Manual separation of the placenta and separation of the placenta. Manual separation of placenta. Surgical interventions in the subsequent period

Manual separation of the placenta is an obstetric operation, which consists in separating the placenta from the walls of the uterus with a hand inserted into the uterine cavity, followed by removal of the placenta.

INDICATIONS

The normal afterbirth period is characterized by the separation of the placenta from the walls of the uterus and the expulsion of the placenta in the first 10-15 minutes after the birth of the child.

If there are no signs of separation of the placenta within 30–40 minutes after the birth of the child (with partial dense, complete dense attachment or placenta accreta), as well as in case of infringement of the separated placenta, the operation of manual separation of the placenta and allocation of the placenta is indicated.

PAIN RELIEF METHODS

Intravenous or inhalation general anesthesia.

OPERATIONAL TECHNIQUE

After appropriate treatment of the surgeon's hands and the external genital organs of the patient, the right hand, dressed in a long surgical glove, is inserted into the uterine cavity, and its bottom is fixed from the outside with the left hand. The umbilical cord serves as a guide to help find the placenta. Having reached the place of attachment of the umbilical cord, the edge of the placenta is determined and it is separated from the wall of the uterus with sawtooth movements. Then, by pulling the umbilical cord with the left hand, the placenta is isolated; the right hand remains in the uterine cavity for control study its walls. The delay of the parts is established when examining the released placenta and detecting a defect in the tissue, membranes or the absence of an additional lobule. A defect in the placental tissue is detected when examining the maternal surface of the placenta, spread out on a flat surface. The delay of the additional lobe is indicated by the detection of a torn vessel along the edge of the placenta or between the membranes. The integrity of the fruit membranes is determined after they are straightened, for which the placenta should be raised.

After the end of the operation, until the hand is removed from the uterine cavity, 1 ml of a 0.2% solution of methylergometrine is injected intravenously simultaneously, and then intravenous drip administration of drugs that have a uterotonic effect (5 IU of oxytocin) is started, an ice pack is placed on the suprapubic region of the abdomen.

COMPLICATIONS

In the case of placenta accreta, an attempt to manually separate it is ineffective. The placental tissue is torn and does not separate from the uterine wall, profuse bleeding, quickly leading to the development of hemorrhagic shock as a result of uterine atony. In this regard, if placenta accreta is suspected, it is indicated surgical removal uterus on an emergency basis. The final diagnosis is established after histological examination.

Inspection birth canal in the postpartum period

Inspection of the birth canal

After childbirth, an examination of the birth canal is mandatory for ruptures. To do this, special spoon-shaped mirrors are inserted into the vagina. First, the doctor examines the cervix. To do this, the neck is taken with special clamps, and the doctor bypasses it around the perimeter, reattaching the clamps. At the same time, a woman may feel pulling sensations lower abdomen. If there are ruptures of the cervix, they are sewn up, anesthesia is not required, since there is no pain receptors. Then the vagina and perineum are examined. If there are gaps, they are sewn up.

Sewing of tears is usually performed under local anesthesia (novocaine is injected into the area of the tear or the genitals are sprayed with a lidocaine spray). If a manual separation of the placenta or an examination of the uterine cavity under intravenous anesthesia was performed, then the examination and suturing are also carried out under intravenous anesthesia (the woman is taken out of anesthesia only after the examination of the birth canal is completed). If there was epidural anesthesia, then an additional dose of anesthesia is administered through a special catheter left in the epidural space since the birth. After the examination, the birth canal is treated with a disinfectant solution.

Be sure to evaluate the amount of bleeding. A tray is placed at the exit from the vagina, where everyone gathers bloody issues, the blood remaining on napkins, diapers is also taken into account. Normal blood loss is 250 ml, up to 400-500 ml is acceptable. Large blood loss may indicate hypotension (relaxation) of the uterus, retention of parts of the placenta, or an unsutured rupture.

Two hours after birth

The early postpartum period includes the first 2 hours after childbirth. During this period, various complications may occur: bleeding from the uterus, the formation of a hematoma (accumulation of blood in a confined space). Hematomas can cause compression of surrounding tissues, a feeling of fullness, in addition, they are a sign of an unsutured rupture, bleeding from which can continue, after a while, hematomas can suppurate. Periodically (every 15-20 minutes), a doctor or midwife approaches the young mother and evaluates the contraction of the uterus (for this, the uterus is probed through the anterior abdominal wall), the nature of the discharge and the condition of the perineum. After two hours, if everything is fine, the woman with the baby is transferred to the postpartum department.

Output obstetric forceps. Indications, conditions, technique, prevention of complications.

overlay obstetric forceps- delivery operation, during which the fetus is removed from the birth canal of the mother with the help of special tools.

Obstetrical forceps are intended only for removing the fetus by the head, but not for changing the position of the fetal head. The purpose of the operation of applying obstetric forceps is to replace the generic expelling forces with the entraining force of the obstetrician.

Obstetric forceps have two branches, interconnected with a lock, each branch consists of a spoon, a lock and a handle. The forceps spoons have a pelvic and head curvature and are designed to actually capture the head, the handle is used for traction. Depending on the device of the lock, several modifications of obstetric forceps are distinguished; in Russia, obstetric forceps of Simpson-Fenomenov are used, the lock of which is characterized by simplicity of the device and considerable mobility.

