3rd Stage of Labor + Immediate PPH

Question 1

Define the 3rd stage of labor

Answer 1

• the period following the birth of the newborn through the expulsion of the placenta

Question 2

3rd Stage of Labor

Average duration, limits of normal

Answer 2

• Average duration: 10 minutes
• Prolonged 3rd stage/retained placenta: > 30 minutes
  
  • 3% of births

Question 3

Signs of placental expulsion

Answer 3

• Small gush of blood - seperation of placenta and decidua
• Lengthening of the umbilical cord
• Rise of the uterus into the abdomen - displaced as placenta moves into the vagina
• Uterus becomes firm and rounded - uterus contracts more firmly when its empty

Question 4

Mechanism of placental seperation

Answer 4

• Shultz (most common) - placenta seperates centrally
  
  • Fetal side of placenta (smooth) comes out first →

membranes are expelled last, with the maternal side of the placenta inside the amniotic sac.

    * Essentially inverts the placenta and amniotic sac and causes the membranes to peel off the remainder of the decidua and trail behind the placenta.
* Majority of bleeding may remain hidden until the placenta and membranes are expelled (blood is captured behind the placenta and inside the amniotic sac)

• Duncan - placenta separates marginally.
  
  • Placenta slides into the cervical opening without inverting → maternal side (with dark red cotyledons), is expelled at the same time as the fetal side.
  • Blood escapes between the membranes and uterine wall and is more likely to be visible externally earlier in the separation process.
  • Amniotic sac is not inverted but trails behind the placenta.
• The memory aid for correctly identifying the mechanisms of placental expulsion: “Shiny Schultz” and “Dirty Duncan.”

Question 5

Describe the means by which the placenta separates

Answer 5

Abrupt decrease in size of the uterine cavity following birth of the neonate → sudden disproportion between the area of implantation and placental size → placenta buckles and separates from the decidua

Question 6

Define “active management” of third stage and the rationale

Answer 6

• Rationale: decreases risk of PPH in general perinatal population
• ICM/FIGO joint statement 3 steps:

1. Controlled cord traction (once pulsation stops in a healthy newborn)
2. Use of a uterotonic agent
3. Fundal massage after expulsion of the placenta.
   * WHO recommends cord traction only by experienced provider and no prolonged fundal massage

Question 7

1st line uterotonic for active management

Answer 7

Pitocin 10 units IM or IV (diluted)

• Can be given*:
  
  • As the anterior shoulder is released under the symphysis pubis
  • During the birth of the neonate
  • After the birth of the infant
  • After placental expulsion.
  • The timing does not influence the amount of bleeding or the rate of PPH
• ***Only if singleton gestation***
• May not be as effective if patient has received large dose of pitocin for induction/augmentation

Question 8

Alternative uterotonics for 3rd stage

(if pitocin unavailable or inappropriate)

Answer 8

2nd line

• Ergot alkaloids (methylergonovine maleate)
• Prostaglandins
• Syntometrine (an oxytocin/ergometrine combination drug not available in the United States) are second-line prophylactic uterotonic agents.

Misoprostol is not as effective for prophylaxis but may be used if other uterotonics are not available.

Question 9

Interventions when the 3rd stage is increasing in length

Answer 9

• Encouraging upright position for the woman
• Nipple stimulation via encouraging the newborn to breastfeed or manual nipple stimulation
• Ensuring an empty bladder, by means of catheterization if indicated.
• If these don’t work and it has been 30 minutes → manual removal of the placenta.
  
  • Nonemergency manual removal of the placenta should occur in a hospital setting, both for reasons of safety and to enable the woman to receive anesthesia or deep analgesia for this usually painful procedure

Question 10

Define immediate and delayed postpartum hemorrhage

Answer 10

• Early or primary - within the first 24 hours postpartum
• Late or secondary when it occurs after 24 hours and up to 6 weeks postpartum

Question 11

Identify the major causes of postpartum hemorrhage

Answer 11

• TONE (atony) – 70%ish
  
  • Overdistended uterus—large fetus, multifetal gestation, polyhydramnios
  • Prolonged labor (all stages)
  • Rapid labor
  • Oxytocin-induced or -augmented labor
  • High parity
  • Postpartum hemorrhage with previous birth
  • Chorioamnionitis
  • Poorly perfused myometrium—hypotension
  • Medications such as magnesium sulfate, nifedipine, and some general anesthetics
  • Uterine abnormalities such as fibroids
• TRAUMA – 10%
  
