Carrying out external methods of excretion of the placenta. Methods for separating the placenta

Childbirth is a difficult and responsible period not only for mother and child, but also for doctors. The birth process is divided into 3 stages: preparation, attempts and childbirth, separation of the placenta. The third stage is very important, since the health of the newly-made mother depends on it. Ideally " children's place"should calve in a timely manner and completely, if this does not happen, then doctors resort to its manual expulsion. Any anomalies of the placenta provoke inflammatory process and heavy bleeding.

Afterbirth - description and structure of the organ

The placenta (children's place) is an embryonic organ that exists only during the period of bearing a child. This is very important organ which provides nutrition, respiration and normal development embryo. In addition, the placenta protects the child from different kind harmful effects. The question of what the afterbirth looks like is of interest to many. Outwardly, the organ resembles a cake, and inside it is a membrane that connects circulatory system mother and embryo.

The composition of the placenta:
Placenta
Umbilical cord
Membrane (aqueous, fleecy, decidual).

The chorionic villi attached to the uterus form the placenta. The placenta with all the membranes is the placenta. The placenta has 2 surfaces: external and internal. The outer (maternal) is adjacent to the wall of the uterus, it consists of lobules (from 15 to 20 pieces), which are covered with a gray membrane on top. Each lobule is pierced by villi through which the vessels pass.

The inner (fruit) surface is adjacent to the fetal egg, and an aqueous membrane envelops it from above. The fruit surface is covered blood vessels, which rush to the root of the umbilical cord attached in the center inner surface placenta.

From the inside, the uterus is covered with 3 membranes: maternal (decidual), fetal (chorion), internal (amnion). Inside the amnion is the amniotic fluid in which the embryo floats. The water shell envelops the placenta and the umbilical cord. Fruit and water membranes are separated from each other.

The umbilical cord connects the embryo to the placenta. 2 umbilical arteries pass through the umbilical cord, through which flows deoxygenated blood And large vein transporting oxygen and nutrients to the fetus. Around the vessels there is an embryonic tissue (Wharton's jelly), which protects them from being squeezed by tissues.

Amniotic fluid fills the fetal egg and protects the embryo from injury.

The placenta is fully formed at the 16th week of pregnancy, and from the 36th week it begins to age. If the pregnancy proceeds normally, then the weight of the fetus is from 3.3 to 3.4 kg, the size of the afterbirth is 15–25 cm, and the thickness is from 2 to 4 cm. Question: “How much does the afterbirth weigh?” interested in future and newly-made mothers, as well as doctors. The normal weight of an organ is about 500 g.

Child seat functions

The afterbirth of pregnant women is an important organ that performs the following functions:

Gas exchange. The placenta transports oxygen from the mother's blood to the fetal circulation carbon dioxide with the help of maternal erythrocytes is brought out. With stenosis or blockage of blood vessels, the child suffers from oxygen starvation, because of which its development is disturbed.

Nutritious. The placenta provides nutrition to the embryo, metabolites are transported back, this is how the excretory function manifests itself.

Endocrine. The placenta produces hormones and biologically active substances that are necessary for the pregnant woman and the fetus ( chorionic gonadotropin, placental lactogen, estriol, progesterone). By the concentration of these substances, it is possible to assess the state of the placenta, and to identify pathologies in the development of the embryo.

Protective. The placenta protects the fetus from the mother's antibodies, and also prevents the penetration of antigens of the embryo into the mother's blood. Thus, the organ prevents immunological conflict between the two organisms. However, the placenta is not able to protect the fetus from drugs, alcohol, nicotine and viruses.
If the development of the afterbirth is disturbed, complications that are dangerous for the mother and child arise.

Possible problems associated with the placenta

One of the most common pathologies of the placenta is low attachment of the placenta. If the problem is determined after the 28th week of pregnancy, then we are talking about placenta previa, which covers the cervix of the uterus. However, only 5% of women have this arrangement until 32 weeks.