CLASSIFICATION

Depending on the position of the fetal head in the small pelvis, the technique of the operation varies. When the fetal head is located in the wide plane of the small pelvis, cavity or atypical forceps are applied. Forceps applied to the head, located in the narrow part of the pelvic cavity (the sagittal suture is almost in a straight size), are called low cavity (typical).

The most favorable variant of the operation, associated with the smallest number complications, both for the mother and the fetus, - the imposition of typical obstetric forceps. In connection with the expansion of indications for CS surgery in modern obstetrics, forceps are used only as a method of emergency delivery, if the opportunity to perform CS is missed.

INDICATIONS

Preeclampsia heavy course, not amenable conservative therapy and requiring the exclusion of attempts.

Persistent secondary weakness labor activity or weakness of attempts, not amenable to medical correction, accompanied by prolonged standing of the head in one plane.

PONRP in the second stage of labor.

The presence of extragenital diseases in a woman in labor, requiring the exclusion of attempts (diseases of the cardiovascular system, myopia high degree and etc.).

Acute fetal hypoxia.

CONTRAINDICATIONS

Relative contraindications- prematurity and large fetus.

CONDITIONS FOR THE OPERATION

Live fruit.

Full opening of the uterine os.

Absence of a fetal bladder.

The location of the fetal head in the narrow part of the pelvic cavity.

Correspondence of the size of the fetal head and the mother's pelvis.

PREPARATION FOR OPERATION

It is necessary to consult an anesthesiologist and choose the method of anesthesia. The woman in labor is in the supine position with her knees bent and hip joints feet. The bladder is emptied, the external genital organs and the inner surface of the thighs of the woman in labor are treated with disinfectant solutions. Conduct a vaginal examination to clarify the position of the fetal head in the pelvis. The forceps are checked, the hands of the obstetrician are treated as if for a surgical operation.

PAIN RELIEF METHODS

The method of anesthesia is chosen depending on the condition of the woman and the fetus and the nature of the indications for surgery. At healthy woman(with the expediency of her participation in the process of childbirth) with weakness of labor activity or acute hypoxia fetus, epidural anesthesia or inhalation of a mixture of nitrous oxide and oxygen can be used. If it is necessary to turn off the attempts, the operation is performed under anesthesia.

OPERATIONAL TECHNIQUE

General technique operations for applying obstetric forceps includes the rules for applying obstetric forceps, which are observed regardless of the plane of the pelvis in which the fetal head is located. The operation of applying obstetric forceps necessarily includes five stages: the introduction of spoons and their placement on the fetal head, the closing of the forceps branches, trial traction, removal of the head, and removal of the forceps.

Rules for the introduction of spoons

The left spoon is held with the left hand and inserted into left side the mother's pelvis under the control of the right hand, the left spoon is introduced first, since it has a lock.

Holding the right spoon right hand and enter into right side mother's pelvis over the left spoon.

To control the position of the spoon, all the fingers of the obstetrician's hand are inserted into the vagina, except for the thumb, which remains outside and is set aside. Then, like a writing pen or a bow, they take the handle of the tongs, while the top of the spoon should be facing forward, and the handle of the tongs should be parallel to the opposite inguinal fold. The spoon is inserted slowly and carefully with the help of pushing movements of the thumb. As the spoon moves forward, the handle of the tongs is moved to horizontal position and drop down. After inserting the left spoon, the obstetrician removes the hand from the vagina and passes the handle of the inserted spoon to the assistant, who prevents the spoon from moving. Then a second spoon is introduced. Spoons of forceps lie on the head of the fetus in its transverse size. After the introduction of the spoons, the handles of the tongs are brought together and they try to close the lock. In this case, difficulties may arise:

The lock does not close because the spoons of the tongs are placed on the head not in the same plane - the position of the right spoon is corrected by shifting the branch of the tongs with sliding movements along the head;

One spoon is located above the other and the lock does not close - under the control of the fingers inserted into the vagina, the overlying spoon is shifted downward;

The branches are closed, but the handles of the tongs diverge strongly, which indicates that the spoons of the tongs are not placed on transverse dimension heads, but on an oblique, oh large sizes the head or too high location of the spoons on the fetal head, when the tops of the spoons rest against the head and the head curvature of the forceps does not fit it - it is advisable to remove the spoons, conduct a second vaginal examination and repeat the attempt to apply the forceps;

· internal surfaces forceps handles do not fit tightly to each other, which, as a rule, occurs if the transverse size of the fetal head is more than 8 cm - a four-fold diaper is inserted between the forceps handles, which prevents excessive pressure on the fetal head.

After closing the branches of the forceps, check whether the forceps have caught soft tissues ancestral pathways. Then a trial traction is carried out: the handles of the forceps are grasped with the right hand, they are fixed with the left hand, index finger of the left hand are in contact with the head of the fetus (if during traction it does not move away from the head, then the forceps are applied correctly).

Next, the actual traction is carried out, the purpose of which is to remove the fetal head. The direction of traction is determined by the position of the fetal head in the pelvic cavity. When the head is in the wide part of the small pelvic cavity, the traction is directed downward and backward, with traction from the narrow part of the small pelvic cavity, the attraction is carried down, and when the head is standing in the outlet of the small pelvis, it is directed down, towards itself and forward.

