# Introduction to Third Stage Labor Complications

The third stage of labor begins after the delivery of the baby and ends with the delivery of the placenta. This critical phase typically lasts between 5-30 minutes but can be fraught with potentially life-threatening complications. Understanding these complications is essential for nursing students as timely recognition and intervention are crucial for preventing maternal morbidity and mortality.

This comprehensive guide explores the major complications of the third stage of labor: retained placenta, injuries to the birth canal, and postpartum hemorrhage (PPH). We will delve into the causes, risk factors, assessment, management strategies, and nursing considerations for each complication. Special attention is given to postpartum hemorrhage management techniques including bimanual compression of the uterus, aortic compression, and uterine balloon tamponade.

# Normal Third Stage of Labor

Before exploring complications, it’s essential to understand the normal physiological processes of the third stage of labor:

The third stage can be managed either expectantly (physiological management) or actively. Active management of the third stage of labor (AMTSL) is recommended by the World Health Organization to prevent PPH and includes:

• Administration of a uterotonic agent (oxytocin is preferred) within 1-2 minutes of birth
• Delayed cord clamping (1-3 minutes after birth)
• Controlled cord traction with counter-traction to the uterus
• Uterine massage after placental delivery

When the normal mechanisms of the third stage are disrupted, complications can arise, leading to potentially serious consequences for the mother.

# 1. Retained Placenta

Retained placenta is a condition where all or part of the placenta or membranes remain in the uterus beyond 30 minutes after the delivery of the baby despite active management. It is a significant cause of postpartum hemorrhage and occurs in approximately 2-3% of vaginal deliveries.

# 1.1 Causes and Risk Factors

# 1.2 Assessment and Diagnosis

Clinical signs that suggest retained placenta include:

• Failure to deliver the placenta within 30 minutes of the baby’s birth with active management
• Incomplete placenta upon examination after delivery
• Continuing vaginal bleeding despite a contracted uterus
• Uterus larger than expected after presumed placental delivery
• Visible placental tissue at the cervical os

Diagnostic measures include:

• Visual Inspection: Careful examination of the delivered placenta for completeness, noting any missing cotyledons or membranes
• Manual Exploration: Digital examination of the uterine cavity
• Ultrasound: Bedside ultrasound can confirm the presence of retained placental tissue
• Laboratory Tests: Complete blood count, coagulation profile, and cross-matching of blood may be performed in preparation for potential hemorrhage

# 1.3 Management Strategies

Management of retained placenta follows a stepwise approach:

# 1.4 Nursing Considerations

Nursing care for patients with retained placenta includes:

• Monitoring: Closely monitor vital signs, bleeding, and uterine tone
• Intravenous Access: Ensure at least one large-bore IV line (16-18 gauge)
• Fluid Resuscitation: Administer crystalloids as ordered and monitor intake/output
• Medication Administration: Prepare and administer uterotonics as prescribed
• Pain Management: Ensure adequate analgesia for procedures
• Preparation for Procedures: Prepare for manual removal, including positioning and assistance
• Post-Procedure Care: Continue monitoring for bleeding and signs of infection
• Prophylactic Antibiotics: Administer as prescribed to prevent infection
• Emotional Support: Provide explanation and reassurance to the patient
• Documentation: Accurately record all assessments, interventions, and responses

# 2. Injuries to the Birth Canal

Birth canal injuries during the third stage of labor can be a significant source of postpartum hemorrhage and morbidity. These injuries encompass damage to any part of the genital tract, including the perineum, vagina, cervix, and uterus. Early recognition and proper management of these injuries are essential to prevent complications.

