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:
  1. Approach to PPH after vaginal delivery
  2. Diagnosis and management of uterine atony
  3. Diagnosis and management of genital tract trauma
  4. 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.