Traction should imitate contractions in intensity: gradually begin, intensify and weaken, a pause of 1–2 minutes is necessary between tractions. Usually 3-5 tractions are enough to extract the fetus.

The fetal head can be brought out in forceps or they are removed after bringing the head down to the exit of the small pelvis and vulvar ring. When passing through the vulvar ring, the perineum is usually cut (obliquely or longitudinally).

When removing the head, serious complications can occur, such as the lack of advancement of the head and slipping of the spoons from the fetal head, the prevention of which consists in clarifying the position of the head in the small pelvis and correcting the position of the spoons.

If the forceps are removed before the eruption of the head, then first the handles of the forceps are spread and the lock is opened, then the spoons of the forceps are removed in the reverse order of insertion - first the right, then the left, deviating the handles towards the opposite thigh of the woman in labor. When removing the fetal head in forceps, traction is carried out with the right hand in an anterior direction, and the perineum is supported with the left hand. After the birth of the head, the lock of the forceps is opened and the forceps are removed.

Obstetric forceps.

Parts: 2 curvatures: pelvic and head, tops, spoons, lock, bush hooks, ribbed handles.

At correct position in the hands - look up, from above and in front - the pelvic bend.

Indications:

1. from the mother's side:

EGP in the stage of decompensation

Severe PTB (BP=200 mm Hg - no pushing)

high myopia

2. on the part of labor activity: weakness of attempts

3. on the part of the fetus: progression of fetal hypoxia.

Conditions for application:

the pelvis should not be narrow

CMM must be fully open (10 - 12 cm) - otherwise you can infringe the CMM separation

the amniotic sac must be opened, otherwise PONRP

The head should not be large - it will not be possible to close the forceps. If it's small, it will slip off. With hydrocephalus, prematurity - forceps are contraindicated

the head should be in the outlet of the small pelvis

Training:

remove urine with a catheter

treatment of the doctor's hands and female genital organs

episiotomy - to protect the perineum

assistant

Anesthetize: intravenous anesthesia or pudendal anesthesia

Technique:

3 triple rules:

1. the direction of traction (this is the pulling movement) cannot be rotated in 3 positions:

on obstetrician's socks

· to myself

on the obstetrician's face

2. 3 left: left spoon in left hand in the left side of the pelvis

3. 3 right: right spoon with right hand into the right half of the pelvis.

putting spoons on the head:

tops facing the conductive head

Spoons capture the head with the largest circumference (from the chin to the small fontanel)

the conductive point lies in the plane of the forceps

Stages:

Introduction of spoons: the left spoon in the left hand as a bow or handle, the right spoon is given to the assistant. The right hand (4 fingers) is inserted into the vagina, a spoon is inserted along the arm, thumb guiding forward. When the branch is parallel to the table, stop. Do the same with the right spoon.

Closing the forceps: if the head is large, then a diaper is clamped between the handles.

Trial traction - whether the head will move behind the forceps. The 3rd finger of the right hand is placed on the lock, fingers 2 and 4 on the Bush hooks, and 5 and 1 on the handle. Trial traction +3 finger of the left hand on the sagittal suture.

Actually traction: over the right hand - the left hand.

Removing the forceps: remove the left hand and spread the jaws of the forceps with it

The placenta is the organ that allows the child to be born in the womb. It supplies the fetus useful material, protects it from the mother, produces hormones necessary to maintain pregnancy and many other functions that we can only guess about.

Formation of the placenta

The formation of the placenta begins from the moment the fetal egg attaches to the wall of the uterus. The endometrium grows together with the fertilized egg, tightly fixing it to the wall of the uterus. In the place of contact between the zygote and the mucosa, the placenta grows over time. The so-called placentation begins from the third week of pregnancy. Until the sixth week, the embryonic membrane is called the chorion.

Until the twelfth week, the placenta does not have a clear histological and anatomical structure, but after, until the middle of the third trimester, it looks like a disk attached to the wall of the uterus. FROM outside the umbilical cord departs from it to the child, and inner side is a surface with villi that float in maternal blood.

Functions of the placenta

The child's place forms a bond between the fetus and the mother's body through the exchange of blood. This is called the hematoplacental barrier. Morphologically, it is a young vessel with a thin wall, which form small villi over the entire surface of the placenta. They come into contact with the gaps located in the wall of the uterus, and blood circulates between them. This mechanism provides all the functions of the body:

Gas exchange. Oxygen from the mother's blood goes to the fetus, and carbon dioxide is transported back.
Nutrition and excretion. It is through the placenta that the child receives all the substances necessary for growth and development: water, vitamins, minerals, electrolytes. And after the body of the fetus metabolizes them into urea, creatinine and other compounds, the placenta utilizes everything.
hormonal function. The placenta secretes hormones that help maintain pregnancy: progesterone, chorionic gonadotropin, prolactin. On the early dates takes on this role corpus luteum located in the ovary.
Protection. The hematoplacental barrier does not allow antigens from the mother's blood to enter the child's blood, in addition, the placenta does not allow many medications, own immune cells and circulating immune complexes. However, it is permeable to narcotic substances, alcohol, nicotine and viruses.

