1. 3rd
stage of labour and its
complications
Dr.Mallika Datta
Assistant Professor (G&O)
Medical College, Kolkata

2. Objectives
• What is the 3rd
stage of labour?
• Enumerate its complications?
• What is the ideal management of 3rd
stage?
(Active management of 3rd
stage of labour)
• What is postpartum haemorrhage, its causes
and its management?
• Management of other complications –
retained placenta, uterine inversion

3. What is 3rd
stage of labour
• Begins with expulsion of the foetus and ends
with expulsion of placenta and membranes
• Average duration – 15 min
• Reduced to 5 min by Active management

4. Normal placental separation
• At beginning of labour, placental attachment
corresponds to an area of 20 cm diameter
• From 2nd
stage of labour, progressive
diminution of the area due to uterine
contraction and retraction, esp after the baby
is delivered
• After birth of the baby, the whole uterus
measures 20 cm by 10 cm

5. Normal placental separation
• So placental surface area is halved
• Thus the inelastic placenta buckles and
separates
• The plane of separation runs through the
deep spongy layer of decidua basalis
• Innumerable torn sinuses with free circulation
from uterine and ovarian vessels now left

6. Control of bleeding
• Torn sinuses obliterated by complete retraction
of the uterine muscles – arterioles passing
through the interlacing fibres are clamped (living
ligature)
• Also thrombosis
• Apposition of the uterine walls (myotamponade)
Thus both placental separation and subsequent
control of bleeding depend on uterine
contraction and retraction

7. Complications of 3rd
stage
• Postpartum haemorrhage
• Retained placenta
• Shock – haemorrhagic or non-haemorrhagic
• Pulmonary embolism – amniotic fluid or air
• Uterine inversion

8. Active management of 3rd
stage of
labour (AMTSL)
3 components
• Administration of uterotonic drug within 1
min of delivery of baby
• Delivery of placenta by controlled cord
traction (CCT)
• Massaging the uterus to make it hard

9. AMTSL contd
• Reduces blood loss to 1/5th
• Reduces risk of PPH by 60%
• Shortens duration of 3rd
stage by half
• Only disadvantage – slight increase in risk of
retained placenta

10. AMTSL – Uterotonic drug
• Within 1 min of delivery, PALPATE THE
ABDOMEN to rule out the presence of an
additional baby(s)
• Give Oxytocin 10U IM
(Refrigeration needed, avoid large IV bolus)
• Alternative drugs – Ergometrine 0.2mg IM
Misoprostol 600μg SL/oral/PR/PV

11. AMTSL - CCT
• One hand to hold cord (clamped close to
perineum)
• Other suprapubic for counter-traction
• Wait for next contraction (2-3min)

12. AMTSL -CCT
• When the uterus contracts, as will be
evidenced by the uterus becoming hard and
globular, or when the extra-vulval portion of
the cord lengthens, gently pull downwards on
the cord to deliver the placenta.
• If placenta does not descend during 30-40sec
of CCT, stop pulling and wait for next
contraction

13. AMTSL -CCT
• The signs of placental separation are:
* The uterus becomes hard and globular
(uterine contraction).
* The extra-vulval portion of the cord lengthens
* There is a sudden gush of blood when the
placenta separates.
* If the fundus of the uterus is gently pushed up
towards the umbilicus, the cord will not
recede into the vagina.

14. AMTSL - contd
• Twist placenta while delivering so that
membranes do not tear off
• EXAMINE the placenta and membranes after
delivery for complete removal

15. AMTSL - Uterine massage
• Massage the uterine fundus until well
contracted
• Repeat massage every 15 min for first 2 hrs
• Ensure that uterus does not become flabby
when massage is stopped

16. Postpartum haemorrhage
• Blood loss in excess of 500 ml following birth
of the baby
• Any amount of bleeding from or into the
genital tract following birth of the baby up to
the end of puerperium which adversely affects
the general condition of the patient as
evidenced by rise in pulse rate and falling
blood pressure

17. Importance
• APH untreated leads to death in 12 hrs
• Obstructed labour untreated leads to death in
2 days
• Infection untreated leads to death in 6 days
• PPH untreated leads to death in 2 hrs

18. PPH – definition contd
• Primary PPH – within 24 hrs of delivery
– 3rd
stage haemorrhage : before expulsion of
placenta
– True PPH : after expulsion of placenta
• Secondary PPH – Beyond 24 hrs and within
puerperium ( 12 wks )
• Minor <1L; Major >1L; Severe >2L

