MOD3-OB2-T7-Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium.pdf

x OB2 OBSTETRICS 2 Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the TRANS 7...

x OB2 OBSTETRICS 2 Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the TRANS 7 Puerperium MODULE 3 Dr. Soledad Chu Crisostomo, MD, FPOGS August 9, 2024 LECTURE OUTLINE How are you going to manage this patient? ○ To answer this question and understand the topic, it is important to I Introduction review and have a clear understanding of the physiologic or normal obstetric that was taught in second year. II Third Stage of Labor Review lecture notes on the conduct of labor and delivery especially on the A. Placental Delivery management of the first stage of labor since mismanagement of this stage will lead to postpartum hemorrhage. III Prolonged Third Stage of Labor Review lectures on labor and delivery in the second year. A. Manual Extraction of the Placenta ○ Stages of labor (difference between a primigravida and a multigravida) B. Placental Inspection ○ Management of the Third stage of labor ○ Expectant versus active management IV Postpartum Hemorrhage (PPH) ○ Prophylactic uterotonics given during this stage A. Definition ○ Signs of placental separation B. Types ○ Mechanisms of placental separation ○ Maneuvers in Placental Delivery (Brandt Andrew’s) and Placental V Causes of Postpartum Hemorrhage (4Ts) inspection A. Tone (Uterine Atony) ○ Normal blood loss during vaginal and CS delivery B. Tissue (Retained Placental Tissues) Dr. Crisostomo C. Trauma (Genital Tract Trauma) D. Thrombin (Abnormalities of Coagulation) E. General Management of Postpartum Hemorrhage II. THIRD STAGE OF LABOR Begins after fetal birth and ends with placental delivery VI Summary ○ Goal: VII Clinical Scenario Delivery of an intact placenta Avoidance of uterine inversion and postpartum hemorrhage VIII Synchronous Sessio VIII Handout Clinical Scenario A. PLACENTAL DELIVERY Signs of placental separation LECTURE OBJECTIVES ○ During the delivery of the placenta, it is very important to wait 1. Given a clinical scenario of a patient with abnormalities of the for the signs of placental separation before attempting to apply third stage labor and postpartum hemorrhage, the student is traction on the cord expected to give the: Maneuvers in placental delivery a. Diagnosis ○ Certain maneuvers like the Brandt-Andrews maneuver is b. Etiology performed to prevent uterine inversion c. Management Placental inspection ○ Once delivered, the placenta is inspected for completeness 🧠 Must Know 📖 Book 📝 Previous Trans Administration of uterotonics ○ Uterotonics like oxytocin, methylergonovine, misoprostol, carboprost, or carbetocin are given to keep the uterus contracted I. INTRODUCTION Over the years, the top three leading causes of maternal mortality III. PROLONGED THIRD STAGE OF LABOR are still: There are instances when the placenta remains partially or totally 1. Obstetrical hemorrhage attached, causing the prolongation of the third stage of labor 2. Hypertension and Heavy bleeding may ensue and manual placental extraction is 3. Infection indicated Hemorrhage can occur during: antepartum, intrapartum, or the ○ Adequate analgesia is mandatory; and postpartum period. ○ Aseptic surgical technique should be observed ○ Postpartum - highest incidence occurs among the three In the absence of a timely and appropriate action, a woman could die within a few hours. A. MANUAL EXTRACTION OF THE PLACENTA In developed countries, postpartum hemorrhage (PPH) is a One hand holds the uterine fundus. The other hand is inserted into preventable and manageable condition. the uterine cavity with the fingertips insinuated between the uterine ○ However in developing countries, like the Philippines, mortality wall and the placenta. from PPH remains high, causing a considerable concern to the A side-to-side sweeping motion of the fingertips as they advance patient, the doctors, and to the national health system into the plane, will peel off the placenta from its uterine attachment. When the placenta has become detached, it is grasped and CASE 37 yr old, G7P5 (5-0-2-5) removed out of the uterine cavity. #1 → Came to the ER with profuse vaginal bleeding → 1-hr PTC, delivered a 4kg at home, assisted by midwife after 20 hours of labor → Dizziness, noted to be pale, profuse vaginal bleeding after placental delivery Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 1 of 12  A. TONE (UTERINE ATONY) Most common cause of obstetrical hemorrhage There is insufficient uterine contraction to arrest bleeding from the blood vessels at the site of placental implantation Risk factors for uterine atony should be identified and anticipated even antenatally so as to prevent such occurrence ETIOLOGY Table 1. Tone Etiology PATHOPHYSIOLOGY RISK FACTORS Figure 1. Manual extraction of the placenta. Multiparity Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage Multiple gestation of Labor and Postpartum Hemorrhage (PPH) Part 1 Over distended uterus Polyhydramnios Macrosomia B. PLACENTAL INSPECTION Prolonged Labor Primiparity Uterine muscle fatigue Augmented Labor Prior PPH Chorioamnionitis Prolonged rupture of membranes Uterine distortion/abnormality Fibroids, placenta previa Anesthetic drugs, MgSO4, Uterine relaxing drugs B-mimetics 1 Over distended Prone to hypotonia after delivery uterus Therefore, women who are multiparous, multiple gestation, polyhydramnios and macrosomia have a greater risk for postpartum hemorrhage. Figure 2. Placental inspection 2 Uterine muscle Common among those with labor Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage fatigue abnormalities (e.g., hypertonic or of Labor and Postpartum Hemorrhage (PPH) Part 1 hypotonic labor) Prolonged labor, as seen more commonly Membranes adhered to the uterine lining (decidua) are separated in primiparas, or labors that are induced or by the gentle retraction with ring forceps, making sure no augmented with uterotonics will lead to placental membranes will be retained. uterine fatigue. This prevents the uterus’ Another method to clear the membrane is to do uterine curettage. ability to contract effectively to arrest ○ Here, the uterine cavity is wiped with a hand wrapped with bleeding at the sites where the placenta gauze. has just detached from the uterus. The placenta is inspected to see if there are no missing Women with prior history of PPH is also at cotyledons. risk for recurrence Uterotonics and antibiotic prophylaxis are given after the procedure. 