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Complication of the Third stage of Labor Post
Partum Hemorrhage
Definition :
Excessive blood loss during or following the 3
rd
stage of labor ( > 500 cc after
vaginal delivery OR > 1000 cc after CS OR decrease in hematocrit by 10% since
admission Or blood loss which affects the general condition of the patient Or
that needs blood transfusion ) . When the loss reaches 1.5L or 25-30% of blood
volume , it is called massive hemorrhage .
Incidence :
Variable according to the level of obstetric care . In the 3
rd
world , it is
responsible for 10-25% of all maternal mortality due to obstetric bleeding .
Types :
1. Primary post-partum hemorrhage : Bleeding occurs during the 3
rd
stage or
within 24 hours after labor ( commonest type ) .
2. Secondary post-partum hemorrhage ( puerperal hemorrhage ) : Bleeding
occurs after the 1
st
24 hours till the end of the puerperium .
Primary Post partum Hemorrhage :
Etiology :
I- A tonic post-partum hemorrhage :
Caused by uterine atony predisposed by :
1. Prolonged labor leading to uterine exhaustion .
2. Retention of a partially or completely separated placenta , placental or
membrane fragment .
3. Overdistension of the uterus as in hydramnios or twins .
4. Antepartum hemorrhage or any cause of marked anemia .
5. Full bladder or rectum .
6. Uterine fibroids .
7. Prolonged anesthesia and Analgesia .
8. Sometimes , there is no apparent cause .
II- Traumatic post-partum hemorrhage :
From lacerations of the perineum , vulva , vagina or cervix , and rarely , an
unrecognized rupture of the uterus .
III- DIC :
( Due to atony + Coagulation defect ) .
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Clinical picture :
I- History or any risk factor .
II- Examination :
1. General examination :
* Signs of bleeding as pallor , tachycardia , hypotension , which may progress to
hypovolemic shock .
* In traumatic bleeding the signs are usually explained by the vaginal bleeding ,
however in rupture uterus , the signs are not explained by the vaginal bleeding
as there is much intraperitoneal Hge .
* In atonic type , signs are also not explained by vaginal bleeding as most of
blood is accumulated in the uterine cavity .
2. Abdominal examination :
* In atonic bleeding , the uterus is large , lax and rising . Pressure on the fundus
causes expulsion of large amounts of blood and blood clots .
* In cases of traumatic bleeding , the uterus is contracted . However , the
traumatic and atonic bleeding may be combined in one case .
* In cases with few days intraperitioneal bleeding , a brownish coloration is seen
around the umbilicus ( Cullen sign ) .
* in cases with intraperitoneal Hge , Shifting dullness is (+) ve .
3- Vaginal examination :
* The bleeding is usually dark in color in cases of atony and more bright red in
cases of lacerations .
* Examine the patient for any laceration in the perineum , cervix or vagina
especially after difficult vaginal delivery .
Prophylaxis :
1. Anemia should be treated during pregnancy , patients with antepartum
hemorrhage , oversize uterus or a history of post-partum hemorrhage should
be delivered in hospital .
2. During labor :
a. Avoid traumatic delivery e.g. application of forceps before full cervical
dilatation .
b. Proper use of analgesia and anesthesia .
c. Proper management of the 3
rd
stage with the routine administration of
ergometrine .
d. Avoid traction on the cord and examine the placenta and membranes after
their delivery to detect any missing part .
e. Examine the birth canal after labor to detect and suture any laceration .
f. The bladder should be always empty .
3. The patient should be watched for 2 hours after delivery .
4. Well equipped hospitals with blood banks should be available .
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Treatment :
I- 1
st
measures to treat shock and replace blood .
