Mudaliar

and
Menon’s
Clinical
Obstetric
s
13TH EDITION
 Chapter 47
COMPLICATIONS
OF THE THIRD
STAGE OF
LABOUR

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The complications encountered in third
stage of labour are:
Postpartum hemorrhage
Retained placenta
Uterine inversion
Postpartum collapse

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POSTPARTUM
HEMORRHAGE
DEFINITION
Postpartum hemorrhage (PPH) is defined as blood loss of more than 500 mL
after vaginal delivery and more than 1000 mL after cesarean section (WHO).
ACOG - A 10% decrease in hematocrit.
A small blood loss that makes the woman hemodynamically unstable is also
termed PPH.

INCIDENCE
Every year, about 14 million women around the world suffer from PPH; 25% of
all maternal deaths are due to PPH (WHO).
In India PPH accounts for 38% of all maternal deaths. PPH occurs in 2–4% of
mothers after vaginal delivery and 6% after cesarean section.

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Severity Volume of blood loss(mL)
Minor 500–1,000
Moderate 1,000–2,000
Severe >2,000
Life-threatening >2,500
Major PPH: Blood loss >1,000 mL and/or blood loss in an
unstable patient irrespective of the amount of blood loss

Primary PPH: occurs within 24 hours of

delivery of the baby
CLASSIFICATION Secondary PPH: hemorrhage occurs 24
hours after delivery, but within 6 weeks
postpartum
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 The chief causes of primary postpartum
hemorrhage are grouped as follows and can be

ETIOLO represented as the 4 ‘T’s:

Uterine atony (tone) (account for >70% of
GY OF cases)

PPH Genital tract trauma (trauma)

Retained placental fragments (tissue)
Coagulation disorders (thrombus)

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 Risk factors:
Multiparity
ATONIC Overdistension of the uterus
PPH Injudicious induction and augmentation of labour
During the normal
process of the third Fibroids
stage of labour, the Anemia
separation, descent
and expulsion of the Antepartum hemorrhage
placenta are not
associated with Prolonged labour
heavy bleeding – Precipitate labour
‘Living ligature’ of
the uterus. Use of halogenated anesthetics
Use of magnesium sulphate and nifedipine
Previous history of PPH

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 Maternal factors
 Multiparity
 Previous history of PPH
 Fibroids complicating pregnancy
 Maternal anemia
Pregnancy complications
 Antepartum hemorrhage
CAUSES  Overdistension of the uterus as in multiple
OF ATONIC pregnancy, hydramnios or macrosomia
Labour complications
PPH  Prolonged labour
 Induction of labour
 Precipitate labour
Effect of drugs
 Anesthetic drugs
 Magnesium sulphate
 Nifedipine

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PREVENTION : ACTIVE MANAGEMENT OF THE
THIRD STAGE OF LABOUR (AMSTL)
The components of AMTSL are:
Administration of inj. oxytocin 10 units IM immediately after the delivery of the
baby (within 1 minute)
Delay clamping the cord for at least 1–3 minutes to reduce the risk of infant
anemia
Controlled cord traction by Brandt–Andrews technique
Postpartum vigilance - the uterine tone should be immediately assessed to
ensure a contracted uterus; thereafter - checked every 15 minutes for 2 hours.
Uterine atony - fundal massage.

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 Amount of
blood loss Percentage of
Class (mL) blood loss Clinical picture
I 500–1,000 15% There are no signs and
symptoms; occasionally, there
may be dizziness. The woman is
in acompensatedstate

II—mild 1,000–1,500 20–25% The woman presents with

CLINICAL tachycardia, hypotension and
increased respiratory rate
FEATURES
III— 1,500–2,000 25–35% There is overt
moderate hypotension,severe
tachycardia,tachypnea with
cold clammy skin, restlessness
and oliguria

IV—severe >2,000 40% The patient is in profound

shock with ↑ pulse ,↑ B.P, air
hunger,renal failure
This is a massive obstetric
hemorrhage requiring urgent
volume replacement

Occult shock:
SI = Heart rate/systolic BP (mmHg)
The normal shock index is 0.5–0.7
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DIAGNOSIS
Atonic PPH Traumatic PPH
Uterus is flabby and large Contracted and appropriate for
postpartum uterus
Blood is dark in colour Fresh, bright red blood
No lacerations or injuries can be found Speculum examination will reveal
lacerations, tear or other injury to the
genital tract.

