JG COLLEGE OF NURSING

Seminar
on
rd
COMPLICATION OF 3
stage of labour

SUBMITTED TO: SUBMITTED BY:

MS. MURIAL CHRISTIE MS. JUHI LABANA
ASS. PROFESSOR S.Y. MSC STUDENT
JG COLLEGE OF NURSING JG COLLEGE OF
NURSING
 INTRODUCTION: The third stage of labour begins from delivery of baby ,
and end to deliver the placenta and the empty bag of waters attached to the
placenta (membranes).
During the Third stage of labour there are two common complication.
Post Partum Heamorrhage
Retained Placenta

1.Post Partum Haemorrhage

POST PARTUM HAEMORRHAGE: Postpartum haemorrhage (PPH) is the

leading cause of maternal mortality. All women who carry a pregnancy beyond
20 weeks gestation are at risk for PPH and its squeal. Although maternal mortality
rates have declined greatly in the developed world, But PPH is remains a leading
cause of maternal mortality elsewhere. National statistics suggest that
approximately 8% of these deaths are caused by PPH. PPH usually ranks in
the top 3 causes of maternal mortality, along with embolism and hypertension. In
the developing world, several countries have maternal mortality rates in
excess of 1000 women per 100,000 live births, and World Health Organization
statistics suggest that 25% of maternal deaths are due to PPH, accounting for
more than 100,000 maternal deaths per year.

DEFINITION: Postpartum haemorrhage is defined as excessive blood loss

during or after the third stage of labor. The average blood loss is 500 mL at
vaginal delivery and 1000 mL at Cesarean delivery.
Objectively, postpartum haemorrhage is defined as a 10% change in hematocrit
level between admission and the postpartum period or the need for transfusion
after delivery secondary to blood loss.

Early postpartum hemorrhage: Its occur just after the delivery of baby or
with in 24 hour of delivery.
 Late postpartum hemorrhage: Most frequently occurs 1-2 weeks after
delivery but may occur up to 6 weeks of postpartum.

INCIDENCE:
Vaginal delivery is associated with a 3.9% incidence of postpartum
hemorrhage. Cesarean delivery is associated with a 6.4% incidence of postpartum
hemorrhage. Delayed postpartum hemorrhage occurs in 1-2% of patients.

MORBIDITY AND MORTALITY:

In the United States, postpartum haemorrhage is responsible for 5% of maternal
deaths. Other causes of morbidity include the need for blood transfusions or
surgical intervention that may lead to future infertility.

ETIOLOGY:
Early postpartum hemorrhage
May result from
Uterine atony
Retained products of conception
Uterine rupture
Uterine inversion
Placenta accreta
Placental hypertrophy
Lower genital tract lacerations
Coagulopathy
Bleeding Disorder
Late postpartum hemorrhage
Retained products of conception
Infection
Subinvolution of placental site

Uterine atony and lower genital tract lacerations are the most common causes of
postpartum hemorrhage.
Factors Predisposing to Uterine Atony Include
Over distension of the uterus secondary to multiple gestations, polyhydramnios,
macrosomia, rapid or prolonged labor, grand multiparity, oxytocin administration,
intra-amniotic infection, and use of uterine-relaxing agents such as terbutaline,
magnesium sulfate, halogenated anesthetics, or nitroglycerin.
In uterine atony, lack of closure of the spiral arteries and venous sinuses coupled
with the increased blood flow to the pregnant uterus causes excessive bleeding.
Active management of the third stage of labor with administration of uterotonics
before the placenta is delivered (oxytocin still being the agent of choice), early
clamping and cutting of the umbilical cord, and traction on the umbilical cord have
proven to reduce blood loss and decrease the rate of postpartum hemorrhage.

DIAGNOSIS:
The onset of postpartum hemorrhage is acute, intervention is immediate, and
resolution is generally within minutes; consequently, laboratory studies or imaging
in the management of the immediate course of this process has little role.
However, it is important to check a patient's
CBC count
Prothrombin time/activated partial thromboplastin time (PT/aPTT) to
exclude resulting anemia or coagulopathy, which may require further
treatment.