Degrees of maturity of the placenta

The degree of maturation of the placenta depends on the duration of the woman's pregnancy. This organ grows with the fetus and dies after birth. There are four degrees of placental maturity:

Zero - in the normal course of pregnancy lasts up to seven lunar months. It is relatively thin, constantly increasing and forming new gaps.
The first - corresponds to the eighth gestational month. The growth of the placenta stops, it becomes thicker. This is one of critical periods in the life of the placenta, and even a minor intervention can provoke detachment.
The second - continues until the end of pregnancy. The placenta is already beginning to age, after nine months of hard work, it is ready to leave the uterine cavity after the baby.
The third - can be observed from the thirty-seventh week of gestation inclusive. This is the natural aging of an organ that has fulfilled its function.

Attachment of the placenta

Most often located or goes to the side wall. But it is finally possible to find out only when two-thirds of the pregnancy is already over. This is due to the fact that the uterus increases in size and changes its shape, and the placenta moves along with it.

Usually, during the current ultrasound examination, the doctor notes the location of the placenta and the height of its attachment relative to the uterine os. The placenta is normal back wall is high. At least seven centimeters should be between the internal os and the edge of the placenta by the third trimester. Sometimes she even crawls to the bottom of the uterus. Although experts believe that such an arrangement is also not a guarantee of successful delivery. If this figure is lower, then obstetrician-gynecologists talk about. If there are placental tissues in the throat area, then this indicates its presentation.

There are three types of presentation:

Complete, when So in case of premature detachment there will be massive bleeding, which will lead to the death of the fetus.
Partial presentation means that the pharynx is blocked by no more than a third.
Regional presentation is established when the edge of the placenta reaches the pharynx, but does not go beyond it. This is the most favorable outcome of events.

Periods of childbirth

Normal physiological childbirth begins at the time of the appearance of regular contractions with equal intervals between them. In obstetrics, three stages of childbirth are distinguished.

The first period is the birth canal must prepare for the fact that the fetus will move along them. They should expand, become more elastic and softer. At the beginning of the first period, the opening of the cervix is only two centimeters, or one obstetrician's finger, and by the end it should reach ten or even twelve centimeters and skip a whole fist. Only in this case the baby's head can be born. Most often, at the end of the disclosure period, amniotic fluid is poured out. In total, the first stage lasts from nine to twelve hours.

The second period is called the expulsion of the fetus. The contractions are replaced by attempts, the bottom of the uterus contracts intensely and pushes the baby out. The fetus moves through the birth canal, turning according to anatomical features pelvis. Depending on the presentation, the child may be born with a head or booty, but the obstetrician must be able to help him be born in any position.

The third period is called the afterbirth and begins from the moment the child is born, and ends with the appearance of the placenta. Normally, it lasts half an hour, and after fifteen minutes the placenta separates from the wall of the uterus and is pushed out of the womb with the last attempt.

Delayed placenta separation

The reasons for the retention of the placenta in the uterine cavity may be its hypotension, placental accreta, anomalies in the structure or location of the placenta, fusion of the placenta with the wall of the uterus. The risk factors in this case are inflammatory diseases uterine mucosa, the presence of scars from caesarean section, fibroids, as well as a history of miscarriages.

A symptom of retained placenta is bleeding in the third stage of labor and after it. Sometimes the blood does not immediately flow out, but accumulates in the uterine cavity. Such occult bleeding can lead to hemorrhagic shock.

placenta accreta

It is called tight attachment to the wall of the uterus. The placenta can lie on the mucous membrane, be immersed in the wall of the uterus to the muscle layer and grow through all layers, even affecting the peritoneum.

Manual separation of the placenta is possible only in the case of the first degree of increment, that is, when it is tightly adherent to the mucosa. But if the increment has reached the second or third degree, then it requires surgical intervention. As a rule, on an ultrasound scan, you can distinguish how the baby's place is attached to the wall of the uterus, and discuss this point with the expectant mother in advance. If the doctor finds out about such an anomaly in the location of the placenta during childbirth, then he must decide to remove the uterus.

Methods for manual separation of the placenta

There are several ways to perform manual separation of the placenta. These can be manipulations on the surface of the abdomen of the woman in labor, when the afterbirth is squeezed out of the uterine cavity, and in some cases, doctors are forced to literally take out the placenta with membranes with their hands.

The most common is Abuladze's technique, when a woman's obstetrician gently massages the anterior abdominal wall with her fingers, and then invites her to push. At this moment, he himself holds his stomach in the form of a longitudinal fold. So the pressure inside the uterine cavity increases, and there is a chance that the placenta will be born by itself. In addition, the puerperal catheterizes the bladder, which stimulates the contraction of the muscles of the uterus. Oxytocin is administered intravenously to stimulate labor.

If manual separation of the placenta through the anterior abdominal wall is ineffective, then the obstetrician resorts to internal separation.

