OBSTETRICS II

3RD AND 4TH STAGE OF LABOR DR. BADUA

3rd And 4th Stage of Labor
Dr. Jo-Ann Badua
May 5, 2016

REVIEW OF STAGES OF LABOR

Stage 1: Onset of labor to full cervical dilatation

Stage 2: Full cervical dilatation to delivery of the

baby

Stage 3: Delivery of the baby to the delivery of the

placenta

Stage 4: Delivery of the placenta to recovery

CORD CLAMPING

The surgeon will clamp and cut the umbilical cord

THIRD STAGE OF LABOR

From the delivery of the baby to the delivery of the

placenta

There are still problems in the 3rd stage despite

good adherence to prenatal check-ups etc.

hematoma to separate the placenta,

and not to enough bleeding to cause
active blood loss

Placental Expulsion results from:

Spontaneous uterine contractions

Downward pressure from retroplacental hematoma

Increase in maternal intra-abdominal pressure

After the delivery of the baby, the mother will feel

a mass (placenta) inside her vagina, so what she
will do is to push it to expel it out.

Without the aid of the midwife or a doctor the

placenta should be delivered spontaneously
2 METHODS OF PLACENTAL SEPARATION
TYPE
DUNCAN
SCHULTZE

HOW
Peripheral
separation
Central
separation

WHAT

WHERE

Dirty

Cotyledons

Shiny

Fetal
Membranes

DURATION OF 3rd STAGE

Usual duration (for the delivery of the placenta):

o
5-15 minutes
o
Even if you are not going to assist its
delivery, the placenta should be delivered
on its own

Delayed: >30 minutes

The absolute time limit for the delivery of the

placenta, without evidence of significant
bleeding, remains unclear
o
No absolute time limit for its delivery

However, period ranging from 30-60 minutes have

been suggested
o
If the placenta has not yet been delivered
for an hour, start to worry
MECHANISMS OF (NORMAL) PLACENTAL SEPARAT ION

Placental shearing
o
Maka-cut ang placenta from its
implantation

Hematoma formation

Expulsion
A. PLACENTAL SHEARING

Shearing of the placental surface as the uterus

contracts after delivery

Reduction in the surface area of the placental

implantation site

Discrepancy of placenta and implantation site

o
Lumiliit na yung uterus, so the placenta
should be detached
B. HEMATOMA FORMATION

Venous occlusion and vascular rupture in the

placental bed

Blood accumulates at the site of implantation

Hematoma grows
o
The more the hematoma grows, the more
the placenta detaches
C. EXPULSION

Placenta detaches, spiral arteries exposed in

the placental bed therefore more bleeding

Muscle bundles occlude and kink-off the BV

BV contract and retract, followed by the expulsion of

the placenta
o
These happen so that there is enough

SIGNS OF PLACENTAL SEPARATION

Uterus becomes firmer and globular

o
Earliest sign to appear
o
The placenta descends into the lower
segment
o
The body of the uterus continues to retract

Kahit nadeliver na yung

baby, nag cocontract pa rin
yung uterus

Sudden gush of blood

o
Escape of retroplacental clot following
complete separation
o
Not a reliable indicator

Sudden gush of blood can

be a perineal or cervical
laceration
o
Duncan method: more bleeding since
peripheral siya
o
Schultze method: less bleeding

Uterus rises in the abdomen

o
Anterior cephalad movement of the
uterine fundus
o
Placenta separates and is pushed into the
LUS, where its bulk pushes the uterus
upwards

Lengthening of the cord

o
Most reliable sign
o
Cord protrudes out of the vagina

Youll feel the tautness of the cord

o
Indicates placenta has descended

OBSTETRICS II

3RD AND 4TH STAGE OF LABOR DR. BADUA

All of these should happen within 30 minutes after

delivery of the baby.

