NOOTAN COLLEGE OF NURSING, VISNAGAR

SUB: OBSTETRIC AND GYNECOLOGY

TOPIC: TEACHING PRACTICE ON “COMPLICATION OF THIRD STAGE”

SUBMITTED TO: - SUBMITTED BY: -

MS. PAYAL VAGHELA MS. TANJIM MANSURI
ASSISTANT PROFESSOR F. Y M.sc NURSING
NCN, VISNAGAR NCN, VISNAGAR

SUBMISSION DATE:
 BIO-DATA
NAME : Mansuri Tanjim Habib Ahmad

YEAR : 1st Year M.sc Nursing

SUBJECT : OBSTETRICAL AND GYNECOLOGICAL NURSING

TOPIC : COMPLICATION OF THIRD STAGE

AV-AIDS : PPT, Black board, Chart

METHODS OF TEACHING : Lecture cum discussion

PLACE : Classroom
DATE :

TIME : 45 minets
General Objective: - At the end of teaching practice, the class will gain adequate knowledge about
the COMPLICATION OF THIRD STAGE.

Specific Objectives: -
At the end of teaching practice on complication on 3rd stage the students will be able to:

✓ To explain about the introduction of postpartum hemorrhage.

✓ To explain about the define, cause, types of postpartum hemorrhage.
✓ To explain about the nursing management.
✓ To explain about the define retained placenta.
✓ To explain about the cause, sing, diagnosis & nursing management.
✓ To explain about the define morbid adherent placenta.
✓ To explain about the cause, diagnosis & nursing management.
✓ To explain about the define puperial inversion of uterus.
✓ To explain about the degree of puperial inversion of uterus, cause, sign& symptoms,
diagnosis & nursing management.
✓ To explain about the define atonic uterus, risk factors, treatment.
SR. TIME OBJECTIVE CONTENT TEACHING & A.V. EVALUATION
NO LEARNING AIDS
PROCESS

1. 15 min To explain INTRODUCTION Lecture cum PPT, How many

about Discussion Chart, complications of
introduction • Postpartum hemorrhage is bleeding Black 3rd stage?
of ppt. from the genital tract after delivery Board
of the baby amounting to 500-600 ml
or more, or any amount of bleeding Introduction of
To explain that can cause deterioration in the PPH?
define, cause, patient's condition. Therefore, a
types & severely anemic mother losing 300
nursing ml of blood may be in a worse state
management. than a woman with packed cell
volume of 40 percent who loses 750
ml of blood during delivery. A
patient may bleed into the broad
ligament and suffers severe shock.
So, “it is the effect anther than the
amount of blood lost those matters".
DEFINITION: -

