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The Immediate Postpartum Period as a Fourth Stage of Labor
THE IMMEDIATE POSTPARTUM PERIOD AS A FOURTH STAGE OF LABOR CARL
'L' .•]AVIm'r, M.D.,
\'Ew YoRK,
K Y.
( Jlro1n the Department of Obstet1·ics and Gynecology, Cornell University Medical College and the New York Hospital)
T
HE immediate postpartum period is defined as that interval after the expression of the placenta unto POmplete re attending obst!:'tricians in each instance. They illustrate the concept of tl1e immediate postpartum period as the fourth stage of labor. 1028
Volume 54 Number 6
FOURTH STAGE OF LABOR
1029
CASE 1.-Mrs. S. S., No. 434572, was a 28-year-old primigravida who had an operative (low forceps) delivery at term (3,800 Gm. infant). Analgesia was given including nembutal, scopolamine, and demerol. The delivery was performed under nitrous oxide, oxygen, and ether anesthesia. The duration of the first stage of labor was sixteen hours ; the second stage lasted thirty -seven minutes; and the third stage, ten minutes. The placenta separated by the Duncan mechanism and was expressed from the vagina in the usual manner. The blood loss in the third stage was 400 c.c. Intramuscular pituitrin and ergotrate were given. After expression of the placenta, bleeding continued and ergotrate was given intravenously on three occasions. The uterus was also packed and a total of 4000 c.c. of blood was given. Oxygen was also administered. As a result of these measures the patient rallied and was sent to her room eight hours after delivery. She regained partial consciousness. Oxygen was continued, as well a.~ pantopon, penicillin, and other measures. Nevertheless, the patient died twentyseven hours and thirty-three minutes after completion of the third stage of labor. An autopsy was not obtained, but a postmortem exploration of the vagina and uterus revealed a small tear in the posterior fornix that communicated with the abdominal cavity. The duration of the fourth stage in this case would be twenty-sevell hours and thirty-three minutes. The patient never reacted completely to the delivery, and there was a pack in the uterus at the time of death, so that firm contraction was never observed. CASE 2.-Mrs. G. G., Nt. 460184, was a 21-year-old primigravida, who was delivered spontaneously at term of a 3,650 Gm. infant. No analgesia was used in labor; nitrous oxide, oxygen, and ether were administered for the delivery. The duration of the first stage of labor was five hours; the second, two hours and two minutes; and the third stage, four minutes. The placenta was expressed in the Schultze mechanism, with a blood loss of 150 c.c. Routine pituitrin and ergotrate were given intramuscularly, and the fundus was held for one hour. Thereafter, the patient was returned to her room in good condition having· reacted completely to the anesthetic. Four and one-half hours after delivery the patient passed some membranes and 250 c.c. of blood clots. A second dose of ergotrate was given. Seven hours after delivery an. additional 800 c.c. in blood clots was expressed from the uterus, and thereafter the fundus remained firm, and no further bleeding occurred. A transfusion of 500 c.c. was given which was repeated in several days because the red count was still low. , The duration of the fourth stage of labor in this patient was seven hours (and not one hour as originally recorded in the labor room), counting from the time the placenta was expressed until the uterus remained firm with no excessive bleeding. CAsE 3.-Mrs. A. D., No. 281078, para i, gravida ii, was delivered spontaneously at term of a 3,500 Gm. infant after a precipitate labor. The duration of the first stage was eight hours; the second, fifteen minutes; and the third, four minutes. The' total blood loss was 30 c.c. No analgesia or anesthetic was required. The uterus was held for an hour after delivery, and it remained firm. This patient had a fourth stage of an hour's duration, the conventional period of time for holding the fundus. Most obstetric cases will fall into this category.
1030
JAVER'l'
Am.