PLACENTAL SEPARATION

Appear within 1-5 minutes

After placental delivery

o
Ascertain that uterus is firmly
contracted. If not, there can be a
pathology of the 3rd stage
PLACENTAL DELIVERY

Must not be forced before signs of placental

separation
o
Therefore, wait for the signs of separation

Traction on the cord must not be used to pull

placenta out of the uterus (can cause uterine
inversion)

Employ the Brandt-Andrews Technique

o
Pressure is applied to body of the uterus
o
Cord kept taut
o
Uterus lifted cephalad with abdominal
hand

Membranes should be grasped, removed

MANAGEMENT: 3rd STAGE OF DELIVERY
2 BROAD CATEGORIES

Active management: Bristol trial and Hinchingbrooke

trial advocate this

Expectant management
o
Physiologic
o
Waiting for the typical signs of placental
separation
o
Most common method in most home
deliveries
Physiologic
Active Management
Management
of 3rd Stage
At delivery of
None, after delivery of
shoulders Can give
Uterotonic
placenta
oxytocin or
methergine
Uterus
Assess size and tone
Assess size and tone
Controlled cord
Cord
None
traction when uterus
Traction
contracts
Variable
Cutting of
Early
Can cut the cord after
the cord
baby or placenta is out

ACTIVE MANAGEMENT OF 3RD STAGE OF LABOR

Administration of a uterotonic prior to the delivery of

the placenta
o
Via IM or incorporated in IVF

Clamping and cutting the umbilical cord

immediately after delivery of the baby

Controlled cord traction with concurrent counter

pressure to the uterus

Prophylactic uterotonic agents

o
Promotes strong uterine contractions
o
Leads to faster retraction and placental
separation and delivery
o
Decrease amount of blood loss
o
Less PPH (postpartum hemorrhage)
o
Reduces incidence of retained placenta

Modified Brandt Andrews Technique

o
Controlled cord traction on the cord
o
Apply pressure cephalad on the uterine
fundus
o
While applying traction on the cord

The findings show a conclusive benefit for active

management
o
Reduction in

Occurrence of PPH

Hgb value of less than 9 g/dl at

24-48 hours pp

Need for BT

Need for therapeutic uterotonic

agents
3rd STAGE BLEEDING

Caused by attempts to hasten placental delivery

o
Wait for the signs of placental separation
before pulling the cord

DONT
o
Do constant kneading, squeezing of the
uterus
o
Force placental delivery before separation
o
Pull cord
Mahirap habulin ang placenta pag naputol yung cord niya.
Magcocontract yung uterus, pati yung cervix mag reretract

MANUAL EXTRACTION/ REMOVAL OF PLACENTA

Manual extraction is NOT indicated until 30 minutes

have elapsed

One hand is inserted through the vagina and into

the uterine cavity
o
The mother should be sedated kasi
ipapasok mo kamay mo hanggang
elbow

Insert the side of your hand in between the placenta

and uterus

Using the side of your hand, sweep the placenta off

the uterus

After most of the placenta has been swept off the

uterus, curl fingers around the bulk of the placenta,
exert gentle downward and outward traction

Then pull the placenta through the cervix and out

into the vagina

EXAMINATION OF PLACENTA AND MEMBRANES

Placenta weight (1/5 fetal weight)

Lobes

Localized calcifications

Blood vessels

Insertion of the cord

Umbilical vessels: AVA

OBSTETRICS II

3RD AND 4TH STAGE OF LABOR DR. BADUA

Cord length
o
Shortened cord of about 32 cms will not
allow vaginal delivery: Mahirap manganak
through vaginal delivery kasi hindi
makababa yung baby
Routine gross examination
Examination of the placenta
o
Examine the placenta also in multiple
pregnancies
FOURTH STAGE OF LABOR
From delivery of the placenta and lasts for an arbitrary
period afterward
1 hour after placental delivery (4 hours)
Following the delivery of the placenta
o
Uterus is 4 cm below the umbilicus
o
Palparte the abdomen and assess uterine size
and tone

Should be firm and contracted

o
Massage the uterus
o
Infuse oxytocin
o
Encourage breastfeeding to promote
endogenous oxytocin release
After sustained uterine ton has been established, do
o
Check presence of any bleeding from lower
genital tract
o
If bleeding is minimal, assess the placenta
from lower genital tract
o
Assess the placenta before repair of an
episiotomy or any lacerations
Agents that promote uterine contraction
o
Oxytocin
o
Exogenous prostaglandins
o
Synthetic ergot alkaloids