19. Causes of Primary PPH
• Atonic (70-80%)
• Traumatic (20%)
• Retained placenta (10%) and retained bits
• Blood coagulopathy

20. Atonic PPH - causes
• Grand multipara
• Over-distension of uterus – hydramnios, twin
• Anaemia and malnutrition
• Antepartum haemorrhage
• Prolonged labour
• Precipitate labour
• Anaesthesia and drugs (tocolytics, magsulph, nifedipine)
• Labour induction/augmentation with Oxytocin
• Uterine malformation
• Uterine fibroid
• Mismanaged 3rd
stage of labour
• Morbidly adherent placenta

21. Management of PPH
• Shout for help
• Rapid evaluation of general condition – look
for shock
• Massage the uterus to make it hard
• Give Oxytocin 10 U IM

22. Management of PPH
• 2 large bore (14 gauge) IV cannulas
• Draw blood for Group and Cross-match, other
tests, requisition 4 units blood
• Rapidly infuse 2L of NS or RL – initial 1L over
20 min. May subsequently give 1.5L colloid
(Haemaccel) while waiting for blood
• Start Oxytocin infusion 20 U in 500 mL at 60
drops/min

23. Management of PPH
• Catheterise the bladder – Foley’s
• Check if placenta has been expelled
• Examine the placenta and membranes to see
if it is complete
• Examine the cervix, vagina and perineum for
tears

24. Management of PPH
• Oxygen by mask 10-15 L/min
• Keep the patient warm
• Non-pneumatic anti-shock garment esp during
transfer
• Commence monitoring and recording – pulse,
bp, respiratory rate, oximeter, type and
amount of fluids infused, urine output, drugs-
type,dose,time, CVP if sited

25. Transfusion
• Main therapeutic goals is to maintain
Hb > 8g/dl
Platelet count > 75,000/cumm
Prothrombin time < 1.5 times mean control
APTT < 1.5 times mean control
Fibrinogen > 1.0 g/L
• Nowadays recommendation is to infuse PRBC
and FFP in 1:1 ratio

26. Evaluation
• Immediate PPH
• Uterus soft and not
contracted
• Placenta examined -
complete
• May be shock
• Atonic uterus
• Immediate PPH
• Placenta examined –
complete
• Uterus contracted
• Tears of cervix, vagina
or perineum

27. Evaluation
• Placenta not delivered
within 30min of delivery
• Immediate PPH
• Retained placenta
• Immediate PPH
• Uterus contracted
• Portion of maternal
surface of placenta
missing or torn
membranes with
vessels
• Retained placental
fragments

28. Evaluation
• Immediate PPH
• Uterine fundus not felt
on abdominal palpation
• Slight or intense pain
• Inverted uterus (may
appear at vulva)
• Immediate PPH
(bleeding is
intraabdominal or
vaginal)
• Severe abdominal pain
• Tachycardia, Shock
• Tender abdomen
• Ruptured uterus

29. Evaluation
• Bleeding occurs more than 24 hrs after
delivery
• Uterus softer and larger than expected for
elapsed time since delivery
• Bleeding is variable, may be foul smelling
• Anaemia
• Delayed/Secondary PPH

30. Atonic uterus – Oxytocic drugs
Drug Dose and route Continuing
dose
Maximum
dose
Precautions &
contraindication
s
Oxytocin
(Syntocinon)
IV infusion:
20-40 units in
1L
60 drops/min
IV infusion:
20U in 1L
40 drops/min
Not more
than 3L IV
fluids
containing
Oxytocin
Do not give as
large IV bolus
Methyl
ergometrine
(Methergin)
IM or IV slowly
0.2mg
Repeat 0.2mg
after 15min.
If required,
0.2mg
repeated 4hrly
Five doses
(Total 1mg)
High blood
pressure,
pre-eclampsia,
heart disease
15-methyl
Prostaglandin
F2α =
Carboprost
(Prostodin)
IM
250μg
IM 250μg
Repeated
every 15min
Eight doses
(Total 2mg)
Asthma

31. Oxytocic drugs contd
• Prostaglandins should not be given
intravenously – the may be fatal.
• Alternative drug – Misoprostol 1000μg per
rectum
• Carboprost 500μg may be given
intramyometrially
• Assess clotting status with bedside clotting
test – failure of clot to form after 7 min or soft
clot that breaks down easily = coagulopathy

32. Atonic uterus – bleeding continues
• Bimanual compression
of uterus
• Aortic compression

33. Atonic uterus – bleeding continues
• Balloon tamponade
Has superseded uterine packing
Foley’s catheter, Bakri balloon, Sengstaken-
Blakemore oesophageal catheter, condom
catheter, urological Rusch balloon
Averts hysterectomy in 78% cases

34. Balloon Tamponade contd.

35. Balloon Tamponade contd.
200-500 mL normal saline
Kept 4-6 hrs
In daytime, with senior staff present, deflate
balloon and see
• Tamponade test: A +ve test (=control of PPH
following inflation of balloon) indicates that
laparotomy is not required.