• "PPH is any amount of bleeding Define

from or into the genital tract postpartum
following birth of the baby up to the hemorrhage?
end of puerperium which adversely
affects the general condition of the
mother evidenced by rise in pulse
rate and falling blood pressure".
•
 • Post Partum Hemorrhage is defined
"as excessive bleeding from the
genital tract at any time following
the baby's birth up to 6 weeks after
delivery".
CAUSE What is the cause
of PPH?
- Mismanaged 3rd stage of labor.
- Anesthesia.
- Initiation of delivery by oxytocin
without increased power of contraction
does not improve the contraction power
by uterine muscles.
- Persistent uterine distension-Retention
of partially separated placenta or bits of
placenta or blood clots interfere with
effective retraction.
TYPES
How many types
1. Primary Post Partum Hemorrhage. of PPH?
2. Secondary Post Partum Hemorrhage.
• Primary post-partum hemorrhage: -
Primary hemorrhage occurs within
24 hours following the birth of the
baby. It is of two types:
1. Third stage hemorrhage: Bleeding
occurs before expulsion of placenta.
2. True post-partum hemorrhage:
Bleeding occurs sub-sequent to
expulsion of placenta.
 NURSING MANAGEMENT What is the
• Prevention: nursing mg?
• Prevention is better than cure is a
well-known proverb. So, patients at
risk should be screened out for
hospital delivery.
• These include:
1. Patients with a previous history of
post-partum hemorrhage.
2. Grand multipara.
3. Patients who have had antepartum
hemorrhage or prolonged labor.
4. Patients with hydramnios, twins, big
babies, and fibroids. All are at risk for PPH
but can be prevented if the below written
measures are followed:
• 1. Emptying the bladder at the end of
first stage of labor.
• 2. Sedation of patients who tend to
push prematurely.
• 3. To avoid prolonged labor.
• 4. To avoid instrumental deliveries.
• 5. To take care and to deliver the
baby slowly between the
contractions.
• 6. Patients with hydramnios, twins,
big babies and fibroids should be
given ergometrine (10.5 mg
intravenously or symmetrize (1 ml)
intramuscularly with the crowning of
the baby's anterior shoulder.
• 7. Allow placenta to separate and the
uterus to contract before attempting to
deliver the placenta.
• 8. Check for a case of dead fetus (i.e.
In abruptio, placenta can anticipate
hypofibrinogenemia).
• Antenatal Management:
• 1. Improvement of health status of
the patient specially to raise the Hb
level as near to normal as possible so
that the patient can withstand the
blood loss.
• 2. High risk patients who are likely
to develop PPH are to be screened
and delivered in a well-equipped
hospital.
• These include:
a. Twins
b. Grand multipara
c. History of previous third stage
 complication
d. Hydramnios
e. APH
f. Severe anemia.
3. In vulnerable groups, blood
grouping and typing
should be done.
• Intranatal Management:
1. During intranatal period, judicious
administration of sedative and
analgesic drugs is done.
2. Hasty delivery of the baby is
avoided. One should take at least 2-3
minutes to deliver the trunk after the
head is born.
3. Baby should be pushed out by
retracted uterus and not to be pulled
out.
4. Local or epidural anesthesia is
preferable to general anesthesia.
5. Third stage should be managed
carefully specially of high-risk
patients.
6. Temptation of fiddling or
kneading with uterus or pulling the
cord should be avoided, so also the
Crede's expression.
7. Examination of the placenta and
membranes should be done in routine
so as to detect at earliest any missing
part.
8. Inj. oxytocin is administered 10
units I/M (intramuscular) or an
intravenous I/V infusion of 20- 40
units oxytocin in 1000 ml of saline or
lactated ringer's solution at the rate of
125 ml/hr.
9. Exploration of the utero-vaginal
canal for evidence of trauma
following difficult labor or
instrumental delivery should be a
routine.
10. The patient should be observed
for about 2 hrs. after delivery. After
being satisfied that the uterus is hard
and contracted, the pulse and B.P. are
within normal limit, then only the
patient should be sent to the ward.
2. 10 min To explain RETAINED PLACENTA: Lecture cum PPT, What is the
about the Discussion Chart, retained
define of DEFINITION: - Black placenta?
Retained • The placenta is said to be retained Board
placenta.
when it is not expelled out even 30
minutes after the birth of the baby".
To explain
about cause, CAUSE What is the
diagnosis, • The causes of retained placenta are: cause?
sing&
symptoms,
1. Placenta completely separated but
nursing retained due to poor voluntary
management. expulsive efforts especially following
exhaustive and prolonged labor.
2. Simple adherent placenta due to
uterine atonicity incases of:
a. Grand multipara
b. Over distension of uterus
c. Prolonged labor
d. Uterine malformation
e. Bigger placental surface are3.
3. Placenta incarcerated following
partial/complete.
4. Morbid adherent placenta-Partial or
rarely complete.
5. Faulty technique to expel the placenta
before it separates (can be due to
 inexperienced staff).
6. A full bladder may stop the adequate
uterine contraction and retraction and
cause difficulty in expulsion of the
placenta.
What is the
DIAGNOSIS diagnosis?

1. Watching the placenta which comes

out after delivery.
2. Noting the signs of absence of
placental separation.
3. Adherent placenta is diagnosed only
during manual removal.

SINGS OF RETAINED PLACENTA

• Presence or absence of the features

of placenta separation depending
on whether it is retained following
separation or not.
• Hour-glass contraction or nature of
adherence is diagnosed during
manual removal.

