Professional Documents
Culture Documents
Contact Name and Job Title (author) Judith Moore, Consultant Obstetrician, City
Hospital Campus
Harriet Pugsley Specialist Registrar
Version 3
Supersedes Version 2
Date on which guideline must be reviewed (this should be one to November 2018
three years)
Explicit definition of patient group to which it applies (e.g. Women in third stage of labour
inclusion and exclusion criteria, diagnosis)
Target audience
Maternity services staff
This guideline has been registered with the trust. However,
clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using
guidelines after the review date.
Management of the Third Stage of Labour, Retained
Placenta and Acute Uterine Inversion
The third stage of labour is defined as the time from delivery of the baby
to expulsion of the placenta and membranes.
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There should be consideration of the use of syntocinon if women
have raised blood pressure.
1. Previous PPH
2. Over-distended uterus:
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multiple pregnancy
polyhydramnios
fibroids uterus
3. Maternal condition:
obesity BMI>35
Pre-eclampsia
Abnormal coagulation
Obstetric cholestasis
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Management of Third Stage of Labour
RETAINED PLACENTA
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Empty urinary bladder
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For Births at Home:
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If these measures fail, or sooner if there is concern about the
woman’s condition, the Registrar should examine the woman to
ensure the placenta is not in the vagina or cervix. The woman
should be offered pain relief (usually Entonox) for this. If she is
unable to tolerate the examination it should be performed in
theatre
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should be started at the end of the procedure and run over four
hours.
Methotrexate
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Hysteroscopic resection of the placenta
Uterine atony
Precipitate labour
Placenta praevia
First degree The inverted fundus extends to, but not beyond, the
cervical ring
Second The inverted fundus extends through the cervical ring but
degree remains within the vagina
Third degree The inverted fundus extends down to the introitus
Fourth The vagina is also inverted
degree
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Management involves treatment of shock and repositioning of the
uterus. This requires teamwork as both should occur simultaneously.
First: call for help. In hospital call the obstetric emergency team via 2222
as this is a life threatening emergency. In the community call for a
paramedic ambulance and arrange transfer into labour suite.
This would be the same in the community setting. The sooner this is
achieved the more likely it is to be successful.
The whole hand, plus two-thirds of the forearm, is placed in the
vagina. Holding the fundus in the palm and keeping the tips of the
fingers at the uterocervical junction, the fundus is raised above the
level of the umbilicus. It may be necessary to apply digital pressure
constantly, sometimes for several minutes. This places the uterine
ligaments under tension. The tension generated relaxes and
widens the cervical ring and facilitates the passage of the fundus
though the ring. The inversion is, thus, corrected.
Send blood for FBC, Clotting and Cross match at least four units of
red cells.
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Once the uterus is replaced, give 10IU IM Syntocinon, deliver the
placenta, and commence a Syntocinon infusion (40IU Syntocinon
in 500mL 0.9% Saline over four hours).
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Monitoring Plan:
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References
Green Top Guideline No. 27: Placenta Praevia and Placenta Praevia
Accreta: Diagnosis and Management. October 2005 RCOG Press.
NICE Intrapartum Care: care of healthy women and their babies during
childbirth. September 2007
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