  • Episiotomy, especially mediolateral
  • Hematoma
  • Lacerations of perineum, vagina, or cervix
  • Ruptured uterus
  • Uterine inversion
• TISSUE – 20%
  
  • Avulsed cotyledon, succenturiate lobe
  • Abnormal placentation—accreta, increta, percreta
  • Retained blood clots
• THROMBIN – coagulopathies - < 1%
  
  • Acquired coagulopathies such as placental abruption, amniotic fluid embolism, disseminated intravascular coagulation, HELLP syndrome, stillbirth, or sepsis
  • Congenital coagulation defects such as von Willebrand’s disease
  • Therapeutic anticoagulation

Question 12

Define 3rd stage hemorrhage

(I think this means early postpartum hemorrhage?)

Answer 12

Cumulative blood loss of 1000 mL or more or blood loss accompanied by sign/symptoms of hypovolemia within 24 hours following the birth (including intrapartum loss).

Question 13

Methylergonovine maleate (Methergine)

• Therapeutic dosage, route of administration
• Action
• Indications
• Contraindications
• Possible side effects

Answer 13

• 0.2 mg IM
  
  • may repeat in 5 minutes, then after q 2-4 hrs
  • ***do not give IV***
• Alpha adrenergic agonist → vascular smooth muscle constriction (both arterial and venous)
• Second line if PPH continues despite oxytocin
• Onset of action 2-5 minutes
• Contraindications: HTN or PEC
• Side effects: cramping, N/V, HTN, seizure, HA

Question 14

Oxytocin (Pitocin, Syntocinon)

• Therapeutic dosage, route of administration
• Action
• Indications
• Contraindications
• Possible side effects

Answer 14

• 10 U IM or
  
  • lasts 2 - 3 hours
• 10 - 80 U diluted in 250 mL - 500 mL NS or LR
  
  • IV rate 125 mL or 250 mL per hour
  • ***DO NOT GIVE IV PUSH*** → hypotension and cardiac collapse
• Increase dose to 40 U with active bleeding
• Onset of action 2 - 3 minutes, effective in 15 - 30 min
• Contraindications: hypersensitivity
• Side effects: cramping, hypoNa with large doses
• FDA black box warning to avoid breastfeeding x 12 hours (?)

Question 15

Dinoprostone (Prostin E2, Cervidil, Prepidil)

• Therapeutic dosage, route of administration
• Action
• Indications
• Contraindications
• Possible side effects

Answer 15

• 20 mg vaginal or rectal suppository
  
  • may repeat q 2 hours
• Prostaglandin induces uterine contractions → stops bleeding
• Used as second line if methergine contraindicated due to HTN
  
  • *Off-label use*
• Contraindications: hypotension, cardiac disease
  
  • *Safe to use in people with asthma*
• Side effects: N/V/D, pyrexia

Question 16

Carboprost tromethamine (Hemabate)

[aka 15-methyl prostaglandin F-2 alpha]

• Therapeutic dosage, route of administration
• Action
• Indications
• Contraindications
• Possible side effects

Answer 16

• 250 mcg IM
  
  • may repeat q 15 - 90 minutes x 8 doses
  • BBW - use recommended dose only in a hospital setting. Avoid BF for first 12 hours
• Prostaglandin induces uterine contractions → stops bleeding
• Used for PPH that hasn’t resolved with oxytocin and uterine massage
• Contraindications: asthma, active cardiac, pulmonary, renal or hepatic disease
• Side effects: broncospasm, N/V/D, HTN, pyrexia
  
  • Heeeemabate (bronchospasm)
  • Hemabutt (diarrhea)

Question 17

Misoprostol (Cytotec)

• Therapeutic dosage, route of administration
• Action
• Indications
• Contraindications
• Possible side effects

Answer 17

• 600-800 mcg sublingual x 1 dose
  
  • Faster onset

OR

• 800 - 1000 mcg per rectum x 1 dose
  
  • Longer duration of action
• Prostaglandin induces uterine contractions → stops bleeding
• Frequently used 2nd line (instead of methergine) for PPH because can use with HTN
• Contraindications: none (?)
• Side effects: N/V/D, abdominal pain, pyrexia with higher doses, shivering

Question 18

Describe and state the purpose of the Brandt-Andrews maneuver

Answer 18

• Determines whether the placenta has seperated
• Maneuver:
  
  • Apply slight downward pressure just above the pelvic brim with the hand that is guarding the uterus, while holding the cord taut with the other hand.
  • If the placenta is still in the uterus, the cord will retract as the uterus is displaced upward into the abdomen by pressure from the abdominal hand.
  • If the placenta has separated and is in the vagina, upward displacement of the uterus will not cause the cord to retract, and additional cord traction can be safely provided while maintaining abdominal counter-traction.