# 2.1 Perineal Tears

Perineal tears are classified into four degrees based on the extent of tissue involvement:

# 2.2 Vaginal Lacerations

Vaginal lacerations can occur in various locations within the vaginal canal:

• Sidewall Lacerations: Often associated with instrumental deliveries or rapid descent
• Periurethral Lacerations: Can cause urinary symptoms if not properly repaired
• Sulcal Tears: May extend deep into the vaginal fornices
• Paravaginal Hematomas: Can form when vessels are damaged without visible lacerations

Management of vaginal lacerations involves:

• Adequate exposure with assistance, lighting, and positioning
• Identification of the apex of the laceration
• Systematic suturing from apex to introitus
• Careful hemostasis throughout repair

# 2.3 Cervical Lacerations

Cervical lacerations occur in approximately 0.2-1.7% of vaginal deliveries and are often associated with:

• Precipitous labor
• Delivery before complete cervical dilation
• Instrumental deliveries
• Large fetal size
• Previous cervical surgery

Signs of cervical lacerations include:

• Persistent bright red bleeding despite a well-contracted uterus
• Blood that appears regardless of uterine massage
• Vital sign changes indicating blood loss

Management involves:

• Visualization of the cervix using ring forceps and adequate lighting
• Repair with absorbable sutures, typically in a figure-of-eight pattern
• Attention to hemostasis and identification of all tears (often occur at 3 and 9 o’clock positions)

# 2.4 Uterine Rupture

Though rare, uterine rupture is a catastrophic complication that can manifest during labor or the third stage. Risk factors include:

• Previous cesarean delivery or uterine surgery
• Trauma (external or internal)
• Excessive use of uterotonics
• Placenta accreta spectrum
• Obstructed labor

Signs of uterine rupture include:

• Severe, persistent abdominal pain
• Hypovolemic shock
• Loss of uterine contour
• Palpable fetal parts through the abdominal wall
• Hematuria (if bladder is involved)

Management typically requires surgical intervention:

• Immediate laparotomy
• Repair of the rupture if possible
• Hysterectomy may be necessary if repair is not feasible
• Aggressive resuscitation with fluids and blood products

# 2.5 Management of Birth Canal Injuries

General principles for managing birth canal injuries include:

1. Initial Assessment:
   • Evaluate the extent of bleeding
   • Assess maternal vital signs
   • Ensure adequate intravenous access
   • Cross-match blood if significant bleeding
2. Visualization:
   • Ensure adequate lighting and exposure
   • Position patient appropriately (lithotomy position)
   • Use assistants for retraction
   • Employ vaginal retractors or speculums as needed
3. Analgesia/Anesthesia:
   • Ensure adequate pain control before repair
   • Options include local infiltration, pudendal block, epidural, or spinal anesthesia
4. Repair Technique:
   • Identify the extent and anatomy of injuries
   • Repair in a systematic fashion, from apex to introitus
   • Use appropriate suture material (typically absorbable)
   • Ensure anatomical alignment
5. Post-Repair Care:
   • Continue monitoring for bleeding
   • Provide adequate analgesia
   • Consider ice packs for perineal injuries
   • Maintain catheterization if necessary

# 2.6 Nursing Considerations

Nursing care for patients with birth canal injuries includes:

• Assessment:
  • Regular monitoring of vital signs
  • Assessment of bleeding (amount, color, presence of clots)
  • Evaluation of pain level
  • Monitoring urine output
• Interventions:
  • Position the patient for optimal visualization during repair
  • Assist with the repair procedure
  • Administer prescribed medications (antibiotics, pain relief)
  • Apply cold therapy to reduce swelling
• Patient Education:
  • Perineal care and hygiene
  • Signs of infection to monitor
  • Pain management techniques
  • Activity restrictions
  • Pelvic floor exercises when appropriate
• Documentation:
  • Location and extent of injuries
  • Repair procedures performed
  • Medications administered
  • Patient response to interventions

# 3. Postpartum Hemorrhage (PPH)

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide, responsible for approximately 25% of all maternal deaths globally. Early recognition and prompt intervention are crucial for preventing severe morbidity and mortality.