36. Atonic uterus – bleeding continues
• Take to OT
• Under anaesthesia, explore uterus for
placental fragments and remove clots
• Repeat uterine massage – if still atonic,
proceed to laparotomy

37. Atonic uterus - laparotomy
• B-Lynch suture
or multiple square
sutures
Work by
compression/tamponade
Avert hysterectomy in
80% of cases

38. Stepwise uterine devascularization
1. Ligation of uterine
arteries – at lateral
border of uterus,
junction of upper and
lower uterine
segments, 2cm inside
myometrium
2. Ligation of utero-
ovarian anastomoses –
Just below ovarian
ligament

39. Ligation of internal iliac arteries
• 2-3cm distal to bifurcation of common iliac.
• Reduces pelvic blood flow by 50%.
• Drop in arterial pulsation, with pressure reduced
to that of venous system.
• Average decrease in pulse pressure is 77% with
one side and 85% with both sides ligated.
• Venous bleeding is easily controlled by
temporary pressure and clot formed remains
there.

40. Atonic uterus – Hysterectomy
• If all else fails, hysterectomy.
• Second consultant to be involved in decision
• May be subtotal – rapidly done, less duration
of exposure to anaesthesia
• Must be total if placenta praevia, uterine
rupture involving lower segment, etc

41. Angiographic arterial embolization
• Angiographic arterial embolization usually with
gelatin sponge
• Either internal iliac or more usually uterine
arteries embolized
• Only in haemodynamically stable patients
• Takes time, usually 60min
• Must be done in radiology department
• Requires experienced radiologist, fluoroscopy,
correct arterial catheters

42. Angiographic arterial embolization
• Temporary distal occlusion for 4 wks
• Some materials may provide permanent
occlusion
• 90-95% success rate
• Best to perform prophylactically
• Or put angiographic catheters in place pre-
operatively/predelivery for high risk cases like
suspected placenta accreta

43. Traumatic PPH

44. Traumatic PPH contd.
• Tears of birth canal are the 2nd
most frequent
cause of PPH
• May coexist with atonic uterus
• Examine and carefully repair
• If bleeding continues assess clotting status
with bedside clotting test

45. Repair of cervical tear

46. Retained placenta
• When placenta is not expelled even 30 min after
delivery of the baby
• Causes:
Placenta completely separated but retained due
to poor expulsive efforts
Simple adherent placenta due to uterine atonicity
– commonest cause
Morbidly adherent placenta
Placenta incarcerated following separation due
to constriction ring

47. Retained placenta
• Accounts for 10% of PPH cases and occurs in
0.5 to 3% of all deliveries
• Risks:
Haemorrhage
Shock – due to blood loss, when prolonged,
frequent attempts to express the placenta
Puerperal sepsis
Recurrence in subsequent pregnancy

48. Retained placenta
• Check for signs of placental separation – if
present, remove placenta by controlled cord
traction
• Avoid forceful traction or fundal pressure – may
cause uterine inversion
• Give Oxytocin 10U IM if not already given for
AMTSL
• Empty the bladder
• DO NOT give ergometrine for retained placenta
as it causes tonic uterine contractions which may
delay expulsion

49. Retained placenta – Manual removal
under GA
• Catheterization,
prophylactic antibiotic
• Hold the umbilical cord
with a clamp. Pull the
cord gently until it is
parallel to the floor.
• Insert the other hand
(long gloves) into the
vagina and up into the
uterus

50. Manual removal under GA
• Let go of the cord and move the other hand to
abdomen in order to support the fundus and
to provide counter-traction during removal to
prevent inversion of the uterus
• Move the fingers of the hand in the uterus
laterally until the edge of the placenta is
located.

