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Third stage of labour (Normal & abnormal)

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Third stage of labour (Normal & abnormal) Dr. Abdalla H. Elsadig MD Definition : 3rd stage of labor: commences with the delivery of the fetus and ends with delivery ... – PowerPoint PPT presentation

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Title: Third stage of labour (Normal & abnormal)


1
Third stage of labour (Normal abnormal)
  • Dr. Abdalla H. Elsadig
  • MD

2
  • Definition
  • 3rd stage of labor commences with the
    delivery of the fetus and ends with delivery of
    the placenta and its attached membranes.
  • Duration
  • - normally 5 to15 minutes.
  • - 30 minutes have been suggested if there is no
    evidence of significant bleeding.
  • The risk of complications continues for some
    period after delivery of the placenta.
  • Fourth stage of labor begins with the delivery
    of the placenta and lasts for 1 hour.

3
Significance
  • Postpartum haemorrhage (PPH)
  • - Maternal mortality.
  • . The maternal mortality rate in the United
    States is approximately 7-10 women per 100,000
    live births 8 of these deaths are caused by
    PPH.
  • . The maternal mortality rates in developing
    world exceeded 1000 women per 100,000 live
    births, 25 of these deaths are due to PPH.
  • - Anemia PPH causes anemia or poor iron. Anemia
    causes weakness and fatigue. prolonged
    hospitalization affects the establishment of
    breastfeeding.
  • - Blood transfusion? transfusion reaction and
    infection.
  • - Emergency anesthetic intervention due to
    severe PPH, retained placenta, and uterine
    inversion.
  • - Sepsis due to exploration or instrumentation
    of the uterus.

4
Mechanism of placental separation
  • Uterine contractions and retraction reduce the
    uterine cavity ? placental detachment and
    expulsion into the lower uterine segment.
  • Retro-placental hematoma.
  • Oxytocin, ergometrin and prostaglandins enhance
    placental separation and expulsion by causing
    uterine contraction .
  • Tocolytics/nitroglycerin and some inhalation
    anesthetics cause uterine relaxation and delay of
    placental separation causing dangerous bleeding
    following delivery.

5
What to do before delivery of the placenta?
6
What to do before delivery of the placenta?
  • 1. Look for signs of placental separation
  • lengthening of the umbilical cord outside.
  • The uterus becomes firm and globular.
  • The uterus rises in the abdomen.
  • A gush of blood.
  • 2. Assess the uterus
  • To exclude an undiagnosed twin
  • To determine a baseline fundal height
  • to detect the signs of placenta separation
  • to detect an atonic uterus.

7
Delivery of the placenta
  • 1. Physiological or expectant management
  • - Wait for the signs of placental separation
  • - Make sure that the uterus is contracted.
  • - Controlled Cord traction the body of the
    uterus is supported above the symphysis pubis by
    the left hand directed upward and backward. Then
    cord traction is applied continuously downward
    and forward with the right hand.
  • 2. Active management
  • - By using one of the following Ergometrine,
    Oxytocin, or Syntometrine (ergometrine oxytocin
    ).
  • - Given at the delivery of anterior shoulder
    or after delivery of the baby.
  • - Immediate delivery of the placenta with CCT.
  • Avoid uterine massage before placental delivery.

8
Mode of drugs administration
  • Oxytocin
  • - 10 IU, intramuscularly with intravenous
    access in place, 10-20 IU is placed in 500-1000
    mL of crystalloid and run quickly.
  • - With cesarean deliveries 5 IU is administered
    as an intravenous bolus, followed by a similar
    infusion.
  • Ergometrine dose is 0.25- 0.5 mg IM or IV.
  • Syntometrine (0.5 mg of ergometrine with 5 IU of
    oxytocin)
  • The dose is 2 mg and
    given IM only.

9
Delivery of membrane
  • By rotating the placenta about the insertion site
    as it descends or grasping the membranes with a
    clamp or artery forceps and drawn down.