40-50% if uterine atony can be arrested when you do

active management of 3rd stage of labor
PPH is a global, political and economic concern
Account 30% in maternal deaths in the 3rd world
Maternal death rate
o
1st world: 7-15/100,000 LB
o
3rd world: 100-200/100,000 LB
o
Philippines: 110/100,000LB (1993)
o
Thebiggest single cause of maternal deaths in
the Philippines is Hemorrhage
o
Blood loss in excess is 500 ml after normal
spontaneous vaginal delivery
o
Blood loss in excess is 1,000 ml after cesarean
section/delivery
o
PPH can be at 24 hours or as long as 6 weeks
after delivery of the baby

Etiology

Cause

Tone

Uterine atony

Trauma

Uterine, cervical, vaginal tears

Tissue

Retained placenta, uterine inversion,

placenta accrete

Thrombin

Coagulation disorders

Role of Pre-natal care in PPH

Recognition of risk factors

o
Multiparity
o
LGW
o
Multiple gestation

Anticipate needs

Plan treatment/management
o
Counseling is important
Prevention

Proper and vigilant monitoring of immediate

postpartum patient

Readily available blood and blood products

Adequate operating facilities

Alert action by experienced OB team

Types of PPH
Primary (Immediate) PPH

Excessive bleeding within 1st 24 hours

70% due to uterine atony

Abnormalities of the 3rd and 4th Stage of Labor

Obstetrics is a bloody business

Post partum hemorrhage

Uterine atony

Tears and lacerations of the birth canal

Vulvovaginal hematomas

Retained placental fragments

Placenta accrete, increta, percreta

Uterine inversion

Late post partum hemorrhage

POSTPARTUM HEMORRHAGE

Postpartum hemorrhage is a nice way of saying we let

women bleed to death

PPH is the leading cause of maternal deaths worldwide

122,500 women die due to childbirth every years

70% of PPH are caused by uterine atony

Secondary (Late) PPH

Excessive bleeding between 24 hours to 6 weeks

postpartum

Due to retained products, infection or both

Complications of PPH

Hypovolemia

Hypotension

Shock acute tubular necrosis

Dilutional coagulopathy

Cardiac arrest... Death

BT reactions
Type
Mild
hypovolemia

Cause
Loss of <20% BV

Manifestations
Mild
tachycardia,
mottled skin,
cold extremities,
decreased UO,

OBSTETRICS II

Moderate
hypovolemia

Severe
hypovolemia

3RD AND 4TH STAGE OF LABOR DR. BADUA

Loss of 20-40%
BV

Loss of >40% BV

dizziness
Tachycardia
>110 bpm RR
>l30/min,
marked pallor,
pale eyelids,
postural
hypotension
Classic signs of
shock,
hypotension,
marked
tachycardia,
oliguria,
confusion,
agitation

Deaths are due to

o
Underestimated blood loss
o
Inadequate fluid replacement
o
Delay in operative intervention

General Measures

IVF (D5 LRS with oxytocin)

Use large bore needles

2 IV lines

Blood transfusion

CBC, typing, crosmatching

Coagulation studies

CVP (5-15 cm H20)

Signs and symptoms

Soft, poorly contracted uterus

EBL> 500ml at vaginal delivery

EBL> 1,000ml at CS delivery

Decreased in Hgb 10% or more

Blood loss requiring transfusion

Management: Conservative

Bimanual massage: first

Aortic compression

IV methylergonovine (0.2mg)

Prostaglandin IV
o
Rectal: Misoprostol

BT started

NO Uterine packing
Atonic Uterus

Bleeding continues

Bimanual compression of uterus

o
Insert hand into thevagina and form a fist into
the anterior fornix
o
Apply pressure against the anterior uterine
wall
o
Press deeply into the uterus abdominally,
pressure on the posterior uterine wall
o
Maintain compression until bleeding stops and
uterine contracts

Management:

