves due to stretching of infundibulopelvic ligament.  Ovaries are dragged along causing pressure on then.  Peritoneal irritation. 52
  53. 53. • Hemorrhage –more if placenta is separated• Pulmonary embolism• If not treated - infection, uterine sloughing can occur. It becomes chronic 53
  54. 54. MANAGEMENT• Immediate assistance is summoned• Two large bore intravenous infusion systems are started, crystalloids, blood should be arranged bladder is cathertized.• Urgent manual replacement is the mainstay of treatment, preferably under GA. Uterine relaxant anaesthetics such as halothane is preferred. Injection pethidine/ diazepamis given• If the placenta is still attached, it should not be removed 54
  55. 55. TWO METHODS OF MANAGING ACUTE INVERSIONI. MANUAL – called JOHNSON’S METHOD.  The part of the uterus which is inverted last is to be replaced first 55
  56. 56.  The protruding mass is thoroughly cleaned with antiseptic solution. Protruding fundus is grasped with the palms of hands with the finger directed towards post fornix. Uterus is lifted through pelvis into the abdomen while applying countersupport over the abdomen. Too much pressure should not be given so as to cause perforation of uterus. Once the uterus is reverted an oxytocin drip is started to increase uterine tone and prevent recurrence. Hand should remain inside uterus till it is well contracted.Placenta should then be removed manually 56
  57. 57. II. HYDROSTATICS OR O’ SULLIVAN’S METHOD  Place the patient in lithotomy position 57
  58. 58.  Head end is lowered 0.5 mt below the level of perineum Prepare a disinfected douche system with large nozzle with a long tube (2 meters) and 3 - 5 ltr warm NS Identity post Fx – easily done in partial inversion & in others identify the point where rugosed vagina becomes smooth vagina. Place nozzle in post Fx. At the same time with other hand hold labia sealed. Ask assistant to start the douche with full pressure Raise reservoir to 2 meters. NS distends post Fx gradually so that it is stretched- circumference of orifice increases- cervical constriction relived - uterus is repositioned Ogueh and Ayida technique:- In this similar procedure is done by using silicon cup in vagina attached with iv tubing 58
  59. 59. SURGICAL INTERVENTIONS May be required in presence of a dense constriction ring. Laprotomy is required. Initially Huntingtons procedure is done in which alli’s forceps are used to grasp the myometrium just inside dimple of fundus systematically and sequentially using forceps on both sides, inverted fundus is then withdrawn from crater to fully correct the inversion 59
  60. 60. IF IT FAILS HAULTAINS OPERATION:- DONE ABDOMINALLY• Ring of tissue is grasped by Alli’s joreeps• A vertical incision is made in middle at the post rim.• A finger is passed through the incision and inverted fundus is pushed up.• Assistant may also push up inverted fundus through vagina 60
  61. 61. Kustner’s Operation:- Done vaginally• Uterus is drawn upwards and forwarded with a valsellum holding at fundus.• POD is opened by a transverse incision on the post vaginal wall• Lt. index finger is introduced along hollow of inverted uterus. Post uterine wall is cut through by a scapel from fundus to ext os.• Inverted uterus is turned inside out and inversion is corrected.• In spinelli’s operation, uteroveseial pouch is opened and uterine incision is made on anterior wall. 61
  62. 62. AFTER REPOSITIONING• Discontinue uterine relaxant/GA• Start infusion of oxytocics• Bi manual ut. Massage is maintained until ut is well contracted and bleeding stops.• Remove placenta if retained.• Careful manual exploration to rule out trauma to genital tract.• Antibiotics• Oxytocics for 24 hrs• Monitor for reinversion 62
  63. 63. AMNIOTIC FLUID EMBOLISM• Complex disorder characterized by abrupt oneset of hypotension, hypoxia and consumptive coagulopathy.• Risk factor include advanced maternal age, placenta previa, pre eclampsia, forceps or caesarean delivery.• Women in late stages of labour or immediately post partum begin gasping for air, suffers seizures or cardiorespiratory arrest occurs 63
  64. 64. MECHANISMAmniotic fluid is forced into circulation either through arent in membranes or placenta. Thromboplastin richliquor containing the debris blocks pulmonary arteriesand triggers coagulation mechanism leading to DIC.There is massive fibrin deposition along the entirepulmonary vasculature leading to cardiopulmonaryarrest.If patient survives this there can be residual neurologicaldamage severe bleeding per vaginun or from veno-puncture sites. 64
  65. 65. MANAGEMENT• There are no data that any type of intervention improves maternal prognosis with amniotic fluid embolism.• Oxygenation, circulatory support blood transfusion is required.• Case fatality rate is 22% 65
  66. 66. THANK YOU 66
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