J, Obst. & Ciynec. December, 1947
Historical Leishman ( 1875) credit:,; Desormeaux ( 1778 to 1830) with the time· honored classification of labor into three stages. Desormeaux was the successor to Baudeloque at the University of Paris in 1811. There is some precedent for dividing labor into four stages. Samuel Bard ( 1808) did so in the first American textbook published in America. He considered the third and fourth stages as the expulsive and placental periods. Smith ( 1858) in England and Edgar (1907) in America both described a preliminary or preparatory stage in addition to the classical description. Milne (1884) said that, while some authors taught four and even five stages, he preferred to use three. All modern textbooks divide labor into three stagrs. Madame Bourgeois ( 160D), the first midwife to write an obstetric textbook, limits the immediate postpartum period to one or two hours, and describes its management as follows: ''As soon as the woman is delivered after a hard labor, she must be put in the skin of a black sheep which has been flayed alive. This is applied to the haek. To the belly is applied the skin of a hare which has also been flayed aliye .... This chases away melancholic blood. In winter these remedies must be kept on two hours and in sumnH'r one hour." Chapman agreed with this! DeLee ( 1913), stated that the accoucher should remain iu the house for an hour, and before leaving should assure himself on the following seven points: i.e., uterus, hemorrhage, placenta, bladder, tears. infant, patient. Stander ( 1936), in addition to the statenwnt referred to above, also said that the hour following delivery was just as importf!nt as the actual third stage from a practical point of vie·w. ;, Morris Leff ( 1939) defined and described the management of the third and fourth stages of labor, the latter constituting the immediate postpartum period. Leff considered the fourth stage at an end when the patient had been returned to her room. This extent of time is insufficient as ::;hown by Case 1. The same author (1945) described the effect of oxytocics on the physiologic picture of the third and fourth stages. Greenberg (1946) gave hi:;; views on the physiology of the contractile and hemorrhagic phases of a fourth stage, which was limited to the first postplacental hour. This period of time is sufficient for the average ease (see Case 3) b11t not for abnormal cases as deRcribecl in Cases ] and 2. The present article is a presentation of a llcfinition of the immediate postpartum period, and a description of its elinieal, anatomic, physiologic, and pathologic characteristics.
Discussion The prevailing coneepts of the iwmediate postpartum period need no revision in order to include it as a part of the process of labor. One need only to reflect on the clinical, anatomic, physiologic, and pathologie characteristics of the immediate puerperium to realize that this period is truly a stage of labor. The clinical aspects of this period include the following: effects from analgesia or anesthesia ; estimating· or measuring the blood loss; postpartum administration of oxytoeics; repairing lacerations or episiotomy; holding the fun· dus for an hour after delivery; checking the pulse, respirations and blood pressure; examining the placenta; raring for the infant (tying the cord, silver nitrate, weight, etc.) ; sometimes removing membranes or a sueeenturiate lobe;
Volume 54
:-.lumber 6
FOUR'l'H S'l'AGE OF LABOR
1031
exploring the uterus or packing it; transfusions; etc.:. When the patient has c.:ompletely recovered from the effects of labor and delivery, including analgesia and anesthesia used in labor, with the uterus remaining firmly contracted without excessive bleeding, the fourth stage of labor may be considered clinically at an end. The anatomic characteristics include the firm, thick fundus or the active segment of the uterus, and the thinner, loosely contracted lower uterine segment and cervix, or passive segment. The placental sitr consists of compressed uterine glands in the basal layer .(Gebhardt's glands), which are invaded by chorionic giant cells according to .T. W. Williams, whose article on the subject was published posthumously in 19:ll. He stated that it was often impossible to detect the placental site grossly in fixed specimens remoYecl after cesarean section. Physiologic characteristics include the alternate contraction and relaxation of the uterus after completion of the third stage. 'l'he placenta has separated along Nitabuch 's layer between the placenta and the decidua vera. Festooning and shortening of the uterine n~uscle fibers reduce the size of the uterus as well as the placental site. Bleeding may continue after the placenta has been expressed. Extreme relaxation or uterine atony at this time may result in postpartum hemorrhage and death, as shown in Table I. The pathologic aspects of the immediate postpartum period constitute important complications. These include: retained membranes, cotyledons, or succenturiate lobes; rupture or inversion of the uterus; vaginal lacerations; postpartum chill; postpartum hemorrhage; convulsions of eclampsia; cardiorespiratory failure; drug or anesthetic rNlctions, and aspiration pneumonia. The various causes of maternal death occurring in the immediate postpartum period serve to make this stage of labor doubly significant. A total of 88 maternal deaths occurring at the New York Lying-In Hospital from 1932 to 1945, includes 28 patients ( 32 per cent) who died during the immediate postpartum period of labor. The causes of death in these patients are given in Table I. Lafferty has reported that 33 per cent of the maternal deaths h1 Philadelphia occurred within the first twenty-four hours of delivery. TABr,E I.
CAUSES OJ.' DEATH IN TilE IMMEDIATE POS'fPARTUM PERIOD OF J~ABOR
Cardiac failure Anesthesia Aspiration pneumonia Rupture of uterus Transfusion reaction
5
4
2 2 2 1
Summary Definition.-The immediate postpartum period may be defined as the interval after expression of the placenta to a satisfactory reaction of the patient to the delivery including a firmly contracted uterus without excessive bleeding.
1032
JAVER'l'
Am.
