management of third stage of labor

1. COMPLICATIONS OF 3RD STAGE
OF LABOUR AND ITS
MANAGEMENT
Submitted to
Mrs Geeta Razdan
Lecturer
College of Nursing,
AIIMS
Submitted By
Mr:Sobin Chandran
Post Bsc 1st year
C.O.N ,AIIMS
Roll no 779

2. OBJECTIVES
At the end of the class, students will able to;
 define labour
 list down the stages of labour
 describe the complications of 3rd stage of labour
 explain the management of 3rd stage bleeding

3. LABOUR
Labour is the series of events that takes place in the genital
organ in an effort to expel the viable products of conception
out of the womb through the vagina in to the outer world.
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4. STAGES OF LABOR
• First Stage – Starts from the onset of true labor pain and ends
with full dilatation and effacement of the cervix.
• Second Stage – Starts from the full dilatation and effacement of
the cervix and ends with the expulsion of fetus from the birth
canal
• Third Stage – Extends from delivery of a baby to the delivery of
placenta and membranes and this stage last for 15 to 30 Mins.
• Fourth Stage – Stage of observation for at least one hour after
expulsion of placenta and membranes

6. COMPLICATIONS OF 3RD STAGE OF
LABOUR
1. Postpartum haemorrhage
2. Retained placenta
3. Shock(Haemorrhagic and Non haemorrhagic)
4. Inversion of Uterus
5. Amniotic fluid embolism
6. Coagulation disorders – Disseminated intra
vascular coagulation

7. POSTPARTUM HEMORRHAGE
• Clinical definition :Any amount of bleeding from the genital
tract following the birth of baby up to the end of puerperium
which adversely affect the general condition of the mother
which is evidenced by increase in pulse rate and falling blood
pressure. PPH is very common and preventable.
• Quantitative definition :amount of blood loss more than 500 ml in normal delivery
and more than 1000 ml in caesarean delivery.

8. TYPES OF PPH
Primary PPH
Haemorrhage occurs within 24 hours following the birth of
baby. There are two types of primary PPH
a. Third stage haemorrhage – Bleeding occurs before
expulsion of placenta
b. True postpartum haemorrhage - Bleeding occurs
subsequent to expulsion of placenta
Secondary PPH
Haemorrhage occurs beyond 24 hours and within
puerperium and also called delayed or late puerperal

9. CAUSES OF PRIMARY PPH
Atonic
Traumatic
Blood coagulopathy

10. ATONIC UTERUS(80%)
• It is the most common cause of PPH. With the separation of
placenta, the uterine sinuses which are torn cannot be
compressed effectively due to imperfect contraction and
retraction of the uterus and bleeding continues

11. TRAUMATIC(20%)
• Trauma to the genital tract usually following operative
delivery even after spontaneous delivery.

12. PRE-DISPOSING FACTORS OF PPH
 Over distension of the uterus
 Multiple Pregnancy
 Polyhydramnios
 Grand multipara
 Large Infant
 hydrocephalous
 Anesthesia
 Prolonged labor

13. PREVENTION
All pregnant woman should be considered as potential candidates for
excessive bleeding.
During antepartum period
o Improve health and nutrition
o Blood group and Hb should be detected early
o Anaemia should be corrected
o Avoid unnecessary vaginal examinations
o Avoid sexual intercourse in last two months
o Maintain normal blood pressure
o All high risk mothers who are likely to develop PPH should be
screened and delivered in well equipped hospital

14. During intra partum period
o Follow strict aseptic technique
o Administer blood and fluid if necessary
o Avoid unnecessary vaginal examination and manipulation of
uterus
oExamination of the placenta and membrane should be done
o temptation of fiddling or kneading with the uterus or pulling
the cord should be avoided.
During postpartum period
o Avoid unnecessary vaginal examination
o Proper cleanliness of vulva after delivery

15. MANAGEMENT OF 3RD STAGE
HAEMORRHAGE
• Palpate the fundus and massage
• Start IV Fluids[ preferably dextrose saline drip]
• Inj. Methergine 0.2 mg or ergometrine 0.25 mg
intravenously
• Catheterize the bladder
• Sedation