TREATMENT
Initial therapy includes

Provide oxygen delivery,

Bimanual massage,
Removal of any blood clots from the uterus,
Empty the bladder,
 And the routine administration of dilute oxytocin infusion (10-40 U in 1000
mL of lactated Ringer solution [LRS] or isotonic sodium chloride solution).
If retained products of conception are noted, perform manual removal or
uterine curettage.
If oxytocin is ineffective, carboprost in an intramuscularly administered
dose of 0.25 mg can be administered every 15 minutes, not to exceed 3
doses.
Misoprostol has been used clinically for the treatment of postpartum
hemorrhage. However, further research is needed to determine the
effectiveness, optimal dosage, and route of administration.

When postpartum haemorrhage is not responsive to pharmacological therapy

and no vaginal or cervical lacerations have been identified, consider the
following more invasive treatment methods:

Uterine packing is now considered safe and effective therapy for the treatment
of postpartum hemorrhage. Use prophylactic antibiotics and concomitant
oxytocin with this technique. The timing of removal of the packing is
controversial, but most physicians favour 24-36 hours. This treatment is
successful in half of patients. If unsuccessful, it still provides time in which the
patient can be stabilized before other surgical techniques are employed.

Fig: Uterine packing Fig: Uterine artery Embolization

 Uterine artery embolization which is performed under local anaesthesia, is a
minimally invasive technique. The success rate is greater than 90%.This
procedure is believed to preserve fertility.

Complications are rare (6-7%) and include fever, infection, and nontarget
embolization.

A Foley catheter with a large bulb (24F) can be used as an alternative to

uterine packing. This technique can be highly effective, is inexpensive, requires
no special training, and may prevent the need for surgery.

The B-Lynch suture technique:A suture is passed through the anterior uterine
wall in the lower uterine segment approximately 3 cm medial to the lateral edge
of the uterus.

The suture is wrapped over the fundus 34 cm medial to the cornual and
inserted into the posterior uterine wall again in the lower uterine segment
approximately 3 cm medial to the lateral edge of the uterus and brought out 3
cm medial to the other edge of the uterus.

The suture is wrapped over the fundus and directed into and out of the anterior
uterine wall parallel to the previous anterior sutures. The uterus is compressed
in an accordion like fashion and the suture is tied across the lower uterine
segment.

The B-Lynch suture technique and other compression suture techniques are
operative approaches to postpartum hemorrhage that have proven to preserve
fertility.

As practitioners become proficient in this technique, it may be considered

before uterine artery or hypo gastric artery ligation and hysterectomy.
 Fig : B- Lynch Suturing
SURGICAL MANAGEMENT
When conservative therapy fails, the next step is surgery with either
bilateral uterine artery ligation or hypogastric artery ligation.
Uterine artery ligation is thought to be successful in 80-95% of patients.
If this therapy fails, hypogastric artery ligation is an option.
However, this approach is technically difficult and is only successful in 42-
50% of patients. Instead, stepwise devascularization of the uterus is now thought to
be the next best approach, with possible ligation of the utero-ovarian and
infundibulopelvic vessels.

Fig: Hysterectomy
NURSING MANAGEMENT
NURSING DIAGNOSIS

Decreased cardiac output related to hypovolemia

Fluid volume deficit related to excessive blood loss
Altered tissue perfusion related to hypovolemia
Pain related to procedures and treatment
Anxiety related to separation from newborn long term impact on self care
and infant care, need for blood transfusion.
Risk for injury related to changes in cerebral tissue perfusion.
Risk for altered parent/infant attachment related to to complication and need
for separation from newborn during treatment.

INTERVENTIONS:

Administer IV fluids as quickly as possible

Administer oxytocics to help contract the uterus
Administer oxygen therapy
Place the client in a trndlenburg position to increase venous return to the
heart.
Monitor vital signs every 5-10min,, and observe the clients color, oxygen
saturation by pulse oxymetry, skin temperature and sensorium.
Palpate the fundus for firmness and massage to restore the tone.
Evaluate the vaginal bleeding, extent of perineal pad saturation, colour.
Consistency of bleeding clots and pooling on the under pad.
Prepare for blood transfusions and administer blood transfusions.
Reassure the mother and family.
Allow the family members to involve in the care.
Explain the physiological process of hemorrhage and interpret medical
treatments and procedures.
Once the bleeding controlled assist the mother and family what happened to
understand and why to anticipate what impact this complication will have on
the post partum while care taking and self care activities and to plan for
special needs at home.
 2.Retained Placenta

RETAINED PLACENTA: Retained placenta is a placenta that stays in the womb

after childbirth. Risks of retained placenta include haemorrhage and infection.
After the placenta is delivered, the uterus should contract down to close off all the
blood vessels inside the uterus. If the placenta only partially separates, the uterus
cannot contract properly, so the blood vessels inside will continue to bleed. A
retained placenta thereby leads to haemorrhage.

