Four case scenarios for Third stage abnormalities
Analysis of the evidence and guidance documents on third stage
abnormalities enabled the topic to be sub-divided into 4 case scenarios
and Algorithms were developed for each. These were as follows:
- Approach to PPH after vaginal delivery
- Diagnosis and management of uterine atony
- Diagnosis and management of genital tract trauma
- Diagnosis and management of retained placenta
Each of the four algorithms are led into from the management of third
stage of labour algorithm in chapter 3. In addition, algorithm one links
to two, three and four.
The themes of (i) maternal assessment of the third stage condition and
haemodynamic stability reflected by vital signs (ii) resuscitation and
(iii) treatment of the condition, are the basis of all four Algorithms.
The four algorithms are shown in Figures 1 to 4, accompanied by a brief
description with reference sources. More detailed evidence summaries for
the action boxes in each algorithm can be found in the Supplementary
materials (s2).
Algorithm 1: Approach to PPH after vaginal delivery (Figure 1).
Thirteen Cochrane reviews were identified that dealt with management of
PPH: the Mousa review (2014)14 was most relevant for
an overall approach to PPH, three referred to uterine atony14,21,33, five for genital tract
trauma48,49,50,51,53 and five for retained placenta.36,37,38,39,41 The ten trials in the Mousa review
dealt with medical management of PPH and acknowledged the lack of
evidence for the sequence of interventions and surgical measures. The
Mousa review did not cover resuscitation. International and national
guidance documents were mostly used to develop the directives for
monitoring, resuscitation and treatment sequences.16,17,18,19,20,35,43,46
The most frequently used definition of PPH after vaginal delivery is
loss of 500mls blood or more. This appears in the Mousa review and is
corroborated in the Meher review15 on core outcomes.
However, given inaccuracies in routine estimation of blood loss,
subjective indicators of blood loss (‘brisk bleeding’) and deterioration
of vital signs (SBP<100mmHg and Pulse >110 bpm)
are also described for identifying PPH. Due to the urgency of PPH
management, maternal assessment of haemodynamic status, initial
resuscitation and immediate measures to stop the bleeding must occur
simultaneously (box 2) and be repeated with increased intensification
until the problem is resolved. Emphasis is placed on diagnosing the
cause of the bleeding. A diagnosis of retained placenta links to
Algorithm 4. Current evidence indicates that initial treatment for PPH
should include uterine massage, oxytocin and tranexamic acid. Refractory
PPH involves further maternal assessment and examination for persistent
uterine atony, genital tract tears, retained placental fragments, and
less commonly coagulopathy from amniotic fluid embolism and uterine
inversion. Initial resuscitation is with crystalloid solutions followed
by blood products, the nature of which will depend on whether the
hospital has an onsite blood bank or group specific blood in an
emergency fridge. Coagulopathy may result from excessive blood loss from
any cause. In tertiary centres it can be managed according to point of
care or haematology results. In a district hospital management is
formulaic relying on either fresh frozen plasma or fresh dried plasma
which can be stored on site as a pharmacy item.
Algorithm 2: Uterine atony (Figure 2).
Three Cochrane reviews were relevant. The Mousa review (2014)14; included ten trials which dealt with medical
management of PPH and acknowledged the lack of evidence for the sequence
of interventions and surgical measures. The other review by Shakur
(2018)33 was on anti-fibrinolytic drugs. Given the
lack of high-level evidence on the treatment of PPH from uterine atony,
an important review on uterotonics for prevention of PPH was considered
(Gallos,2018)21; it was deemed reasonable to infer
efficacy for treatment from efficacy for prevention. As previously
described, international and national guidance
documents15,16,17,18,19,20,43, RCTs on individual
treatments22,34 and case series were all used to
construct this algorithm. Three articles on temporising management for
women who need emergency referral which include Non-pneumatic Anti-shock
Garment (NASG), uterine tourniquet and Balloon Tamponade (BT) were also
referenced24, 29,31,32, as well as the Algorithms for
PPH devised by the South African Confidential Enquiry into Maternal
Deaths. 28,35
Monitoring and resuscitation together with medical measures to arrest
bleeding from uterine atony are sequenced in the algorithm. Recommended
medications (oxytocin, Syntometrine, misoprostol, Carboprost and TXA)
are given and alternatives indicated in the situation of specific
contraindications, lack of cold chain and stock-outs of medications.16,17,18,19,20,21,22,23,35,43 Heat stable carbetocin
was not included as treatment, because most of the evidence to date on
its use is for prevention. 34
For surgical interventions, laparotomy with uterine compression sutures,
balloon tamponade and uterine artery ligation can be performed with
appropriately trained non-specialist doctors at district hospital level;
with hysterectomy being a last resort where the skill is available.
However, the evidence for the timing and nature of surgical
interventions is mostly from expert opinion or based on case series
which are included as the evidence. 24,25,26,27,28Most evidence for success of balloon tamponade, which is widely used, is
based on case reports but two recent RCTs suggest lack of efficacy and
increased risk of adverse outcomes. 25,30 Balloon
tamponade is included in the algorithm pending more research with the
proviso that it should be a temporising rather than therapeutic measure
and abandoned if it fails to control bleeding within 20 minutes.
Hysterectomy is a life-saving procedure for intractable uterine atony,
but the skill is unlikely to be available at district hospital level
where non specialists supervise maternity. 27,28,35 In
this situation, temporising methods (BT, Uterine tourniquet and NASG)24,31,32, advice from a specialist and referral to
more specialised care are necessary.