Question 19

Describe the technique for delivering the placenta using maternal effort

Answer 19

• Once the placenta has separated, the parent may spontaneously expel it by pushing.
• The midwife can also use a combination of the Brandt–Andrews maneuver and controlled cord traction.
  
  • ​Cord traction should not be performed without guarding the uterus → may avulse cord or invert uterus.
• Grasp the placenta with both hands as it is being expelled. Slowly guide the placenta out, perhaps following the curve of Carus to allow membranes to follow and not tear.
  
  • If there appear to be more membranes than immediately are expelled, continue to hold the placenta and either twist it slowly or grasp the membranes with ring forceps to gently extract the membranes (“teasing” out the membranes)
• Palpate the fundus abdominally to assess if the fundus is firm.
  
  • Routine vigorous massage to stimulate uterine contraction has not been shown to decrease the incidence of hemorrhage.
    
    • May be indicated to express clots through the cervix if excessive bleeding is present, but it is not indicated if the estimated blood loss is normal.

Question 20

Normal umbilical cord anatomy/inspection

Answer 20

• 3 vessels (2 arteries, 1 vein)
  
  • If only 2 vessels → send placenta to pathology and notify pediatrics
• Length usually 55-60 cm (range 30 - 90 cm)
  
  • Only measure if it seems abnormal
  • Long cord: > 75 cm - associated with knots and fetal entanglement.
  • Short cords: < 32 cm - may be associated with limited fetal movement.
• Look for knots, hematomas, tumors, cysts, edema, and the amount of Wharton’s jelly (affects width of cord)
  
  • Normal width: 1 to 2 cm
• Insertion site: where the cord inserts in relation to the body of the placenta — central, eccentric, or marginal (Battledore placenta).
  
  • Determine whether the cord is inserted directly into the placenta or is attached by exposed vessels (velamentous cord insertion)
  • Centric and eccentric (off-center) insertions are variations of normal; however, velamentous and marginal insertions are unusual and associated with a risk of vasa previa should one of these vessels tear when the membranes rupture.

Question 21

Normal placental anatomy/inspection

Answer 21

• Shape is usually round to slightly oval
• Approximately 2 to 3 cm in thickness
• Fetal surface is smooth
  
  • May need to invert membranes to examine
  • Look closely for torn or intact blood vessels leading into the membranes → may indicate a missing or intact succenturiate (accessory) lobe.
• Maternal surface is usually smooth with indentations at the edges of cotyledons, but may have gritty white areas of calcification. (generally quantity of calcifications has no clinical importance).
  
  • Missing cotyledon is differentiated from a simple tear in the placenta without loss of tissue by holding the placenta, maternal surface up, so that the cotyledons fall into place against each other
    
    • Missing cotyledon - surrounding pieces will not fit together smoothly.
• Pale placenta - immature neonates and anemia.
• Green placenta - extended exposure to meconium

Question 22

Inspection of membranes

Answer 22

• Place the placenta maternal side down
• Place a hand inside the membranes on the fetal surface of the placenta and hold the membranes up to simulate the sac they once were
• If the membranes are ragged and do not form a sac, they may be incomplete.
• If a portion of the membranes is missing, membranes may still be within the uterus - not a sensitive indicator of retained membranes.

Question 23

Identify steps to take in managing immediate postpartum hemorrhage (PPH):

Answer 23

• Palpate the woman’s uterus (~80% of immediate PPH is 2º to uterine atony).
  
  • External uterine massage may be the only intervention necessary
  • ​If bleeding continues → next steps.​
• ​Consult. Depending on the amount and rate of bleeding, ask for another practitioner to come to the bedside, or if in an out-of-hospital setting, initiate emergency transport.
• R/o bleeding from a laceration by examining the perineum, vulva, vagina, and cervix.
  
  • Suture any active bleeding vessels
  • If bleeding is not 2° to a laceration or the uterus is atonic → next steps
• Catheterize the patients’s bladder so a full bladder will not interfere with uterine contractility ​
• Order a uterotonic agent, if one was not administered earlier with release of the anterior shoulder of the newborn.
  