3 Chorioamnionitis Often associated with prolonged rupture of membranes (PROM). IV. POSTPARTUM HEMORRHAGE (PPH) 4 Uterine Presence of uterine abnormalities like A. DEFINITION distortion/ uterine myomas, and placenta previa are Traditionally, PPH is defined as: abnormality always factors that can cause insufficient ○ Vaginal Spontaneous Delivery (VSD): Blood loss of ≧ 500 uterine contractions. mL after the completion of the 3rd stage of labor Diagnosing the presence of these ○ Cesarean Section (CS): Blood loss ≧1000 mL conditions (chorioamnionitis and uterine However, almost half of all women who delivered, shed more than abnormalities) during the prenatal these amounts when losses are carefully measured checkups is therefore necessary. According to the American College of Obstetrician and 5 Uterine relaxing Medications used as anesthetics or those Gynecologist (ACOG) in 2017, PPH is defined as: Blood loss ≧ drugs given to treat medical; conditions during 1000 mL accompanied by signs and symptoms of hypovolemia pregnancy like magnesium sulfate for preeclampsia and beta-mimetics for B. TYPES bronchial asthma can cause uterine PPH is also classified as: relaxation. ○ Early: within the first 24 hours post delivery Therefore, one has to be meticulous in ○ Late: after 24 hours post delivery asking for the patient’s present and past The time of hemorrhage is important because certain causes are medical history. related to its occurrence. EVALUATION AND MANAGEMENT V. CAUSES OF POSTPARTUM HEMORRHAGE Initial evaluation attempts to differentiate uterine atony from other In determining the etiology of postpartum hemorrhage, causes of PPH remember the 4 Ts: Genital laceration: another common cause of PPH and can coexist with uterine atony 1 Tone Abnormal uterine contractility 2 Tissue Retained products of conception 1 Palpate uterus for atony If there is atony, uterus is soft and boggy on bimanual 3 Trauma Genital tract trauma examination Blood clots and hemorrhage are noted during uterine 4 Thrombin Abnormalities of coagulation massage Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 2 of 12  2 Inspect to exclude birth canal laceration and uterine rupture Persistent bleeding despite a firm well-contracted uterus suggests that hemorrhage is most likely coming from lacerations. Lower genital tract, vagina, and cervix are inspected to locate source of bleeding Examination is easier if done under anesthesia Bleeding may be caused by both uterine atony and Figure 4. Surgical management: Conservative laceration after forceps or vacuum-assisted vaginal delivery. Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage If there are no lower genital tract lacerations and the uterus of Labor and Postpartum Hemorrhage (PPH) Part 2 is well-contracted and there is still supracervical bleeding, manual exploration of the uterus is done to exclude uterine ANGIOGRAPHIC EMBOLIZATION tear and rupture. This is routinely performed after internal podalic version, Another modality that is being used for intractable hemorrhage breech extraction, or successful vaginal birth after CS when surgical access is difficult. delivery Fertility is not impaired Complications that may occur: 3 Inspect the placenta for completeness ○ Iatrogenic iliac artery rupture Since retained placental tissue can impair efficient uterine ○ Uterine ischemic necrosis contraction ○ Uterine infection 4 Massage uterus and administer uterotonic agents SURGICAL MANAGEMENT: HYSTERECTOMY BLEEDING UNRESPONSIVE TO UTEROTONIC AGENTS TOTAL HYSTERECTOMY NON-SURGICAL SURGICAL If everything fails, total hysterectomy is done, leaving the Performed before resorting to surgical Conservative ovaries behind, especially if the patient is young. intervention especially if fertility has to Hysterectomy Uterine Artery Ligation Internal Iliac Artery Ligation be conserved NON-SURGICAL MANAGEMENT Bimanual Uterine Compression Balloon Tamponade Uterus is positioned with the fist A balloon is placed in the uterine of 1 hand inserted in the vagina, cavity and is filled with 60-80 mL pushing the anterior fornix against of saline. It is removed after the anterior abdominal wall which 12-24 hours if bleeding subsides. is being held by the other hand. The open tip permits continuous Figure 5. Surgical management: Hysterectomy Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage Abdominal hand is also used to drainage of blood from the uterus. of Labor and Postpartum Hemorrhage (PPH) Part 2 massage the uterus. B. TISSUE (RETAINED PLACENTAL TISSUES) Another cause of postpartum hemorrhage is retained placental tissues Inspection of the placenta after delivery should be done routinely Check for completeness of the placenta ○ If there are missing placental cotyledons, the uterus should be Figure 3. Third degree perineal tear (left); Fourth degree perineal tear (right). manually explored and the fragment should be removed. Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage Succenturiate or accessory lobe of Labor and Postpartum Hemorrhage (PPH) Part 2 ○ Occasionally, retention of an accessory lobe may cause postpartum hemorrhage. SURGICAL MANAGEMENT: CONSERVATIVE ○ Aside from causing uterine atony, retained placental tissue or Uterine compression is also done through surgical means. cotyledon may cause uterine self-involution and puerperal Absorbable sutures are used to compress the anterior and infection. posterior uterine wall together. If no evidence of placental detachment, consider complete Complications of these procedures may include: placenta accreta or variant ○ Uterine ischemic necrosis with peritonitis ○ Causes prolongation of the first stage of labor, complete ○ Uterine wall defects accreta or its variant should be considered. ○ Uterine cavity synechiae Adjunctive surgical procedures are used before resorting to hysterectomy in cases where fertility has to be conserved. These conservative procedures are used before resorting to hysterectomy in cases where fertility has to be conserved. ○ These include: Ligation of the uterine artery Ligation of the internal