L10: Complications of 3rd Stage of Labor Flashcards
Retained Placenta
Def of Retained Placenta
Failure of delivery of placenta èin 30 minutes after delivery of fetus.
Incidence of Retained Placenta
1%
Types of Retained Placenta
- Retained separated placenta
- Retained non separated placenta
Etiology of Retained Separated Placenta
1) Uterine atony.
2) Constriction ring.
3) Rupture uterus.
Etiology of Retained non-separated Placenta
1) Uterine atony.
2) Abnormally adherent placenta
3) Abnormal shape of placenta: Placenta membranacea & succenturiate placent
Pathogenesis of Abnormally adherent placenta
Layer of fibrinoid tissue () trophoblasts & decidua basalis (Nitabuch layer) is absent or ↓ → chorionic villi penetrate deeply.
Etiuology & RF for Abnormally adherent placenta
Types of Abnormally adherent placenta
Complications of Retained Placenta
Dx & Managment of Causes of Retained Placenta
- Uterine atony
- Constriction ring
- Rupture uterus
- adherent placenta
Dx of Uterine atony
Severe bleeding + lax uterus
TTT of Uterine atony
Give ergometrine & do gentile uterine massage (to stimulate uterine contraction) then try to deliver placenta by 1 of the following:
a. Brandt-Andrew’s maneuver
b. Crede’s method:
c. Manual removal
TTT of Uterine atony
- Crede’s Method (Technique)
TTT of Uterine atony
- Crede’s Method (Complications)
TTT of Uterine atony
- Manual removal of placenta (Technique)
TTT of Uterine atony
- Manual removal of placenta (Complications)
- Perforation of uterus.
- Retained parts of placenta or membranes.
- Infection.
Dx of Constriction ring
TTT of Constriction ring
- Deep general anesthesia & amyl nitrite.
- Manual removal or placenta.
Dx of Rupture uterus
TTT of Rupture uterus
- laparotomy to deliver placenta.
- repair uterus or do hysterectomy.
Dx of adherent placenta
TTT of Adherent placenta
TTT of Adherent placenta
- Ordinary (simple) adherence & partial placenta accreta
- Remove as much as possible from placenta & insert uterine pack
- if bleeding continues → bilateral uterine artery ligation, bilateral internal iliac artery ligation or hysterectomy.
TTT of Adherent placenta
- Complete placenta accreta, placenta increta or placenta percreta
Puerperal Inversion of Uterus
Def of Puerperal Inversion of Uterus
Body of uterus is partially or totally turned inside out (it may occur during 3rd stage of labor è placenta is still attached or after 3rd stage is over).
Incidence of Puerperal Inversion of Uterus
Very rare (1/20000 of deliveries).
Types of Puerperal Inversion of Uterus
Etiology of Puerperal Inversion of Uterus
- Spontaneous inversion
- Induced (iatrogenic) inversion
Etiology of Puerperal Inversion of Uterus
- Spontaneous
Etiology of Puerperal Inversion of Uterus
- Induced (iatrogenic) inversion
Degrees of Puerperal Inversion of Uterus
Dx of Puerperal Inversion of Uterus
- Symptoms
- Signs
Dx of Puerperal Inversion of Uterus
- Symptoms
Dx of Puerperal Inversion of Uterus
- Signs
Dx of Puerperal Inversion of Uterus
- Signs (1st degree)
Dx of Puerperal Inversion of Uterus
- Signs (2nd degree)
Dx of Puerperal Inversion of Uterus
- Signs (3rd degree)
Prevention of Puerperal Inversion of Uterus
TTT of Puerperal Inversion of Uterus
TTT of Puerperal Inversion of Uterus
- 1st Aid
TTT of Puerperal Inversion of Uterus
- O’Sullivan’s hydrostatic pressure method
TTT of Puerperal Inversion of Uterus
- Ogueh & Ayida
TTT of Puerperal Inversion of Uterus
- Manual reposition of uterus
Manual reposition of uterus
- Time
as soon as possible because any delay will lead to constriction of cervix & make uterus edematous & difficult to be replaced.
Manual reposition of uterus
- technique
Post-Partum Hemorrhage
Def of PPH
Abnormal or excessive bleeding from genital tract after delivery of fetus till end of puerperium (6 weeks after delivery).
Incidence of PPH
- In developed countries: In developing countries: 4% of all deliveries & 6% in CS
- high - the commonest cause of maternal mortality (30%).
the commonest cause of maternal mortality
PPH
Types of PPH
1ry & 2ry
Def of 1ry PPH
- Excessive bleeding from genital tract during 3rd stage of labor or èin first 24 hours after delivery.
- > 500 ml after vaginal delivery or > 1000 ml after CS or blood loss that affects general condition of patient.
- Average normal blood loss = 300 ml.
Etiology of 1ry PPH
- Atonic (Commonest cause)
- Traumatic
- Coagulopathy
- Combined
Etiology of 1ry PPH
- Atonic
- Multiparity.
- Over distention of uterus
- PH.
- Uterine fibroids.
- Uterine relaxants (tocolytics).
- Halogenated anesthesia.
- Chorioamnionitis.
- Severe anemia.
- Full bladder or rectum.
- Prolonged labor or precipitate labor.
- Retained placenta, placental fragments, pieces of membranes or blood clots.
- Idiopathic.
Etiology of 1ry PPH
- Traumatic
- Lacerations of perineum, vulva, vagina, or cervix.