# 3.1 Definition and Classification

Traditional definitions of PPH have relied on estimated blood loss thresholds:

• Primary (Early) PPH: Blood loss ≥500 mL following vaginal delivery or ≥1000 mL following cesarean delivery within the first 24 hours after birth
• Secondary (Late) PPH: Excessive bleeding occurring between 24 hours and 12 weeks postpartum

However, more recent approaches recognize that clinical signs of hemodynamic compromise may be more important than absolute blood loss volume. The American College of Obstetricians and Gynecologists (ACOG) defines PPH as “cumulative blood loss ≥1000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 hours after birth, regardless of delivery route.”

# 3.2 Causes and Risk Factors

The causes of PPH are often remembered using the mnemonic “4 T’s”:

Risk factors for PPH include:

# 3.3 Assessment and Diagnosis

Early recognition of PPH is critical for effective management. Assessment includes:

• Visual Estimation of Blood Loss: Though subjective and often inaccurate, it remains common practice. Blood loss is frequently underestimated by 30-50%.
• Quantitative Blood Loss Measurement (QBL): More accurate methods include:
  • Weighing soaked materials (1 gram = 1 mL blood)
  • Calibrated drapes and collection bags
  • Pictorial guides for standardized estimation
• Vital Signs Monitoring: Tachycardia, hypotension, and tachypnea may indicate significant blood loss
• Physical Assessment:
  • Uterine tone evaluation (firm vs. boggy)
  • Inspection of the genital tract for lacerations
  • Assessment for signs of retained placental tissue
  • Evaluation of bladder fullness
• Laboratory Assessment:
  • Complete blood count (CBC)
  • Coagulation studies (PT, PTT, fibrinogen, D-dimer)
  • Crossmatching for potential transfusion

# 3.4 Management Strategies

Management of PPH follows a stepwise approach, beginning with conservative measures and escalating as needed:

# 3.4.1 Bimanual Compression of the Uterus

Bimanual uterine compression is a critical first-line mechanical intervention for managing PPH due to uterine atony. It’s an effective temporizing measure while preparing for other interventions.

# 3.4.2 Aortic Compression

Aortic compression is a life-saving emergency measure used in cases of severe hemorrhage to reduce blood flow to the uterus while other interventions are being prepared.

# 3.4.3 Uterine Balloon Tamponade

Intrauterine balloon tamponade is an effective intervention for the management of PPH when medical management fails. The technique works by creating pressure against the bleeding placental bed and stimulating uterine contraction.

# 3.4.4 Pharmacological Management

# 3.4.5 Surgical Management

When medical and mechanical interventions fail to control PPH, surgical interventions become necessary. These are typically performed in a sequential manner, from less to more invasive:

1. Uterine Compression Sutures:
   • B-Lynch suture: Vertical brace suture that compresses the uterus
   • Hayman suture: Modified and simplified version of B-Lynch
   • Cho sutures: Multiple square sutures
2. Uterine Devascularization Procedures:
   • Uterine artery ligation
   • Utero-ovarian artery ligation
   • Internal iliac (hypogastric) artery ligation
3. Interventional Radiology:
   • Uterine artery embolization
4. Hysterectomy:
   • Subtotal hysterectomy (faster, less blood loss)
   • Total hysterectomy (may be necessary for cervical/lower uterine segment bleeding)

# 3.5 Nursing Considerations

The nurse plays a critical role in the management of PPH. Key nursing responsibilities include:

• Prevention and Early Recognition:
  • Identify risk factors during antepartum and intrapartum care
  • Participate in active management of the third stage
  • Monitor blood loss accurately using quantitative methods
  • Assess vital signs and uterine tone regularly
• Emergency Response:
  • Activate rapid response team/code protocols
  • Establish large-bore IV access (two lines if possible)
  • Draw blood for laboratory studies and cross-match
  • Administer oxygen and initiate fluid resuscitation
  • Assist with uterine massage and other interventions
• Medication Administration:
  • Prepare and administer uterotonics and other medications
  • Monitor for side effects and therapeutic response
  • Document administration times and doses accurately
• Assistance with Procedures:
  • Assist with bimanual compression
  • Prepare equipment for balloon tamponade insertion
  • Monitor balloon drainage output
  • Prepare for operative procedures if needed
• Ongoing Monitoring:
  • Assess vital signs frequently (q5-15min during active hemorrhage)
  • Monitor output from all drains and catheters
  • Assess for signs of continuing blood loss
  • Monitor laboratory values and maintain fluid balance sheet
• Emotional Support:
  • Provide explanations to the patient and family
  • Offer reassurance and presence
  • Consider psychological impact of traumatic birth experience
• Documentation:
  • Record accurate blood loss estimates
  • Document all interventions with times
  • Maintain detailed fluid balance records
  • Record ongoing assessments

