The document discusses postpartum hemorrhage (PPH) and strategies for managing the third stage of labor to prevent PPH. It notes that the third stage of labor begins after delivery and ends with delivery of the placenta, taking on average 15-20 minutes. Active management of the third stage, involving administration of uterotonics and controlled cord traction within 5-10 minutes, is preferred over passive management and helps decrease bleeding, PPH risk, and maternal mortality. The placenta can separate via the Schultze or Duncan method. Uterine contractions are key to separation, and oxytocin is used if the placenta does not separate on its own.

1. PPH
(Postpartum
Hemorrhage)

2. Third stage of labor
 Begins after delivery of baby and ends at the delivery of placenta
 Plays crucial role in PPH
 If third stage is managed properly, PPH can be prevented
 Average duration of third stage => 15-20 mins
 If third stage duration 30 mins or more => Prolonged third labor/retained
placenta

3. Third stage can be managed by
Passively
• Duration = 15-20 mins
• Waiting for spontaneous expulsion
of placenta
• Chances of PPH & Maternal
mortality are more
• Since human placenta is deciduate,
it has to shed off after delivery
Actively
• Duration = 5-10 mins
• If Active management of third labor
= 5-10 mins, then:
Decrease in bleeding
Decrease chance of PPH
Decrease Maternal mortality
Active Management is the preferred method of third stage
management and is the best method to prevent PPH

4. Delivery of Placenta is the main event in third stage delivery and it occurs by two methods
Schultze method:
 Placenta starts separating from centre
 Retroplacental clot is formed
(haemostatic – blood loss is less)
 Bleeding is evident only after entire
placenta is separated
 Shiny fetal side of placenta comes first
 Most common method
Duncan method:
 Placenta starts separating from
periphery
 No retroplacental clot formed (blood
loss is more)
 Bleeding is evident as soon as
placenta separates
 Dull maternal side of placenta which
comes first
 Less common method

5. General points
 Most important factor responsible for placental separation is uterine contractions
 In all cases of Retained placenta, 1st management is increase uterine contractions by giving oxytocin
(Methergin, prostaglandins are not recommended)
 If even after giving oxytocin, placenta is not getting separated, then, manual removal of placenta is done in
OT under general anaesthesia
 Line of separation of placenta lies along Zona Spongiosa
 Living liqature:- Middle layer of myometrium, has fibres in criss cross manner in which blood vessels are
there in between them (when uterus contracts, blood vessels constricted)
 Height of uterus immediately after delivery is just below the umbilicus (~-20 weeks of pregnancy)
Signs of placental separation:
1. Sudden rush of blood per vagina
2. Suprapubic bulge
3. Height of uterus increases slightly
4. Apparent lengthening of cord (permanent)
Most important – Feel the placenta in vagina > lengthening of cord

6. Steps in Active Management of Third
Stage of Labor (AMTSL)
1. Administer u
 No more than one prior low transverse caesarean section
 Clinically adequate pelvis
 No other uterine scars or previous rupture
 Physician immediately available throughout active labour to monitor
labour and for emergency LSCS if required
 Availability of anesthetist for emergency LSCS

7. ABSOLUTE CONTRAINDICATION FOR
VBAC
 Prior classic, T shaped incision or other transmural uterine surgery
 Contracted pelvis
 Medical or obstetric complication that preclude vaginal delivery
 Patient refusal
 Inability to immediately perform caesarean section because of unavailable
surgeon or anaesthetist, inadequate staff or facility
 Previous rupture or scar dehiscence
 Non reassuring fetal status
 Previous 2 LSCS

8. Factors influencing VBAC
1. PREVIOUS VAGINAL DELIVERY
Those woman who gave birth vaginally atleast once are 9-28 times
more likely to have a successful VBAC and the success rate is 83-95%
2. PRIOR VBAC
It is the single best predictor for successful VBAC with an
approximately 87-90% planned VBAC success rate
3. LARGE FOR GESTATIONAL AGE/ MACROSOMIA
Successful VBAC with suspected macrosomia infants > 4000gm often
have a vaginal delivery rate of only 50-60%.
There is absolute risk of 3.6% for uterine rupture. Discourage VBAC
attempts in those gestations with EFW-4250gm or more.