iliac artery NOTE: These procedures may be technically difficult and successful in only half of the cases. Figure 6. Placenta succenturiata/accessory placental lobe. B-Lynch Suture Hayman Suture Cho-Square Suture Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage (PPH) Part 2 PLACENTA SUCCENTURIATA / ACCESSORY PLACENTAL LOBE Normally, the blood vessels taper as they approach the outer margin of the placenta, if upon inspection this is not observed but Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 3 of 12  instead blood vessels are noted traversing the placental To highlight the anatomy and to identify membrane, the presence of an accessory lobe should be highly 3 MRI invasion of adjacent structures considered. These placental tissues are either removed by curettage or uterine lavage ACCRETE SYNDROME: MANAGEMENT In some instances, the placenta cannot be detached even if Possibility of an accrete syndrome should be recognized as much manual extraction is done. Placenta accreta or its variants should as possible antenatally by looking for risk factors be considered. 1. TIMING AND PLACE OF DELIVERY ACCRETE SYNDROME A major decision on the management Abnormal placental adherence to the myometrium Considerations include the availability of an appropriate surgical ○ Due to partial or total absence of the decidua basalis and team, anesthesia, intensive care unit, and a blood bank imperfect development of fibrinoid or Nitabuch layer. A team of composed consultants from obstetrics, surgery, urology Partially or total lacking of the decidual spongy layer and absent and interventional radiology should be available during the delivery physiological line of cleavage causing some or all cotyledons to be Cesarean delivery should be done in a tertiary care hospital densely adherent to the myometrium. Timing of delivery is individualized ○ This decidual deficiency prevents normal placental separation Take into consideration the risk of fetal immaturity against during the third stage of labor. serious adverse maternal consequences of an emergency Some studies have suggested that the Accrete Syndrome is not Cesarean section. solely caused by anatomical layer deficiency Elective delivery is usually recommended to be done between The cytotrophoblastic may cause decidual invasion through 34-37 weeks but the team should also be prepared to manage it in angiogenesis especially in areas with endometrial defects seen in an emergency situation previous surgical uterine trauma, like in previous CS, hysterotomy, myomectomy, endometrial ablation and curettages. 2. MEDICAL AND SURGICAL MANAGEMENT Confirmation of percreta or increta almost always mandates hysterectomy ACCRETE SYNDROME: CLASSIFICATION Conservative management has been attempted in some to conserve fertility ACCRETA: INCRETA: PERCRETA: This is done by leaving the placenta in situ, to be spontaneously Villi Attaches to the Invades the Penetrates to or resorbed with the use of methotrexate. myometrium myometrium through the serosa Monitoring is done by serial sonography or MRI imaging. Numerous complications may occur like: 1 Sepsis 2 DIC 3 Pulmonary Embolism 4 Arteriovenous Malformation Majority of these patients eventually undergo hysterectomy. Figure 7. Accrete syndrome: classification It is important that antenatally, one has to get a good history of the Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage (PPH) Part 2 patient looking for risk factors that would cause retained placental tissue and a syndrome to prevent the occurrence of postpartum hemorrhage and its complications. Total placenta accrete: abnormal adherence may involve ALL lobules of the placenta Table 2. Tissue Etiology Focal placenta accrete: if all or part of a single lobule is abnormally attached PATHOPHYSIOLOGY RISK FACTORS In clinical practice, these 3 variants are encountered in this ratio: Retained Manual removal of placenta Placenta Accreta: 80% placenta/membranes Succenturiata/ accessory placental lobe Placenta Increta: 15% Accreta Prior uterine surgery Placenta Percreta: 5% Increta Placenta previa Percreta Multiparity ACCRETE SYNDROME: DIAGNOSIS Highest risk factors C. TRAUMA (GENITAL TRACT TRAUMA) ○ Placenta previa and prior Cesarean section Suspected if bleeding persists despite a well contracted uterus ○ More likely if both Placenta previa and Cesarean section are Lacerations to the perineum, vagina, cervix, large episiotomy, combined extension, ruptured uterus and uterine inversion ○ Bleeding from coexisting placenta previa will typically prompt Second most common cause of postpartum hemorrhage evaluation. However, in some women who do not have Trauma could be in the form of gentle laceration or hematoma, associated previa. Placenta accreta will not be identified until extension of CS incision, uterine rupture, and uterine inversion. third stage of labor when an adherence placenta is Risk factors for these conditions should be identified so that gentle encountered trauma could be anticipated and prevented during delivery. IMAGING MODALITIES FOR ANTEPARTUM IDENTIFICATION OF Table 3. Trauma Etiology ABNORMAL PLACENTAL IN-GROWTH PATHOPHYSIOLOGY RISK FACTORS To measure myometrial thickness and to Operative delivery (forceps) look for structures like: Laceration of cervix, Precipitous delivery placental vascular lacunae vagina or perineum Macrosomia, Shoulder dystocia ULTRA placental bulging to the posterior Puerperal hematoma 1 Mediolateral episiotomy SONOGRAPHY bladder wall and absence of the normal hypoechoic Deep engagement retroplacental zone between the Extension/laceration at CS Malposition placenta and the uterus Malpresentation 3D sonography Highly predictive of myometrial invasion Prior uterine surgery (CS, Uterine rupture 2 and Doppler color myomectomy, curettages) flow mapping Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 4 of 12  Excessive cor traction 5 Post operative care includes use of antibiotics, low residue diet, Uterine inversion Grand multiparity laxatives, hygiene and pelvic floor exercises are done. Placenta accreta, increta, percreta PUERPERAL HEMATOMAS All women who delivered vaginally, especially in cases of forceps delivery, the lower genital tract, vaginal canal, cervix, and uterus Location: vulva, vulvavaginal, paravaginal, and retroperitoneal should be explored for the location of laceration. areas ○ Other risk factors: precipitous delivery, fetal macrosomia, shoulder dystocia, and large mediolateral episiotomies. RISK FACTORS Deep engagement of the presenting part seen in prolonged labor, malposition, and malpresentation are prone to have extension 1 Use of episiotomy and laceration during cesarean section. 