II- Atonic type :
a. Bleeding before delivery of the placenta : Give ergometrine and massage
the uterus gently to induce uterine contractions and deliver the placenta by
Brandt-Andrews or Crede's method . If these fail , do manual removal of
the placenta under anesthesia .
b. Bleeding after delivery of the placenta .
i. Massage the uterus and give ergometrine if not already given .
ii. If the delivered placenta and membranes are available , they should be
inspected for any missing portion that should be removed .
iii. If the uterus fails to respond , it should be explored under anesthesia to
extract any placental fragment , pieces of membranes or blood clots .
iv. If exploration is negative , misoprostol 800 – 100 ug is given rectaly .
Intramuscular injection of 0.25 mg methyl prostaglandin F2a ( repeated
every 15-90 min for maximum of 8 doses ) is also very effective .
Intramyometrial injection of 1mg prostaglandin F2a r better 0.25mg methyl
prostagaudin F2a may be tried in cases following caesarean section PGF can
also be given as vaginal or rectal suppositories ( 20 mg every 2 hours ) .
v. If atony persists , do Bimanual compression under anesthesia ( the closed
fist in the anterior fornix and the abdominal hand behind the fundus ) .
Bimanual compression may be maintained between 5 and 30 minutes until
the uterus is firmly contracted . Blood transfusion , ergometrine and
oxytoxin should be maintained .
vi. If all the above measures fail to control bleeding it is better resort to the
surgical alteratives which are :
Unilateral or bilateral uterine artery ligation .
Unilateral or bilateral internal iliac artery ligation distal to the posterior
parietal division .
Unilateral or bilateral infundibulopelivc ligament ligation or better
bilateral ovarian artery ligation at the measovarium to preserve ovarian
and tubal blood supply .
If the bleeding continues , a rapidly performed hysterectomy is done .
vii. Recently , many nonsurgical method are tried aiming at avoiding surgery .
There methods include intrauterine balloon compression , merine artery
embolization or direct intra-arterial injection of vasconstricting agents .
However these methods are not widely used and needs more evaluation .
N. B.
: Old methods to control atonic postpartum Hge :
a. Hot intra-uterine douche ( 5% dettol at 48 C ) to stimulate uterine
retraction . However , this method is not used now as the ecbolic drugs are
much more effective in this respect .
b. Intrauterine packing to compress the uterine cavity . However , this
method needs experience not to perforate the uterus , also this method
invites infection .
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c. Pulling on the cervix by a pair of ring forceps to induce uterine prolapse
resulting in kinking of the uterine artery . However , this method weakens
uterine supports and may not succeed as ovarian artery branches are not
occluded .
III- Traumatic post-partum hemorrhage
: Treated according to the
type of injury ( Details ) .
VI- Treatment of DIC
: Sec DIC .
N.B.
: After care of postpartum Hge :
1. Ecbolics to maintain uterine contraction till stopping of bleeding .
2.Treating the resulting anemia through proper nutrition specially supplying
proteins , vitamin and mineral preparation specially iron .
3. Antibiotic for prevention of infection .
Secondary post-partum Hemorrhage :
Etiology :
1. Retained placental fragment , a piece of membranes , a blood clot , or the
formation of a placental polyp .
2. Infection . Bleeding may occur due to separation of a septic retained part or
the bleeding may originate from the placental site , an infect caesarean section
wound or an infected laceration of the genital tract .
3. Submucous fibroid which becomes extruded in the uterine cavity to form a
submucous fibroid polyp or infection in a fibroid .
4. Choriocarcinoma .
5. local gynecological lesions e.g. cervical erosion or carcinoma of the cervix .
6. Puerperal inversion of the uterus .
7. Estrogen withdrawal bleeding ( in cases given estrogen to suppress lactation).
Management : According to the cause .
N. B.
:
Non surgical methods for controlling massive postpartum hemorrhage :
1. Arterial embolization : Entailing intra-arterial injection of embolizing material
( polyvinyl alcohol particles or gel foam pellets ) . Arteriography should be
done before ( to assess the condition ) and after the procedure ( to assess the
results ) . Angiography can detect bleeding > 2 ml/min .
2. Intra-arterial injection of vasopressor agent ( dopamine HCL or vasopressin ) .
3. The MAST suite ( Military Anti Shock Trouser ) : Composed of double
polyvinyl suite with 3 components , one abdominal and 2 legs . Each
component can be inflated separately with foot pump ( pressure = 40 – 65
mmHg ) to decrease bleeding by increasing the PR . Side effects are
hypoventilation , lactic acidosis , hyperkalemia , decreased urine output ,
skin injury and hypotension if rapidly deflated .
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Petained Placenta
Definition :
Failure of placental delivery within 1/2 hour after delivery of the fetus .
Incidence : 1 % .
Etiology :
I- Retention of a separated placenta :
1. Atony of the uterus ( details ) .
2. contraction ring leading to hour-glass contraction of the uterus .
3. Rarely , the placenta may pass into the peritoneal cavity through a complete
rupture of the uterus .
II- Retention of a nonseparated placental :
1. Atony of the uterus .
2. Abnormal adhesion of the placental which may be either :
a. Simple adhesion ( in which manual separation can be done easily ) .
b. Pathological adhesions ( the decidua basalis is absent or defective so the
chorionic villi penetrate the uterine muscles ) . In such cases , there is no
line of cleavage between the placenta and uterine wall . These conditions
occur more in placenta previa due to defective decidual reaction in the
lower segment , Pathological adhesions may be :
i. Placenta accreta ( partial or complete ) : Chorionic villi invade the inner
myometrium only .
ii. Placenta increta : Villi invade deeply in the uterine muscle .
iii. Placenta percreta : Villi invade very deep in the uterine muscles up to
the peritioneal coat ( but no penetration ) .
iv. Penetrating placenta into the peritoneal cavity .
Complications :
1. Post-partum hemorrhage mainly due to uterine atony .
2. Shock ( both hemorrhagic and neurogenic ) .
3. Puerperal sepsis .
4. Subinvolution .
5. Formation of a placental polyp or rarely give rise to choriocarcinoma .
6. Complications of the method of treatment ( Crede method , anesthesia ,
hysterectomy , IIAL … etc . ) .
Clinical Picture :
1. Bleeding occurs only if part or all the placenta is separated . Lower abdominal
colics may also be present .
2. Signs of bleeding or neurogenic shock ( due to uterine cavity distension ) .
3. In cases of uterine atony , the uterus is lax and the bleeding , if present , is
severe .
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4. Vaginal examination will diagnose :
a. Hour-glass contraction .
b. Placental adhesions .
c. Rupture of the uterus .
Treatment :
I- In cases of uterine atony :
1. Give ergometrine and do gently massage of the uterus to stimulate it to
contract and then deliver the placenta by one of the following methods
respectively :
a. Brandt-Andrews maneuver ( see before ) .
b. If fails , do Crede's method : Evacute the bladder and massage the uterus
to stimulate in to contract , then grasp the fundus with four fingers
behind and the thumb in front to squeeze the placenta and then push the
fundus downwards and backwards to expel the placenta . Although it is
easy to do , yet it has the following disadvantages :
i. It is shocky , so general anesthesia in needed .
ii. It may be unsuccessful especially in markedly obese patients , non-
cooperative patients , patients with rigid abdominal wall , placental
adhesions and contraction ring .
iii. It may cause inversion of the uterus or partial separation of the
placenta , leading to postpartum hemorrhage , if done on a lax uterus .
iv. Retention of a placental fragment may occur .
c. If the above fails do manual removal of the placenta : Under general
anesthesia and strict aspesis , introduce the right hand and follow the
cord to the placenta and then pass the hand to the lower edge of the
placenta and by a sawing movement from side to side separate the
placenta while the fundus is steadied by a hand on the abdomen . Grasp
the placenta and deliver it out and inspect it to detect any missing
fragment . Give ergometrine and massage the uterus . Prophylactic
antibiotics are given to guard against puerperal sepsis . The possible
complications are :
i. Perforation of the uterus .
ii. Sepsis .
iii. Retained placental fragments .
iv. Post-partum hemorrhage .
II- contraction ring :
Give the patient deep anesthesia + amyl nitrite inhalation before manual
removal of the placenta .
III- Adherent placenta :
1. In simple adhesion , manual separation and removal of the placenta presents
no difficulty . This can also be done in cases of partial placenta accreta .
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2. In cases of complete accreta , increta and percreta :
a. Hysterectomy is the standard treatment .
b. An alternative treatment attempted in young women is to leave the
placenta in situ to undergo autolytic changes after cutting the cord short
and give the patient antibiotics and observe for development of infection
and DIC ( how ? ) .
IV- Rupture of the uterus : See maternal injuries .
Puerperal Inversion of the uterus
Definition
:
The uterus is partially or completely turned inside out .
Incidence :
Very rare ( 1 : 20000 deliveries ) .
Etiology :
1. Usually induced : By pressing on the fundus or traction on the cord while the
uterus is lax .
2. Spontaneous :
a. Precipitate labor .
b. Traction by the fetus on a very short cord .
c. Submucous fundal fibroid .
d. Straining or coughing while the uterus is very lax especially if the cervix
is torn or gaped .
Degrees :
1
st
degree : The fundus is depressed but does not pass outside the cervix .
2
nd
degree : The inverted fundus protrudes through the cervix .
3
rd
degree : The whole uterus ( including the cervix ) is inverted and may even
drag the vagina and appear outside the vulva .
1
st
and 2
nd
degrees are called incomplete , while 3
rd
degree is called complete
inversion .
Clinical picture :
I- Symptom :
1. Bleeding unless the placenta is completely attached .
2. Lower abdominal pain .
3. Mass protruding through the vulva in cases with complete inversion .
II- Signs :
1. Profound shock out of proportion to the amount bleeding due to traction on
the peritoneum and pressure on the adnexa .
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2. By abdominal examination : Cupping of the fundus is felt in the 1
st
and 2
nd
degrees and absence of the uterus in the 3
rd
degree .
3. In the 2
nd
and 3
rd
degrees , the inverted uterus appears as a soft purple colored
mass in the vagina or at the vulva . The placenta may or may not be attached
to it .
4. Rarely , the shock and bleeding may be minimal or absent and the condition
is discovered later on in the puerperium as a subacute form with varying
amount of vaginal bleeding and foul discharge due to infection .
Prophylaxis :
Avoid traction on the cord or pressing the fundus while the uterus is lax .
Treatment :
I- Acute puerperal cases :
1. 1
st
aid measures ( Antishock measures + Blood transfusion ) .
2. Reduce the inversion :
a. Manually under anesthesia : Countertraction on the cervix by ring forceps
may be helpful . If the cervix is not relaxed , give amyl nitrite + 0.3 – 0.6
ml of 1/1000 adrenaline . If the placenta is still attached , do not remove it
unless its bulk interferes with reduction , then give ergometrine , do hot
intrauterine douche and massage the uterus .
b. Using hydrostatic pressure : By pushing fluid through a nozzle of a
douche into the vagina ( O'Sullivan method ) .
II- Subacute cases :
1. Using Aveling repositer .
2. Surgical measures ( in chronic cases and some subacute cases ) .
a. Vaginal operations .
i. Spinelli operation : The cervix and the surrounding fibrosis are cut
anteriorly and then reposit the uterus .
ii. Kustner operation where the cervix is cut posteriorly .
b. Abdmonal operations :
i. Dobbin's operation where the cervix is cut anteriorly .
ii. Halltain's operation where the cervix is cut posterioly .
III- Chronic cases :
1. Reposition through the above described operations .
2. Vaginal hysterectomy in cases complicated by marked sepsis or in old
patients .