Placenta separation technique

The technique of manual separation of the placenta is removing it from the uterine cavity in pieces. An obstetrician in a sterile glove inserts his hand into the uterus. At the same time, the fingers are maximally brought to each other and extended. To the touch, she reaches the placenta and carefully, with light chopping movements, separates it from the wall of the womb. Manual removal of the afterbirth must be very careful not to cut through the wall of the uterus and cause massive bleeding. The doctor gives a sign to the assistant to pull the umbilical cord and pull out the child's place and check it for integrity. The midwife, meanwhile, continues to feel the walls of the uterus to remove any excess tissue and make sure that there are no pieces of the placenta left inside, as this can provoke a postpartum infection.

Manual separation of the placenta also involves uterine massage, when one hand of the doctor is inside, and the other gently presses on the outside. This stimulates the receptors of the uterus, and it contracts. The procedure is performed under general or local anesthesia under aseptic conditions.

Complication and consequences

Complications include bleeding in the postpartum period and hemorrhagic shock associated with massive blood loss from the vessels of the placenta. In addition, manual separation of the placenta can be dangerous and the development of postpartum endometritis or sepsis. Under the most unfavorable circumstances, a woman risks not only her health and the possibility of having children in the future, but also her life.

Prevention

In order to avoid problems in childbirth, it is necessary to properly prepare your body for pregnancy. First of all, the appearance of a child should be planned, because abortions violate the structure of the endometrium to some extent, which leads to a dense attachment of the child's place in subsequent pregnancies. It is necessary to diagnose and treat diseases in a timely manner genitourinary system, as they may affect reproductive function.

Timely registration of pregnancy plays an important role. The sooner the better for the child. Doctors obstetricians and gynecologists insist on regular visits to the antenatal clinic during the period of gestation. Be sure to follow the recommendations, walks, proper nutrition, healthy sleep and physical exercises, as well as the rejection of bad habits.

METHODS FOR ISOLATION OF SEPARATED AFTERNATION

PURPOSE: To isolate the separated afterbirth

INDICATIONS: Positive signs of separation of the placenta and the ineffectiveness of attempts

ABULADZE'S METHOD:

Perform a gentle massage of the uterus, in order to reduce it.

With both hands, take the abdominal wall into a longitudinal fold and invite the woman in labor to push. The separated placenta is usually born easily.

KREDE-LAZAREVICH METHOD: (used when the Abuladze method is ineffective).

Bring the bottom of the uterus to the middle position, with a light external massage, cause uterine contraction.

Stand to the left of the woman in labor (facing the legs), grasp the bottom of the uterus with your right hand, so that thumb was on the front wall of the uterus, the palm was on the bottom, and four fingers were on rear surface uterus.

Squeeze out the placenta: compress the uterus in the anteroposterior size and at the same time press on its bottom in the direction down and forward along the axis of the pelvis. The separated afterbirth with this method easily comes out. If the Krede-Lazarevich method is ineffective, the placenta is manually isolated according to the general rules.

Indications:

no signs of separation of the placenta within 30 minutes after the birth of the fetus,

blood loss exceeding the allowable

third stage of labor

The need for rapid emptying of the uterus with previous difficult and operative labor and the histopathic state of the uterus.

2) start intravenous infusion of crystalloids,

3) provide adequate pain relief (short-term intravenous anesthesia (anaesthesiologist!

4) tighten the umbilical cord on the clamp,

5) through the umbilical cord, insert a sterile gloved hand into the uterus to the placenta,

6) find the edge of the placenta,

7) with sawing movements, separate the placenta from the uterus (without applying excessive force),

8) without removing the hand from the uterus, remove the placenta from the uterus with the outer hand,

9) after removing the placenta, check the integrity of the placenta,

10) control the walls of the uterus with the hand in the uterus, make sure that the walls of the uterus are intact and there are no elements of the fetal egg,

11) make a light massage of the uterus, if it is not dense enough,

12) remove the hand from the uterus.

Assess the condition of the puerperal after surgery.

In case of pathological blood loss, it is necessary:

replenish blood loss.

Carry out measures to eliminate hemorrhagic shock and DIC syndrome (topic: Bleeding in the afterbirth and early postpartum period. Hemorrhagic shock and DIC syndrome).

18. Manual examination of the walls of the uterine cavity

Manual examination of the uterine cavity

1. Preparation for the operation: treatment of the surgeon's hands, treatment of the external genitalia and inner thighs with an antiseptic solution. Put sterile liners on the anterior abdominal wall and under the pelvic end of the woman.

2. Narcosis (nitrous-oxygen mixture or intravenous injection of sombrevin or calypsol).

3. The genital slit is bred with the left hand, the right hand is inserted into the vagina, and then into the uterus, the walls of the uterus are inspected: if there are remnants of the placenta, they are removed.

4. With a hand inserted into the uterine cavity, the remains of the placenta are found and removed. The left hand is located at the bottom of the uterus.

Instrumental revision of the cavity of the postpartum uterus

A Sims speculum and a lift are inserted into the vagina. The vagina and cervix are treated with an antiseptic solution, the cervix is fixed by the front lip with bullet forceps. A blunt large (boumon) curette makes an audit of the walls of the uterus: from the bottom of the uterus towards the lower segment. The removed material is sent for histological examination (Fig. 1).

