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
* 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.
Atonic uterus fails to contract and retract sufficiently to facilitate adequate placental separation.
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.
Is a localised spasm of uterine muscle just above the lower segment, this
prevents descent of the placenta. Lewis and Chamberlain (1990).
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).
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.
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.
Occurs when operators hand is quickly withdrawn from uterus whilst fundal pressure present.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
* 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
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.
Implications for care
Booking - good history taking.
Treatment of anaemia
Careful management of labour
Maternal exhaustion or dehydration avoided
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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