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Maternal Newborn Nursing

19.9 Complications in the Third Stage of Labor

Maternal Newborn Nursing19.9 Complications in the Third Stage of Labor

Learning Objectives

By the end of this section, you will be able to:

  • Explain the clinical manifestations, treatment, and nursing actions in the event of a retained placenta
  • Explain the clinical manifestations, treatment, and nursing actions in the event of an immediate postpartum hemorrhage
  • Explain the clinical manifestations, treatment, and nursing actions in the event of an inverted uterus

During the third stage of labor, the placenta and the membranes are birthed. Several complications can occur during this stage. The placenta or parts of the placenta can be retained inside the uterus. The placenta can be implanted into the muscle of the uterus as well. Complications with the placenta can lead to postpartum hemorrhage, which can be a life-threatening complication. The nurse is prepared to treat postpartum hemorrhage quickly.

Retained Placenta

If the placenta has not delivered spontaneously within the expected 30 minutes, the health-care provider will determine if manual removal is indicated. If manual removal is not possible, the anesthesia provider is alerted of the need for a possible dilation and curettage (D&C) or hysterectomy. Occasionally, the placenta will partially detach, and the birthing person will begin to bleed and pass clots vaginally. This is an emergency situation requiring manual removal before the 30-minute waiting period. Nursing actions include emotional support and education of the birthing person and support person, requesting assistance in notifying the anesthesia provider of the probable need for surgery, administering pain medication, and administering uterotonics once the placenta is delivered.

Risk factors for retained placenta include uterine atony, placenta accreta spectrum, cervical closure, premature birth, and previous retained placenta (Perlman & Carusi, 2019). Congenital uterine anomalies such as bicornuate uterus increase the risk of retained placenta. Complications of retained placenta include postpartum hemorrhage, endometritis, and retained placental tissue.

Cervical Closure

After birth of the infant, the cervix remains open until the birth of the placenta. Complications can occur if the cervix closes prematurely. In those cases, the placenta becomes trapped in the uterus. Trapped placentas can lead to postpartum hemorrhage. Treatment is administration of nitroglycerine to relax the uterus and cervix for manual extraction of the placenta. After removal of the placenta, oxytocin should be given to contract the uterus to decrease hemorrhage risk. The nurse will monitor vital signs, observing for hypotension, tachycardia, and inadequate oxygen saturation.

Preterm Birth

In the third stage of labor, delayed umbilical cord clamping is recommended for the preterm fetus. Preterm infants have increased incidences of blood transfusion, poor circulation, and intraventricular hemorrhage (Bennett et al., 2019). Delayed cord clamping can help prevent some of these complications. However, preterm birth has a higher incidence of retained placenta. If the placenta has not delivered within the expected 30 minutes, the nurse should prepare for transferring the birthing person to the operating room for a D&C to remove the placenta.

Spontaneous Abortion

The loss of a pregnancy prior to 20 weeks’ gestation is called a spontaneous abortion (SAB). It can be complete or incomplete. With an incomplete abortion, products of conception, such as fetal or placental tissue, can be retained. If the tissue can be seen at the cervical os, the health-care provider can remove it using ring forceps. If the tissue cannot be removed and bleeding is present, the person is taken to surgery to have a D&C to remove those products. Infection and bleeding can occur if the uterus is not free of all products of conception.

Placenta Accreta

Placenta accreta is the invasive adherence of part or all of the placenta to the uterus. Placenta accreta spectrum disorder describes all invasive placenta occurrences (Oppenheimer & Singh, 2022). Table 19.13 lists the different types of placentas in the placenta accreta spectrum disorders. The incidence of these disorders has increased as the rate of cesarean births has increased. The pregnant person’s risk is much higher, the more cesarean births that person has experienced. Other risk factors are age at delivery of 35 years or older, in vitro fertilization, placenta previa, and prior uterine surgery (Oppenheimer & Singh, 2022). The mortality rate of pregnant persons with placenta accreta spectrum disorder is approximately 7 percent.

Placental Accreta Spectrum Disorders Description
Grade 1: Placenta accreta Abnormal adherent placenta
Adherent to the superficial myometrium
Grade 2: Placenta increta Abnormally invasive placenta
Penetrate the uterine muscle but not to its full thickness
Grade 3: Placenta percreta Abnormally invasive placenta
Penetrates the wall of the uterus, perforates the serosa, and may grow into the bladder or other pelvic tissue or organs
Table 19.13 Placenta Accreta Spectrum Disorders (Oppenheimer & Singh, 2022)

Real RN Stories

Name: LW, RN
Years in practice: 16
Clinical setting: In-hospital labor and birth unit
Facility location: South Carolina

I remember being the labor nurse for a 21-year-old patient having her first baby. The labor and birth of the baby went well. Then, the midwife waited for signs of placenta separation. After 30 minutes the midwife attempted a manual removal and asked me to notify the physician backup that she was unable to separate the placenta from the uterine wall. The placenta was still undelivered when the physician arrived. After examining the patient, the physician informed the patient that the placenta was adhered to the uterus and a D&C was needed. Informed consent was obtained and I witnessed the consent. The patient had an epidural and the anesthesiologist re-dosed it for the procedure. The physician performed the D&C but was unable to prevent the uterus from continuing to bleed heavily. At this time a decision was made by the physician to perform a hysterectomy. The physician brought the patient’s husband into the operating room and explained the situation to both the patient and her husband about the cause, need for, and long-term effects of a hysterectomy on a patient at the age of 21. After facing the future of no more biological children, the patient consented to the hysterectomy. This was not an easy decision for either the physician or the patient and her husband, but I will never forget this physician’s patience when trying to prevent having to perform the hysterectomy and answering all the questions from the patient and her husband. When the pathology report on the uterus became available, the report stated the patient experienced placenta increta.