- Rupture uterus.
- Acute inversion of uterus.
Etiology of 1ry PPH
- Coagulopathy
- DIC.
- Thrombocytopenia
- Von Willebrand’s disease
- hemophilia
Etiology of 1ry PPH
- Combined
….
Dx of 1ry PPH
Dx of 1ry PPH
- Hx
- History of PPH in previous delivery.
- Presence of predisposing factors.
- Time of onset of bleeding: During 3rd stage of labor or after delivery of placenta.
- Amount of blood loss.
Dx of 1ry PPH
- Ex
Dx of 1ry PPH
- Ex (General)
Signs of hypovolemic shock.
Dx of 1ry PPH
- Ex (Abdominal)
Consistency of uterus & fundal level
Dx of 1ry PPH
- Ex (Local)
a) Inspection for amount of bleeding, color &
clotting of blood.
b) Inspection of perineum, vulva, vagina & cervix
for lacerations.
c) Manual exploration of uterus for any defect or
retained placental parts.
Dx of 1ry PPH
- INVx
- CBC
- coagulation profile
DDx 1ry PPH
Compare between Atonic PPH & Traumatic PPH
Prevention of 1ry PPH
Prevention of 1ry PPH
- Antepartum
- Detection & correction of anemia.
- Hospital delivery è ready cross-matched blood for high-risk cases.
Prevention of 1ry PPH
- Intrapartum
- Proper use of Analgesia & Anesthesia.
- Avoid prolonged labor.
- Avoid traumatic deliveries (e.g., application of
forceps before full cervical dilatation). - Active management of 3rd stage of labor →↓atonic PPH.
- Routine examination of placenta & membranes to ensure complete expulsion
Prevention of 1ry PPH
- Postpartum
- Exploration of birth canal after any difficult or instrumental delivery.
- Administration of rectal PGs (misoprostol).
- Careful observation in 4th stage of labor (1-2 hours after delivery
Arrest of Bleeding in 1ry True PPH
- Inspection of placenta & membranes
- Uterine massage
- Ecbolics
- Exploration of uterine cavity & birth canal under anesthesia
- Bimanual compression of uterus
- Balloon tamponade (tamponade test)
- Surgical TTT
- Other less commonly used methods to arrest bleeding
Arrest of Bleeding in 1ry PPH
- Traumatic PPH
Treated according to type of injury.
Managment of 1ry PPH
- 1st Aid
Arrest of Bleeding in 1ry PPH
…
Managment of 1ry PPH
- 1st aid measures & resuscitation
- Arresting bleeding
- After care of PPH
Arrest of Bleeding in 1ry PPH
- Coagulopathy
a) Treatment of the cause.
b) Fresh blood, FFP, or platelet transfusion.
c) Antifibrinolytics.
Managment of 1ry PPH
- Arresting Bleeding
Arrest of Bleeding in 1ry Atonic PPH
- Bleeding before delivery of placenta
Immediate delivery of placenta.
Arrest of Bleeding in 1ry PPH
- Atonic PPH
- Bleeding before delivery of placenta (3rd stage bleeding)
- Bleeding after delivery of placenta (true 1ry PPH)
Arrest of Bleeding in 1ry Atonic PPH
Arrest of Bleeding in 1ry Atonic PPH
- Bleeding after delivery of placenta (true 1ry PPH)
Arrest of Bleeding in 1ry True PPH
- Ecbolics
a- Oxytocin drip: 20 units in 500 ml normal saline.
b- Ergometrine (Methergin): 0.25-0.50 mg IV or IM.
c- PGs: rectal or IM or intra-myometrial in CS.
Arrest of Bleeding in 1ry True PPH
- Inspection of placenta & membranes
Any missed part → removed manually under anesthesia.
Arrest of Bleeding in 1ry True PPH
- uterine Massage
….
Arrest of Bleeding in 1ry True PPH
- Exploration of uterine cavity & birth canal under anesthesia.
…
Arrest of Bleeding in 1ry True PPH
- Bimanual compression of uterus
▪ Under general anesthesia → uterus is firmly compressed for 5-30 minutes () closed fist of Rt hand
in anterior vaginal fornix & Lt hand abdominally behind body of uterus.
▪ Compression is maintained till uterus is firmly contracted (during this period, Ecbolics & blood
transfusion are given).
Arrest of Bleeding in 1ry True PPH
- Balloon tamponade (tamponade test):
Hydrostatic balloon catheter is inserted in uterus& filled è 200-500 ml warm saline to control Hge
Types of Uterine compression sutures
- B-Lynch suture.
- Modified B-Lynch suture.
- Vertical compression sutures.
- Square compression sutures.
Arrest of Bleeding in 1ry True PPH
- Surgical treatment
a- Bilateral uterine artery ligation
b- Bilateral internal iliac artery ligation.
c- Bilateral ovarian artery ligation.
d- Uterine compression sutures
e- Supra-vaginal hysterectomy: if other measures failed.
Managment of 1ry PPH
- After care of PPH
Arrest of Bleeding in 1ry True PPH
- Other less commonly used methods to arrest bleeding
Def of 2ry PPH
Abnormal or excessive bleeding from genital tract () 24 hours & 6 weeks after delivery.
Etiology of 2ry PPH
TTT of 2ry PPH
Complications of 3rd stage of labor
Complications of PPH