DEFINITION: Retained placenta is defined as a placenta that has not

undergone placental expulsion within 30 minutes of the babys birth where the
third stage of labor has been managed actively.
CAUSES OF RETAINED PLACENTA:
1. Uterine Atony: The most common type of retained placenta is where the
uterus does not contract enough or stops contracting for the placenta to come
out from the uterus.
2. Trapped Placenta: It occurs when the placenta detaches from the uterus but
gets trapped behind the closed cervix. It usually happens when the cervix
begins to close before the placenta is completely removed.
3. Placenta Adherens: When complete or a part of the placenta is firmly
attached to the uterine wall, it is known as placental adherens. In rare cases, it
happens when the part of the placenta is deeply embedded into the wall of the
uterus, known as placenta accreta. It is more likely to occur when the
placenta embeds itself in a previous C-section scar.
4. Succenturiate Lobe: Retained placenta can also develop when a small
piece of placenta is connected to the main part by a blood vessel that is left
behind in the uterus. This blood vessel is known as a succenturiate lobe.
RISK FACTORS OF RETAINED PLACENTA:
We cannot predict if any of the above cases could happen to a mother. However,
certain factors increase the risk of the condition.
Premature labor or giving birth before the 34th week of pregnancy.
Induction or augmentation of labor.
Lobulated placenta.
Previous cases of retained placenta.
Having more than five births previously.
Conceiving after the age of 35.
Giving birth to a stillborn baby.
Prolonged first or second stage of labor.
Previous uterine surgery.

SIGNS AND SYMPTOMS OF RETAINED PLACENTA:

Fever
Foul smelling discharge containing large tissue residue
Persistent bleeding
Severe cramps and contractions
Delay in milk production
DIAGNOSIS OF RETAINED PLACENTA:

A careful examination

In a few cases, doctor may not diagnose the missing part of the placenta.
But, when you begin to experience the symptoms after delivery, it signals
the retention.
 Ultrasound scan to check for retained placental fragments in the womb.

COMPLICATION OF RETAINED PLACENTA :

If the placental tissue is left in the uterus, it cannot contract properly, and the
blood vessels continue to bleed.

Primary Postpartum Haemorrhage (PPH)

Secondary Postpartum Haemorrhage.

MANAGEMENT OF RETAINED PLACENTA:

1. Manual removal of placenta: Insert a catheter to empty the bladder, and give
you intravenous antibiotics to prevent any infection. You will also get a local
anesthesia, either spinal or epidural. The practitioner will then place her hand
inside the uterus to remove the placenta. You will require more intravenous
drugs after the manual placental removal for the uterus to contract .

Fig : Manual removal of placenta

2. Controlled cord traction: This is performed when the placenta is separated
from the uterus, but is still not able to come out. In this case, your doctor will
gently pull the umbilical cord to help rid the body of the placenta .

3. Curettage: In the case of placenta accreta, manual removal is done partially,

and curettage removes the rest. Under this method, a curette is used to remove
the placental debris from the uterus through scrapping .

Fig : Controlled cord traction Fig : Curettage

4. Hysterectomy: In the case of placenta excreta, where the placenta is deeply

grown into the uterus, hysterectomy helps. It is a surgical process of uterus
removal. The drawback in this treatment is you cannot carry pregnancies in the
future.
SUMMARY:

Today we have discussed about the third stage of labour, and complication of third
stage of labour that is ; Post partum haemorrhage and Retained Placenta in detail
with Definition, cause, risk factors symptoms and treatment of the PPH and
Retained placenta and its nursing management also. This topic help us in our
clinical posting and during practical examination.

BIBLIOGRAPHY:

Boback M Irene & Jenson Margaret Maternity & Gynaecologic Care,

mosby company (5th edition) page no;964-971
DC Dutta (2004) text book of obstetrics ( 6 th edition) India:; new central
book agency page no: 433-444.
Myles (2003) text book for midwives (14th edition), Philadelphia;
Churchill livingstone publishers, page no:625-653
WHO, The prevention and management of puerperal infections

BJOG: An International Journal of Obstetrics & Gynaecology

Journal-obgyn-india.com
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