10
Umbilical cord management
  • cord clamping Delayed until the cord is
    pulseless, usually 2-4 minutes, ??Hb, ?iron
    stores in the newborn and ?levels of early
    childhood anemia.
  • Method of cord clamp

11
Physiological Versus Active Management
12
What to do after delivery of the placenta?
13
Immediately after delivery of the placenta
  • Determine the fundal position and size of the
    uterus.
  • Ensure that the uterus is contracted (can be
    enhanced with oxytocin and uterine massage).
  • Examine the placenta for completeness and
    detection of abnormalities.
  • Suturing of lacerations.
  • Uterine exploration
  • - No longer recommended for normal deliveries
    or those following previous cesarean delivery.
  • - Is justified in patients with bleeding
    originating high in the genital tract.
  • - The cervix should be visualized after all
    forceps deliveries

14
Fourth stage
  • Observe the vital signs.
  • palpate the abdomen to assess and monitor uterine
    tone and size.
  • Do uterine massage.
  • Ensure continuous infusion of oxytocin.
  • Encourage early breastfeeding to promote
    endogenous oxytocin release.
  • assess the lower genital tract for bleeding.
  • repair of an episiotomy or any lacerations.
  • Close observation every 15 minute for the next
    hour.

15
THANKS
16
COMPLICATIONS
Postpartum hemorrhage
  • Uterine atony.
  • Retained placenta.
  • Trauma.
  • Uterine inversion.

17
Postpartum hemorrhage ( PPH)
  • Def is an excessive blood loss from the genital
    tract after delivery of the baby. It is divided
    into primary and secondary PPH.
  • Primary PPH blood loss of 500 ml or more in the
    first 24 hours after delivery.
  • Causes
  • Uterine atony.
  • Genital tract trauma.
  • retained placental tissue.
  • Uterine inversion.
  • Coagulation disorders
  • - Inherited coagulopathy.
  • - Abruptio placentae.
  • - Retained dead fetus.
  • - Amniotic fluid embolism.

18
Uterine Atony
  • Inability of the uterus to contract and retract
    effectively.
  • The uterus increases in size (retained products)
    and is felt soft and boggy.
  • The patient has a rapid, thready pulse with a
    decrease in BP. The patient may also looks pale
    and apprehensive.

19
Uterine Atony
  • Factors predisposing
  • Over-distension of the uterus multiple
    pregnancy, poly-hydramnios or fetal macrosomia.
  • Retained products of conception the placenta ,
    placental cotyledon or fragments or a large
    amount of membranes.
  • large placental site multiple pregnancy.
  • Prolonged labor weak or incoordinate uterine
    action or mechanical difficulty will leading to
    uterine exhaustion and atony.
  • Placenta praevia inability of the lower uterine
    segment to contract and retract.
  • Abruptio placentae interstitial uterine
    hemorrhage and later hypofibrinogenaemia.
  • Grand-multiparity (a parity of 5 or more) ?
    fibrous tissue of the uterus ? muscular tissue.
  • Operative deliveries C/S general anaesthesia
    that relax the myometrium, such as Halothane and
    Cyclopropane.
  • multiple fibromyomata (leiomyomata), especially
    of the interstitial type resulting in ineffective
    uterine contraction and retraction.
  • full bladder.

20
Genital tract trauma
  • Causes
  • perineal laceration or episiotomy obvious
    bleeding.
  • Vaginal or cervical lacerations or tears tend to
    occur over the perineal body, periurethral area
    and over the ischial spines al.
  • Lacerated or ruptured uterus.
  • Predisposing factors
  • Difficult labor.
  • Precipitate labor.
  • previous caesarean section.
  • Instrumental delivery forceps, Ventouse or CS.
  • Genital tract trauma is suspected when there is
    continuous bleeding and the uterus is well
    contracted, particularly after an oxytocic drug
    has been given

21
Retained placental tissue
  • Uterine atony
  • Morbidly adherent placenta
  • - Due to abnormal development of decidua
    basalis.
  • - Causes previous CS, placenta previa, manual
    removal of placenta or uterine curettage.
  • Degrees 1) accreta (80). 2) increta. 3)
    percreta.
  • Diagnosis 1) antenatally U/S MRI
  • 2) in 3rd stage commonly
  • Caught of placenta by the retraction ring at the
    junction of the upper and lower segments
    following an Ergometrine injection than
    Syntometrine or Oxytocin injections.