J, Obst. & Gynec. December, 1947
'l'he duration will vary from the traditional hour, under normal conditions, to many hours when abnormal conditions arise. Ordinarily, the period will be of sixty minutes' duration, the conventional interval of time for holding the fundus. 'l'he concept was illustrated with case reports. This period has definite clinical, anatomic, physiologic, and pathologic ~haracteristics that justifies its inclusion iu the definition of labor as a separate fourth stage. 'l'hese characteristics are the anticlimax to the preceding three stages of labor. Twenty-eight, or one-third of a total number of eighty-eight maternal deaths occurred, or w·ere recognized, in the immediate postpartum period. The commonest cause was postpartum hemorrhagE>. Emphasis should he placed on this stage by recording its events as part of the labor history. The characteristics of the immediate po:-;tpartnm period a~; a stage of labor should be publicized nationally. It is expected that such a program will serve to reduce the number of prrventable matel'na l
References Bard, Samuel: Compendium o£ Midwifery, New York, 1808, Collins and Perkins, p. 105. Bourgeois, Madame: Quoted from Robb, John:s Hopkins Hospital Bulletin, 4: 75, 1893. Busey, S. C.: Hirst's System o£ Obstetrics, Philadelphia, 1888, Lea Bros. & Co., p. 479. Chapman: See Bourgeois. DeLee, J. B.: Principles and Practices of Obstetrics, Philadelphia, 1913, W. B. Saunders Co., pages 114, 319. Edgar, J. C.: P,ractice of Obstetrics, Philadelphia, 1907, Blakiston 's Son & Co., p. 423. Greenberg, E.: AM. J. 0BST. & GYNEC. 52: 746-755, 1946. Jewett, C.: Practice of Obstetrics, Philadelphia, 1901, Lea Bros. & Co., p. 192. King, A. F.: Obstetrics, Philadelphia, J 903, Lea Bros. & Co. ' Lafferty, H. D.: AM. J. 0BS1'. & GYNEr. 41: 342-345, 1941. Leff, Morris: Labor, Sur g., Gynec. & Obst. 68: 224-229, 1939. Leff, Morris: AM. J. Onsr. & GYNEC. 49: 743-748, 1945. Leishman, W.: Midwifery, Philadelphia, 1875, Lea Bros. & Co., p. 275. Stander, H. J.: Williams Obstetrics, New York, 1936, D. Appleton Century Co., p. 427. Smith, W. '1'.: Obstetrics, London, 1858, Churchill, p. 290.
'L' .•]AVIm'r, M.D.,
\'Ew YoRK,
K Y.
( Jlro1n the Department of Obstet1·ics and Gynecology, Cornell University Medical College and the New York Hospital)
T
HE immediate postpartum period is defined as that interval after the expression of the placenta unto POmplete re
Volume 54 Number 6
FOURTH STAGE OF LABOR
1029
CASE 1.-Mrs. S. S., No. 434572, was a 28-year-old primigravida who had an operative (low forceps) delivery at term (3,800 Gm. infant). Analgesia was given including nembutal, scopolamine, and demerol. The delivery was performed under nitrous oxide, oxygen, and ether anesthesia. The duration of the first stage of labor was sixteen hours ; the second stage lasted thirty -seven minutes; and the third stage, ten minutes. The placenta separated by the Duncan mechanism and was expressed from the vagina in the usual manner. The blood loss in the third stage was 400 c.c. Intramuscular pituitrin and ergotrate were given. After expression of the placenta, bleeding continued and ergotrate was given intravenously on three occasions. The uterus was also packed and a total of 4000 c.c. of blood was given. Oxygen was also administered. As a result of these measures the patient rallied and was sent to her room eight hours after delivery. She regained partial consciousness. Oxygen was continued, as well a.~ pantopon, penicillin, and other measures. Nevertheless, the patient died twentyseven hours and thirty-three minutes after completion of the third stage of labor. An autopsy was not obtained, but a postmortem exploration of the vagina and uterus revealed a small tear in the posterior fornix that communicated with the abdominal cavity. The duration of the fourth stage in this case would be twenty-sevell hours and thirty-three minutes. The patient never reacted completely to the delivery, and there was a pack in the uterus at the time of death, so that firm contraction was never observed. CASE 2.-Mrs. G. G., Nt. 460184, was a 21-year-old primigravida, who was delivered spontaneously at term of a 3,650 Gm. infant. No analgesia was used in labor; nitrous oxide, oxygen, and ether were administered for the delivery. The duration of the first stage of labor was five hours; the second, two hours and two minutes; and the third stage, four minutes. The placenta was expressed in the Schultze mechanism, with a blood loss of 150 c.c. Routine pituitrin and ergotrate were given intramuscularly, and the fundus was held for one hour. Thereafter, the patient was returned to her room in good condition having· reacted completely to the anesthetic. Four and one-half hours after delivery the patient passed some membranes and 250 c.c. of blood clots. A second dose of ergotrate was given. Seven hours after delivery an. additional 800 c.c. in blood clots was expressed from the uterus, and thereafter the fundus remained firm, and no further bleeding occurred. A transfusion of 500 c.c. was given which was repeated in several days because the red count was still low. , The duration of the fourth stage of labor in this patient was seven hours (and not one hour as originally recorded in the labor room), counting from the time the placenta was expressed until the uterus remained firm with no excessive bleeding. CAsE 3.-Mrs. A. D., No. 281078, para i, gravida ii, was delivered spontaneously at term of a 3,500 Gm. infant after a precipitate labor. The duration of the first stage was eight hours; the second, fifteen minutes; and the third, four minutes. The' total blood loss was 30 c.c. No analgesia or anesthetic was required. The uterus was held for an hour after delivery, and it remained firm. This patient had a fourth stage of an hour's duration, the conventional period of time for holding the fundus. Most obstetric cases will fall into this category.
