Abnormalities of the third stage labour Flashcards

1
Q

Abnormalities of the third stage of labor
- Features
- Types

A

Third stage of labor – lasts from the infant’s delivery to the delivery of the placenta and the
cords.

  • Postpartum hemorrhage (PPH)
  • Vaginal wall hematoma
  • Amniotic fluid embolism (AFE)
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2
Q

Postpartum hemorrhage (PPH)

What is it
Types

A

a. Definition: more than 500mL in the first 24 hours following vaginal birth

b. Types:
i. Primary PPH – blood loss within 24 hours
ii. Secondary PPH – blood loss from 24 hours to 12 weeks postpartum.

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3
Q

Postpartum hemorrhage (PPH)

Causes

A

4 T’s of
primary PPH

Tone (uterine atony) – failure of uterine to contract postdelivery leading to
severe myometrial bleeding

ii. Tissue weakness (abnormal placental separation – retention or incomplete
detachment)

iii. Trauma

iv. Thrombin (hypocoagulability)

Secondary PPH
- Retained placenta
- Infection

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4
Q

Postpartum hemorrhage (PPH)

Risk factors

A

i. Low placental implantation
ii. Uterine overdistension (polyhydramnios, multiparity)
iii. Prolonged labor and assisted delivery
iv. Antepartum bleeding (placental previa and abruption)
v. Uterine anomalies
vi. Episiotomy
vii. Vaginal, cervical or perineal lacerations
viii. C-section scar dehiscence
ix. HELLP, DIC, sepsis

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5
Q

Postpartum hemorrhage (PPH)

Management

A
  • General
  • Abnormal placental
    separation (accrete,
    incerta, percreta)
  • Birth trauma
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6
Q

Postpartum hemorrhage (PPH)

General management

A

i. Monitor
ii. Visual inspection (also with speculum) to assess amount of blood loss, if
placenta was expelled and to rule out extra-uterine bleeding source.
iii. Control bleeding and replace fluid loss as needed.
iv. Oxygenation

Transexamic acid (stops fibrinolysis and reduces mortality)

vii. Blood transfusion and FFP (in extreme cases and excluded coagulopathies)

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7
Q

Postpartum hemorrhage (PPH)

Mangement for

Abnormal placental
separation (accrete,
incerta, percreta)

A

If placenta was not expelled

  • Palpate uterus to assess its contractility
  • Attempt controlled cord traction.
  • If fails use uterotonic agents (oxytocin, misprostol, carboprost) and
    attempt again.
  • If fails then ultrasound exploration or vaginal exploration for retained
    placental tissue. Followed by cervical dilatation and curettage under epidural analgesics with oxytocin. Antibiotics are used in case of
    infection
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8
Q

Postpartum hemorrhage (PPH)

Management for Birth trauma

A

If placenta was expelled

  • Massage uterus to expel clots
  • Uterotonic agents (oxytocin, misprostol, carboprost)
  • Bimanual compression of uterus – maintained pressure on the anterior
    uterine wall from the anterior vaginal fornix until bleeding is controlled
  • Uterine tamponade
  • Uterine compression sutures (B-Lynch suture) – controlling atonic
    bleeding while preserving the anatomical integrity of the uterus. Use
    absorbable suture.
  • Vascular ligation
  • Hysterectomy (last resort)
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9
Q

Vaginal wall hematoma

A
  1. Causes:

a. Vaginal and perineal lacerations by assisted delivery

  1. Symptoms
    a. Anemia
    b. Pelvic pain
    c. Urine retention
  2. Diagnosis
    a. Visible bleeding
    b. Vaginal examination – in deep bleedings where bleeding is not visible a bulge can be felt
    c. Ultrasound
  3. Management

a. Venous bleeding controlled by compression
b. Arterial bleeding

i. Superficial – drainage and ligature of vessels.
ii. Deep – incision, drainage, suturing and antibiotics.

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10
Q

Amniotic fluid embolism (AFE)

A
  1. Diagnosis

a. Sudden development of ARDS and shock in patients in labor or recently delivered

  1. Pathomechanism
    a. Amniotic fluid enters maternal circulation via tears in the placental membrane →
    triggers anaphylaxis shock like response → DIC is followed bleeding to massive bleeding
  2. Management
    a. Supportive (oxygenation)
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