2 Operative delivery Prior uterine surgeries like cesarean section, myomectomy, curretages put the patient at risk for uterine rupture. 3 Rupture of blood vessels with any associated laceration, as seen Excessive cord traction without waiting for placental separation in in cases of hematoma an atonic uterus specially on multigravidas will resort to uterine 4 Underlying blood coagulopathy inversion. ○ Placenta accreta also increases the risk of uterine inversion SIGNS & SYMPTOMS GENITAL TRACT LACERATION Patients will present with: Genital trauma may be located on ○ Tense and tender swelling ○ Anterior perineal structures ○ Ecchymotic skin Labia ○ Complaints of pelvic pressure, pain, or inability to void Anterior Vagina The changes in vital signs are usually disproportionate to the Urethra amount of blood loss. Clitoris ○ Posterior perineal structures DIAGNOSIS Posterior vaginal wall Perineal muscles Ultrasound, CT scan, and MRI are used for diagnosis of Anal sphincter hematomas above the pelvic diaphragm to assess the extension, location, size, and their resolution. Table 4. Degree of Involvement MANAGEMENT Degree Involvement Fourchette, perineal skin, vaginal mucous membrane 1 Small (3cms), Incision and evacuation of blood clots, 3rd Anal sphincter expanding ligation of bleeders, and primary closure hematomas are done. Extension through rectal mucosa exposing lumen of 4th rectum 3 Imaging Ultrasound, MRI Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage 4 Antibiotics, analgesia, and even gut perfusion, are given. of Labor and Postpartum Hemorrhage (PPH) Part 2 Figure 8. Third degree perineal tear (left); Fourth degree perineal tear (right). Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage (PPH) Part 2 Morbidity from genital tract trauma associated with childbirth may Figure 9. Vulvar hematoma have immediate and long term effects on the physical, Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage psychological, social well-being of the woman even after delivery. of Labor and Postpartum Hemorrhage (PPH) Part 2 If not repaired correctly, this laceration may develop into a rectovaginal fistula or relaxed vaginal outlet. UTERINE INVERSION ○ This may affect the daily life and sexual activities of the patient. Displacement of the uterine fundus may also be encountered during the third stage of labor MANAGEMENT This prevents the myometrium from contracting, causing hypotension from hemorrhage, and also from neurogenic shock. 1 Usually deferred until placenta delivery In uterine inversion, the uterus is seen outside of the introitus with the inner portion turned outside. 2 Superficial lacerations with little to no bleeding are usually not ○ There are cases when the placenta is still attached to the repaired. inverted uterus. 3 Deeper perineal lacerations causing significant hemorrhage are the ones being repaired 4 Effective analgesia/anesthesia, clear visualization, capable assistance, and sufficient resuscitation of hypovolemia are mandatory. Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 5 of 12  RISK FACTORS FOR UTERINE INVERSION 1 Fungal placental implantation 2 Uterine atony 3 Cord traction applied before placental separation 4 Abnormally adhered placentation (accrete syndrome) DIAGNOSIS OF UTERINE INVERSION Hemorrhage, shock, and severe 1 Clinical signs & symptoms pelvic pain 2 Bimanual examination Figure 10. Uterine inversion Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage 3 Imaging Ultrasound, MRI of Labor and Postpartum Hemorrhage (PPH) Part 2 CLASSIFICATIONS OF UTERINE INVERSION MANAGEMENT OF UTERINE INVERSION Uterine inversion is classified as acute, subacute, or chronic JOHNSON MANEUVER depending on the onset of the inversion. Repositioning of the inverted uterus is done manually with this maneuver Most common type If the placenta has separated, the uterus is replaced by pushing 1 Acute Happens immediately or 24 hours after delivery up on the inverted fundus with the palm of the hand and fingers, 2 Subacute 24 hours to 4 weeks postpartum in the direction of the long axis of the vagina Care is taken to not apply too much pressure so as not to 3 Chronic Beyond 4 weeks perforate the uterus with the fingertips Tocolytics or general anesthesia is given for uterine relaxation It can be also classified as: prior to reposition and also to provide analgesia. However, if the placenta is still attached, the uterus is replaced with the placenta in 1 1st degree Incomplete or partial situ. 2 2nd degree Complete Once replaced, the placenta is manually removed but if uterine repositioning fails with the placenta still attached, the placenta is 3 3rd degree Prolapse peeled off and the uterus is then reposed. After repositioning, tocolysis is stopped and uterotonic drugs like oxytocin are given. If manual reposition is not successful, laparotomy is performed using Huntington’s or Haultain’s procedure. Figure 13. Johnson Maneuver Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage Figure 11. Classification of Uterine inversion of Labor and Postpartum Hemorrhage (PPH) Part 2 Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage (PPH) Part 2 AVOIDANCE OF UTERINE INVERSION Wait for signs of placental separation before applying careful traction on the umbilical cord EXPRESSION OF PLACENTA Placental expression should never be forced ○ Traction should be gentle or else the umbilical cord may snap Perform the Brandt Andrew maneuver BRANDT ANDREW MANEUVER Hand is not pushing the uterus through the birth canal, but instead, elevates the uterus on the abdomen while the umbilical cord is held in position Figure 14. Huntington’s Procedure Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage (PPH) Part 2 Figure 12. Brandt Andrew Maneuver Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage (PPH) Part 2 Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 6 of 12  E. GENERAL MANAGEMENT OF