Obstetric lecture

Date: 16/4/2015
Dr. Alia Kareem

Complications of third stage of labour

Prolonged third stage(Retained placenta):
Definition : is a failure of placental delivery within 30 minutes after
delivery of fetus with active management of 3rd stage or within 60
minute with physiological management of 3rd stage.
Because the incidence of PPH increases significantly after that times
,therefore it seems logically to start some active intervention in attempt to
delivery placenta after 30 to 60 min in the third stage in absence of active
bleeding.
Incidence of retained placenta: the overall incidence is 2% at term &
markedly increased with very preterm and preterm pregnancies.

Mechanism (Pathophysiology of retained placenta): Separation of the

placenta occurs because of the reduction of volume of the uterus due to
uterine contraction and the retraction (shortening) of the lattice-like
arrangement of the myometrial muscle fibers. A cleavage plane develops
within the decidua basalis and the separated placenta lies free in the lower
segment of the uterine cavity. This normally takes between 5 and 10
minutes.
The retained placenta is occur due to either:
retention of placenta into uterus after separation (trapped
placenta)
total or partial failure of placental separation (adherent
placenta)which occurs due to either poor contractile forces
exerted by myomaterium underlying placental bed in spite of
normal anatomy or myomaterium invasion by chorionic villi(
morbidly adherent placenta). Each of these conditions requires a
specific clinical approach.

-Trapped placenta: Is a retention of placenta into uterus after separation.

It`s often occurs due to intravenous administration of ergometerine
when the onset of uterine contraction is very rapid. This tends to close the
cervix at the same time of the placental separation. The clinical findings
of trapped placenta include small ,contracted globular fundus with some
vaginal bleeding &cord lengthening, indicative of placental separation,
and the placental margin may palpable through the closed cervical os. On
U/S examination ,the entire myomaterium is thickened with clear
demarcation may be seen between it &placenta. Delivery of trapped
placenta can be achieved by:
Using controlled cord traction ,encourages the delivery
Releasing the cord clamp to allow blood trapped in the placenta to
drain.
Short term tocolytic (IV glycerol trinitrates) or general anesthesia
for uterine relaxation.
-Adherent placenta : is a total or partial failure of placental
separation. Clinical findings with adherent placenta are broad &high
uterine fundus with weak or abscent myomaterium contractions. On U/S ,
the myomaterium appears thick &contracted in all area except where
placenta remains attached ,uterine wall remains <2cm in thickness,
placenta is in upper segment and Doppler flow is present between
placenta & myomaterium . Management options of adherent placenta due
to poorly contractile myomaterial fibers include the following :
1- In absence of active bleeding, myomaterium contraction can be
stimulating by using uterotonic drugs(injected systematically or
into umbilical vein) before resorting to manual removal.An
injection of utrerotonic agent into umbilical vein is recommended
as 1st line management of adherent placenta by WHO.
2- IF there`s active bleeding , manual removal should be attempt
immediately.
Technique of Manual Placental Removal
Adequate analgesia is mandatory, and aseptic surgical technique should be used.
After grasping the fundus through the abdominal wall with one hand, the other hand is
introduced into the vagina and passed into the uterus, along the umbilical cord. As
soon as the placenta is reached, its margin is located, and the border of the hand is
insinuated between it and the uterine wall . Then with the back of the hand in contact

with the uterus, the placenta is peeled off its uterine attachment by a motion similar to
that used in separating the leaves of a book. After its complete separation, the placenta
should be grasped with the entire hand, which is then gradually withdrawn.
Membranes are removed at the same time by carefully teasing them from the decidua,
using ring forceps to grasp them as necessary. The risks of manual removal of
placenta are endometritis (6.7% compared with 1.8% following spontaneous delivery)
and uterine trauma( uterine wall perforation).

Morbidly adherent placenta :is an invasion of myomaterium by

chorionic villi due to primary or secondary deficiency of deciduas basilis.
There are three types according to the depth of invasion:
1. Placenta accreta. Placenta is abnormally adherent to the uterine wall.
2. Placenta increta. Placenta is abnormally invading into the uterine
wall.
3. Placenta percreta. Placenta is invading through the uterine wall to
reach serosa or adjacent organ.
Incidence of placenta accrete increase from 1/30000 at 1950 to 1/ 2500
in the 1980s, 1 in 535 in 2002, and 1:210 in 2006) deliveries due to
increase the rate of C/S.
Risk factors for morbidly adherent placenta:
Placenta previa & LSCS(risk of morbidly adherent placenta is 67%
if there`s placenta previa and previous four c/s)
Previous uterine surgery
Previous history of uterine curettage
Submucos myoma
Asherman`s syndrome
Advanced maternal age
Multiparous women
Clinical Course and Diagnosis of morbidly adherent placenta:
- Before delivery:
-placental villi at the site of a previous cesarean scar may lead to
uterine rupture before labor .
-Antepartum hemorrhage with placenta accreta is common and usually
the consequence of coexisting placenta previa
-Suspected from placenta previa and previous LSCS
-History of heamaturia if invade bladder

- Diagnosis can be made by using Doppler U/S as early as 2nd

trimester.MRI can be useful when U/S findings are equivocal &for
assessment of depth of invasion.
After delivery:
-retained placenta
-primary PPH
at c/s:
- invading of serosa,
-failure of placenta separation,
-excessive bleeding at implantation site
surgical options for treatment of morbidly adherent placenta
includes the following:

-Cesarean hysterectomy(that remains the procedure of choice)

-Conservative techniques that include the following:
Leave placenta in situ with weekly follow up by S.B-HCG and
U/S. Methotrexate can be used to speed the degeneration.
Remnants can be removed by curettage or manually if B-HCG
becomes undetectable.
over sewing of placental bed
Resection of the implantation site
Many factors effect the choice of treatment:

Hemodynamic state of patient and amount of bleeding

Fertility desire of patient
Extension and depth of invasion
Patient`s understanding and acceptance the risks of delayed
heamorrhage ,infection and death with conservative approaches.
If the placenta accrete is highly suspected or diagnosed before delivery,
preoperatively, patient counseling and full consent about risks of
heamorrhage, transfusion and hysterectomy should be undertaken. Also,
The following precautions should be undertaken at theater room:

 The presence of consultant obstetrician ,consultant anesthetist,If

bladder or bowel involvement is suspected ,attendance of
urologist or surgeon is necessary.
Provision of adequate blood
If placental delivery is unsuccessful or heamorrhage is uncontrolled,
the hysterectomy should be proceeded. If the patient is
heamodynamically stable and strongly desired future fertility with
understanding and acceptance of all risks, conservative management may
be considered.

(Algorithm of management of retained placenta)

placenta not delivered within30-60 min

-2IV lines, blood preparing for possible signficant bleeding
-signs of seperations

pl acenta not seperated

no active
bleeding and
heamodynamical
state of patient
is stable

active bleeding
or
heamodynamical
state of patient
is unstable

myomaterium contraction can be stimulating by

using uterotonic drugs(injected systematically or
into umbilical vein)

manual removal
of
placentashouldb
e attempting

placenta seperated(trapped placenta)

Using controlled
cord traction
,encourages the
delivery

Releasing the
cord clamp to
allow blood
trapped in the
placenta to drain.

Short term tocolytic (IV glycerol trinitrates) or general

anesthesia for uterine relaxation.

ifplacenta failed to delivery,manual

removal shouldbe attampting

cleavage plane is
distinict
the placenta can
be removed
manually

cleavag plane is undistinct

the morbidly adherent placenta is
suspected and manage as placenta accreta

Acute uterine inversion:

Definition: is a condition where the uterus is partially or completely
turned inside out.

Incidence: Uterine inversion is a rare complication occurring during the

third stage of labour. It has a reported incidence of between 1:2000 and
1:6000.
Degree:
first-degree inversion, the inverted wall extends to but not through
the cervix.
second-degree inversion, the inverted wall protrudes through the
cervix but remains within the vagina.
third-degree inversion, the inverted fundus extends outside the
vagina.
fourth degree or total inversion, both the vagina and uterus are
inverted.
Eitiology:
Mismanagement of third stage of labour: by strong traction on an
umbilical cord attached to a placenta implanted in the fundus
while the uterus is relax.
a fundal placenta
a short cord
a morbidly adherent placenta( accreta ,increta peracreta) .
Diagnosis : is by clinical presentation which include the following:
Acute lower abdominal pain
nuerogenic shock: stretching the cervix causes vagal stimulation,
thus the woman will demonstrate signs of cardiovascular collapse
and shock. Although haemorrhage is commonly present, the
symptoms will be out of proportion to the estimated blood loss .
heamorrhgic shock
inverted uterus may be obvious at the introitus.
the lack of a palpable uterus in the abdomen
the feeling of a dimple in the uterine fundus
Management: All the following steps should be done rapidly&
simultaneously:
Call help
Resuscitate the patient
Withhold oxytocine until correction

 not remove the placenta if it is still attached until the uterus is

replaced and contracted.

Immediately replace the uterus through the cervix by manual

reposition.( if the inverted uterus has prolapsed beyond the vagina, it is
replaced within the vagina firstly &then pushing up on the fundus with the
palm of the hand and fingers in the direction of the long axis of the vagina ,
Tocolysis may be helpful to relax thecervical ring, Once reduced, maintain hand in

uterine cavity until a firm contraction occurs, and IV oxytocin is being given).

If manual replacement is unsuccessful, patient should be

transferred to theater room and manual replacement should be
trying again with help of tocolytics or general anesthesia to relax
uterus. If this is failed ,hydrostatic replacement (O'Sullivan's) is
used (The vagina is filled by 2-5 ml of warmed normal saline while
introitus is sealed by fist of hand or by ventous cup under
tocolytics or general anesthesia ).The reduction is usually achieved
in 510min. If all this fails, a laparotomy (3%) may be necessary.
Tow techniques had been described, Huntingdon`s procedure
and Haultain`s procedure. Hungtindon`s procedure involves the
placement of Alli`s forceps in the dimple of the inverted uterus&
using upward traction to replace the uterus.Haultain`s procedure
involve making vertical incision in cervical ring posteriorly which
facilitate the replacement .The incision is then repaired.
POST-REPLACEMENT CARE
Once the inversion is corrected, infuse oxytocin 20 units in 500
mL IV fluids (normal saline or Ringers lactate) at 10 drops per
minute.
Give a single dose of prophylactic antibiotics after correcting
the inverted uterus.