9. 4. INDICATION FOR PRIOR CESAREAN SECTION
Non recurrent causes – Breech, Fetal distress
Success rate was less for –Dystocia, Failure to progress.
5. MATERNAL OBESITY
As the maternal weight increases (BMI>30), the rate of VBAC
success decreases

10. 6. OTHER FACTORS
 At or after 40 weeks of gestation
 Previous preterm caesarean section
 Advanced maternal age
ALL THESE ARE ASSOCIATED WITH A DECREASED LIKELIHOOD OF
PLANNED VBAC SUCCESS

11. Monitoring of labour with a previous
caesarean section.
 Establish IV line
 Blood for cross-matching to be sent
 Clear fluids are to be allowed. Fluid replacement same as normal labour
 Maternal monitoring –PR every half hourly, BP-2 hourly till she progresses
to established labour
 Oxytocin can be used for induction/augmentation of labour after
amniotomy. Titration of dose has to be done with careful fetal and
maternal monitoring
 Record FHR continuously
 Record progression of labour in partogram

12. Signs of scar dehiscence
 Unexplained maternal tachycardia
 Pain at incision site
 Deceleration of FHR on CTG – Prolonged deceleration or variable decelerations
that are persistent and severe is the most specific sign of uterine rupture
 Meconium stained liquor
 Scar tenderness
 Fresh bleeding PV
 Sudden cessation of uterine contractions or there is receding of presenting
part on PV examination
 Fetal parts palpable superficial on Per abdomen examination
 Hematuria

13. Complications in pregnancy with previous
caesarean section
 UTERINE RUPTURE
Complete rupture
When all layers of uterine wall are separated . It includes extrusion of
intrauterine contents into the abdominal cavity
Incomplete /Partial rupture or Scar dehiscence
Uterine muscle is separated but visceral peritoneum is intact. This includes
extrusion of intra uterine contents into the broad ligament

14. Symptoms of uterine rupture
 Pain in lower abdomen/ incision site (Ranging from mild to severe and
sometimes a tearing sensation)
 Shoulder pain
 Uterine contraction often diminishes in intensity and frequency
 Dizziness and weakness
 Gross hematuria

15. Signs of uterine rupture
 Tenderness over the whole abdomen
 Distension of the abdomen
 Uterine contour not well maintained
 Fetal parts more superficially palpated
 Fetal heart sound absent
 Bleeding Pv, hematuria may or may not be present
 Receding of the presenting part on PV examination

16. Management of uterine rupture
Exploratory laparotomy followed by repair or hysterectomy.
REPAIR THE UTERINE DEFECT - it is technically feasible if:
- hemostasis can be achieved
- the patients need to retain fertility
CESAREAN HYSTERECTOMY - It is required:
- If extension into broad ligament vessels
- Uncontrolled uterine bleeding
- The presence of placenta accreta

17. Maternal mortality and morbidity
 The vast majority of maternal deaths in women with prior caesarean
section arise due to medical disorders
-THROMBOEMBOLISM
- PRE ECLAMPSIA
- SURGICAL COMPLICATIONS
- UTERINE RUPTURE
 No statistically significant difference between planned VBAC
(17/10,000)and ERCS (44/10,000)
 Maternal mortality is higher in women with unsuccessful VBAC

18. Perinatal mortality and morbidity
 Planned VBAC carries a 2-3/10,000 additional risk of birth related perinatal
death when compared with ERCS
 VBAC is estimated with 10/10,000 risk of antepartum still birth beyond 39
weeks of gestation and 4/10,000 risk of delivery related perinatal death
 VBAC reduces the risk of TTN/RDS in fetus.

19. THANK YOU