# 4. Best Practices and Recent Updates

The management of third stage complications continues to evolve. Here are three important recent updates and best practices that nursing students should be aware of:

# 4.1 Enhanced Risk Assessment Protocols

Nurses should advocate for the use of standardized risk assessment tools and ensure that prevention strategies are implemented based on identified risk factors. This includes ensuring adequate supplies of uterotonics are available for high-risk patients and that cross-matched blood is readily accessible if needed.

# 4.2 Simulation-Based Training

Nursing students should actively participate in simulation training opportunities and understand the importance of clear communication and role clarity during emergencies. Familiarity with the location of emergency equipment and protocols through simulation training can significantly improve response in actual emergencies.

# 4.3 Bundle Approach to PPH Management

Nursing students should familiarize themselves with the components of hemorrhage bundles and understand their role within each stage. Knowledge of the location and contents of PPH carts, familiarity with unit-specific protocols, and comfort with quantitative blood loss measurement techniques are essential skills.

# 5. Conclusion

Complications of the third stage of labor represent significant challenges in obstetric care and contribute substantially to maternal morbidity and mortality worldwide. Understanding the pathophysiology, risk factors, assessment strategies, and management approaches for retained placenta, birth canal injuries, and postpartum hemorrhage is essential for all nursing students planning to work in maternal care settings.

Key takeaways from this comprehensive guide include:

• The importance of active management of the third stage of labor to prevent complications
• The critical need for early recognition of abnormal bleeding patterns and prompt intervention
• The value of a systematic approach to assessment and management using established protocols
• The essential role of teamwork and clear communication during obstetric emergencies
• The effectiveness of mechanical interventions such as bimanual compression, aortic compression, and balloon tamponade
• The importance of continuous nursing assessment and documentation throughout the third stage and beyond

As a nursing student, developing proficiency in these skills and knowledge areas will prepare you to be an effective member of the maternal care team and contribute to the safety and wellbeing of mothers during this critical period. Remember that while complications of the third stage can be dramatic and stressful, a calm, organized approach following established protocols can significantly improve outcomes.

# 6. References

1. American College of Obstetricians and Gynecologists. (2022). Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology, 140(2), e110-e128.
2. World Health Organization. (2022). WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization.
3. Evensen, A., Anderson, J. M., & Fontaine, P. (2022). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician, 95(7), 442-449.
4. California Maternal Quality Care Collaborative. (2022). OB Hemorrhage Toolkit V 3.0. Retrieved from https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit
5. Royal College of Obstetricians and Gynaecologists. (2023). Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG, 124(5), e106-e149.
6. Dahlke, J. D., Mendez-Figueroa, H., Maggio, L., et al. (2022). Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines. American Journal of Obstetrics & Gynecology, 213(1), 76.e1-76.e10.
7. Weeks, A. (2022). The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go next? BJOG, 122(2), 202-210.
8. Shakur, H., Roberts, I., Fawole, B., et al. (2021). Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet, 389(10084), 2105-2116.
9. Lalonde, A. (2022). Prevention and treatment of postpartum hemorrhage in low-resource settings. International Journal of Gynecology & Obstetrics, 117(2), 108-118.
10. Su, L. L., Chong, Y. S., & Samuel, M. (2022). Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database of Systematic Reviews, 4, CD011689.