NURSING MANAGEMENT Nursing mg?

• A separated placenta (retained one)
is expelled by CCT (Controlled Cord
Traction). An unseparated retained
placenta is removed manually under
GA (general anesthesia) as explained
below otherwise:
It can lead to complications like:
a. Hour-glass contraction
b. Morbid adherent placenta.
• During the period limit of normal
expulsion of placenta, the patient is
to be watched carefully for evidence
of: a. Any bleeding either revealed
or concealed.
b. Note signs of separation of
placenta.
• The bladder should be emptied using
a rubber catheter.
• Note the vital signs especially blood
pressure.
• Any bleeding during this period
should be managed as outlined in the
II1rd stage bleeding.
• If the placenta is separated but
retained, it should be expelled by
controlled cord traction.
• If the placenta is unseparated and
retained, then manual removal of
placenta is to be done under general
anesthesia.
3. 5 min To explain ADHERANT PLACENTA (Placenta Lecture cum PPT, What is the
about the Discussion Chart, placenta acreta?
acreta)
Adherent Black
placenta Board
(placenta DEFINITION
acereta). Define placenta
• Placenta accreta is "an extremely rare acreta?
form in which the placenta is directly
anchored to the myometrium
partially or completely without any
intervening decidua".

CAUSE Cause of placenta

acreta?

• the probable cause is 'Defective

Decidua Formation! The condition is
usually associated when the placenta
happens to be implanted in lower
segment (Placenta Previa) or over the
previously injured sites as in
cesarean section, dilatation and
curettage operation, manual removal,
myomectomy.
• Separation becomes difficult.
DIAGNOSIS What is the
diagnosis?
The diagnosis is made only during:
1. Manual removal (when the plane of
cleavage between on the placenta and
the uterine wall cannot be made).
2. Pathological confirmation includes:
a. Absence of decidua basalis.
b. Absence of Nitabuch's fibrinoid
layer.
c. Varying degree of penetration of
the villi into the muscle bundles
(increta) or up to the serosal
(Percreta) layer.
RISK PLACENTA ACCERETA
Risk factors?
• The risks include:
1. Hemorrhage
2. Shock
3. Infection
4. Inversion of uterus (rarely)
NURSING MANAGEMENT What is the
nursing mg?
1. Assess the condition of the patient.
2. Check the vital signs specially blood
pressure and pulse rate.
3. In partial morbid adherent placenta,
where major separation is possible, the
adherent area is to be separated gently
with the fingers paying more attention.
4. Effective uterine contraction with
hemostasis is achieved by oxytocin and
if necessary, by intrauterine plugging.
5. If the uterus fails to contract, then
directly go for hysterectomy.
6. Conservative treatment is done in
women desiring another child. It
consists of cutting the umbilical cords
high as possible leaving behind the
placenta, which autolysis in due course
of time. There is risk of infection in
this management, so that woman is
given appropriate antibiotics.
4. 10 min To explain PUERPERAL INVERSION OF Lecture cum PPT, What is the
about the UTERUS Discussion Chart, puerperal
Puerperal Black inversion of
inversion of Definition Board uterus?
uterus. "It is the turning inside out of the uterus. It
is one of the rare but serious complication Define of
of 3rd stage of labor. Inversion often starts puerperal
Explain about with a dimple in the fundus uterine and inversion of
define, degree may continue till the uterus completely uterus?
of PIU, cause, turns inside out".
sign&
symptoms,
nursing DEGREE OF PUPERIAL INVERSION How many
management. OF UTERUS degrees of
puerperal
Inversion of uterus is of three degrees: inversion of
1. First degree uterus?
2. Second degree
3. Third degree
1. First Degree: In first degree, the
depressed fundus reaches up to the internal
orifice or there is dimpling of the fundus.
2. Second Degree: In this, the body of
uterus is inverted up to the level of internal
orifice. The fundus protrudes through the
external orifice into the vagina. First and
second degrees are incomplete inversions.
3. Third Degree (Complete inversion)
a. In this stage, the uterus and cervix are
completely inverted.
b. Fundus protrudes outside the vaginal
introitus.
c. There may be inversion of the vagina
in an advanced 3rd degree.
d. The endometrium with or without the
attached placenta is visible outside the
vulva.
What is the
CAUSES cause?
• The causes are basically divided into
two:
1. Spontaneous that accounts for about
40%.
2. Induced those accounts for about
60%.
- Spontaneous 40%: Spontaneous
inversion of the uterus is rare but if
present, then it can be due to local
atony of the placental site over the
fundus associated with sharp rise of
intra-abdominal pressure just like in
case of sneezing, coughing, or bearing
down effort. It sometimes linked with:
a. short cord
b. Placenta accreta
c. Fundal attachment of the placenta
- Induced 60%: This is mostly a cause of
mismanage-ment of third stage of
labor: The factors that may aggravate it
are:
a. Pull on cord while uterus is
atonic.
b. Improper Crede's expression on
atonic uterus.
c. Improper/faulty technique used
in manual removal of placenta.
d. Short cord pulling on the fundus
during delivery.
e. Forced expulsion of placenta by Sign&
putting downward pressure on symptoms?
uterus.
SIGN & SYMPTOMS
1. Inversion develops shortly
during/after 3rd stage of labor.
2. In acute inversion, there is extreme
shock out of proportion to blood
loss.
3. In chronic inversion symptoms are:
a. Persistent vaginal bleeding.
b. Pelvic pain.
c. Something coming down
per vagina.
d. Difficulty in passing urine.
SIGNS
1. There may be evidence of shock.
2. Anemia is present from mild to
moderate degree.
3. In first degree inversion, there is
cupping of fundus.