Algorithm 3: Genital tract trauma (Figure 3).
There were 30 Cochrane reviews, involving 185 trials. Most of the trials
focused on prevention of perineal tears and management of second stage
labour. One was the Mousa 2014 PPH overview 14, four
were on surgical repair 48,49,50,51, and one on the
use of prophylactic antibiotics. 53
Guidance documents (NICE16,43,
FIGO17, RCOG18,
WHO19, and ACOG20 guidelines) based
on evidence and expert opinion, were all reviewed. They all give
guidance on the management of perineal tears. There is additional RCOG
guidance53 on the management of third- and
fourth-degree perineal tears and WHO recommendations on use of
tranexamic acid. 23 Guidance on diagnosis and
management of uterine rupture was from case reports and expert opinion.27,28,35
Genital tract trauma can be identified on routine inspection after
vaginal delivery as described in the third stage algorithm or can be
actively looked for in cases of refractory PPH not responding to initial
management measures. The site of trauma can be perineum (first-,
second-, third- and fourth-degree tears), vaginal and cervical tears,
vulval and vaginal haematomas, and uterine rupture. Diagnosis of
perineal and vaginal tears and haematoma can be made in labour ward, but
complex high vaginal and cervical tears may require examination with
appropriate analgesia or anaesthesia. Uterine rupture can be diagnosed
by uterine exploration and confirmed by laparotomy.
Genital tract trauma associated with PPH requires all the monitoring and
resuscitation interventions described in case scenario 1, with
intensification of both when there is haemodynamic instability.
Vaginal, simple cervical, and first- or second-degree perineal tears can
be sutured in labour ward with local analgesia. 48Complex high vaginal, cervical and third-degree tears require repair
with good visualisation for their extent, and appropriate analgesia or
anaesthesia in an operating theatre.
Third- and fourth-degree tears are specialised procedures. Cochrane
reviews and guidance on the surgical technique indicates no difference
between overlapping and end to end techniques. 48, 49,
50 ,51, 52, 53 At district hospital, the appropriate skill is often not
available, and the patient would need to have vaginal packing to control
any bleeding and referral to a specialised centre. There is also
evidence for antibiotic cover in these patients. 53
Suspected uterine rupture requires a laparotomy and may be amenable to
surgical repair.27,28,35 Extensive ruptures especially
with uterine artery involvement need a hysterectomy. The skill for this
is not usually available at a district hospital so temporising measures
will need to be performed and urgent referral to the next level of care
with the appropriate skill. Case series with the uterine tourniquet
technique31 shows that it reduces blood loss during
transfer, and a cluster randomised controlled trial of the NASG shows a
non-significant reduction in recovery from shock.32
Algorithm 4. Retained placenta/placental products (Figure 4).
There were 18 Cochrane reviews, involving 166 trials. Most of the trials
focused on AMTSL and prevention of PPH, rather than management. Five
were identified that dealt with management of retained placenta. One was
the Mousa 2014 PPH overview 14 which indicates there
is minimal evidence on surgical procedures, and the Chongsomchai review
which recommends prophylactic antibiotics after manual removal of
placenta (MROP).41 Three were on treatments found to
be ineffective; intraumbilical vein oxytocin36,37,
nitroglycerine38 and
prostaglandins.39
NICE6,43, FIGO17,
RCOG18, WHO19,
ACOG20 and
SA-NCCEMD35guidelines based on evidence and expert opinion, were all reviewed. NICE
provides the definition of prolonged third stage of labour. They all
give guidance on the management of retained placenta by manual removal
of placenta (MROP) which is a skilled procedure.
Review articles on balloon tamponade are included.24,25,30 References for Algorithm 2 are referred to
for use of uterotonics and laparotomy procedures.
Retained placenta is diagnosed if it is not expelled within 30 mins of
delivery of the baby if AMTSL was employed or one hour for passive
management. 14,16,17,18,19,20,43 It may be detached
and lying at the cervical os or in the vagina, it may be still attached,
and rarely but more seriously it can be abnormally adherent. The
location can be ascertained by vaginal examination or by ultrasound if
the skill is available. Despite placental delivery there can be residual
placental fragments /products which may cause PPH or uterine sepsis.
The retained placenta algorithm (figure 4) may be entered from the
approach to PPH algorithm (figure 1) when bleeding; or the third stage
algorithm if it occurs without bleeding
Retained placenta associated with PPH requires all the monitoring and
resuscitation interventions described in Algorithm 1, with
intensification of both when there is haemodynamic instability.
Management of retained placenta requires removal which can be by repeat
controlled cord traction (CCT), or manual removal from the vagina, both
of which can be performed in labour ward by a midwife or general doctor.16,17,18,19,29,35,43 When the placenta is still
attached, a full manual removal of placenta (MROP) is required without
delay, preferably in the operating theatre; or in labour ward with
adequate analgesia, followed by a five-day course of broad-spectrum
antibiotic. 41
MROP may be followed by PPH from placental site bleeding and uterine
atony, the management of which follows the treatment in case scenario 2;
with sequential uterotonics and TXA, followed by balloon tamponade.
Similarly, laparotomy and further surgical measures are required, as
already described for algorithm 2, if medical and BT fails to control
the bleeding. 16,17,18,19,20,26,27,28,35,43
If MROP is complicated due to morbid adherence, it may require uterine
curettage under ultrasound, specialist advice and assistance if
available; and laparotomy for conservative surgical measures or
hysterectomy, if the skill is available.