Rice. 1. Instrumental revision of the uterine cavity

TECHNIQUE OF MANUAL EXAMINATION OF THE UTERINE CAVITY

General information: retention in the uterus of parts of the placenta is a formidable complication of childbirth. Its consequence is bleeding, which occurs shortly after the birth of the placenta or more late dates. Bleeding can be heavy life threatening puerperas. Retained pieces of the placenta also contribute to the development of septic postpartum diseases. With hypotonic bleeding, this operation is aimed at stopping the bleeding. In a clinical setting, before the operation, inform the patient about the need and essence of the operation and obtain consent for the operation.

Indications:

1) defect of the placenta or membranes;

2) control of the integrity of the uterus after surgical interventions, prolonged childbirth;

3) hypotonic and atonic bleeding;

4) childbirth in women with a scar on the uterus.

Workplace equipment:

1) iodine (1% iodonate solution);

2) cotton balls;

3) forceps;

4) 2 sterile diapers;

6) sterile gloves;

7) catheter;

9) consent form for medical intervention,

10) anesthesia machine,

11) propafol 20 mg,

12) sterile syringes.

Preparatory stage of the manipulation.

Execution sequence:

Remove the foot end of Rakhmanov's bed.

Perform bladder catheterization.

Put one sterile diaper under the woman in labor, the second - on her stomach.

Treat the external genitalia, inner thighs, perineum and anal area with iodine (1% iodonate solution).

Operations are performed under intravenous anesthesia against the background of inhalation of nitrous oxide with oxygen in a ratio of 1: 1.

Put on an apron, clean your hands, put on a sterile mask, gown, gloves.

The main stage of the manipulation.

Left hand spread labia, and the right hand, folded in the form of a cone, is inserted into the vagina, and then into the uterine cavity.

The left hand is placed on the anterior abdominal wall and the wall of the uterus from the outside.

The right hand, located in the uterus, controls the walls, placental site, uterine angles. If lobules, fragments of the placenta, membranes are found, they are removed by hand

If defects in the walls of the uterus are detected, the hand is removed from the uterine cavity and a cerebrotomy is performed, the rupture is sutured or the uterus is removed (doctor).

The final stage of the manipulation.

11. Remove gloves, immerse in a container with a disinfectant

means.

12. Put an ice pack on the lower abdomen.

13. Conduct dynamic monitoring of the state of the puerperal

(control of blood pressure, pulse, color of skin

integument, condition of the uterus, secretions from the genital tract).

14. As prescribed by the doctor, start antibiotic therapy and administer

uterotonic agents.