22
Inversion of the uterus
  • the fundus of the uterus descends through the
    uterine body and cervix into the vagina, and
    sometimes protrudes through the vulva. This ?
    traction on peritoneal structures ? vasovagal
    vasodilatation neurogenic chock.
  • Predisposing factors
  • mal-management of the third stage inappropriate
    traction during CCT or too rapid removal during
    MRP.
  • ?intra-abdominal pressure relaxed uterus
    (fundal pressure).
  • Previous history of inversion ( 33).
  • Cornual placenta ( cornual pockets).

23
Management of (PPPH)
  • Two important principles
  • The bleeding must be stopped.
  • the blood volume must be restored.
  • guidelines for PPH management
  • Call for help ( senior staff, midwives,
    anesthetists and hematologists).
  • Ensure at least two peripheral infusion lines
    with large-bore IV canulae.
  • Blood sample should be taken for a full blood
    count, coagulation studies and blood group and
    cross-matching.
  • Start intravenous fluid ( Hartmanns or saline).
  • Give blood when it is available.
  • Give intravenous oxytocic drugs ( methergine or
    syntocinon).
  • Examination to determine the cause.

24
Management of (PPPH)
  • Uterine atony the placenta has delivered
  • Resuscitate the patient as mentioned above.
  • Stimulate uterine contraction by
  • - Uterotonics IV ergometrine (0.5 mg), IV
    Syntocinon (5 iu) or IM syntometrin ( 1ml)
    30-40 units of syntocinon in 40 ml of normal
    saline run at 10 ml/hr.
  • uterine massage and bimanual compression.
  • Packing of the uterine cavity (gauze/balloon
    insufflation).
  • If no response give prostaglandin analogues
    e.g. Carboprost Hemabate, 0.25 mg every 15-90
    min. up to 8 doses given by deep IM or Gemeprost
    intramyometrial or misoprostol rectally.
  • If still no response, then go for examination
    under anesthesia and surgery ( uterine arteries
    ligation, infundibulo-pelvic vessels ligation
    internal iliac artery ligation, compression
    sutures or hysterectomy).

25
Management of (PPPH)
  • Uterine atony the placenta not delivered
  • Resuscitate the patient as mentioned above.
  • Ensure uterine contraction.
  • try to deliver the placenta by controlled cord
    traction.
  • if the placenta not delivered, then take the
    patient to the theatre for manual removal of the
    placenta under general anesthesia.
  • Ergometrine should be given and syntocinon in a
    drip should be set.

26
Management of (PPPH)
  • Trauma
  • Is suspected when the bleeding persists, with
    well contracted uterus.
  • Full exploration under general anesthesia for the
    vulva, the vagina, cervix and uterus.
  • Vaginal and cervical lacerations should be
    sutured.
  • Ruptured uterus is treated by repair or subtotal
    hysterectomy.

27
Management of (PPPH)
  • Uterine inversion
  • The condition is diagnosed in various ways
  • - Acute complete inversion absent uterus on
    abdominal examination.
  • - Incomplete inversion presence uterine
    dimpling on abdominal examination.
  • The treatment includes
  • Resuscitation manual replacement prior to
    onset of shock.
  • manual replacement under general anesthesia
    (shock) if fails
  • OSullivans hydrostatic method the vagina is
    filled with warm saline which is gradually
    instilled into the vagina by means of a douche
    can and tubing. The introitus is blocked with
    assistants fist. 4 to 5 L of saline will balloon
    the vagina, distend the uterus and so, reverse
    the inversion.
  • Laparotomy (Haultains) incision in the muscular
    ring in the posterior uterine wall and correction.

28
Management of (PPPH)
  • DIC
  • Maintain the intravascular volume.
  • Administer fresh frozen plasma(FFP) at a rate to
    keep the activated partial thromboplastin
    control ratio lt 1.5.
  • Administer packed platelet to maitain a platelet
    count gt 50 109/L.
  • Administer cryoprecipitate to keep the fibrinogen
    level gt 1 gm/L.

29
  • thanks
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