Succenturiate Lobe of the Placenta

An accessory lobe of the placenta that is separate from the main placenta is called a succenturiate lobe. The blood vessels feeding the lobe usually run through the membranes to the extra lobe. Figure 19.20 illustrates a succenturiate lobe and vessels. If these vessels cross the cervix, they can create a vasa previa. During the third stage of labor, the succenturiate lobe can be retained, which can cause postpartum hemorrhage or infection if not removed.

Image of placenta with succenturiate lobe.
Figure 19.20 Succenturiate Lobe with Placenta The main placenta sits at the top of the photograph. The succenturiate lobe is distal to the main placenta. The vessels feeding the extra lobe are seen connecting to the main placenta. (credit: “Figure 2: Leash of blood vessels running through the membranes connecting succenturiate lobe to main placental disc” by Snigdha Kumari et al/Edorium Journals, CC BY 4.0)

Immediate 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. When hemorrhage occurs during the third stage of labor or the first hour after birth, it is considered an immediate postpartum hemorrhage. The American College of Obstetricians and Gynecologists recommends that postpartum persons who have lost more than 500 mL of blood after a vaginal delivery be assessed by the health-care provider. There are multiple causes of postpartum bleeding. Table 19.14 describes the causes of postpartum hemorrhage using the four T’s.

Considerations for PPH Cause for PPH
Tone Uterine atony*
Trauma Lacerations or uterine rupture
Tissue Retained placenta or clots
Thrombin Clotting-factor disorder (most likely genetic and listed in problem list of prenatal record)

*Most common cause—70 percent of postpartum hemorrhages.

Table 19.14 Four T’s of PPH (Bienstock et al., 2021)

Uterine Atony

Uterine atony is the most common cause of postpartum hemorrhage. The uterus can become atonic after chorioamnionitis, magnesium sulfate infusion, prolonged or precipitous labor, overdistention of the uterus due to twins or macrosomia, or cesarean birth. Nursing actions in the first hour after delivery include assessment of the location and tone of the uterus. Upon discovery of uterine atony, the nurse will start vigorous uterine massage. Treatment of uterine atony can be oxytocin (Pitocin), methylergonovine (Methergine), misoprostol (Cytotec), carboprost (Hemabate), tromethamine (Tham), and/or tranexamic acid (Cyklokapron). A full bladder can displace the uterus and not allow it to contract efficiently. The nurse empties the bladder to prevent or treat uterine atony.

Retained Fragments of the Placenta

After the placenta is delivered, the health-care provider will examine the placenta and membranes for completeness. Retained placental fragments or membranes can cause immediate postpartum hemorrhage. When fragments are retained in the uterus, the uterus is unable to contract properly to stop the spiral arteries from attempting to feed the placenta. If retained fragments are suspected, the health-care provider will manually evacuate the uterus.


Cervical and vaginal lacerations can cause immediate postpartum hemorrhage. Careful inspection is very important. If the nurse notices heavy vaginal bleeding and the uterus is contracted, inspection of the vagina for lacerations should occur. The health-care provider can assess for cervical lacerations using ring forceps to evaluate the completeness of the cervix. Lacerations are repaired using absorbable sutures. Figure 19.21 illustrates a cervical laceration.

Image of cervix with a laceration at the right side.
Figure 19.21 Cervical Laceration This cervix has a laceration at the 3 o’clock position. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Inversion of the Uterus

When the uterus turns inside out, protruding through the vagina, called inversion of the uterus, it is a life-threatening complication in the third stage of labor (Kumari et al., 2022). This occurs more often with active management of the third stage. However, other risk factors can be precipitous labor, manual removal of the placenta, and traction on a short umbilical cord. The signs of uterine inversion are hemorrhage, shock, and pelvic pain. The nurse attempts to massage the uterus, but the fundus cannot be palpated. The most common complication is hypovolemic shock and vagal response to sudden stretching of the uterine ligaments (Kumari et al., 2022). Rapid treatment is necessary. 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. Uterotonics will be administered once the uterus is returned to the proper position. The nurse will monitor for worsening signs of shock. Figure 19.22 illustrates a uterine inversion.

Image of the uterus turning inside out and coming out of the vagina.
Figure 19.22 Inversion of the Uterus Inversion of the uterus is defined as the uterus turning inside out, protruding through the vagina, and causing a life-threatening complication in the third stage of labor. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

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