abnormal third stage of labour
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POSTPARTUM HEMORRHAGE
Definitions:
Primary postpartum hemorrhage:
Blood loss at delivery within 24 hours
exceeding:
Vaginal delivery: > 500 ml ( 500 ml isconsidered
physiological)
Cesarean delivery: > 1000 ml ( 1000 ml is
considered
physiological).
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Secondary postpartum
hemorrhage:
Excessive blood loss > 24 hours
and < 12 weeks postpartum
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Etiology:
Lack of efficient uterine contraction (uterine atony)
commonest cause of primary PPH.
Retained parts of the placenta.
Vaginal or cervical lacerations. Uterine rupture rare.
Clotting disorders, uterine inversion, or rupture
extremely rare.
Risk
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Risk factors:
Risk factors for primary PPH include first pregnancy,maternal obesity, a large baby, twin pregnancy, prolonged
or
augmented labor, and antepartum hemorrhage. High
multiparitydoes not appear to be a strong risk factor, either in
high- or low-income countries, even after controlling for
maternal age. Despite the identification of risk factors,
primary
PPH often occurs unpredictably in low-risk women.
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Complications:
Hypovolemic shock, disseminated
intravascular coagulation
(DIC), renal failure, hepatic failure,adult respiratory
distress syndrome, and death.
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Management
:Primary postpartum hemorrhage
Obtain help (multidisciplinary approach).
Vigorous uterine massage until firm.
Identify and repair any vaginal and cervical lacerations.
Place initial suture above the apex. Ensure adequateexposure; if necessary, transfer patient to surgical suite.
Manually explore the uterus; ensure adequate intravenous
(IV) access.
Laboratory tests: complete blood count with plateletconcentration,
blood type, antibody screen, fibrinogen, fibrin split
products, prothrombin time, and partial prothrombin time.
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Administer uterotonic drugs :
1. Oxytocin 2080 IU in 1000 ml of normal saline
(NS),fast IV drip, and/or
2. Misoprostol 8001000 g rectally
3. Methergine 0.2 mg intramuscular (IM) (if
evidence ofhypertension do not administer) every 24 hours,
and/or
4. Carboprost tromethamine (Hemabate;
prostaglandinF2 *PGF2+) 0.25 mg IM every 1590 minutes.
Maximum dose is 2 mg (do not administer if asthma
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Rectal misoprostol is a useful first-line drug for
the treatmentof PPH. Compared with a combination of IM
syntometrine
injection and oxytocin infusion, rectal
misoprostol 800 g is associated with astatistically significant
reduction in the number of women who
continued to
bleed after the intervention and those who
required medical
co-interventions to control the bleeding.
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During the administration of
uterotonic agents, bimanualcompressionmay control
hemorrhage. The physician
places his or her fist in the
vagina and presses on theanterior surface of the uterus
while an abdominal hand
placed above the fundus
presses on the posterior wall.
Thiswhile the Blood for
transfusion made available.
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suture bleeding sites.
uterine artery ligation.
B-Lynch stitch for uterine compression.
Hysterectomy.
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B-Lynch compressive sutures
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Uterine Artery Ligation
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RETAINED PLACENTA
Definition:
The placenta is undelivered at > 30 minutes
after deliverydespite active management of the third
stage.
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Etiology: Preterm birth: incidence is inversely
proportional to gestational
age.
Cord avulsion: incidence is 3% with controlled
cord traction. Placenta accreta.
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Complications:Hemorrhage
infection,
genital tract trauma
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Management: Provide adequate anesthesia.
Attempt manual extraction.
Once placental margin is identified, gently peel the
placenta from the uterine wall and remove it.May
considerultrasound to ascertain if placental removal is
complete.
Palpate and massage the fundus until firm.
injection of oxytocin (10 or 20 IU in 1 or2 ml) in NS (1819 ml) is effective in the management of
retained placenta at 2030 minutes by decreasing the
need for manual placental removal compared with NS
alone or expectant management.
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Removal of Abnormal
Placenta
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UTERINE INVERSION
:Definition
Collapse of the uterine fundusinto the endometrial cavity.
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Risks:Excess cord traction.
fundal pressure.
fundal cord insertions.
abnormal placentations.
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Summon anesthesia and nursing staff.
Provide large-bore access and IV fluid therapy.
Withhold uterotonic agents.
To decrease bleeding, avoid separating theplacenta.
Consider pharmacological uterine relaxation:
magnesium sulfate IV bolus
terbutaline IV 0.25 mg subcutaneously 1 nitroglycerin 50500 g orally or by anesthesia
Management
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Manual manipulation of the uterus
Rare surgical intervention (laparotomy) if cannot
correctby vaginal manipulation alone:
Huntington procedure clamps are placed on
the round ligaments 2 cm deep in the inversion andgentle
upward traction applied. Repeat clamping as
necessary.
Haultain procedure an incision is made in the
posterior
portion of the inversion ring to increase its size
and to reposition the uterus.
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Uterotonic agents when uterus repositioned:
Oxytocin 2040 IU/L NS IV, Methergine 0.2 mgIM
every 6 hours as needed, or Hemabate 0.25 mg
IMrepeated every 2560 minutes as needed.
Treat PPH or retained placenta as mentioned
above.
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