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Obstetric emergencies

Free Lecture notes obstetric emergencies

Third Stage of Labour

* Time of potential hazard.

* P P H. remains an important cause of maternal morbidity and mortality

(WHO 1989).

* Retained placenta may necessitate manual removal.


Prolonged third stage.


* Above 30 minutes if managed third stage. (Lewis and Chanderlain 1990).

* Above one hour if physiological if maternal condition is good and without undue blood loss.


Uterine inertia

Atonic uterus fails to contract and retract sufficiently to facilitate adequate placental separation.

Full Bladder

Occupies space in the pelvis impeding uterine contraction and retraction( Beisher and Makay (1986).

Mismanaged third stage

Too much handling or touching may cause dysrhythmic uterine contractions.

Placenta may only partially separate Zahn and Yeamans (1990)

Controlled cord traction before syntometrine has taken effect

May also cause dysrhythmic contractions. Placenta may only partially separate.

Constriction ring

Is a localised spasm of uterine muscle just above the lower segment, this

prevents descent of the placenta. Lewis and Chamberlain (1990).

Uterine abnormality

Retained placenta is more common if the uterus is bicornate ( having 2


Pre - term birth

Particularly in very early gestation and induced labour for medical reasons

Legro et al (1994).

Morbid adherence

This is most common in women who have had previous D and C LSCS,

placenta previa. Also more common in female birth Khog et al (1991).


Decidua basalis (where ovum rests and covers the maternal surface of

placenta) therefore chorionic villi are attached to myometrium Jaffe et al



The villi deeply invade the myometrium.


The villi have penitrated the myometrium and even as far as the serous coat of the uterus, (very rare) ? hysterectomy.

If adherance is focal or sometimes partial, manual removal is indicated or possibly curettage.

Percreta may have hysterectomy as attempts to remove can result in uterine perforation and fatal haemorrhage. Other treatments include leaving the placenta to be re- absorbed, methodrexate is sometimes used as it destroys trophoblastic tissue and aids reabsorbtion.

Implications for care

Call assistance and medical staff increased risk of haemorrhage and shock if placenta retained.

Empty the bladder.

Blood for x match and clotting.

lVl commenced

Explanation to woman.


Prepare for theatre.

Acute inversion of the Uterus

* Rare but serious. The uterus is partially or totally turned inside out.


Cause is mismanagement of third stage most common when placenta is situated in the fundus.

Short cord.

Manual removal

Occurs when operators hand is quickly withdrawn from uterus whilst fundal pressure present.

Precipitate delivery - if woman is upright.


Cause unknown ? uterine atony or increase in abdominal pressure i. e. coughing / sneezing.

Implications for Care

* Replacement of uterus to prevent shock.

* If this is not possible, should be replaced inside the vagina

* foot of the bed raised to reduce traction on fundipulopelvic ligaments, also

to alleviate shock.

* Commence lVl, crystaloid (plasma expanders). * Blood for x match.

* Pain relief i.e. Morphine 15mg.

* If placenta still attached should be left as to remove could precipitate

torrential haemorrhage

* Prepare for theatre.

* Psychological care of woman and partner.

* Post op ergometrine 250 - 500mg is given to ensure uterine contraction

and control of bleeding.

* Post op check by obstetrician.

* Post natal exercises

Primary Post Partum Haemorrhage (pph)

5 - 7 % of all normal deliveries


Failure of uterus to contract and retract therefore living ligatures not effective

Increased risk factors

Previous pph.

High parity therefore fibrous tissue replaces muscle fibre with each subsequent pregnancy therefore contraction and retraction is less efficient. Not shown in all studies Combs et al (1991).

Multiple pregnancy and macrosomia therefore uterus is over distended it may not contract and retract well. There may also be a much larger placental site. Anaemia less able to withstand any blood loss

APH increases risk of anaemia.

Placenta praevia contractile ability of lower segment of uterus is deficient therefore control of bleeding is poor.

Pro- longed labour? Due to weak or un co-ordinated contractions or? Uterine exhaustion.

Pre - eclampsia therefore more likely to have operative delivery or induced labours. Also some drugs which prevent seizures may contribute to uterine atony.

Fibroids - may interfere with retraction

Mismanagement too much handling may disrupt the rhythm of myometrium activity therefore causing only partial separation of the placenta.

Retained placenta - or clot may diminish contractions

Toclytic drugs given to suppress uterine activity in a pre term labour may

contribute to causing atony.

Uterine inversion.


Implications for care

Booking - good history taking.

Treatment of anaemia

Careful management of labour


Maternal exhaustion or dehydration avoided

Urinalysis -ketones.

Bladder care.

Good management of third stage.

If PPH summon help.

If no contraction - locate fundus rub up contraction

Oxytocic drug However midwife should not administer above two 500mg

doses of ergometrine maleate as may cause severe peripheral vaso

constriction increase SVR and a sharp rise in BP (Lewis and Chamberlain 1990).

Delivery of placenta

Catheter to empty the bladder

If placenta not removed ? Manual removal – medical

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