Chapter 68 Complications of the third stage of labour

After reading this chapter, you will be able to:

• understand the reason why complications arise in the third stage of labour

• discuss the midwife’s management in emergency situations

• outline further treatments which may be necessary

• discuss the implications of these complications for women and their partners.

Postpartum haemorrhage

Postpartum haemorrhage (PPH) is a significant cause of maternal mortality and morbidity (Knight et al 2008, Lewis 2007). It may happen without warning after any delivery. The only professional in attendance for the majority of births is the midwife, whose prompt action may spare the mother dangerous blood loss and save her life. It is essential that midwives have a thorough understanding of this subject. Maternity services must have a policy for management of PPH so that all members of the multidisciplinary team work together and attend regular ‘fire drills’ to ensure quick and appropriate responses (Lewis 2007).

Definition

PPH is defined as excessive bleeding from the genital tract occurring any time from the birth of the baby to the end of the puerperium.

• Primary PPH occurs in the first 24 hours. This is the most common and most dangerous type, complicating approximately 6% of all births (Carroli et al 2008).

• Secondary PPH occurs after 24 hours and before the end of the puerperium, and affects approximately 2% of deliveries (Alexander et al 2002).

Primary PPH is often defined by the estimated blood loss. Traditionally, a loss of 500 mL or more has been regarded as a PPH (WHO 1990), yet this may be considered as a normal physiological blood loss if a woman is not anaemic (Rogers & Chang 2008).

Estimating blood loss after birth is notoriously difficult. Bleeding may be hidden; and if visible, it is likely to be underestimated (Prasertcharoensuk et al 2000, Toledo et al 2007). However, regular clinical simulations may improve blood loss estimation (Bose et al 2006).

Hence, defining PPH by estimating blood loss may have little clinical usefulness, and, therefore, the word ‘excessive’ is used to mean any amount which adversely affects the mother.

When estimating blood loss to define PPH, Coker & Oliver (2006) propose that if blood loss is estimated as 500 to 1000 mL and there are no clinical signs of maternal compromise, staff should be alerted to monitor the woman and be ready for possible action. Should the estimated blood loss be above 1000 mL or the mother shows any sign of compromise, then prompt action must be taken to resuscitate and arrest bleeding. The Royal College of Obstetricians and Gynaecologists (2009) have used these principles to define minor and major PPH. The guidelines suggest that with a minor PPH (a blood loss of 500 to 1000 mL, with no maternal compromise) basic measures need to be undertaken, and when a major PPH is diagnosed (a blood loss of over 1000 mL or clinical shock present) a full obstetric protocol must be followed (see website).

PPH from uterine atony

The immediate cause of primary placental site PPH is failure of the uterus to contract and retract adequately. As there is a placental circulation of approximately 600 mL/min at term (Blackburn 2007), if the uterine arteries are not ligated by the muscle fibres surrounding them, blood loss can be rapid and dangerous. This may occur because the myometrium is atonic, or because retained placental tissue prevents effective uterine contraction.

Prediction and risk factors

It is not possible to predict a PPH accurately, but the risk is increased in certain circumstances:

• Previous PPH or retained placenta.

• Multiple pregnancy, polyhydramnios and fetal macrosomia: All may cause uterine over-distension, leading to poor retraction. In multiple pregnancy, there is a larger placental site, which is more likely to encroach upon the poorly retractile lower uterine segment, thus increasing the risk of haemorrhage.

• Anaemia may affect the ability to withstand haemorrhage.

• Antepartum haemorrhage from placenta praevia or abruptio placentae may subsequently result in PPH. With placenta praevia the retractile ability of the lower uterine segment is deficient and therefore control of bleeding from the placental site is poor. A Couvelaire uterus may occur in severe, concealed placental abruption and the damaged muscle fibres fail to contract and retract effectively (Fig. 68.1). Women who have had an antepartum haemorrhage may be anaemic, increasing the threat from PPH.

• Prolonged labour: If contractions were weak or uncoordinated during labour, it may continue into the third stage. The uterus will fail to contract and retract effectively. Occasionally, prolonged labour, because of mechanical difficulty, may lead to uterine exhaustion and atony.

• Previous caesarean section and caesarean section.

