10.9 Complications and Medical Interventions During the Third Stage of Labor

During the third stage of labor, the placenta and the membranes are delivered. Several complications can occur during this stage, such as retention of the placenta inside the uterus, placenta accreta (implantation of the placenta into the muscle tissue of the uterus), postpartum hemorrhage, and inversion of the uterus.

Retained Placenta

If the placenta has not delivered spontaneously within 30 minutes after delivery of the newborn, the health care provider will determine if manual removal is indicated. If manual removal is not possible, a dilation and curettage (D&C) or hysterectomy may be performed. If the placenta partially detaches, significant vaginal bleeding with clots indicates a medical emergency.^[1]

Risk factors for retained placenta include uterine atony, placenta accreta, cervical closure, premature birth, previous retained placenta, and congenital uterine anomalies such as bicornuate uterus. Complications of retained placenta include postpartum hemorrhage and endometritis.^[2]

Placenta Accreta

During a normal pregnancy, the placenta anchors to endometrium (i.e., the tissue that lines the uterus). During placenta accreta, the placenta attaches into the uterine myometrium (the muscular tissue of the uterus). Placenta accreta is associated with a history of previous cesarean section, as well as advanced maternal age and multiparity. It is typically diagnosed during an ultrasound performed during gestation. The American College of Obstetricians and Gynecologists (ACOG) recommends cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation to optimize neonatal maturity and minimize the risk of maternal bleeding. If the placenta doesn’t deliver spontaneously, a hysterectomy is typically performed, and the mother is admitted to the intensive care unit to monitor for excessive bleeding. Postpartum hemorrhage is the most common complication associated with the placenta accreta.^[3]

Postpartum Hemorrhage

Total blood loss greater than or equal to 1,000 mL or blood loss and signs or symptoms of hypovolemia within 24 hours after birth is considered postpartum hemorrhage (PPH). Signs of concealed hemorrhage causing hypovolemia include heart rate equal or greater than 110 beats per minute, blood pressure equal or less than 85/45 mmHg, O2 saturation <95%, and confusion.^[4]

When hemorrhage occurs during the third stage of labor or the first hour after birth, it is considered an immediate postpartum hemorrhage. PPH is a medical emergency and causes approximately one-quarter of all maternal deaths. Research indicates many deaths associated with PPH can be prevented with prompt recognition and timely and adequate treatment.^[5],[6]

There are multiple causes of postpartum bleeding that can be remembered using the mnemonic called The Four T’s of PPH1,24:

• Tone: Uterine atony
• Trauma: Lacerations or uterine rupture
• Tissue: Retained placenta, blood clots, or placenta accreta
• Thrombin: Clotting-factor disorder

The most common cause of PPH is uterine atony, meaning lack of proper contraction of the uterine muscles. Uterine atony causes 70% of PPH cases. The uterus can become atonic after prolonged or precipitous labor, overdistention of the uterus due to twins or macrosomia, cesarean birth, chorioamnionitis, or magnesium sulfate infusion. Nursing actions in the first hour after delivery include assessment of the location of the fundus and tone of the uterus. If uterine atony is suspected, the nurse initiates the agency’s PPH protocol and starts vigorous fundal massage, also called uterine massage. Fundal massage involves squeezing the uterus to stimulate it to contract and putting pressure on the blood vessels to help stop the bleeding. The nurse also instructs the client to empty their bladder because a full bladder can displace the uterus and not allow it to contract efficiently. Medical treatment of uterine atony may include oxytocin, methylergonovine, misoprostol, carboprost, tromethamine, and/or tranexamic acid.^[7],[8]

Cervical and vaginal lacerations can cause immediate postpartum hemorrhage. If the nurse notices heavy vaginal bleeding and the uterus is contracted, the health care provider is contacted to inspect the vagina and cervix for lacerations that are repaired using absorbable sutures. Retained placental fragments and/or clots can cause immediate postpartum hemorrhage because the uterus is unable to contract properly. The health care provider is notified for evacuation of the uterus. Blood product transfusions or clotting factors are administered as indicated for PPH caused by blood clotting disorders.^[9],[10]

Inversion of the Uterus

Inversion of the uterus is a life-threatening complication that refers to the uterus turning inside out and protruding through the vagina. See Figure 10.67^[11] for an illustration of uterine inversion. Risk factors include precipitous labor, manual removal of the placenta, and traction on a short umbilical cord. Signs of uterine inversion include hemorrhage, pelvic pain, and the absence of a fundus on palpation of the abdomen. Hypovolemic shock due to bleeding and a vagal response can occur due to sudden stretching of the uterine ligaments, requiring emergency treatment. The health care provider will attempt to reposition the uterus by placing a fist in the uterus and keeping it in that position until the uterus contracts while monitoring for worsening signs of shock. Uterotonics are administered after the uterus is returned to the proper position to promote further contraction. If medical interventions are not successful, a hysterectomy is performed.^[12]