Placenta previa is a dangerous complication of pregnancy in which the placenta moves into the lower segment of the uterus. This pathology occurs in re-children, especially after an abortion and postpartum complications. Complications can be provoked by neoplasms, anomalies in the development of the uterus, low implantation gestational sac. Placenta previa increases the risk uterine bleeding and premature birth.

Placenta accreta is a condition characterized by tight attachment afterbirth to uterus. Because of low location placentas of the chorionic villus grow into the myometrium or into the entire thickness of the uterus. As a result, the afterbirth does not go away on its own.

Dense attachment differs from the previous pathology only in that the chorionic villi grow to a shallower depth into the wall of the uterus and provoke retention of the placenta. In addition, this anomaly provokes bleeding during childbirth. And in the first and second cases, they resort to the manual separation of the placenta.

Placental abruption is a pathology that is characterized by premature (before the birth of a child) separation of the placenta from the uterine wall. In this case, the uteroplacental vessels are damaged, and bleeding occurs. The intensity of symptoms depends on the area of ​​detachment. With a slight detachment are shown natural childbirth followed by examination of the uterine cavity. With a strong detachment, a caesarean section is indicated.

Premature maturation of the placenta is characterized by early maturation or aging of the organ. In this case, the following types of placenta are observed:
Thin - less than 2 cm in the 3rd semester of pregnancy. This problem is typical for preeclampsia, intrauterine fetal retention, the threat of abortion.
Thick - more than 5 cm at hemolytic disease and diabetes.
It is necessary to carry out diagnostics and treatment.

Late maturation is more often diagnosed in women with diabetes smoking pregnant women, with Rh-conflict of mother and child and congenital anomalies fetal development. A small placenta is unable to perform its functions, and this threatens with stillbirth and mental retardation child. Increased risk of placental infarcts, inflammation of the placenta or fetal membranes (eg, ascending bacterial infection placenta 3 degree), as well as placental neoplasms.

The birth of a child's place

The phrase: “The afterbirth has departed after childbirth” baffles many primiparous women. After all, the 3rd stage of childbirth, when the placenta is born, is also very important, this is how the uterus is cleaned. Doctors monitor the woman, evaluate her condition, monitor her heartbeat and try to determine how much blood she has lost. To assess the degree of blood loss, a metal sudok is placed under the woman. It is important to constantly empty the bladder so that it does not delay the separation of the placenta.

After about 2 hours and no more than 220 ml of blood loss, the afterbirth comes out after childbirth. With bleeding and retention of the placenta, an external expulsion of the organ is performed. It is very important to completely remove the placenta after childbirth, because even a small piece of it can cause dangerous complications: severe uterine bleeding or purulent infection.

Signs of placenta separation

The process of separating the baby's place with the umbilical cord and fetal membranes is called the birth of the placenta. There are several characteristic features placenta compartments:

Schroeder's sign - the state, shape and height of the uterus changes. With the separation of the placenta, the uterus becomes flatter, and its bottom rises to the navel. The uterus deviates to the right.

Alfred's sign - the free end of the umbilical cord lengthens. After the birth of the child, the umbilical cord is crossed, and its second end goes into the vagina. The doctor puts a clamp on its end. When the afterbirth descends into lower part uterus, the umbilical cord also lengthens.

A sign of Mikulich is an urge to push. This symptom does not appear in all women in labor.

Klein's sign - after attempts, the umbilical cord, which protrudes from the vagina, lengthens. If after the end of the attempts the length of the umbilical cord does not decrease, then the placenta has separated from the uterus.

Sign of Klyuster-Chukalov - when you press the suprapubic area, the umbilical cord lengthens. After graduation physical impact the umbilical cord remains motionless.
If at the 3rd stage of labor the woman in labor feels normal, the placenta has not separated, and there is no bleeding, then the waiting period is extended to 2 hours. If after this time the condition of the woman in labor has not changed or even worsened, then the placenta is removed manually.