4. Bimanual examination shows

protrusion of fundus inside the uterine
cavity.
5. In second degree, the fundus cannot
be felt, bimanually round and firm
swelling with soft bleeding surface is
felt protruding through the cervix in What are the
the vagina and the swelling remains nursing mg?
often covered with placenta.
6. In 3RD degree-per abdomen, fundus
cannot be felt. The mass protrudes
outside the vulva.

NURSING MANAGEMENT

1. For this, proper third stage

management is done to prevent
complications.
2. For cases without shock infuse
Ringer's lactate Fastly
3. Arrange for adequate blood
 transfusion.
4. In recent cases, immediate
treatment is replacement of uterus
under general anesthesia.
5. Give the patient Inj. Ritodrine IV
for 15 minutes.
6. The part of uterus lying near the
cervix should be first pushed inside
followed by that of the fundus.
7. If the placenta is still adherent, it
should not be removed before
manual replacement unless the bulk
of placenta interferes in manual
replacement.
8. After replacement, the hand is kept
inside the uterus when Methergine
0.2 mg is given intravenously.
9. Inj. Oxytocin is given I.V. in drip
to prevent recurrence of inversion.
10. Patient is given blood
transfusion.
5. 8 min To explain ATONIC UTERUS Lecture cum PPT, What is the
about the • Atonic-Loss of muscular tone or Discussion Chart, atonic uterus?
Atonic uterus. Black
strength to contract.
Board
Define of the
Explain DEFINITION atonic uterus?
define, cause,
risk factors & • "It is a condition in which the uterus
treatment.
fails to contract with normal strength,
duration and intervals during
childbirth. In other words, the uterus
become weak and lacks the normal
tone. It is a serious complication of
third stage of labor”. A uterus
without tone and an important cause
of PPH. In other word's a relaxed
uterus.
What are risk
RISK FACTORS factors?