  • Oxytocin (Pitocin) is the most commonly used agent, either 10–40 units in 1000 mL solution administered IV at a rapid rate (500 mL/hr), titrated to uterine tone, or 10 units IM while large-bore IV access started.
  • If a uterotonic agent was administered with the birth of the neonate, consider a 2nd agent (e.g. Cytotec, Hemabate).
  • Continue administration of additional uterotonic agents to treat uterine atony. ​
• If bleeding continues and you are in an out-of-hospital site → emergency transfer to a hospital (can be cancelled if controlled quickly).
• If bleeding continues → 2nd IV with NS in preparation for blood transfusion and maintenance of intravascular volume.
• Verify that a physician has been called; while waiting for emergency services arrival, proceed to the following steps: ​
• ​Initiate bimanual compression of the woman’s uterus to treat uterine atony.
• If in a hospital, the blood bank should be notified and type and cross-match for 2 units prepared.
• ​If retained products of conception are suspected to be the cause of the bleeding, proceed to performing an intrauterine exploration.
• Additional anesthesia or pain management methods may be needed at this point.
• ​After bleeding has been controlled, discuss and explain the situation to the patient and family
• ​Continue to collect the blood lost and calculate the running total of loss.
• Assess the patients’s response to PPH by repeat labs (Hgb/Hct) and symptoms during the first 24 to 72 hours postpartum.
  
  • Tolerance of blood loss is contingent upon many factors → some patients will be symptomatic (e.g., syncope) at different Hgb than others.
• Management, including blood transfusions, will need to be individualized.
• Antibiotics following uterine exploration is controversial (no strong evidence either way). Individualization is indicated, and consultation may be a reasonable action.
• ​Document all procedures and the woman’s responses. Include any consultations/referrals if appropriate.

Question 24

Describe proper technique for bimanual compression of uterus

Answer 24

• Extend the fingers of one hand and squeeze the extended fingers close together, gently insert this hand into the vagina, and close the fingers into a fist as the hand enters the vagina.
• ​Position the fist palmar side up into the anterior fornix. ​
• Direct pressure to the lower uterine segment/uterine corpus by applying pressure inward and upward against the anterior wall of the uterus.
• Simultaneously, place the other hand externally on the abdomen and grasp the uterus between the two hands. ​
• Apply pressure to the uterus trapped between the two hands by massaging it using pressure directed against the posterior wall of the uterus, primarily in the area of the fundus and corpus of the uterus with the abdominal hand. This compression places direct pressure on the bleeding uterine vessels while stimulating the uterus to contract, an action that will also provide continuous compression. ​
• Continue bimanual compression until bleeding is controlled and uterine atony is resolved. The effectiveness of this intervention can be ascertained by momentarily releasing the pressure on the uterus and evaluating uterine consistency and bleeding at that moment.
• Be aware that atony may seem to be resolved before it actually is, so bimanual compression should not be discontinued until the uterus is firm for several minutes. Removal of the hand and reinsertion increases pain/discomfort and risk of infection.
• ​If bimanual compression provides a response but uterine atony does not resolve, continue compression until a physician is present.

Question 25

Describe proper technique for inspection of perineum, vagina and cervix

Answer 25

• Ensure hemostasis, analgesia, lighting, and proper positioning (comfortable to both patient and midwife)
• Insert 3 or 4 fingers into the vagina to provide space to allow visualization of the cervix and possibly the apex of a vaginal tear.
• Or use Sims retractor with pressure against the anterior vaginal wall for better visualization of the vagina.
• Use sterile gloves
• Actions to be taken include: ​
  
  • ​Assessing whether the laceration is hemostatic or bleeding
  • ​Identifying the exact location of the laceration so that it can be charted/communicated and to other providers
  • Determining which type of laceration is present and whether the laceration requires repair
• Be sure to visualize:
  
  • Periurethral
  • Periclitoral
  • Labial
  • Fourchette
  • Perineal
  • Rectal areas
    
    • If a 3rd or 4th° laceration suspected, don an additional glove and insert the index finger into the rectum to assess the integrity of the rectal sphincter. With palmar side up, gently lift upward, to expose the full extent of the laceration. Remove glove after the rectal examination.
  • 4 sections of vaginal vault: anterior, posterior, left/right lateral
  • Cervix - use 2 ring forceps to “walk” around cervix inspecting section between ring forceps each time. If anything is bleeding, clamp it while you prepare to suture.