MANAGEMENT OF PPH
The objectives of treatment are to:
Correct hypovolemia and maintain circulatory volume by timely replacement
of IV fluids, blood and components
Correct atonicity and control the bleeding either by medical or surgical
methods

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 Two large-bore intravenous cannulae - preferably 16 gauge.
Blood should be drawn for cross-matching and the
estimation of hemoglobin, packed cell volume, coagulation
profile, baseline urea and electrolytes.
Fluid replacement - crystalloid solutions such as 0.9% saline
at the rate of 500 mL in 15 minutes to restore systolic blood
pressure.
The bladder should be catheterised, and a strict input–
output record should be maintained.
RESUSCITATIO Pulse, BP, respiration and other vitals should be checked.
N The woman should be kept warm.
Oxygen - by facemask - 8–10 litres/minute.
Blood transfusion should be started - ideally within 30
minutes.
Fresh frozen plasma (FFP) - to correct clotting deficiencies.
Cryoprecipitate – if fibrinogen levels are very low and when
there is active oozing - useful when volume overload is the
concern.

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 MEDICAL
1. Oxytocic METHODS
Oxytocin Methylergometrine PGF2α
drugs
Dose 20 units of inj. oxytocin 0.2 mg given 250 µg IM
in 500 mL of NS or RL intravenously
run at 60 dpm minute (should be avoided
in hypertensive and
cardiac patients)

Maintenance 10 units in 500 mL of If necessary, it can Can be repeated

dose NS run at 20 dpm be repeated every 4 every 15 minutes
hours IM or IV
Maximum dose 4 doses 8 doses

2. Intravenous tranexamic acid

CONTROL OF In recent years, tranexamic acid is
recommended by slow IV bolus of 1g
BLEEDING followed by further 1 g four hours later
(WHO).
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BIMANUAL COMPRESSION OF THE
UTERUS
Wearing sterile gloves, insert a hand into the vagina
and remove any blood clots from the lower part of the
uterus or cervix

Form a fist and place it into the anterior fornix and

apply pressure against the anterior wall of the uterus.

With the other hand, press deeply into the abdomen

behind the uterus, applying pressure against the
posterior wall of the uterus.

Maintain compression until bleeding is controlled and

the uterus contracts and becomes hard.

Care must be taken to avoid aggressive massage that

can injure the large vessels of the broad ligament.

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COMPRESSION OF ABDOMINAL AORTA
The abdominal aorta is compressed against
the vertebrae a few centimetres superior to
the sacral promontory.
The bifurcation into the common iliac
arteries is just distal to this point.
The femoral pulse is palpated.
Successful aortic compression is defined as
the absence of a femoral pulse and
unrecordable blood pressure in a lower
limb.
An external aortic compression device is
also available.

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 Conservative
• Tamponade techniques—gauze, balloons,
condom, gloves
Conservative surgical techniques
• Vessel ligation—uterine, ovarian, internal
PERSISTENC iliac
E OF • Uterine vertical full-thickness sutures
BLEEDING IN – Compression suture (B-Lynch, 1997)
SPITE OF ALL – Modified B-Lynch (Hayman, 2002)
• Uterine horizontal full-thickness sutures
MEASURES – Square suture
– Figure-of-eight stitch
– Combination of sutures
• Uterine artery embolisation
• Hysterectomy

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 Tamponade techniques
Condom
CONSERVATI A large Foley’s catheter
VE Sengstaken-Blakemore tube
TECHNIQUES
Rüsch urologic hydrostatic balloon
SOS Bakri tamponade balloon

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 The most commonly
used of these are the
Foley’s catheter and
condoms.
Two to three Foley’s
catheters are inserted into
the uterine cavity and the
individual Foley’s bulbs
distended with 60–80 ml
of saline. Depending on
the response, these can be
left in situ for up to 24
hours.

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A saline drip is
connected to a condom
and is inserted into the
uterine cavity. The
condom is distended
with 100 ml of saline
and kept distended.
Whenever a
tamponade technique is
used, there should be
counter pressure from
the uterus by starting a
20-unit oxytocin drip.