POSTPARTUM HEMORRHAGE Preoperative preparedness for patients identified as high risk, comes the need for good history taking, prenatal care, and high index of suspicion. Initial management approach includes: ○ Assessment of hemodynamic status and thorough evaluation to determine cause of bleeding ○ Breathing - oxygen administration ○ Circulation - obtain IV access to ensure adequate circulating blood volume Notify blood bank Multidisciplinary approach in the management Figure 15. Haultain’s Procedure Source: Doc Crisostomo’s Lecture Video on Abnormalities of the Third Stage VI. SUMMARY of Labor and Postpartum Hemorrhage (PPH) Part 2 Postpartum hemorrhage is still the world’s leading cause of maternal mortality D. THROMBIN (ABNORMALITIES OF COAGULATION) Risk factors or possible occurrence of the abnormalities of the third stage of labor and postpartum hemorrhage should be determined WHY IS IT A WOMAN DOES NOT BLEED TO DEATH DURING antenatally and anticipated during delivery CHILDBIRTH? A good history taking and a thorough physical examination are necessary 1. MECHANISM OF NORMAL HEMOSTASIS Mismanagement of the third stage of labor causes prolongation of this stage leading to complications in hemorrhage During placental separation, blood vessels at the implantation site Causes of postpartum hemorrhage are the 4 T's are avulsed. ○ Tone - abnormal uterine contractility Hemostasis is achieved by the myometrial contraction which ○ Tissue - retained products of conception compresses these blood vessels. ○ Trauma - genital tract trauma This is followed by clot formation and obliteration of the blood ○ Thrombin - coagulation abnormality vessel lumen → bleeding will stop Multidisciplinary approach is needed in the management 2. PREGNANCY-INDUCED HYPERVOLEMIA VII. CLINICAL SCENARIO Maternal adaptation during pregnancy Blood volume of a pregnant woman with a normal CASE 37 yr old, G7P5 (5025) pregnancy-induced hypervolemia usually rises in a range of #1 Came to the ER with profuse vaginal bleeding 1-hr PTC, 30-60% (1500-2000 mL for an average-sized woman) delivered a 4kg at home, assisted by midwife after 20 Thus, women tolerate blood loss during delivery without a hours of labor Dizziness, noted to be pale, profuse decrease in postpartum hematocrit vaginal bleeding after placental delivery Hypovolemia may not be recognized until a large amount of blood DIAGNOSIS has been lost (e.g. Preeclamptic patients) From the clinical scenario given at the start of this lecture, can 3. INHERENT INCREASE IN THE COAGULABILITY STATE you now give the possible causes of postpartum hemorrhage DURING PREGNANCY BECAUSE OF HORMONES and the risk factors that caused the bleeding of this patient? Postpartum hemorrhage can be encountered in the presence of MANAGEMENT pre-existing clotting abnormalities like in hemophilia, Von How would you manage her condition? Willebrand Disease and hypofibrinogenemia. DIC, HELLP Syndrome and use of anticoagulants also affect the blood clotting status of the patient. VIII. SYNCHRONOUS SESSION Risk factors should be known since management of hemorrhage is directed on the cause or pathology. STAGES OF LABOR (Difference between a Primigravida and a Multigravida) Table 5. Thrombin Etiology First Stage - starts with the active labor until full cervical dilatation (10cm) PATHOPHYSIOLOGY RISK FACTORS Second Stage - from full cervical dilatation until the delivery of the Preexisting clotting abnormalities baby History of coagulopathy or ○ For first and second stage of labor, it is prolonged in (Hemophilia, Von Willebrand liver disease primigravid while fast in multigravid Disease, Hypofibronogenemia) Third Stage - from the delivery of the baby until the delivery of the Disseminated Intravascular placenta Sepsis Coagulation (DIC) After 5-10 minutes of delivery of the baby, the uterus will contract followed by the delivery of the placenta. HELLP syndrome (Hemolysis, When do we consider a prolonged third stage of labor? Elevated Liver Enzymes, Low Intrauterine Fetal Demise ○ Majority says: after 30 minutes, you will expect excessive Platelet Count) bleeding Use of Anticoagulants Hemorrhage MANAGEMENT OF THE THIRD STAGE OF LABOR Expectant versus Active management Expectant Management ○ Observe and wait for the placenta to separate to allow it to be delivered spontaneously ○ By the aid of nipple stimulation or gravity Oxytocin is released when the baby sucks the nipple. Early Intrapartum Management of the newborn Active Management ○ Late cord clamping Wait for the pulses of the umbilical cord to stop before clamping and cutting the cord ○ Cord traction ○ Immediately give prophylactic uterotonics Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 7 of 12  Oxytocin given within 1 minute → NORMAL BLOOD LOSS IN VAGINAL AND CS DELIVERY immediate effect because it has a half-life of 3 to 5 minutes CS has more bleeding as compared to vaginal delivery Do NOT give oxytocin via IV bolus Traditionally, PPH is defined as: because it can cause hypotension in ○ Vaginal Spontaneous Delivery (VSD): Blood loss of ≧ Oxytocin (FIRST patients. It must be given via 500 mL after the completion of the 3rd stage of labor 1 ○ Cesarean Section (CS): Blood loss ≧1000 mL CHOICE) intramuscular or IV infusion. Oxytocin has an antidiuretic effect According to the American College of Obstetrician and when given with high dosage → not Gynecologist (ACOG) in 2017, PPH is defined as: Blood loss ≧ given left and right. 