• Pre-eclampsia/hypertensive disease in pregnancy: Both increase the risk of induction and operative deliveries. Coagulopathy is also a potential complication of hypertensive disease, and some drugs used to prevent seizures may contribute to uterine atony.

• General anaesthesia: Uterine atony may occur if anaesthesia is prolonged, and is especially likely if halogenated anaesthetic agents are used.

• Fibroids: May interfere with efficient contraction and retraction.

• Mismanagement of the third stage of labour: Unnecessary massaging, squeezing or otherwise ‘fiddling’ with the uterus can disrupt the rhythm of myometrial activity, causing only partial separation of the placenta.

• Retained placenta and blood clots: Unless the uterus is empty, it cannot retract completely.

• Tocolytic drugs: Drugs given to suppress uterine activity in preterm labour may cause atony in the third stage should labour progress.

• Induced or augmented labours: Uterine inefficiency necessitating the use of oxytocics may contribute to PPH.

• Inversion of the uterus: Any degree of uterine inversion will interfere with efficient contraction and retraction.

• Chorioamnionitis.

• Grand multiparity has been associated with PPH, but high parity on its own is not considered to be a risk (Page 2006). Women who have borne several children are more likely to have a history of risk factors. Iron stores, in particular, may be depleted when there are short inter-pregnancy intervals. Thereby, a comparatively small blood loss may produce signs of underperfusion.

• Disseminated intravascular coagulation may occur secondarily to other major problems, including concealed abruptio placentae, amniotic fluid embolus, severe pre-eclampsia and eclampsia. It can also follow prolonged retention of a dead fetus in utero.

• Medical disorders such as idiopathic thrombocytopenia and inherited coagulopathies, such as von Willebrand’s disease also increase the risk of both primary and secondary PPH (Chi & Kadir 2007).

Figure 68.1 Couvelaire uterus.

(From Beischer et al 1997.)

Prophylaxis

Pregnancy

Preventing PPH begins at the initial booking interview when midwives will identify women at higher risk. Any woman whose history suggests that she is at risk should be booked for a hospital birth where immediate and effective treatment can be provided. Conditions such as anaemia should be treated with iron and folic acid supplements. In severe cases, intramuscular iron or even blood transfusion may be required to raise the haemoglobin levels prior to delivery.

Labour

During labour, careful management will reduce the likelihood of PPH. For women at risk:

• An intravenous cannula is inserted and blood samples are taken.

• Haemoglobin level is estimated and the blood group confirmed.

• Serum is saved, thereby speeding up the process of cross-matching donor blood, should it become necessary.

The midwife will monitor the progress of labour and avoid dehydration and exhaustion. An obstetrician should be called for signs of prolonged labour (Ch. 63). An oxytocin infusion may be required which should be maintained for at least 1 hour after the end of the third stage. The bladder should be kept empty, as a full bladder may impede efficient uterine action.

Correct management of the third stage of labour is crucial. The midwife should discuss the management of the third stage with the woman, preferably before labour commences. Active management of the third stage is associated with reduction in PPH (Prendiville et al 2000). The use of fundal massage following the delivery of the placenta is recommended to reduce the risk of PPH (Hofmeyr et al 2008). Breastfeeding or nipple stimulation will also help the uterus to contract, though it is not an effective treatment for PPH. Ergometrine maleate 500 mcg should be available. Accurate estimation of blood loss and timely observation of vital signs will enable early detection and prompt treatment.

The National Institute for Health and Clinical Excellence (NICE) (2005) guidelines suggest that women at risk of haemorrhage during or following caesarean section may be offered intra-operative blood cell salvage (see website). Guidelines for women who refuse blood transfusion have been recommended by a previous Confidential Enquiry into Maternal and Child Health (CEMACH) report (Lewis 2004) (see website).

Treatment

The principles of management are:

• arrest bleeding

• resuscitate the mother

• replace fluids.

Units vary in the management of PPH, especially with pharmacological protocols (Winter et al 2007). This may be due to limited research on the specific treatment combinations for PPH. Midwives should follow their hospital guidelines as appropriate.

Before delivery of the placenta

Prolonged brisk bleeding prior to the delivery of the placenta should alert the midwife to take action. Skilled medical assistance should be summoned immediately, whilst the midwife must remain with the mother for support and commence treatment. If at home, the midwife should deliver the placenta, if possible, before transferring the woman to hospital.