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Tamponade with uterine
packing
Under anesthesia, a long,
sterile roll of gauze tape is
used to pack the uterus tightly
from the fundus downwards.
The end of the tape is
brought out through the
vagina and left there for 24
hours.
This method may be useful in
cases where laparotomy
cannot be performed, in cases
of PPH in jaundice and DIVC.
Uterine vacuum retraction
system
Principle: Creating a vacuum-
negative pressure.

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CONSERVATIVE
SURGICAL
TECHNIQUES
Uterine compression sutures
The objective of this procedure is to effectively
compress the myometrium to reduce the bleeding.
The B-Lynch brace suture was the earliest method.
Currently: Cho suture (multiple, square sutures) are
available.
These procedures result in good hemostasis
without grave complications and also preserve future
fertility in most women.
Delayed complications such as uterine necrosis,
pyometra and uterine synechiae can occur, more
often with Cho sutures.

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Stepwise devascularisation of the uterus
The vessels supplying the uterus are ligated step-by-
step to reduce the blood flow to the uterus.
In this technique, the uterine artery, uterine–ovarian
anastomosis and descending cervical branch of the
uterine artery are ligated successively on one side and
then on the other.
This results in an 85% reduction in the pulse pressure
and promotes hemostasis and clot formation.
Uterine artery embolisation
In the face of acute hemorrhage, it is logistically
challenging and not always possible or available in most
places.
Femoral artery - anterior division of the internal iliac
artery - gelatin particles are injected into the vessels to
occlude them.
Resuscitative endovascular balloon occlusion of the
aorta (REBOA) has recently been attempted to
temporarily occlude the aorta.

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HYSTERECTOMY
Hysterectomy is the definitive treatment.

Performed when bleeding is not controlled quickly with other measures

and if the blood loss is >2,000 mL.
Indications:persistent atonic PPH, rupture uterus- where repair is not
possible and abnormal placentation with placenta increta, accrete or
percreta.
Subtotal hysterectomy is the procedure of choice.

It is a life-saving measure and should be performed without hesitation

irrespective of parity. It should not be put off until the woman is moribund.

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 The fundus of the uterus must be grasped and
massaged to make it contract.
If the placenta shows signs of separation-remove by
Brandt–Andrews technique.
When there is no evidence of placental separation -
retained placenta.

PPH WITH PPH DURING CESAREAN DELIVERY

PLACENTA The uterus is compressed and uterotonic agents are
IN SITU administered.
If bleeding persists after these measures -
compression test.
The angles should be identified, and hemostasis
secured.
It is important is for the obstetrician to weigh the
benefits against the possible risks quickly as decision-
making has to be swift in cases of PPH.

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ASSESSMENT OF BLOOD LOSS
Blood drape consists of a conical plastic sheath
sutured over another broad plastic sheath . This is
placed under the buttocks of the mother after
placenta is delivered and the blood loss from the
uterine cavity collects in the conical bag. The
markings in the bag indicate the volume of blood
loss.
One cannot emphasise too strongly the necessity
for adequate and timely blood transfusion.

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 TRANSPORTING THE
PATIENT
To combat shock, a non-pneumatic anti-shock
garment (NASG) can be used.
NASG is only a temporary method to prevent shock
and is not a treatment for PPH.
The NASG acts by shunting the blood accumulating in
the lower extremities back to the vital organs including
the brain, heart and lungs.

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Monitoring of the patient following Complications of PPH
PPH
Hypovolemic shock and renal failure
Continuous monitoring
Multiorgan failure
Review fluid balance, electrolytes
and coagulation status Infections

Continue oxytocin infusion for Venous thromboembolism

another 12 hours Occult myocardial ischemia
Antibiotics Transfusion-related problems
Check hematocrit after 24 hours Dilutional coagulopathy
Hematinics at discharge Anemia, fatigue, orthostatic
 Secondary PPH can also occur in hypotension
these women - report if there is Postpartum anemia -postpartum
further bleeding depression
Sheehan’s syndrome
Maternal death