1000 mL accompanied by signs and symptoms of hypovolemia Uterine atony → give OXYTOCIN ○ Monitor the vital signs (FIRST CHOICE uterotonic) ○ Talk to the patient: is the patient stuporous, drowsy? Powerful stimulant causing tetanic IX. HANDOUT CLINICAL SCENARIO uterine contractions For the following Clinical scenario, determine the following (No NEVER give BEFORE the delivery of output required to be submitted) Methylergonovine 2 the baby because it can cause uterine ○ MOST probable cause or Ergonovine fracture or the baby might die due to ○ Risk Factors the tetanic uterine contractions. ○ Diagnosis It can cause hypertension. ○ Management Not used in the Philippines because it is banned 3 Misoprostol 37 yr old, G7P5 (5025) is seen at the ER because of Can cause uterine contractions but is now used as an abortifacient A profuse vaginal bleeding. Delivered 1 hour prior to admission. She delivered to a 4.5 kg baby after 22 hours of labor. SIGNS OF PLACENTAL SEPARATION (Difference between a Primigravida and a Multigravida) CASE 1 Once the baby is delivered, the uterus will contract causing it to On Palpation of the Uterus of the Patient, it is noted to be soft change its form from discoid to globular (Calkins sign) and and boggy becomes firm What is the MOST PROBABLE cause of PPH? Followed by either sudden gush of blood (Duncan mechanism) or ○ Uterine atony lengthening of the visible portion of the umbilical cord (Schultze You should first think of uterine atony as it is the most mechanism). It depends on how the placenta separates. common cause of EARLY postpartum hemorrhage Uterus will contract, and then the placenta will start to separate (hemorrhage occurs after 24 hours of delivery). either centrally or peripherally Evaluation and management of uterine atony: ○ Centrally - the umbilical cord will now lengthen but with no ○ Palpate uterus for atony healing because the peripheral membrane is still intact, and ○ Inspect to exclude birth canal laceration then slowly, the peripheral membranes will detach causing a ○ Inspect the placenta for completeness sudden gush of blood. ○ Massage uterus and administer uterotonic agents The presenting part will be the shiny part of the fetus CASE 2 (Schultze = shiny) ○ Peripheral - peripheral part separated but central part is still On palpation of the uterus, it is firm and globular noted coming attached and umbilical cord will not lengthen. out of the introitus There would be a sudden gush of blood first, then slowly, What is the MOST PROBABLE cause of PPH? the central part will detach causing the umbilical cord to ○ Genital tract laceration lengthen. It is not a case of uterine atony because the uterus is The presentation is Duncan mechanism (Duncan = dirty) noted to be firm and globular; however trauma and atony IMPT: Wait for these signs before applying gentle traction; can co-exist. otherwise, the umbilical cord might snap causing the placenta to This is not a case of retained placental tissues, because remain inside the uterus, hence, manual extraction. it will not contract very well if there is a barrier which is the retained placental tissue. Ritgen’s Maneuver What is the management? (to prevent perineal laceration) ○ For small, non-bleeding laceration: Try to give support to the perineum, the left hand is placed on the Observation and use of packing (shall be removed before fetal occiput to control the speed of delivery and keep the fetal the patient goes home) head flexed. ○ When the hematoma is expanding: ○ As much as possible try to control the delivery of the head Ligation and suture MECHANISMS OF PLACENTAL SEPARATION Once the placenta detaches and now majority of the placenta is in the vagina → the fundus of the uterus will rise in the abdomen The fundus of the uterus can be palpated abdominally ○ Hard and contracted Bleeding will now stop or be minimal once the placenta has separated ○ Because the uterus will be contracting since there’s no placenta that will hinder the uterus to contract MANEUVERS IN PLACENTAL DELIVERY (BRANDT ANDREWS) AND PLACENTAL INSPECTION Brandt Andrews Maneuver: Performed to prevent uterine inversion Placental inspection: ○ To make sure the cotyledons are complete and there are no membranes remaining otherwise these will lead to PPH Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 8 of 12 CASE 3 CASE 30 year old, G1P1 (0-1-0-0), hypertensive, delivered a The patient complained of severe pain just prior to her delivery of B preterm, SGA stillbirth baby. She had eclamptic seizure during labor and delivery. There was profuse bleeding a 4.5 kg fresh stillbirth baby. PE: BP = 80/60 mmHg palpatory, from the vagina and site of IV line insertion. There is HR = 110 bpm; RR = 22 cpm hematuria noted in the urine bag. What is the MOST PROBABLE cause of PPH? ○ Uterine rupture What is the MOST possible cause of the PPH? In cases of uterine rupture, the baby is usually stillborn Uterine rupture and uterine inversion both present with Blood dyscrasia severe pain, however for uterine inversion, the baby is What will be the management? already delivered, thus the baby is alive Highest risk factor is previous Cesarean Section, Treatment of coagulation specifically the classical incision type The first sign that the uterus will rupture is if you observe SUMMARY abnormal fetal heart tones, indicating that the baby is Postpartum hemorrhage is the world’s leading cause of maternal under distress mortality. What is the management? Risk factors should be determined antenatally and anticipated ○ If the patient is still desirous of pregnancy: during delivery. Repair Good history taking and a thorough physical examination are ○ If it is beyond repair: necessary. Perform hysterectomy CASE 4 X. APA REFERENCES The patient complained of severe pain after placental delivery Abnormalities of the Third Stage of Labor and Postpartum and the uterus cannot be palpated abdominally Hemorrhage and Other Disorders of the Puerperium (Part 1 and What is the MOST PROBABLE cause of PPH? 2). Moodle Video Lecture 2024. ○ Uterine inversion Avoidance of uterine inversion: XI. REVIEW QUESTIONS ○ Wait for signs of placental separation ○ Placental expression not forced before placental separation No. QUESTIONS ○ Care in umbilical cord traction 1 Two weeks after delivery, the patient came for postnatal Expression of placenta: Brandt Andrew maneuver to prevent check-up. The uterus is palpated slightly above the uterine inversion (one hand is placed between the symphysis symphysis pubis. On internal examination, there is lochia pubis and the fundus, once the placenta is separated, gently do rubra and the cervix is 2 cm dilated. What is the diagnosis? traction on the umbilical cord, and then check the placenta) A. Uterine subinvolution What is the management? B. Uterine atony ○ Manual repositioning of the uterus C. Normal postpartum finding CASE 5 D. Cervical laceration The contracted uterine fundus is palpated at the level of the 2 What is the MOST common cause of early postpartum umbilicus but the placenta is undelivered for more than 30 hemorrhage? minutes despite attempts on cord traction