Module 7: Complications in the third stage and perineal trauma

Question 1

Define a PPH

Answer 1

Blood loss of 500ml or more during and after childbirth.
Severe PPH is defined as blood loss of over 1000mL OR any amount of blood loss postpartum that causes maternal compromise

Question 2

State the difference between a primary and secondary PPH

Answer 2

Primary PPH - occurs within the first 24 hours following birth
Secondary PPH - occurs between 24 hours and 6 weeks postpartum.

Question 3

4 causes of PPH

Answer 3

Tone (70%) - atonic uterus, precipitate labour, prolonged labour, polyhydramnios, multiple pregnancy, full bladder

Trauma (10-20%) - Lacerations, episiotomy, uterine rupture, uterine inversion, extensions/lacerations at LSCS.

Tissue (10-20%) - Retained products

Thrombin (1%) - Coagulation disorders, thrombocytopenia, pre-eclampsia, dead fetus, severe infection, abruption, amniotic fluid embolus.

Question 4

PPH management

Answer 4

Get help
Identify the cause of bleeding
Fundal massage
Give an oxytocic
Empty bladder
Ensure no retained products/placenta delivered
Manual removal if not delivered
Ensure active bleeding sites controlled
Syntocinon infusion
Collect bloods for FBC, cross matching and haemoglobin
IV fluids in a volume at least 3 times the measured volume lost.

Prophylaxis - avoid anaemia, dehydration, prolonged labour, empty bladder regularly, oxytocic’s for 3rd stage, check history.

Question 5

Drugs used for PPH

Question 6

Uterine inversion causes

Answer 6

Incorrect management, short cord, precipitate labour, manual removal, pathologically adherent placenta, spontaneous with no obvious cause.

Question 7

Uterine inversion classification

Answer 7

First degree - fundus reaches the internal os

Second degree - the body of the uterus is inverted to the internal os

Third degree - the uterus, cervix and vagina are inverted and are visible.

Question 8

Uterine inversion management

Answer 8

Get help
Manual or surgical replacement
Correction of shock
Oxytocic once uterus is replaced to normal position

Question 9

Perineal trauma

Answer 9

First degree injury to the skin only

Second degree injury to the perineum involving perineal muscles but not involving the anal sphincter

Third degree injury to the perineum involving the anal sphincter complex, 3a, 3b, 3c

Fourth degree injury to the perineum involving the external anal sphincter and internal anal sphincter and anal epithelium.

Question 10

Episiotomy

Answer 10

Is a surgical incision made into the perineum which if required should be performed only immediately prior to birth to enlarge the vaginal outlet and to assist the birth of the baby.

WHO recommends an episiotomy rate of no more than 10% for normal deliveries.

Question 11

Indications for episiotomy

Answer 11

Fetal distress
Short or rigid perineum
Shoulder dystocia
Fetal malposition
An instrumental or breech delivery
Previous pelvic floor surgery

Question 12

Puerperal infection (sepsis) risk factors

Answer 12

LSCS and wound infections
PROM
Chorioamnionitis
Prolonged labour
Bladder catheterisation
Internal fetal monitoring
Retained placental fragments
Episiotomy, lacerations or haematoma
Endometritis

Question 13

Endometritis

Answer 13

Most common cause of puerperal infection. Higher incidence with LSCS and women with IDDM (2.5x more likely)

Signs and symptoms, Temp >38, tachycardia, chills, anorexia, nausea, fatigue, lethargy, pelvic pain, uterine tenderness, offensive lochia

Treatment antibiotics