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 This is usually due to trauma in labour
Should be suspected if brisk bleeding persists despite
adequate uterine retraction – can lead to
TRAUMATI decompensation.
C Vaginal hematomas: Vaginal lacerations, extension of
POSTPART episiotomies, and forceps application can lead to vaginal
hematomas due to injury to the vaginal and pudendal
UM arteries. Vaginal packing – exploration – achieving
hemostasis by closing the dead space.
HEMORRH Cervical lacerations : broad ligament hematoma
AGE
Colporrhexis: Tearing of the posterior vaginal fornix
which extends into the POD - extensive intraperitoneal
bleeding or broad ligament hematoma - a hysterectomy
with subsequent vaginal repair of the tear.
Uterine rupture: The primary sign of uterine rupture is
fetal bradycardia. Fetal tachycardia and decelerations may
also indicate uterine rupture. Other signs are vaginal
bleeding, abdominal tenderness, maternal tachycardia and
circulatory collapse.
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 Rare causes of PPH - do not respond to
conventional management.
DIVC can develop following severe pre-
eclampsia, eclampsia, amniotic fluid
PPH DUE embolism (AFE), abruption, prolonged fetal
demise or HELLP syndrome.
TO
Rapid infusion of fluids can also result in
COAGULAT dilutional coagulopathy.
ION
In massive transfusion, if the components
FAILURE are not replaced adequately – clotting
failure can occur.
Conditions such as von Willebrand
disease and idiopathic thrombocytopenic
purpura can also present with PPH.

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SECONDARY
POSTPARTU
M
HEMORRHA Causes of secondary postpartum hemorrhage
GE  Retained placental bits and membranes
 Infected retained tissue
 Infection and scar dehiscence following
DEFINITION cesarean section
Any heavy bleeding  Submucous fibroids
from the genital tract  Von Willebrand disease
occurring 24 hours  Idiopathic thrombocytopenic purpura
after delivery to 6  Choriocarcinoma
weeks postpartum.  AV malformation

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Clinical features
The bleeding may be continuous or very
heavy, leading to hemodynamic instability,
foul-smelling lochia, subinvolution of the
uterus and fever.

Diagnosis
A high vaginal swab for culture.
An ultrasound scan would reveal the
presence or absence of retained products.
If the bleeding follows cesarean section or if
an AV malformation is suspected - Doppler
and MRI.
Suspected bleeding disorders -
hematological investigations.

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 Broad-spectrum antibiotics
Manual vacuum aspiration of the retained
products of conception is a safe technique
The tissues obtained should be sent for
culture and histopathological examination
If there is clinical evidence of sepsis:
Evacuation of retained products should be
delayed for 12–24 hours
MANAGEMENT Retained products following cesarean section
are rare, in the presence of heavy bleeding,
scar dehiscence should be the first diagnosis
rather than that of retained products
Occasionally, bleeding may be very severe,
and it may become necessary to undertake
uterine artery ligation, embolization or
hysterectomy
Oxytocic drugs are rarely effective

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 DEFINITION
A placenta is said to be retained when it is not separated
and expelled within half to one hour after the delivery of
RETAINED the baby.
PLACENTA
PATHOGENESIS
Trapped placenta: Placenta is separated but does not get
expelled due to inefficient uterine contractions or as a
result of the formation of a constriction ring.
Atonic non-detached placenta or placenta adherens:
Placenta does not get separated from the uterus due to
inefficient uterine contractions and atony of the uterus.
Uterine anomalies and submucous fibroids can also result
in non-detachment of the placenta.
Adherent placenta: It is an invasive placenta with
abnormal placentation and invades the myometrium to
varying depths.

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 When a placenta is not expelled within 15–20 minutes
The first step is to catheterise the bladder
Her pulse and blood pressure should be recorded
MANAGEMEN A hand may be placed on the abdomen behind the
T fundus of the uterus to check for uterine retraction
In the meantime, adequate blood and component
should be kept ready

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 Performed in the operation theatre under
general anesthesia using aseptic technique
under antibiotic cover
Lithotomy position
One hand on abdomen
MANUAL The vaginal hand in shape of a cone
REMOVAL OF follows the umbilical cord into the uterine
cavity
THE PLACENTA
Lower end of placenta is located and
fingers are inserted into the placental bed
With sweeping movements, the placenta
is stripped from the uterine wall

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 The abdominal hand exerts firm counter
pressure.

When there is total separation of the

placenta, intravenous oxytocics are given to
promote uterine contraction.

Following manual removal, the birth canal is

checked for tears

Placenta is checked to see if it is complete.

Blood transfusion if necessary, should be

started without delay.

Even after manual removal, continue oxytocin

drip to prevent uterine atony.

Continuous bladder drainage

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 Definition
Adherent placenta has been defined as abnormal
adherence of the placenta—either in whole or in part—to
the underlying uterine wall. Pathologically, there may be a
complete or partial absence of the decidua basalis,
especially the spongiosa, thus placing the trophoblast in
direct contact with the myometrium.

ADHERENT Types of adherent placenta

PLACENTA Placenta accrete: Placental villi are attached to the

myometrium
Placenta increta: Trophoblast has invaded the
myometrium
Placenta percreta: Villi have penetrated the myometrium
to reach or to cross the serosa
Risk factors
Maternal age, high parity, previous cesarean delivery,
placenta previa and previous adherent placenta

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Antenatal diagnosis
Greyscale USG predicts abnormal placentation with a sensitivity
of 77–86% and a specificity of 63–88%
MRI

Diagnosis in labour
Partial separation presents with bleeding in the third stage of
labour
A completely adherent placenta does not give rise to bleeding
and should be suspected when there is a well-contracted uterus
with a non-separated, retained placenta without bleeding

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TREATMENT
If diagnosed postpartum

Single cotyledon: Removed from the uterine wall and excessive bleeding
may be controlled with oxytocics.
Entire placenta or a large part of the placental bed: Prompt
hysterectomy under antibiotic cover.
Preserve her fertility: The placenta may be left in situ after counselling
the woman and explaining to her the possible risk of bleeding/infection
and the possible need for an emergency hysterectomy and treated with
methotrexate therapy.
While on methotrexate, the woman should be monitored with weekly
USG for the size of the placenta, Doppler of the placental site for
vascularity, serial β-hCG measurements, investigations for evidence of
infection and hematological parameters for evidence of methotrexate
toxicity.

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If diagnosed in the antenatal period

Tertiary care centre + multidisciplinary approach

Experienced senior obstetric and anesthetic staff

A blood bank to support massive transfusion

The pre-delivery hematocrit should be raised to 30.

When placenta accrete is suspected or present, serial USG should be done

every 3–4 weeks to know the depth of placental invasion

Delivery timing – individualised: 34–35 weeks in adherent placenta and 36–

37 weeks in uncomplicated placenta previa

Counselled regarding hysterectomy, profuse hemorrhage, transfusion,

increased complications and maternal death

General anesthesia or a continuous epidural can be given

Surgical technique: A classical cesarean - the cord is ligated and cut as close
to the placenta as possible

Oxytocics are given

No attempt should be made to remove the placenta

A cesarean hysterectomy should be carried out with the placenta

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 Risks of severe sepsis and torrential
hemorrhage.
Strong fertility desire: interventional
radiology and uterine artery embolisation can
be carried out.
Arterial ligation to reduce the blood flow to
the placental site can also be undertaken.
CONSERVATI
Systemic/intraumbilical administration of
VE methotrexate can be used.
METHODS
All women managed conservatively should
be carefully monitored for regression and
autolysis of the placenta and evidence of
impending sepsis.
All preparations should be available for an
emergency hysterectomy.

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SEQUELAE OF ADHERENT OR RETAINED
PLACENTA
The following sequelae may occur in this condition:
Puerperal infection
Subinvolution of the uterus
Secondary postpartum hemorrhage
The formation of placental polyps

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PUERPERAL INVERSION OF THE UTERUS
1 in 2000 deliveries
Inversion of the uterus refers to the uterus being turned inside out-may occur
immediately after delivery.
Caused either by pressure on the uterus from above or by traction on the umbilical
cord from below in the presence of an atonic uterus and a soft, dilated cervical os.

•Injudicious attempts at the •Fundal implantation of the placenta

removal of the placenta •Short umbilical cord
•Excessive cord traction with an •When the woman is on tocolysis and
unseparated placenta the uterus is relaxed
•Fundal pressure and squeezing the •Manual removal of the placenta
placenta down •Uterine malformations
•Placenta accreta •Prolonged labour
•Uterus overdistended

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DEGREES OF
INVERSION
Inversion can
present as acute
inversion within
24 hours of
delivery or in the
puerperal period
as chronic
inversion.