Abuladze method. After emptying the bladder, a gentle massage of the uterus is performed in order to contract. Then, with both hands, they take the abdominal wall into a longitudinal fold and offer the woman in labor to push ( rice. 110). The separated placenta is usually born easily. Fig.110. Isolation of placenta according to Abuladze Genter's method. Bladder empty, the bottom of the uterus is brought to the midline. They stand on the side of the woman in labor, facing her legs, hands clenched into a fist, put the back surface of the main phalanges on the bottom of the uterus (in the area of the tube corners) and gradually press downward and inward ( rice. 111); the woman in labor should not push. Fig.111. Genter's reception Crede-Lazarevich method. It is less careful than the methods of Abuladze and Genter, so it is resorted to after the unsuccessful application of one of these methods. The technique of this method is as follows: a) empty the bladder; b) bring the bottom of the uterus to the middle position; c) with a light massage, they try to cause uterine contraction; d) become to the left of the woman in labor (facing her legs), grasp the bottom of the uterus with the right hand so that the first finger is on the front wall of the uterus, the palm is on the bottom, and 4 fingers are on the back of the uterus ( rice. 112); e) the placenta is squeezed out: the uterus is compressed in an anteroposterior size and at the same time it is pressed on its bottom in the direction down and forward along the axis of the pelvis. The separated afterbirth with this method easily comes out. Fig.112. Squeezing the afterbirth according to Krede-Lazarevich Failure to follow these rules can lead to spasm of the pharynx and infringement of the afterbirth in it. In order to eliminate spastic contraction of the pharynx, 1 ml of a 0.1% solution of atropine sulfate or noshpu, aprofen is administered, or anesthesia is used. Usually, the afterbirth is born immediately by polysty; sometimes, after the birth of the placenta, it is found that the membranes connected to the child's place linger in the uterus. In such cases, the born placenta is taken in the palms of both hands and slowly rotated in one direction. In this case, the membranes are twisted, which contributes to their gradual detachment from the walls of the uterus and removal to the outside without breakage ( rice. 113, a). There is a way to select shells according to Genter; after the birth of the placenta, the woman in labor is offered to lean on her feet and raise her pelvis; at the same time, the placenta hangs down and, with its weight, contributes to the exfoliation of the membranes ( rice. 113b).Fig.113. Isolation of shells a - twisting into a cord; b - the second method (Genter). The woman in labor raises the pelvis, the placenta hangs down, which contributes to the separation of the membranes. The born afterbirth is subjected to a thorough examination to ensure that the placenta and membranes are intact. The placenta is laid out on a smooth tray or on the palms of the mother's surface up ( rice. 114) and carefully examine it, one slice after another. Fig.114. Inspection of the maternal surface of the placenta It is necessary to examine the edges of the placenta very carefully; the edges of the whole placenta are smooth and do not have dangling vessels extending from them. After examining the placenta, proceed to the examination of the membranes. The placenta is turned upside down, and the fetal side up ( rice. 115,a). The edges of the shell rupture are taken with fingers and straightened, trying to restore the egg chamber ( rice. 115b), in which the fetus was located along with the waters. At the same time, attention is paid to the integrity of the aqueous and fleecy membranes and find out if there are torn vessels between the membranes extending from the edge of the placenta. Fig.115 a, b- inspection of shells Presence of such vessels ( rice. 116) indicates that there was an extra lobule of the placenta that remained in the uterine cavity. When examining the shells, they find out the place of their rupture; this allows, to a certain extent, to judge the place of attachment of the placenta to the wall of the uterus. Fig.116. Vessels running between the membranes indicate the presence of an additional lobule. The closer the placenta is to the rupture of the membranes from the edge of the placenta, the lower it was attached to the wall of the uterus. Determining the integrity of the placenta is essential. Delay in the uterus of parts of the placenta is a formidable complication of childbirth. Its consequence is bleeding, which occurs shortly after the birth of the placenta or at a later date. postpartum period. Bleeding can be very strong, threatening the life of the puerperal. Retained pieces of the placenta also contribute to the development of septic postpartum diseases. Therefore, the particles of the placenta remaining in the uterus are removed by hand (less often with a blunt spoon - curette) immediately after the defect is established. The delayed part of the membranes does not require intrauterine intervention: they become necrotic, disintegrate and come out together with the secretions flowing from the uterus. After the examination, the placenta is measured and weighed. All data on the placenta and membranes are recorded in the history of childbirth (after examination, the placenta is burned or buried in the ground in places established by sanitary supervision). Next, the total amount of blood lost in the afterbirth period and immediately after childbirth is measured. After the birth of the afterbirth, the external genitalia, the perineum and inner thighs are washed with a warm weak disinfectant solution, dried with a sterile napkin and examined. First, the external genitalia and perineum are examined, then the labia are pushed apart with sterile swabs and the entrance to the vagina is examined. Examination of the cervix with the help of mirrors is performed in all primiparous, and in multiparous at the birth of a large fetus and after surgical interventions. All unsutured ruptures of the soft tissues of the birth canal are the entrance gate for infection. In addition, ruptures of the perineum further contribute to the prolapse and prolapse of the genital organs. Cervical ruptures can lead to cervical eversion, chronic endocervicitis, erosions. All these pathological processes can create conditions for the occurrence of cervical cancer. Therefore, ruptures of the perineum, the walls of the vagina and the cervix must be carefully sewn up immediately after childbirth. Sewing up soft tissue tears in the birth canal is a prevention of postpartum infectious diseases. The puerperal is observed in the delivery room for at least 2 hours. general state women, count the pulse, inquire about well-being, periodically palpate the uterus and find out if there is bleeding from the vagina. It should be borne in mind that sometimes in the first hours after childbirth, bleeding occurs, most often associated with a reduced tone of the uterus. bleeding from it are moderate, the puerperal woman is transported to the postpartum department in 2-3 hours. Together with the puerperal, they send her birth history, where all entries must be made in a timely manner.

The placenta is responsible for ensuring the life and breathing of the unborn child, protects from harmful substances. The tight attachment of the child's place to the tissues affects the condition of the woman after childbirth, contributes to bleeding. Manual separation of the placenta is carried out when the organ is attached to the walls of the uterus or attached to the scars.

The placenta, an organ that helps in the development of the fetus during pregnancy, appears on the 7th day after the egg is attached to the walls of the uterus. The complete formation of the organ is completed at week 16.
When carrying a fetus, the weight of the placenta, its size and density increases. Maturation allows you to fully provide for the unborn child essential vitamins and minerals.

Structure:

villi are responsible for the supply of oxygen and nutrients through the umbilical cord to the fetus;
membrane divides vascular systems for mothers and children. Membrane delays harmful substances acting as a natural barrier.

How much does the placenta weigh after childbirth? The average weight of the placenta is 600 grams. Thickness normally reaches 3 cm, width - from 18 to 25 cm.

The placenta performs the following functions:

fetal nutrition;
gas exchange;
hormone production;
protective function.

The location of the organ in the uterus is important. With the correct course of pregnancy, the placenta is attached in the upper part of the cavity. Low position or abnormal presentation is a pathology.

Indications for manual separation of the placenta are detected during pregnancy using ultrasound or during childbirth. Normally, it comes out after the baby is born. If after half an hour the baby's place is not born, or heavy bleeding begins, the placenta is removed manually.

The reasons

Separation of the placenta manually is carried out with complete increment, improper attachment to the uterus, hypotension. Untimely assistance will lead to inflammatory processes, scarring, bleeding.

Why the placenta does not separate after childbirth:

the placenta is firmly attached to the uterus;
the whole organ has grown into the female organs.

The dense increment is divided into full and partial. The villi of the placenta do not penetrate into the deep layers of the epidermis and do not cause heavy bleeding. Pathologies can be determined during pregnancy with the help of ultrasound or during labor. Dense attachment occurs in 4% of multiparous, and 2% of mothers expecting their first child.