Identify the cause

o
Palpate uterus
o
Visualize cervix
o
Explore uterine cavity
A. UTERINE ATONY
Definition:

MC postpartum hemorrhage

Loss of tone in the uterine musculature

Normally, uterine muscles compress the vessels and

reduce blood flow

75-80% of postpartum hemorrhage

Risk Factors

Overdistended uterus
o
Big baby
o
Polyhydramnios
o
Multiple gestation

Uterine muscle exhaustion

o
Infection
o
Anatomic defect,
o
Myoma

Intraamniotic infection: ruptured BOW

Functional/ anatomic distortion of uterine-myoma

(bicornate uterus)

Rapid labor, precipitate labor

o
Use up all ATP -> muscle fatigue
o
200MVU every contractions

Hispanic of Asian ethnicity

Operative delivery
o
CS
o
Forceps delivery

Grand multiparity: >5 deliveries

History of postpartum hemorrhage

Magnesium sulfate treatment: tocolytic agent

Aortic compression
o
Press on the abdominal aorta to decrease
blood supple to the uterus to the spiral vessels
that are not ligated

Management: Surgical Approach

Establish circulatory system

If atony is not corrected: SURGERY

o
Hypogastric artery ligation (anterior branch of
internal iliac is ligated)
o
Uterine artery ligation (CS)

OBSTETRICS II
o

3RD AND 4TH STAGE OF LABOR DR. BADUA

B-Lynch Procedure: Applicable if patient is
stable and bimanual uterine compression
successfully arrests the bleeding

Hysterectomy (consider patients

reproductive history, desire of pregnancy)

Subtotal and Total hysterectomy is

advisable

B. BIRTH CANAL INJURIES

Lacerations to the
o
Cervix
o
Vagina
o
Extension of the episiotomy
o
Perineum
o
Anus
o
Rectum

Uterine rupture
Risk Factors

Precipitous delivery

Operative delivery

Previous uterine surgery (rupture)

Malposition

Deep engagement

Forceps extraction/delivery
Management

Identify/visualize source

Prompt repair

First stitch placed slightly above the apex of the tear

Proper exposure

Call for assistance

For 4th degree lacerations, lacerated anus is apposed

by interrupted sutures
C. UTERINE RUPTURE

<1% of women on TOL (trial of labor) after cesarean

delivery
Risk Factors:

Prior CS birth: classical (vertical incision in the uterus) >

low transverse

Prior myomectomy

Operative delivery: midforceps

Grand multiparity: weak uterine muscles

Excessive use of labor inducing agents

Types
Complete Rupture

Full thickness separation of the uterine wall from the

endometrial cavity to the serosal cavity

Baby and contents spill into the peritoneal cavity

Baby may die or suffer from neurologic complications if

the baby survives

Catastrophic bleeding
Incomplete/ Dehiscence

Separation of muscle except uterine mucosa

Baby ma survive

Symptoms

Vaginal bleeding

Sharp pain between contractions

Contractions slow down, become less intense

Recession pain on previous scar

Uterine atony

Maternal tachycardia

Hypotension
Management

Intervene quickly and successfully

Establish the diagnosis

Prevent maternal and fetal morbidity

o
10-30 minutes

Factors to consider
o
Type and extent of rupture
o
Degree of hemorrhage
o
Condition of the mother
o
Desire for future childbearing

Immediate laparotomy
o
Repair is possible

Hysterectomy: last resort

***NOTE:

Maintain a high level of suspicion

When in doubt, act quickly

D. HEMATOMAS
VULVO-VAGINAL HEMATOMAS
Etiologies:

Inadequate hemostasis during repair of the episiotomy

Vulvar varicosities
Risk factors

Vulvo-vaginal varicosities

Instrumental deliveries

Prolonged 2nd stage labor

Signs and Symptoms

Severe pain, greater than that with

the episiotomy, increasing intensity
o
Always look at the
perineum of the patient

Developing anemia, hypovolemia

Swelling is tense and tender

Rectal pain and swelling

Cause

Injury to the branches of the pudendal artery may

extend into the anterior triangle into the colles facia
o
Inferior rectal
o
Perineal Posterior labial