The degree of uterine contraction should be assessed. If the fundus feels soft, the first consideration is to stimulate uterine contraction and give an oxytocic drug. Oxytocin 10 international units (iu) may be given intramuscularly, causing the uterus to contract within 2.5 minutes. Syntometrine (oxytocin 5 iu and ergometrine 500 mcg) should be avoided if there is a history of hypertension. There is also some evidence that ergometrine may cause the placenta to become entrapped (Begley 1990, Cotter et al 2001, Hammar et al 1990), thus exacerbating the bleeding.

The bladder should be empty before another attempt is made to deliver the placenta with controlled cord traction and the genital tract should be inspected to exclude traumatic haemorrhage.

If the placenta cannot be delivered, prepare for the doctor to perform a manual removal of the placenta and membranes under anaesthetic. Retained placenta is discussed later.

After delivery of the placenta

The following principles should be applied when a minor PPH is diagnosed. The order in which the actions are to be taken may vary and where possible actions should be taken simultaneously:

• Call for assistance.

• ‘Rub up’ a contraction: Massaging the uterus will usually stimulate a contraction and expel any blood clots (Fig. 68.2).

• Give oxytocic drug: Drug protocols vary. The drugs of first choice for uterine atony are oxytocin and ergometrine (Mousa & Alfirevic 2007). The following may be considered:

Intramuscular Syntometrine.

Intravenous or intramuscular injection of oxytocin 5–10 iu followed by ergometrine 250–500 mcg. This may be given intramuscularly or, cautiously, intravenously in the absence of hypertension. No more than two doses of ergometrine may be administered (Joint Formulary Committee 2008).

An intravenous infusion of 40 iu of oxytocin in 500 mL of normal saline over 4 hours should be commenced.

• Ensure the bladder is empty. Passing a catheter is useful, as a full bladder can impede uterine contraction and retraction.

• Intravenous access is needed to obtain blood samples and an infusion needs to be commenced to replace fluids if not already done.

Figure 68.2 ‘Rubbing up’ a contraction. The left hand is cupped over the uterus and massages it with a firm circular motion in a clockwise direction.

(From Boyle (2002) Radcliffe Publishers, with permission.)

It is essential that these steps are taken as soon as the midwife suspects that the uterus is failing to contract and bleeding is unusually heavy. In most cases they are effective if used in good time. Delay will result in further blood loss and the woman’s condition can deteriorate rapidly.

The placenta and membranes are examined to ensure that they are complete. If not, an exploration and evacuation of the uterus is carried out by an obstetrician under anaesthesia.

With PPH, the midwife should not elevate the foot of the bed as this encourages blood to pool within the uterine cavity, which would hinder uterine contraction and retraction. The woman’s legs may be elevated on pillows, taking care to avoid undue pressure on the calves, which would predispose to venous thrombosis.

Reflective activity 68.1

Find out how emergency transfer of a woman from her home to hospital is managed in your area.

Massive obstetric haemorrhage

This is a life-threatening event, characterized by severe maternal compromise. A blood loss of 1000 to 1500 mL or more, or any lesser amount which causes a sustained fall in systolic blood pressure, constitutes a ‘massive obstetric haemorrhage’.

In addition to the measures taken above for a minor PPH, the following should be done:

• The multidisciplinary protocol or ‘drill’ for managing severe haemorrhage should be initiated at once. The team should include the midwife caring for the woman and key senior staff, including midwives, obstetricians, haematologists and anaesthetists. Portering staff should be available for transfer of specimens for laboratory analysis. One member of staff should take responsibility for documenting all care given during the emergency.

• Maternal resuscitation should begin immediately, including oxygen therapy.

• Intravenous access with two large-bore (at least 16G) cannulae and a central venous pressure line are inserted.

• Blood samples are taken for full blood count, cross-matching and clotting studies. At least six units of cross-matched blood are requested.

• Two litres of crystalloid may initially be infused. This should be followed by colloid, which is more efficient in expanding the intravascular volume (Plaat 2008). All maternity units should keep at least two units of emergency group O Rhesus-negative blood in the blood fridge. This may be used while awaiting cross-matched supplies. Blood should be passed through a warming device and infused as rapidly as possible.

• In addition to oxytocin and ergometrine, the following drugs may be considered if the uterus remains atonic: