Complications in the Third Stage of Labor
Key Points
- Third-stage complications are dominated by placental-delivery failure and hemorrhage mechanisms.
- Retained placenta and uterine atony are major drivers of immediate postpartum hemorrhage.
- Rapid quantification of blood loss and protocolized intervention are essential for survival.
Pathophysiology
The third stage requires efficient placental separation and sustained uterine contraction for hemostasis. When placental tissue remains, separation is delayed, or uterine tone is inadequate, spiral vessels remain open and severe bleeding can follow.
Complications can also involve cervical trapping, invasive placentation, laceration bleeding, or inversion-related collapse. Nursing response emphasizes immediate recognition, cause-targeted intervention, and continuous reassessment of perfusion.
Classification
- Placental-separation complications: Retained placenta, retained fragments, trapped placenta due to cervical closure.
- Hemorrhage complications: Immediate postpartum hemorrhage (often uterine atony-related).
- Structural/trauma complications: Laceration bleeding and uterine inversion contexts.
Nursing Assessment
NCLEX Focus
Priority questions ask which bleeding pattern indicates uterine atony versus laceration and what to do first.
- Track placental delivery timing and signs of incomplete separation.
- Quantify blood loss and assess for hypovolemia signs (tachycardia, hypotension, low oxygenation).
- Assess fundal tone/location and bladder status that may worsen atony.
- Inspect for laceration-related bleeding if uterus is firm but bleeding persists.
Nursing Interventions
- Initiate vigorous fundal support/massage when uterine atony is suspected.
- Empty bladder to improve uterine contraction efficiency.
- Administer ordered hemorrhage medications rapidly and coordinate provider intervention.
- Prepare for manual evacuation or operative management when retained tissue is suspected.
Hemorrhage Emergency
Immediate postpartum hemorrhage can escalate within minutes; delays in quantification and treatment increase mortality risk.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| uterotonics | Oxytocin, methylergonovine, misoprostol, carboprost | First-line treatment for uterine atony and prevention of ongoing blood loss. |
| antifibrinolytics | Tranexamic acid context | Supports clot stability in active hemorrhage pathways. |
Clinical Judgment Application
Clinical Scenario
Fifteen minutes after birth, placental delivery is incomplete and bleeding rapidly increases with a boggy fundus.
Recognize Cues: Delayed separation, heavy bleeding, and poor uterine tone. Analyze Cues: Retained tissue and atony are likely contributing to acute hemorrhage. Prioritize Hypotheses: Immediate priority is hemorrhage control and perfusion preservation. Generate Solutions: Fundal intervention, medication pathway, blood-loss quantification, and urgent provider escalation. Take Action: Execute hemorrhage bundle and prepare for procedural management if needed. Evaluate Outcomes: Uterine tone improves and blood loss decreases, or advanced intervention proceeds rapidly.
Related Concepts
- nursing-care-during-the-third-stage-of-labor - Baseline surveillance that detects early complication trends.
- nursing-care-during-the-fourth-stage-of-labor - Continuation phase for hemorrhage and involution monitoring.
- postpartum-hemorrhage - Major emergency outcome of third-stage complications.
- uterine-atony - Most common immediate postpartum hemorrhage cause.
- placenta-accreta-spectrum - Invasive placentation increases retained placenta and bleeding risk.
Self-Check
- Which findings distinguish atony-related bleeding from laceration-related bleeding?
- Why does retained placental tissue prevent effective uterine hemostasis?
- Which first actions should the nurse prioritize in immediate third-stage hemorrhage?