Labor Stage 3: Laceration and Episiotomy

by Veronica Gillispie, MD, FACOG

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    00:02 Now we'll talk about postpartum hemorrhage.

    00:06 So postpartum hemorrhage can be divided into primary versus secondary.

    00:11 Primary postpartum hemorrhage occurs within the first 24 hours after delivery.

    00:16 Secondary postpartum hemorrhage anywhere from 24 hours up to 12 weeks after delivery.

    00:21 It is important to know the difference because the causes are different.

    00:26 Postpartum defined by blood loss is greater than 500 cc for a vaginal delivery.

    00:32 And then greater than a 1000 cc for cesarean delivery.

    00:36 So when we think of primary postpartum hemorrhage and our causes we think of the 4 T's.

    00:41 That's Tone, Tissue, Trauma and Thrombin Disorders.

    00:45 We're going talk about each of these in a little detail.

    00:47 Tone is important because this accounts for 80 percent of the causes of postpartum hemorrhage.

    00:54 So there are some risk factors for you uterine atony.

    00:56 First is the extension of the uterus.

    00:58 Anything that distends the uterus such as multifetal gestation or polyhydramnios can cause the uterus to have difficulty contracting leading to uterine atony and being a cause of postpartum hemorrhage.

    01:10 Also uterine infection such as in the case of chorioamnionitis.

    01:14 Rapid or prolong labor.

    01:16 Fibroids or Grand multiparous.

    01:18 Again anything that's going to interfere with the ability of uterus to contract can lead to uterine atony.

    01:24 And that can lead to postpartum hemorrhage.

    01:27 Moving on to tissue.

    01:29 This refers to retain products of conception.

    01:32 We can see this when there's an extra lobe of the placenta that may be missing.

    01:36 Or if we have an abnormal placentation such as placenta acreta, placenta increta or placenta percreta.

    01:44 Trauma refers to any lacerations to the cervix, the vagina, the perineum.

    01:49 This can also include hematomas.

    01:53 And then thrombin disorder is that anything that will prevent clotting to take place.

    01:57 Such as DIC or in HELLP syndrome.

    02:02 Now when we look at our causes of late postpartum hemorrhage or secondary postpartum hemorrhage, that's infection such as metritis.

    02:09 Retain products of conception.

    02:11 So again if we have a lobe that's left behind.

    02:14 Subinvolution or coagulation defects.

    02:19 So when we talk about our treatment for postpartum hemorrhage.

    02:22 The treatment is directed to the cause.

    02:24 But remember no matter what the cause is, the initial step in management will always be destabilize the patient.

    02:33 So when we think about our management, we first want to call for help.

    02:38 We want to make sure that we have whoever we need to help us in this situation including another obstetrician, nurses and the help of our anesthesia colleagues.

    02:47 You want to begin resuscitation.

    02:49 If someone is bleeding, the first thing you want to do is start two large bore IV needles.

    02:54 Remember as they continue to bleed, it's going to be very difficult to get IV access if you not already establish that.

    03:00 You also want to give IV fluids and you want to start calling for blood.

    03:04 You want to check lab.

    03:06 You can to see where you're starting.

    03:08 So these labs will include a CBC, a type-in screen, PT, PTT, INR, and Fibrinogen.

    03:16 Now I don't know how quickly you get your labs back in your hospital.

    03:20 But sometimes when we need our lab results back quicker than we can get them from the lab.

    03:25 So there's a quick way you can check to see if someone is going in DIC.

    03:28 It's called the Red Top Tube Test.

    03:31 You take a red test tube that has a red top.

    03:35 Put 2 to 3 cc of mom's blood into that test tube and you leave it alone for about 6 minutes.

    03:42 You'll expect her blood to clot and stay clotted for 6 to 10 minutes.

    03:47 If the blood does not clot it that time, then you can suspect that patient is going into DIC.

    03:53 Next you want to consider the etiology.

    03:55 Remember we're going to direct our therapy to whatever the cause of postpartum hemorrhage is.

    About the Lecture

    The lecture Labor Stage 3: Laceration and Episiotomy by Veronica Gillispie, MD, FACOG is from the course Intrapartum Care.

    Included Quiz Questions

    1. Injury to the perineal muscles and the anal sphincter complex
    2. Injury to the vaginal epithelium and vulva skin but leaving the muscles intact
    3. Injury to the perineal muscles, but not including the anal sphincter
    4. injury to the perineum, anal sphinter complex, and rectal mucosa
    5. Injury to the vaginal epithelium and the cervix
    1. ...has a high risk of extending to a third or fourth degree injury during delivery.
    2. ...has a longer healing time.
    3. ...typically is more painful during healing.
    4. ...always involves the anal sphincter complex.
    5. ...is less effective in creating space for delivery.
    1. First degree laceration
    2. Second degree laceration
    3. Third degree laceration
    4. Fourth degree laceration
    5. Fifth degree laceration

    Author of lecture Labor Stage 3: Laceration and Episiotomy

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG

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