1. Placenta previa or abruptio

placenta: In both of the above
conditions the muscle fibers that are
present in the myometrium are
damaged at placental site.
2. Retained placenta: When the whole
or part of the placenta is left inside
the uterus causes interference with
the contraction of the uterus even a
small piece of the placenta or a
blood clot left inside the uterus can
keep it in a state of atonicity.
3. Incomplete separation of the
placenta: When the whole placenta
with its membrane do not come out
and after detaching from the uterine
wall and a part of.
4. A bladder which is full: Normal
uterine contractions are affected
when bladder is full.
5. High parity: A mother with more
than five pregnancies too interfere
with the uterine contractility as due
to repeated stretching the
myometrium can lose the strength
and will not be able to contract
firmly.
6. Multiple pregnancies: In order to
accommodate two or more than two
babies the uterus automatically
enlarges (increase in size) and after
 delivery the overstretched uterus
takes a long time to contract firmly.
7. Polyhydramnios: It affects the same
as multiple pregnancy as in
polyhydramnios the amount of
amniotic fluid is increased threefold
(approximately more than 3 liters),
overstretching the uterus and again
after delivery it needs time or takes
a lot of time to contract firmly.
8. Large baby: (fetal macrosomia as in
diabetic mother) Same as
polyhydramnios and multiple
pregnancies can also overstretch the
uterus.
9. Prolonged labor: A labor extended
more than 12 hrs. causes exhaustion
(muscles of myometrium) by
repeated contractions and can
further (exhausted muscles) no
longer contract in a proper manner
(uterus inertia).
10. Anemic mother: A lack of red
blood cells due to low hemoglobin.
In such cases even in case of a
small blood loss it can lead to
 serious consequences and put the
mother at risk of PPH because her
blood does not clot as early as in a
non-anemic mother.

TREATMENT What are

treatment give?

1. Uterine massage: It is the first step in

management of uterine atony. This
should be continued till the uterus
starts to contract.
2. Pharmacological therapies:
a. Oxytocin: This initiates
rhythmic contractions of the
uterus, compressing the spiral
arteries which help and prevent
bleeding.
b. Methylergometrine: Not used
because of its side effects like
hypertension.
c. Carboprost can be used in
cases where oxytocin cannot
be used. Prostaglandins are
never ever given intravenously
as this can prove fatal.
 d. Arrange blood and transfuse it,
if required.
e. If still bleeding continues:
i. Examine the placenta for completeness
(no retained bits).
ii. If the placenta has some missing
fragments like absence of a portion
of maternal surface or torn
membranes with vessels than suspect
retained placenta and remove the
remaining placental tissue.
iii. Assess clothing status (at the bedside)
if a clot is not formed after 7 minutes
or a soft clot break.
 SUMMARY

My name Mansuri Tanjim Habib Ahmad of 1st year M.Sc. nursing. I give practice teaching on the
“COMPLICATION OF 3RD STAGE”.

✓ Introduction of postpartum hemorrhage.

✓ Define, cause, types of postpartum hemorrhage.
✓ Nursing management.
✓ Define retained placenta.
✓ Cause, sing, diagnosis & nursing management.
✓ Define morbid adherent placenta.
✓ Cause, diagnosis & nursing management.
✓ Define puperial inversion of uterus.
✓ Degree of puperial inversion of uterus, cause, sign& symptoms, diagnosis & nursing
management.
✓ Define atonic uterus, risk factors, treatment.
 Bibliography
1. Basvanthappa B.T: “TEXTB O O K OF MIDWIFERY AND REPRODUCTIVE HEALTH
NURSING”; first edition2006, Jaypee brother publication, New Delhi.

2. Dutta D.C: “TEXTBOOK OF OBTETRICS”; 6 TH Edition, 2004; new central book agency publication, Calcutta.

3. Anamma Jacob, “A COMPREHENSIVE TEXTBOOK OF MIDWIFEREEY”, 1stedition, 2005, Jaypee

brother medicalpublication; New Delhi.

4. Kumari Neelam; (2010); 1st edition; “MIDWIFERY AND GYNAECOLOGICAL NURSING”; s.vikas
and company;Jalandhar city.

5. Myles: “TEXTBOOK OF MIDWIVES”; Fourteenth edition, 2003; Elsevier publisher, Philadelphia.

6. Rao Kamini: “TEXTB O O K OF MIDWIFERY AND OBSTETRICS FOR NURSES”; first edition,
2011, Elsevierpublisher, Philadelphia.