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 Acute puerperal inversion of the uterus: pain,
hemorrhage or sudden collapse - hemorrhagic or
neurogenic.
If the placenta is still attached to the inverted fundus
and appears at the vulval introitus, it can be easily
mistaken for retained placenta; in such cases, inversion
will be missed.
Per abdomen: May not be able to feel the uterine
fundus. Alternatively, it may be felt as a dimple.
CLINICAL
The inverted uterus: Dark red, fleshy mass at the
FEATURES introitus. If the placenta is still attached, it should be left
in place until reduction.
On vaginal examination, the cervical os cannot be
palpated.
Differential diagnosis: Polyps or prolapse of the uterus
When in doubt, emergency USG - locate the fundus of
the uterus.

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  Prompt recognition and treatment are crucial.
 Vasovagal shock should be treated with the ABC of
resuscitation.
 The placenta should not be detached until the uterus is
replaced and contracted.
 The uterus should be replaced immediately under
anesthesia and tocolytics to relax the constriction ring.
Manual replacement
1. Principle: the portion that comes down last should be
replaced first.
MANAGEMEN 2. Cervical canal is the last to come down, and it should be
replaced first, and the fundal portion should be replaced
T last.
3. The protruding fundus is held with the palm of the hand
and the fingers are directed towards the posterior fornix;
steady upward pressure is applied.
4. In the majority of cases, during the replacement of an
inverted uterus, the fundal portion flops back into
position once the greater part of the inverted uterus has
been replaced.
5. The other hand should be placed on the abdomen to
support the uterus as it is being replaced

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Tocolytic agents such as ritodrine, magnesium
sulphate or terbutaline can be used to relax the
uterus during manual repositioning.
Once the correction is achieved, oxytocic drugs
are given to assist uterine contraction and to
prevent recurrence.
If the placenta is attached to the fundus, it is
removed after repositioning the inverted uterus.
If removed prior to repositioning, major
hemorrhage can occur, which may not be
controllable.

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 The woman is placed in the Trendelenburg position.
A sterile douche system is prepared using warmed
normal saline and an ordinary IV administration set.
The nozzle of the douche is placed in the posterior
fornix.
At the same time, the labia are sealed over the nozzle
with the other hand.
O’SULLIVA An assistant is asked to turn on the douche with full
N’S pressure.
HYDROSTA In this method, water distends the posterior fornix of
the vagina gradually so that it stretches - the
TIC circumference of the orifice increases - relieves
METHOD cervical constriction and results in the correction of
the inversion.

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 SURGICAL REPLACEMENT OF THE
UTERUS
Huntington’s method: Allis forceps are
placed at the dimple of the inverted fundus
and gentle upward traction is applied. The
forceps are further advanced till the fundus
is repositioned.
Haultain’s technique: If the constriction
ring still prohibits repositioning, it is incised
posteriorly with a longitudinal incision. The
fundus is reposited and the uterus is repaired
in two layers.
After repositioning, the fundus should be
massaged carefully, uterine contractions
promoted, and the patient treated for shock
and collapse. Appropriate antibiotics should
be given.

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Prevention
One should wait for signs of placental separation before attempting placental
removal by controlled cord traction.
Fundal pressure should not be applied.

CHRONIC PUERPERAL INVERSION

In some cases, inversion may not be recognised at the time of its occurrence
and the diagnosis is made at a later date.
The woman suffers repeated hemorrhage and a slight rise in temperature.
The exposed endometrium has a granular, shaggy appearance due to chronic
congestion and infection, particularly over the placental site.
Vaginal examination: Globular swelling, with the soft, thickened
endometrium and a hyperemic appearance.

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Diagnosis
Differentiate inversion from prolapse of the uterus: Globular nature of the
mass, with its velvety surface, the absence of the external os at its lower end,
and the presence of the ring of the dilated cervical canal above the mass.
A fibroid polyp: On bimanual examination, the fundus of the uterus is
palpable in its normal position in case of a fibroid polyp. A careful vaginal
examination with the finger introduced into the cervical canal, the pedicle of
the fibroid polyp may be palpable.

Management
The immediate treatment is to combat infection with antibiotics.
Later, under an anesthetic to replace the inverted uterus.
 If unsuccessful, Spinelli’s or Haultain’s surgery may be performed.

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NON-HEMORRHAGIC POSTPARTUM COLLAPSE
Amniotic fluid embolism
Cerebrovascular accidents in eclampsia
Anesthesia complications
Pulmonary embolism
Drug toxicity and anaphylaxis
Hypoglycemia and ketoacidosis in diabetes

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