MatWeb Obstetrics Simplified Diaa M.

EI-Mowafi, MD Associate Professor, Department of Obstetrics & Gynecology, Benha Faculty of Medicine, Egypt Complications of the Third Stage of Labour

Include: 1- Postpartum haemorrhage. 2- Retained placenta. 3- Inversion of the uterus. 4- Obstetric shock (collapse). POSTPARTUM HAEMORRHAGE Definition: It is excessive blood loss, from the genital tract after delivery of the foetus exceeding 500 ml or affecting the general condition of the patient. Types: (1)Primary postpartum haemorrhage: Bleeding occurs during the 3rd stage or within 24 hours after childbirth. It is more common. (2)Secondary postpartum haemorrhage: Bleeding occurs after the first 24 hours until 6 weeks ( the end of puerperium). PRIMARY POSTPARTUM HAEMORRHAGE Aetiology: (A) Placental site haemorrhage: (I) Atony of the uterus: is the cause of primary postpartum haemorrhage in more than 90% of cases. The factors that predispose to uterine atony are:

1- Antepartum haemorrhage. 2- Severe anaemia. 3- Overdistension of the uterus. 4- Uterine myomas. 5- Prolonged labour exhausting the uterus. 6- Prolonged anaesthesia and analgesia. 7- Full bladder or rectum. 8- Idiopathic. (II) Retained placenta. (III) Disseminated intravascular coagulation (DIC). (B) Traumatic haemorrhage: Rupture uterus, cervical, vaginal , vulval or perineal lacerations. Diagnosis: (A) General examination:

The general condition of the patient is corresponding to the amount of blood loss.

In excessive blood loss, manifestations of shock appear as hypotension, rapid pulse, cold sweaty skin, pallor, restlessness, air hunger and syncope. (B) Abdominal examination: In atonic postpartum haemorrhage: The uterus is larger than expected, soft and squeezing it leads to gush of clotted blood per vaginum.

In traumatic postpartum haemorrhage: The uterus is contracted. Combination of the 2 causes may be present. (C) Vaginal examination: In atony: Bleeding is usually started few minutes after delivery of the foetus. - It is dark red in colour. - The placenta may be not delivered. In trauma: Bleeding starts immediately after delivery of the foetus. - It is bright red in colour. - Lacerations can be detected by local examination. Management: (A) Prevention: (I) During pregnancy:

1. Detection and correction of anaemia.

2. Hospital delivery with ready cross-matched blood for high risk patients as: - Antepartum haemorrhage. - Previous postpartum haemorrhage. - Polyhydramnios and multiple pregnancy. - Grand multipara. (II) During labour: 1- Proper use of analgesia and anaesthesia. 2- Avoid prolonged labour by proper oxytocin which should be extended to the end of the 3rd stage if used.

3- Avoid lacerations by : - Proper management of the 2nd stage. - Follow the instructions for instrumental delivery (see later). 4- Routine use of ecbolics in the 3rd stage of labour. 5- Routine examination of the placenta and membranes for completeness. (III) Postpartum:

1. Exploration of the birth canal after difficult or instrumental delivery as well as precipitate labour.

2. Careful observation in the fourth stage of labour (1-2 hours postpartum). (B) Treatment: (I) Restoration of blood volume: Urgent cross-matched blood transfusion with the other antishock measures is given. Colloids and/or crystalloids therapy can be started till availability of the blood. (II) Arrest of bleeding: i) Placental site bleeding: (a) Before delivery of the placenta: The placenta should be delivered by; - Ergometrine and massage with gentle cord traction if failed, - Brandt -Andrews manoeuvre if failed do, - Crds method if failed do, - manual separation of the placenta. (b) After delivery of the placenta: The following steps are done in succession if each previous one fails to arrest bleeding:

1. Inspection of the placenta and membranes : any missed part should be removed manually under anaesthesia.

2. Massage of the uterus and ecbolics as: - Oxytocin drip: 10-20 units in 500 ml glucose 5% or normal saline. It may be given (5 units) directly intramyometrial in case of C.S. - Ergometrine (Methergin) : 1-2 ampoules (0.25-0.50 mg) IV or IM. - Syntometrine 0.5 mg IV if available. (3)Prostaglandins (PGs ): - 0.25 mg methyl PG F2a IM ( Prostin methyl ester ) or - 1 mg PG F2a intramyometrial in case of C.S. or - 20 mg PG E2 (Prostin E2) rectal suppositories every 4-6 hours. (4) Bimanual compression of the uterus: - Under general anaesthesia, the uterus is firmly compressed for 5-30 minutes between the closed fist of the right hand in the anterior vaginal fornix and the left hand abdominally behind the body of the uterus. - The compression is maintained until the uterus is firmly contracted. During this period, blood transfusion,oxytocin and ergometrine are given. (5) Bilateral uterine artery ligation: - The surgeon stands on the left side of the patient to control the procedure more. - The uterus is grasped by the assistant and elevated upwards and to the opposite side of the uterine artery which will be ligated to expose the vessels coarse through the broad ligament. - A large atraumatic needle with no. 1 chromic cutgut, O-vicryl or O-Dexon is passed through and into the myometrium from anterior to posterior 2-3 cm medial to the uterine vessels. - The needle is brought forward through avascular area in the broad ligament lateral to the uterine artery and vein. The suture is tied anteriorly.

- In case of caesarean section, the sutures are placed 2-3 cm below the level of uterine incision under the reflected peritoneal flap which should be displaced downwards with the bladder to avoid ligation of the ureters. - If caesarean section was not done, peritoneal incision is not indicated and bladder can be simply pushed downwards. - Uterine artery ligation is haemostatic by reducing the pulse pressure to the uterus as 90% of its blood supply is from the uterine vessels. - Collateral circulation and recanalization of the uterine vessels will be established within 6-8 weeks. - It has a success rate of 95%. (6) Bilateral ligation of ovarian supply to the uterus: If bleeding continues after uterine arteries ligation a second mass bilateral ligation is done high up in the site of anastomosis between the uterine and ovarian arteries near the cornua of the uterus. (7) Bilateral internal iliac artery ligation: - The posterior peritoneum lateral to the infundibulo-pelvic vessels is opened. - The ureter is indentified on the posterior leaf of the broad ligament and retracted medially. - The bifurcation of the common iliac artery at the level of the sacroiliac joint is identified and the internal iliac vessels are identified and ligated with no.1 non-absorbable silk suture. - Most surgeons do not close the peritoneum over this area. - It has a success rate of 40%. (8) Hysterectomy: Subtotal hysterectomy which is more rapid and easy than total hysterectomy is done. Other less commonly used methods to arrest bleeding: (1) Uterine packing: - Under general anaesthesia. - Foley's catheter is applied. - Packing the whole uterus, cervix and vagina with a sterile gauze starting from the fundus downwards in tightly packed layers where each roll of gauze is tied to the next. - It is removed after 6-12 hours. (2) Foleys balloon :

A large Foleys catheter balloon is inflated to control haemorrhage from lower uterine segment which may result from placenta praevia or cervical pregnancy. (3) Aortic compression: The aorta is compressed manually against the lumbar spines through the abdomen providing temporary control of heavy bleeding till preparing for surgical interference. (4) Radiographic trans-arterial immobilisation: By a trained radiologist selective immobilisation of the pelvic vessels may be done using the angiographic techinque. ii) Lacerations: are dealt with (see maternal obstetric injuries). Complications: 1- Maternal death in 10% of postpartum haemorrhages. 2- Acute renal failure. 3- Embolism. 4- Sheehans syndrome. 5- Sepsis. 6- Anaemia. 7- Failure of lactation. SECONDARY POSTPARTUM HAEMORRHAGE Aetiology: (1)Retained parts: of the placenta, membranes, blood clot or formation of a placental polyp. (2) Infection: - separation of infected retained parts. - infected C.S. wound. - infected genital tract lacerations. - infected placental site.

(3) Fibroid polyp: necrosis and sloughing of its tip. (4) Subinvolution of the uterus. (5) Local gynaecological lesions: e.g. cervical ectopy or carcinoma. (6) Choriocarcinoma. (7) Puerperal inversion of the uterus. (8) Oestrogen withdrawal bleeding: if oestrogen was given for supression of lactation. Treatment: depends on the cause: (1) Retained parts: (a) with minimal bleeding : can be spontaneously expelled using: - ergometrine and - antibiotics. (b) with severe bleeding : vaginal evacuation under anaesthesia is indicated. (2) Infection : antibiotics. (3) Other causes : treatment of the cause.

03.08.99