Complications in 3rd stage of

labour
 Learning outcomes

Postpartum hemorrhage
-Primary postpartum hemorrhage
Secondary postpartum hemorrhage
 Postpartum hemorrhage
Definition: Hemorrhage occurring after delivery
Quantitive terms : blood loss more than or equal to 500
ml in vaginal deliveries.
- 1000ml in cesarean section.
Primary postpartum hemorrhage
- Blood loss 500ml or more within 24 hours.
Atonic postpartum hemorrhage
-Prevents proper contraction and retration of uterus.
Traumatic postpartum hemorrhage
-Trauma in labour
Secondary postpartum hemorrhage
-Sudden loss of blood from genital tract after first 24
hours postpartum and within 6 weeks of delivery.
 Classification of primary postpartum
hemorrhage
Type Volume of blood loss(ml)
Minor 500-1000
Major 1000-2000
Major-Moderate 1000-2000
Major-Severe More than 2000
Cause of primary postpartum
hemorrhage
 Atonic postpartum hemorrhage
Cause:
Maternal Pregnancy Labour Effect of drugs
complications
Multiparity Antepartum Prolong labour Anesthetic drugs
hemorrhage
Previous history PPH Overdistension of Induction of labour Magnesium sulfate
uterus as in multiple
pregnancy ,
hydramnios or
macrosomia
Fibroids complicating Precipitate labour Nifedipine
pregnancy
Maternal anemia
 Prevention
Active management of the third stage of
labour(AMSTL)
1) Administration of Inj.Oxytocin 10 units IM
after delivery of baby.
2) Cord clamping after cessation of cord
pulsations , followed by removal of placenta
by traction and countertraction during uterine
contraction
3) Uterine massage
Uterine massage
 Clinical features
Increase pulse rate and pallor
Drop in blood pressure
Restlessness
Fainting attacks
Sweating
Air hunger
 Management
Prophylaxis
-Good antenatal and internatal care.
- In antenatal general nutrition should
improved and persisting anemia should treat.
- Determined their blood group.
- Curative treatment
- Correct hypovolemia
- Correct atonicity
Replacement of loss of blood

Call for HELP

2 large bore intravenous cannula , preferably 16 gauge inserted
Blood should be drawn for crossmatching , estimation of hemoglobin ,
packed cell volume, coagulation tests , baseline urea and electrolytes.
Fluid replacement commend immediately. 0.9 % saline infused at 500ml
in 15 minutes to restore systolic pressure.
Bladder should be catherised and record the input-output .
Check pulse, BP, respiration and other vital signs.
Palpate uterus and ensure atonic PPH.
Atonicity confirmed-starts 20 units of inj.oxytocin in 500ml of NS or RL and
run it at rate of 20-40 drops per minutes.
Blood transfusion started as soon as possible ideally within 30 minutes
Oxygen should be given by facemask at rate 8-10 minutes.
Control of bleeding

Atonic uterus noticed often after placenta expelled.

1) Recheck placenta to confirm all the placental lobes
and membrane are expelled.
2)No response to oxytocin drip, inj. Methylergometrine
0.25mg can be given intravenously. Avoid this drug in
maternal hypertension or heart disease. Can be
repeated 4 doses.
3) If bleeding continues , inj prostaglandins can be
given in the dose of 250ugm IM and can be repeated 8
doses.
4)Rectal misoprostol tablets in dose of 800ugm used.
Management options for unresponsive
hemorrhage
Conservative
Tamponade techniques-gauze , balloons, condom , gloves
Conservative surgical techniques
Vessel ligation-uterine,ovarian,internal iliac
Uterine vertical full thickness sutures
- compression suture(B-lynch)
- modified B-lynch
Uterine horizontal full-thickness suture
- Square suture
- Figure of eight
- Combination of sutures
Uterine artery embolisation
Hysterectomy
Tamponade techniques

1)Sengstaken-Blakemore tube
2)A large foleys catheter
3) Rusch urologic hydrostatic balloon
SOS Bakri tamponade balloon
Condom
Traumatic postpartum hemorrhage
Cause:
- Trauma in labour
- Perineal lacerations
- Episiotomy wounds
- Cervical lacerations
- Colporrhexis
 Secondary postpartum hemorrhage
Cause:
- Retention of portions of placenta and membranes .
Rare: submucous fibromyoma and choriosacroma
Presentation :
- general conditions of patient- depends upon amount of blood loss.
Bleeding persistent , foul smelling lochia , subinvolution of uterus &
fever
Diagnosis :
Ultrasound
Management :
High vaginal swab take for culture
Broad spectrum antibiotic should start
Uterus evacuated under anesthesia
Bleeding severe- uterine cavity ligation or hysterectomy .