51. Manual removal under GA
• Detach the placenta
from the implantation
site by keeping the
fingers tightly together
and using the edge of
the hand to gradually
make a space between
the placenta and the
uterine wall (slicing
movements)

52. Manual removal under GA
• Proceed slowly all around the placental bed until
the whole placenta is detached from the uterine
wall.
• Remove the placenta by traction on cord
• Uterine hand remains inside to explore the cavity
• Give Oxytocin infusion/ IV methergin
• Assistant massages fundus
• Examine the placenta
• Examine for tears of cervix or vagina

53. Problems encountered during Manual
removal
• Hour-glass contraction/constriction ring:
 Localized contraction of circular muscles
 Often at junction of upper and lower segment
 Can be relaxed by deepening the plane of
anaesthesia- halothane is useful
• Morbidly adherent placenta - no plane of
cleavage found

54. Morbid adherent placenta
• The placenta is directly
anchored on to the
myometrium either
partially or completely
without any intervening
decidua
• Absence of decidua
basalis and poor
development of
Nitabuch’s fibrinoid layer
• 1 in 550 deliveries

55. Morbid adherent placenta
• Accreta – No
decidua or
Nitabuch’s layer
• Increta –
penetration of
villi in to
myometrium
• Perceta –
penetration up
to serous layer

56. Morbid adherent placenta
• Risk factors:
 Prior Caesarean delivery
 Placenta praevia
Risk of placenta praevia being accreta in unscarred
uterus: 3%
With one prior CS, risk of pl praevia being accreta is 11%
With two prior CS, 40%
With 4 or more prior CS, 67%
 Prior uterine surgery like D&C, manual removal,
myomectomy, synechiolysis
 Increasing maternal age and parity

57. Morbid adherent placenta -
management
• With prior CS and placenta praevia, try to
diagnose accreta by imaging (USG and MRI) and
prepare pre-delivery
• Partial/focal accreta – Remove placenta
piecemeal and give oxytocics. If bleeding
continues, hysterectomy
• Total placenta accreta – Hysterectomy in parous
women. Otherwise clamp cord close to
attachment and leave placenta to be autolyzed.
• Uterine artery embolization, methotrexate

58. Uterine inversion
• Rare and life-
threatening
• Uterus is turned inside
out, partially or
completely
• 1 in 20,000 deliveries
• Leads to shock,
haemorrhage,
embolism, chronic-
infection

59. Uterine inversion degrees
• First degree – dimpling
of uterine fundus,
remains above level of
internal os
• Second degree – fundus
passes through cervix
but remains in vagina
• Third degree (complete)
– endometrium visible
outside vulva

60. Uterine inversion contd.
Spontaneous 40% - due to sudden cough,
sneeze, bearing down when uterus still atonic
Iatrogenic – faulty management of 3rd
stage
sith pulling the cord or fundal pressure when
uterus is atonic

61. Uterine inversion - management
• Call for help
• Treat shock
• Correction under deep sedation or GA
• Thoroughly cleanse the inverted uterus using
antiseptic solution.
• Apply compression to the inverted uterus with
a moist, warm sterile towel until ready for the
procedure

62. Manual correction
• Wearing high-level
disinfected or sterile
gloves, grasp the
inverted uterus and
push it through the
cervix in the direction of
the umbilicus to its
normal anatomic
position, using the
other hand to stabilize
the uterus

63. Manual correction contd.
• The part of the uterus that came out last (the
part close to the cervix) should go in first.
• After replacement, leave hand inside until the
uterus becomes contracted by parenteral
oxytocic
• If the placenta is still attached, manually
remove it after correction of inversion and
after uterus becomes contracted

64. Hydrostatic correction – O’Sullivan’s
method
• Woman in deep
Trendelenburg position
• Sterile douche system
with large nozzle, long
tubing, warm water
reservoir 3-5L
• Nozzle in posterior fornix
• Seal labia with other hand
• Douche with pressure
raising reservoir to 2 m

65. Uterine inversion contd.
• If fails, Laparotomy under
GA
• Haultain’s operation
• Incise the constricting
cervical ring vertically,
posteriorly
• Apply traction while
assistant also attempts
correction vaginally
• After correction, close the
posterior cervico-uterine
incision

66. To summarize
• AMTSL is recommended for ALL deliveries,
with 10 U Syntocinon IM, CCT and uterine
massage
• PPH is a dire emergency. Management
involves t/t of shock with IV fluids, other
supportive t/t including blood transfusion,
uterotonics, ensuring complete removal of
placenta, detection and repair of injuries.

67. To summarize
• A placenta not separated within 30 min
requires manual removal. Failure to find a
cleavage during removal indicates morbid
adherent placenta, which may need
hysterectomy
• Uterine inversion is rare but produces shock.
Manual or hydrostatic correction is needed.

68. • Any questions ?
THANK YOU