The first part of this chapter describes two relatively common third stage complications, retained placenta (1–2%) and primary postpartum haemorrhage (PPH 3–4%) and the rare, but very grave, complication of inversion of the uterus. The chapter concludes with an account of some of the commoner abnormalities of the placenta and cord.
RETAINED PLACENTA
When Syntometrine has been given as described in Chapter 11, with the crowning of the head or the delivery of the anterior shoulder, separation of the placenta will usually occur within a few minutes of the delivery of the baby. Certainly, if the placenta is undelivered at 20 minutes it should be considered to be ‘retained’.
CAUSES
1. Placenta separated but undelivered
In such cases there have usually been signs of placental separation – bleeding, alteration of the shape of the uterus, lengthening of the cord. If the signs have been missed, bleeding into the uterine cavity will occur because the uterus cannot retract fully until it is empty. The fundus will therefore appear broad and boggy, thus disguising the fact that separation has occurred. Failure to recognise the signs of separation is one of the commonest forms of mismanagement of the third stage.
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In this situation the fundus should be rubbed up to make it contract and the placenta removed by the Brandt–Andrews method. The cord is pulled gently, and the other hand presses the uterus upwards so as to prevent inversion. A slight seesawing motion is imparted by both hands, and provided separation has occurred the placenta should be delivered. It is likely to be accompanied by a considerable volume of accumulated blood.
TREATMENT
Intervention becomes necessary either because of bleeding or when 20 minutes have elapsed. An attempt should be made to remove the placenta by rubbing up a contraction and applying cord traction as described previously. If the placenta remains adherent the cord may break. If this occurs, or the attempt is unsuccessful, manual removal of the placenta under anaesthesia should be performed.
This should not be delayed because of the risk of haemorrhage from partial separation. The procedure itself, however, is not without risk from infection and damage to the uterus.
1. The hand covered with antiseptic cream is introduced into the vagina, following the cord.
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2. The fingers begin to separate the placenta from the uterine wall. Never grasp the placenta until it is separated.
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3. Note that the abdominal hand presses the uterus into the placenta and prevents tearing of the lower segment.
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4. The placenta is inspected at once to see that it is complete and, if there is any doubt, the uterus is re-explored. Ergometrine or oxytocin is then given and the uterus rubbed up to make it contract.
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PRIMARY POSTPARTUM HAEMORRHAGE
Primary Postpartum Haemorrhage is blood loss from the birth canal of 500 ml or more within 24 hours of delivery. After 24 hours, abnormal bleeding is classed as Secondary Postpartum Haemorrhage.
CAUSES
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