A. Retained placental tissue What is the MOST PROBABLE cause of PPH? B. Genital tract lacerations ○ Placenta accreta C. Blood dyscrasia It is not a case of uterine inversion because the uterine D. Uterine atony fundus is palpated at the umbilicus 3 What is the usual cause of vaginal hematoma in a vaginal Placenta has not been delivered for more than 30 delivery with episiotomy? minutes and cannot be detached thus a case of placenta A. Presence of coagulopathy accreta. B. Non-ligation of the blood vessels above the angle of the The patient may have had a procedure that damaged the episiotomy wound uterine lining (curettage, myomectomy, prev CS) from her C. Stretch and rupture of a blood vessel without an past pregnancies considering her history of being a associated laceration multipara, this may predispose to placenta accreta. D. Inadequate prenatal iron and calcium intake What is the management? ○ Hysterectomy 4 What is NOT a complication of the angiographic Leave the uterus behind especially if the patient is still embolization in treating intractable postpartum young. hemorrhage? A. Uterine infection CASE 6 B. Uterine ischemic necrosis The patient came 2 weeks post VSD with placenta delivered by C. Infertility manual extraction with foul smelling reddish vaginal discharge / D. Iatrogenic iliac artery rupture bleeding and hypogastric pain 5 A G1P1 had continuous vaginal bleeding after placental What is the MOST PROBABLE cause of PPH? delivery. The uterus is 16 weeks size and soft on palpation. ○ Retained placental tissues On placental inspection, blood vessels are noted Because manual extraction of the placenta was done, traversing the placental membranes and a red fleshy tissue there may have been placental tissue left behind is palpated at the cervical os. The vital signs are stable and This is the most common cause of LATE postpartum normal. What is the MOST likely diagnosis? hemorrhage A. Uterine inversion What is the management? B. Prolapse of the cervix ○ Inspect the placenta C. Uterine rupture Inspect for a membrane that may have been supplied by D. Retained Succenturiate lobe an Accessory lobe Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 9 of 12  6 A Primipara delivered by forceps delivery to a 4.0 kg baby. XII. RATIONALIZATION Which of the following HIGHLY SUGGEST genital tract laceration as the cause of post partum hemorrhage over No. RATIONALIZATION uterine atony? 1 CORRECT ANSWER: A. Uterine subinvolution A. Delivery of macrosomic baby B. Delivery by forcep extraction Uterine subinvolution is described as a slowing of the process C. Parity of the patient of shrinking of the uterus. Possible causes include endometritis, D. Persistence of vaginal bleeding despite a contracted retained placental fragments, pelvic infection, and uterine uterus fibroids. Signs and symptoms are prolonged lochial flow, 7 Degree of Involvement of genital tract laceration located on profuse vaginal bleeding, and a large, flabby uterus. the muscles of the perineal body A. 1st B is wrong because uterine atony presents with a soft and B. 2nd boggy uterus on bimanual examination. C. 3rd D. 4th C is wrong because a normal postpartum finding would be a firm and well-contracted uterus palpated below the umbilicus. 8 Which of the following can the postpartum hemorrhage be attributed to in preeclamptic patients with abruptio D is wrong because lacerations are suspected if there is still placenta? bleeding despite a well-contracted uterus. A. Retained placenta B. Overstretched uterus Source: Batch 2025 Ratio C. Uterine trauma on cesarean section D. Coagulation alteration 2 CORRECT ANSWER: D. Uterine Atony 9 Which of the following risk factors predispose a parturient UTERINE ATONY to uterine atony? Most common cause of obstetrical hemorrhage A. All of the choices The amount of uterine contractions are not enough to B. Polyhydramnios and macrosomic baby stop the bleeding at the site of where the placenta is C. Primaparity and multiparity implanted. D. Prolonged labor and preciptous labor A is wrong because retained placental tissue can impair efficient uterine contraction and is also considered a possible 10 In the presence of uterine atony, which of the following cause for postpartum hemorrhage. It is the most common would be best to perform to prevent hemorrhage due to cause of late postpartum hemorrhage. uterine inversion during the third stage of labor? A. Proceed with manual extraction of the placenta after B is wrong because genital laceration is another common cause delivery of the baby of postpartum hemorrhage and can even coexist with uterine B. Administer uretonic before performing the Brandt Andrew’s atony. maneuver C. Wait for placental separation before performing Brandt C is wrong because blood dyscrasias are not considered the Andrew’s maneuver most common cause of early postpartum hemorrhage. D. Massage uterus and perform Brandt Andrew’s maneuver when there are signs of placental separation Source: Batch 2025 Ratio 11. TRUE/FALSE. Infection is the leading cause of maternal 3 CORRECT ANSWER: B. Non-ligation of the blood vessels mortality. above the angle of the episiotomy wound A. TRUE B. FALSE A is wrong because while coagulopathies can lead to bleeding 12. In the presence of uterine atony, which of the following disorders,the vulva is not a common site for spontaneous would be BEST to perform to prevent hemorrhage due to bleeding. Bleeding from coagulopathies is more likely to occur uterine inversion during the third stage of labor? in internal organs or other tissues. A. Proceed with manual extraction of the placenta after delivery of the baby B is correct because the most common cause of vulvar B. Administer uterotonic before performing the Brandt hematoma is trauma during childbirth. Most puerperal Andrew’s maneuver hematomas arise from bleeding lacerations related to C. Wait for placental separation before performing Brant operative deliveries or episiotomy, and failure to ligate the Andrew’s maneuver bleeders or blood vessels may result in expanding D. Massage the uterus and perform Brandt Andrew’s hematomas. maneuver when there are signs of placental separation C is wrong because stretch and rupture of a blood vessel without an associated laceration is one of the common causes of vulvar hematomas. Vulvar hematomas can occur when blood vessels in the vulvar area, particularly the labia, stretch and rupture due to various factors. However, the most common cause of vulvar hematoma is trauma during childbirth. D is wrong because inadequate prenatal iron and calcium intake would not be directly associated with an increased risk of developing a vulvar hematoma. Vulvar hematomas typically result from trauma or injury to the vulvar area, such as during childbirth, sexual intercourse, or other activities that cause strain on the genitalia. They are not typically caused by nutritional deficiencies. Source: Batch 2025 Ratio Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 10 of 12  4 CORRECT ANSWER: C. Infertility 7 CORRECT ANSWER: B. 2nd Angiographic Embolization is another modality that is being used for intractable hemorrhage when surgical access is difficult. Fertility is not impaired in this procedure. However, complications that may occur include Iatrogenic iliac artery rupture (D), Uterine ischemic necrosis (B), and Uterine infection (A). A, B, and D are wrong because they are all complications of Angiographic Embolization. Source: Batch 2025 Ratio 5 CORRECT ANSWER: D. Retained succenturiate lobe 8 CORRECT ANSWER: D. Coagulation alteration The presence of an accessory lobe (retained succenturiate One of the risk factors of abruptio placenta is preeclampsia. lobe) should be highly considered in this case since blood Bleeding happens due to reduction or absence of blood-clotting vessels are noted traversing the placental membranes and a proteins. Out of all the choices, only coagulation alteration is a red fleshy tissue is palpated at the cervical os on placental complication of abruptio placenta and not the bleeding itself. inspection. Take note that normally, the blood vessels taper as they approach the outer margin of the placenta. A is wrong because the risk factor for developing bleeding due to retained placenta is placenta previa and prior CS. A is wrong because uterine inversion is the displacement of the uterine fundus during the third stage of labor where the uterus B is wrong because risk factors for bleeding due to is seen outside of the introitus with the inner portion turned overstretched uterus are multiparity, multiple gestation, outside. polyhydramnios, and macrosomia. B is wrong because prolapse of the cervix occurs when pelvic C is wrong because bleeding due to trauma happens due to floor muscles and ligaments stretch and weaken until they no lacerations or hematoma. longer provide enough support for the uterus. Bleeding is not apparent in this condition unless it progresses to a severe type. Source: Batch 2025 Ratio C is wrong because uterine rupture is a more common cause of 9 CORRECT ANSWER: A. All of the Choices bleeding during the second half of pregnancy where a high index of suspicion based on a good clinical history about All of the choices are correct as they are all part of risk factors previous delivery and uterine operations may strongly point to of PPH related to tone. the development of uterine rupture. Source: Batch 2025 Ratio Source: Batch 2025 Ratio 10 CORRECT ANSWER: A. Massage the uterus and perform 6 CORRECT ANSWER: D. Persistence of vaginal bleeding Brandt Andrew’s maneuver when there are signs of despite a contracted uterus placental separation Genital tract trauma The goal during the third stage of labor is the delivery of an is the persistent bleeding despite a firm, well intact placenta and avoidance of uterine inversion and contracted uterus suggesting that hemorrhage is postpartum hemorrhage. In this case, it is best to massage the most likely from a laceration. uterus to stimulate uterine contraction and perform Brandt Suspected if bleeding persists despite a well Andrew’s maneuver when there are signs of placental contracted uterus separation to facilitate a careful traction in the umbilical cord to Lacerations to the perineum, vagina, cervix, large express the placenta. episiotomy, extension, ruptured uterus and uterine inversion. A is wrong because manual extraction of the placenta is only Second most common cause of PPH done when there is prolonged third stage of labor. A and B is wrong because they are risk factors of PPH related B is wrong because administration of uterotonic is not a to trauma, although delivery of macrosomic baby and by forcep prerequisite before performing the Brandt Andrew’s maneuver. extraction can cause laceration of cervix, vagina and perineum that leads to genital tract trauma, bleeding despite well C is wrong because it is the signs of placental separation that contracted uterus is still highly suggestive that the cause of should be waited before performing Brant Andrew’s maneuver PPH is genital tract laceration. instead of the actual placental separation. C is wrong because risk factor for trauma with uterine inversion Source: Batch 2025 Ratio as pathophysiology would be grand multiparity. 11 CORRECT ANSWER: B. False Source: Batch 2025 Ratio Over the years, the top three leading causes of maternal mortality are still 1) Obstetrical hemorrhage, 2) Hypertension and 3) Infection Source: MOD3-OB2-T7-Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 11 of 12  12. Answer: D. Massage the uterus and perform Brandt Andrew’s maneuver when there are signs of placental separation The goal during the third stage of labor is the delivery of an intact placenta and avoidance of uterine inversion and postpartum hemorrhage. In this case, it is best to massage the uterus to stimulate uterine contraction and perform Brandt Andrew’s maneuver when there are signs of placental separation to facilitate a careful traction in the umbilical cord to express the placenta.. A is wrong because manual extraction of the placenta is only done when there is prolonged third stage of labor. B is wrong because administration of uterotonic is not a prerequisite before performing the Brandt Andrew’s maneuver. C is wrong because it is the signs of placental separation that should be waited before performing Brant Andrew’s maneuver instead of the actual placental separation. Source: Batch 2025 Ratio Group 3B & 4B | Abnormalities of the Third Stage of Labor and Postpartum Hemorrhage and Other Disorders of the Puerperium 12 of 12