1030
JAVER'l'
Am.
J, Obst. & Ciynec. December, 1947
Historical Leishman ( 1875) credit:,; Desormeaux ( 1778 to 1830) with the time· honored classification of labor into three stages. Desormeaux was the successor to Baudeloque at the University of Paris in 1811. There is some precedent for dividing labor into four stages. Samuel Bard ( 1808) did so in the first American textbook published in America. He considered the third and fourth stages as the expulsive and placental periods. Smith ( 1858) in England and Edgar (1907) in America both described a preliminary or preparatory stage in addition to the classical description. Milne (1884) said that, while some authors taught four and even five stages, he preferred to use three. All modern textbooks divide labor into three stagrs. Madame Bourgeois ( 160D), the first midwife to write an obstetric textbook, limits the immediate postpartum period to one or two hours, and describes its management as follows: ''As soon as the woman is delivered after a hard labor, she must be put in the skin of a black sheep which has been flayed alive. This is applied to the haek. To the belly is applied the skin of a hare which has also been flayed aliye .... This chases away melancholic blood. In winter these remedies must be kept on two hours and in sumnH'r one hour." Chapman agreed with this! DeLee ( 1913), stated that the accoucher should remain iu the house for an hour, and before leaving should assure himself on the following seven points: i.e., uterus, hemorrhage, placenta, bladder, tears. infant, patient. Stander ( 1936), in addition to the statenwnt referred to above, also said that the hour following delivery was just as importf!nt as the actual third stage from a practical point of vie·w. ;, Morris Leff ( 1939) defined and described the management of the third and fourth stages of labor, the latter constituting the immediate postpartum period. Leff considered the fourth stage at an end when the patient had been returned to her room. This extent of time is insufficient as ::;hown by Case 1. The same author (1945) described the effect of oxytocics on the physiologic picture of the third and fourth stages. Greenberg (1946) gave hi:;; views on the physiology of the contractile and hemorrhagic phases of a fourth stage, which was limited to the first postplacental hour. This period of time is sufficient for the average ease (see Case 3) b11t not for abnormal cases as deRcribecl in Cases ] and 2. The present article is a presentation of a llcfinition of the immediate postpartum period, and a description of its elinieal, anatomic, physiologic, and pathologic characteristics.