17. MANAGEMENT OF TRUE P.P.H
Uterus hard and contracted
(Traumatic)
Exploration
Suturing on the tear sites
 Call for extra help
 Commence I.V line with a wide bore cannula
 Send blood for cross matching and ask for at least 2 units of
blood
 Rapidly infuse normal saline 2 litres till blood is available
Immediate measures
Feel the uterus by abdominal palpation
If uterus is atonic
• Massage the uterus to make it hard
• Inj. Methergine 0.2mg I. V.
• Add oxytocin 10 units in 500 ml of NS / RL at the rate of 40
drops/min.
• Examine the expelled placenta
• Catheterise the bladder
If uterus remain atonic

18. Uterus atonic
• Inj. Prostaglandin or Misoprostol
1000 micro gram per rectum
Uterus atonic
• Uterine massage and
bimanual compression
Uterus atonic
• Tight intra uterine
packing under GA
Uterus atonic Hysterectomy
•Blood transfusion
•Continue oxytocin drip

20. CAUSES OF SECONDARY PPH
• Retained bits of cotyledon or membranes
• Infection and separation of slough over a deep cervico-
vaginal laceration
• Endometritis and subinvolution of the placental site
• Secondary haemorrhage from caesarean section

21. MANAGEMENT OF SECONDARY
PPH
Principles are
1. To assess the amount of blood loss and replace the lost
blood
2. To find out the cause and take appropriate steps to rectify
it Supportive Thereapy
3. Blood transfusion
Administer methergin
Administer antibiotics

22. RETAINED PLACENTA
• The placenta is said to be retained when it is not expelled out even after 30 minutes after the
birth of the baby
• Failure of the placental separation may be mechanical or a result of abnormal penetration of the
trophoblast in to the uterine wall. This is placenta Accreta. It indicates superficial penetration
of the muscle. Deeper penetration is called placenta Increta.
• Placenta percreta indicates that the trophoblast has grown to or completely through the serosa.

24. MANAGEMENT OF RETAINED PLACENTA
• To express the placenta by controlled traction
• Manual removal of placenta
• Management of shock
• Antibiotics to prevent infection

25. INVERSION OF UTERUS
Life threatening condition in which the uterus is turned outside
partially or completely. The incidence is about 1 in 20000 deliveries
Degree of uterine inversion
• 1st Degree - Fundus is depressed while reaching up to internal OS
• 2nd Degree - The fundus passed through the cervix but lies inside
the vagina.
• 3rd Degree – The endometrium with or without the attached
placenta is visible outside the vulva.

27. MANAGEMENT OF INVERSION OF UTERUS
• To replace that part which is inverted last
• To apply counter support by the other hand placed on the
abdomen
• After replacement, the hand should remain inside the uterus
until the uterus become contracted by Inj. oxytocin
• The placenta remove manually only after uterus become
contracted
• Proper management of shock

28. SHOCK
It is a state of circulatory inadequacy with poor tissue perfusion
resulting in generalized cellular hypoxia
Causes
Trauma Haemorrhage
Fluid loss Hypertension & Pre-
eclampsia
Neurogenic shock Sepsis
Pulmonary embolism Anaesthesia and drugs

29. CLINICAL FEATURES OF SHOCK
1.Cold and clammy skin
2.Tachycardia
3.Hypotension
4.Oligurea followed by anuria
5.Cyanosis
6.Pallor

30. MANAGEMENT OF SHOCK
• Infusion and Transfusion
• Foot end elevation of bed
• Resuscitate patient – oxygen by mask or mechanical ventilation
• Monitor BP, HR, CVP
• Inotropic agents to treat hypotension
• Maintain I/O chart
• Antibiotics
• Stop bleeding as soon as possible
Basic management of hemorrhagic shock is to stop bleeding and
replace the volume which has been lost. Prompt diagnosis and
immediate resuscitation is essential to prevent multiple organs
failure.

31. AMNIOTIC FLUID EMBOLISM
Spontaneous embolism of amniotic fluid debris, fetal squamous
cells, mucus, vernix in small pulmonary artery leading to serious
degree of respiratory distress. It occurs only 2%. This condition
may be fatal to the mother.
Risk Factors
• Vigorous labor contractions
• Through fetal membranes as in marginal separation of placenta

32. DIC
It develops due to coagulation defect
Treatment
• Supportive treatment
• O2 inhalation
• Maintenance of BP
• Management of coagulopathy

33. CONCLUSION
The complications of third stage of labour are more crucial for
the mother as most of the complications are fatal.

35. THANK YOU..