Placenta ingrowth into the uterus carries more dangerous consequences for woman. The cause of the appearance of pathology are surgical interventions, inflammatory processes, scars on female organs previous caesarean section.

Reasons for manual separation of the placenta:

determining the presence of an anomaly during pregnancy;
after the birth of the child, severe bleeding appeared;
when trying, a child's place does not appear;
the shape of the uterus has changed, it has become denser;
the umbilical cord is pulled into the vagina with pressure on the abdomen.

Manual removal of the placenta 30 minutes after childbirth avoids the occurrence of subsequent complications for the woman. The operation is carried out immediately, since bleeding often leads to the removal of the reproductive organs.

In the case when the placenta does not appear, and there is no discharge, hemorrhoidal shock is possible. The accumulation of blood in the uterine cavity leads the body to serious condition, which threatens the life of a woman in labor during childbirth.

Operation technique

The allocation of the placenta normally occurs with the help of contractions and attempts. If the placenta has not been delivered within the first 30 minutes, it will need to be manually separated from the uterus. This will avoid negative consequences in the form of blood loss, removal of an organ.

Types of techniques for manual separation of the placenta:

reception of Abuladze. It is carried out by increasing the pressure in abdominal cavity during an attempt;
Genter's method. The obstetrician clenches his hand into a fist and presses on the bottom of the uterus. Due to palpation, the child's place is separated and comes out;
Krede-Lazarevich method. The afterbirth is squeezed out by hand.

If these methods are ineffective, surgical intervention is used. The postpartum procedure is performed under general anesthesia.

Algorithm for manual separation of the placenta:

manipulations are carried out under sterile conditions;
general anesthesia is introduced;
empty the bladder;
the doctor inserts one hand into the vagina to the level of the bottom of the uterus;
separates the placenta from the walls with the edge of the palm so that no parts remain;
gently pull the umbilical cord so that the placenta comes out;
check the uterine cavity, there should be no accumulation of blood and remnants of placental tissue in it;
the afterbirth is checked for integrity, if necessary, sent for laboratory research;
a woman in labor is given drugs to accelerate the contraction of the uterus.

If the blood loss was more than 0.5% of the body weight of the woman in labor, she is given a transfusion. General anesthesia helps during manipulation removes pain and spasms, relaxing the female organs.

The remaining parts of the placenta can cause inflammation. Symptoms are pain in the abdomen, bleeding, fever. In this case, vacuum cleaning and antibiotic treatment are performed.

Effects

After the operation to remove the placenta, doctors conduct an examination. Checking the birth canal allows you to assess the condition of the cervix. It is determined how much blood loss was in a woman in labor. The retention of parts of the placenta in the uterus will require additional manipulations.

How long does the discharge last after manual separation of the placenta? With the right operation uterine bleeding last up to 14 days. An earlier end of discharge indicates the presence of a pathology, for example, endometritis.

Complications after manual separation of the placenta:

heavy bleeding;
the appearance of defects in the uterus due to the influence of a doctor;
hemorrhagic shock;
sepsis - blood poisoning during the procedure;
endometritis - inflammation of the reproductive organs;
death, often due to blood loss.

The consequences of manual separation of the placenta can lead to the removal of organs or the death of a woman in labor. At proper treatment the woman will quickly recover, and in the future it will be possible to have children.

What can hurt after manual separation of the placenta:

drawing pains in the region of the uterus. They are associated with the contraction of the organ and the return of its former form;
discomfort in the vagina. Appear due to muscle strain during the operation;
headaches may be associated with the use of general anesthesia.

To avoid complications after manual removal of the placenta, you must carefully monitor your well-being, personal hygiene and intake. medicines. If symptoms such as increased discharge, fainting, and severe pain, you need to seek medical attention.

Preventive measures

To avoid the increment of a child's place, before planning a pregnancy, it is necessary to perform preventive measures. They will help maintain the health of the reproductive organs and give birth to a healthy child.

Prevention:

plan a conception necessary tests to exclude pathologies of the uterus;
cure infectious diseases reproductive system;
do ultrasound during pregnancy;
regularly visit a gynecologist;
eat a balanced diet, exclude harmful foods;
give up alcoholic beverages and smoking;
lead an active lifestyle, attend gymnastics for pregnant women.

If you have had surgery before caesarean section a woman should Special attention give a scar on the uterus. Timely examination will help to identify the wrong increment in time and immediately use manual separation of the placenta during childbirth.

After natural childbirth scars also form if a uterine rupture occurs. In this place, the mucosa is damaged, and the placenta is able to form and attach to the damaged area.

Operations on the genital organs affect the health of a woman. After the separation of the placenta, it is recommended to observe personal hygiene in order to avoid infection of the genital organs. In the first few months, you can not lift weights, engage in physical activity.

In subsequent pregnancy, it is necessary to monitor the condition of the placenta. The operation affects the bearing of the fetus, as it affected the uterine cavity.

Placenta accreta affects not only the health of the baby, but also the course of childbirth. The appearance of bleeding, the absence of the placenta from the uterine cavity indicate the presence of a life-threatening pathology for a woman. Manual separation of the placenta is carried out immediately after determining the main signs. The operation allows you to save reproductive organs and avoid removing them.