Discussion The prevailing coneepts of the iwmediate postpartum period need no revision in order to include it as a part of the process of labor. One need only to reflect on the clinical, anatomic, physiologic, and pathologie characteristics of the immediate puerperium to realize that this period is truly a stage of labor. The clinical aspects of this period include the following: effects from analgesia or anesthesia ; estimating· or measuring the blood loss; postpartum administration of oxytoeics; repairing lacerations or episiotomy; holding the fun· dus for an hour after delivery; checking the pulse, respirations and blood pressure; examining the placenta; raring for the infant (tying the cord, silver nitrate, weight, etc.) ; sometimes removing membranes or a sueeenturiate lobe;
Volume 54
:-.lumber 6
FOUR'l'H S'l'AGE OF LABOR
1031
exploring the uterus or packing it; transfusions; etc.:. When the patient has c.:ompletely recovered from the effects of labor and delivery, including analgesia and anesthesia used in labor, with the uterus remaining firmly contracted without excessive bleeding, the fourth stage of labor may be considered clinically at an end. The anatomic characteristics include the firm, thick fundus or the active segment of the uterus, and the thinner, loosely contracted lower uterine segment and cervix, or passive segment. The placental sitr consists of compressed uterine glands in the basal layer .(Gebhardt's glands), which are invaded by chorionic giant cells according to .T. W. Williams, whose article on the subject was published posthumously in 19:ll. He stated that it was often impossible to detect the placental site grossly in fixed specimens remoYecl after cesarean section. Physiologic characteristics include the alternate contraction and relaxation of the uterus after completion of the third stage. 'l'he placenta has separated along Nitabuch 's layer between the placenta and the decidua vera. Festooning and shortening of the uterine n~uscle fibers reduce the size of the uterus as well as the placental site. Bleeding may continue after the placenta has been expressed. Extreme relaxation or uterine atony at this time may result in postpartum hemorrhage and death, as shown in Table I. The pathologic aspects of the immediate postpartum period constitute important complications. These include: retained membranes, cotyledons, or succenturiate lobes; rupture or inversion of the uterus; vaginal lacerations; postpartum chill; postpartum hemorrhage; convulsions of eclampsia; cardiorespiratory failure; drug or anesthetic rNlctions, and aspiration pneumonia. The various causes of maternal death occurring in the immediate postpartum period serve to make this stage of labor doubly significant. A total of 88 maternal deaths occurring at the New York Lying-In Hospital from 1932 to 1945, includes 28 patients ( 32 per cent) who died during the immediate postpartum period of labor. The causes of death in these patients are given in Table I. Lafferty has reported that 33 per cent of the maternal deaths h1 Philadelphia occurred within the first twenty-four hours of delivery. TABr,E I.
CAUSES OJ.' DEATH IN TilE IMMEDIATE POS'fPARTUM PERIOD OF J~ABOR
Cardiac failure Anesthesia Aspiration pneumonia Rupture of uterus Transfusion reaction
5
4
2 2 2 1
Summary Definition.-The immediate postpartum period may be defined as the interval after expression of the placenta to a satisfactory reaction of the patient to the delivery including a firmly contracted uterus without excessive bleeding.
1032
JAVER'l'
Am.
J, Obst. & Gynec. December, 1947
'l'he duration will vary from the traditional hour, under normal conditions, to many hours when abnormal conditions arise. Ordinarily, the period will be of sixty minutes' duration, the conventional interval of time for holding the fundus. 'l'he concept was illustrated with case reports. This period has definite clinical, anatomic, physiologic, and pathologic ~haracteristics that justifies its inclusion iu the definition of labor as a separate fourth stage. 'l'hese characteristics are the anticlimax to the preceding three stages of labor. Twenty-eight, or one-third of a total number of eighty-eight maternal deaths occurred, or w·ere recognized, in the immediate postpartum period. The commonest cause was postpartum hemorrhagE>. Emphasis should he placed on this stage by recording its events as part of the labor history. The characteristics of the immediate po:-;tpartnm period a~; a stage of labor should be publicized nationally. It is expected that such a program will serve to reduce the number of prrventable matel'na l
References Bard, Samuel: Compendium o£ Midwifery, New York, 1808, Collins and Perkins, p. 105. Bourgeois, Madame: Quoted from Robb, John:s Hopkins Hospital Bulletin, 4: 75, 1893. Busey, S. C.: Hirst's System o£ Obstetrics, Philadelphia, 1888, Lea Bros. & Co., p. 479. Chapman: See Bourgeois. DeLee, J. B.: Principles and Practices of Obstetrics, Philadelphia, 1913, W. B. Saunders Co., pages 114, 319. Edgar, J. C.: P,ractice of Obstetrics, Philadelphia, 1907, Blakiston 's Son & Co., p. 423. Greenberg, E.: AM. J. 0BST. & GYNEC. 52: 746-755, 1946. Jewett, C.: Practice of Obstetrics, Philadelphia, 1901, Lea Bros. & Co., p. 192. King, A. F.: Obstetrics, Philadelphia, J 903, Lea Bros. & Co. ' Lafferty, H. D.: AM. J. 0BS1'. & GYNEr. 41: 342-345, 1941. Leff, Morris: Labor, Sur g., Gynec. & Obst. 68: 224-229, 1939. Leff, Morris: AM. J. Onsr. & GYNEC. 49: 743-748, 1945. Leishman, W.: Midwifery, Philadelphia, 1875, Lea Bros. & Co., p. 275. Stander, H. J.: Williams Obstetrics, New York, 1936, D. Appleton Century Co., p. 427. Smith, W. '1'.: Obstetrics, London, 1858, Churchill, p. 290.