OBSTETRICS II

3RD AND 4TH STAGE OF LABOR DR. BADUA

o
Urethral
o
Deep and dorsal arteries to the clitoris
Injury to the branches of the uterine artery result to
vaginal and paravaginal hematoma

Management
SUPERFICIAL

Unilateral swelling, with edema, ecchymosis

o
Evacuation and ligation
o
Eliminate dead space (suture in layers)
DEEP

Swelling can be intravaginal

Branches of the uterine arteries are injured

RETROPERITONEAL

Less obvious, uterine arteries involved

US, IVP, CT scan

Explore laparotomy ASAP

Identify, ligate bleeders

o
Hypogastric artery ligation
TREATMENT OF VULVAR HEMATOMA: STEP-BY-STEP SURGICAL
APPROACH

An incision is made at the most distended point of the

hematoma

The incision is then deepened and the blood clots

scooped out

The bleeding vessels are identified and tied up

The incision is closed by applying different layers of

stitches

A drain may be put in the wound for 24 hours to allow

any oozing blood to flow out

Proper antibiotics are prescribed and the patient kept

under close observation

Blood transfusion is given if necessary

E. RETAINED PLACENTAL FRAGMENTS
Definition

Small fragments of the plancenta have not been

expelled out
Cause

Poor maternal expulsive effort

Prolonged labor

Morbidly adherent placenta

Have to do
o
Routine inspection of placenta when
delivered. Count the cotyledons etc.
o
Routine uterine exploration

Placental villi attached to the myometrium rather than

the endometrium where basalis and functionalis layers
are found. Functionalis layer has the compacta and
basal layer. Placenta should be attached to the basal
layer of the endometrium (decidua basalis)

Results from

Absence of decidual basalis

Imperfect development of Nitabuchs layer

o
An anatomic and immunologic barrier
between the fetal and the maternal tissues
kaya it will attach directly to the myometrium
Types of Placenta Accreta according to depth of invasion
Types
Incidence
Description
Placenta
75-80%
Placenta
accrete: MC
attaches to the
myometrium but
does not
penetrate it
Placenta increta
17%
Placenta
penetrates the
myometrium
Placenta
5%
The worst form,
percreta
placenta
penetrates the
entire
myometrium up
to the uterine
serosa. Placenta
may attach to
other organs like
bladder
(anteriorly) or
rectum
(posteriorly

Management
Retained placenta fragments: Placental removal following
vaginal delivery

Initial post-partum condition

Condition following placental delivery

Attempted manual removal

Attempted removal by sharp curettage

RETAINED PLACENTAL FRAGMENTS: MANUAL REMOVAL UNDER GA

Catheterization, prophylactic antibiotic

Hold the umbilical cord with a clamp. Pull the cord

gently until it is parallel to the floor

Insert the other hand (long gloves) into the vagina and
up into the uterus

Then proceed with manual evacuation of placenta

F. ABNORMAL ADHERENCE OF THE PLACENTA
Placenta Accreta

Abnormal firm adherence of placenta to the uterine

wall

Placenta Accreta: Types Accdg to the number of Cotyledons

that have penetrated the myometrium

Total: all cotyledons (placenta accrete basalis)

Partial: few cotyledons

Focal: single cotyledons

Clinical diagnosis

Cannot separate the placenta from its uterine

attachment because of absence of cleavage
No signs of placental separation >30 minutes
Please no further attempts made to remove!!

OBSTETRICS II

3RD AND 4TH STAGE OF LABOR DR. BADUA

May cause more bleeding, perforation and

infection
Sometimes, the patient may complain of bloody urine
o

Incidence

10 fold rise in past 50 years

Risk factors

Previous CS

Maternal age: the older the age, the higher the risk

Prior curettage

Ashermans syndrome: associated with septic abortion

History of endometrial ablation

History of irradiation

Hypertension

Smoking

Placenta previa: Especially if the placenta is implanted

anteriorly or at the LUS
Prenatal Diagnosis
Ultrasound

Loss of normal hypoechoic retroplacental zone

o
Usually dapat may hypoechoic area
pagtapos mag implant ng placenta, seen in
UTZ

Multiple vascular lacunae giving a Swiss Cheese

appearance

Blood vessels or placental tissue bridging the uterineplacental margin, myometrial bladder interface or
crossing uterine serosa

Retroplacental myometrial thickness < 1mm

Numerous coherent vessels visualized in basal view

Confirm with MRI, usually UTZ is enough to diagnose

Cause

Mismanagment of the 3rd stage of labor??? Iatragenic

Excessive traction of cord while placenta still attached

Predisposing Factors

Adherent placenta, baka may placenta accreta

Short cord
o
Normal length: 55 cms. in average
o
Short cord: 32 cms.

Congenital predisposition

Increased intrabdominal pressure

Manual removal of placenta

General anesthesia

Uterine weakness

Precipitate delivery
Uterine Inversion Types
TYPE 1: Complete

Inverted fundus extends beyond the cervix

TYPE 2: incomplete/partial

Inverted fundus lies above cervix, stays within the

uterine cavity
TYPE 3: Prolapsed inversion

Corpus is out of the introitus, pati cervix and part of the

vagina

Management
Planned CS + Hysterectomy

With adequate BT, antibiotics

Safest and most common

Lower mortality
Conservative Management (Preserve fertility)

Leave placenta, slough off in time, methotrexate

Localized resection and repair

Embolization of pelvic vessels

Curettage

Oversew defect: tahiin mo lang yung defect

Cystectomy???
o
If the placenta is adhered to the bladder
o
Ask for the help of a Urologist
Complications

Damage to bladder, rectum, urethra etc.

o
The patient may have a urinary catheter for
life

Post-operative bleeding, repeated surgery

Amniotic fluid embolism

Consumptive coagulopathy

Infection, that cant be treated by oral antibiotics

Multisystem organ failure

Maternal death: high (6-7%)

G. UTERINE INVERSION

The uterus turns inside out, nakikita mo na yung

nabaliktad na endometrial cavity

Usually during or after placental delivery

Rare but potentially fatal, Death usually due to

neurogenic shock

Classification According to onset of inversion

ACUTE: inversion before cervical ring contraction

SUB-ACUTE: inversion after cervical ring has formed,

nag invert siya pero masikip na ung ring

CHRONIC: 4 weeks has elapsed from the cervical ring

formation
Signs and Symptoms

Acute abdominal pain

Sudden and profuse hemorrhage

Bradycardia due to parasympathetic effect of traction

on the uterine ligaments

Shock

Fatal but 85% maternal survival if corrected early and

properly
Management

2 IV infusion

Repositioning of the uterus under GA

Add Oxytocin to IVF

Bimanual massage
MANUAL REPLACEMENT OF INVERTED UTERUS

Palm of hand on center of fundus with extended fingers

Fundus pushed upward through cervix

OBSTETRICS II

3RD AND 4TH STAGE OF LABOR DR. BADUA

Maintain hand on the fundus, oxytocin drip

Wait till the uterus contracts

WHEN TO REMOVE STILL ATTACHED PLACENTA?

(CONTROVERSVIAL)

More blood loss if placenta is removed prior to

repositioning

If placenta partially detached, remove placenta first

Make sure na hindi placenta accreta

To tight cervical ring

Incised via vaginal approach

Laparotomy (rare)

Prophylactic antibiotics
H. LATE POST PARTUM HEMORRHAGE

Bleeding after 24 hours following delivery until 6 weeks

after delivery
Commonly associated with uterine sub-involution due
to
o
Infection (endometritis, myometritis)
o
Retained placental fragments
o
Abnormal healing at the placental site

Physical Exam

Soft uterus, larger than expected

o
Normally, after delivery of the placenta,
immediately the uterus should be 4cm below
the umbilicus
o
If still at the level of the umbilicus, subinvoluted uterus na
Management
CONSERVATIVE

Ultrasound: identify retained products

Antibiotics

Oxytocin

Curettage
Notetakers:
Niz Gundayao
Michael Chio
Adrian Ang
Carra Esteban