Methods for expelling a child's place

The follow-up period takes little time, but this does not reduce its complexity. At this stage, the risk of uterine bleeding increases, which threatens the woman's life. After all, if a child's place is not born, then the uterus can no longer contract, and the blood vessels do not close. Then doctors use emergency methods placenta compartments:

Abuladze method. The doctor performs a gentle massage of the uterus, then captures abdominal wall behind the longitudinal fold and asks the woman in labor to push. The external separation of the afterbirth by the Abuladze method does not cause pain, it is quite simple and effective.

Genter's method. The bottom of the uterus leads to the midline. The doctor turns sideways to the woman so as to see her legs, clenches his hands into fists, presses the back surface of the main phalanges to the fundus of the uterus. The doctor gradually presses, moving the placenta down and inward. A woman in labor should not push.

Krede-Lazarevich method. This method is used if the previous methods were ineffective. The bottom of the uterus is brought to the middle position, with the help of a light massage, its contractions are stimulated. Then the obstetrician should stand on the left side of the woman so as to see her legs, grab the bottom of the uterus right hand so that 1 finger rests on its front wall, the palm on the bottom, and 4 fingers on the back surface. The doctor then squeezes out the placenta by squeezing the uterus with one hand while pushing the placenta out with the other.
This effective ways separation of the placenta, which is used if the child's place has independently separated from the uterus. In this case, the doctor simply facilitates his exit.

In the presence of bleeding without signs of separation of the placenta or the absence of these signs for 2 hours after delivery, the doctor performs a manual expulsion of the placenta. This is a dangerous and complex procedure during which anesthesia is used.

Inspection of the placenta

The question of what is done with the placenta after childbirth is of interest to many women. First of all, the placenta is given for histology to ensure its integrity. After all, as already mentioned, even a small part of it that remains inside can provoke inflammation. The organ is laid out on a tray with the maternal surface up and the lobules are examined. Particular attention should be paid to the edges, the child's place should be smooth, without broken vessels.

Then the placenta is turned upside down with the fruit surface, and the shell is carefully examined. The doctor should straighten each tear and carefully examine the fleecy membrane for damage to the blood vessels.

Histological examination of the afterbirth allows you to restore clinical picture, reveal its presentation. If, as a result of examination of the placenta, it turns out that the organ has not come out completely, then the uterus is cleaned. This procedure is carried out manually or using a curette (special spoon).

Examination of the afterbirth after childbirth allows you to identify even the fetal membranes that linger in the uterine cavity. In this case, cleansing is not carried out, the membranes come out along with lochia (postpartum discharge).

After the examination, the placenta is weighed, the data is recorded on the card and the woman in labor is given a conclusion on the study of the placenta. After the above procedures, the afterbirth is disposed of.

Then the doctor evaluates blood loss, examines the woman's birth canal, rinses them antiseptic solution, sews up gaps. Then the woman in labor is sent to the postpartum ward, where her condition is monitored for another 3 hours. This is due to an increased risk of bleeding after childbirth due to a decrease in uterine tone.

Prevention of retained placenta consists in timely treatment chronic diseases, management healthy lifestyle life during pregnancy planning and during gestation. Besides, future mom should allocate at least 10 hours of sleep, avoid excessive physical activity, stress, walk on fresh air at least 4 hours, eat right. It is important to avoid crowded places, use multivitamin complexes.

Thus, the placenta is a temporary, but very important organ that connects the body of the mother and fetus, performs respiratory, nutritional and protective function. Timely and correct separation of the placenta guarantees successful ending childbirth and the absence of health problems in the future.

Follow-up principles:

Emptying the bladder immediately after the birth of the fetus;

Control of hemodynamic parameters of the mother;

Control of blood loss;

In the normal course of labor after the birth of the fetus, any mechanical effect on the uterus (palpation, pressure) until signs of placental separation appear is prohibited.

If, after the appearance of signs of separation of the placenta, its independent birth does not occur, then techniques for isolating the placenta can be used to reduce blood loss.

Techniques for isolating the separated placenta.

1. Reception Abuladze (Fig. 40) After emptying the bladder, the anterior abdominal wall is grasped with both hands in a fold. After that, the woman in labor is offered to push. The separated placenta is born as a result of an increase in intra-abdominal pressure.

2. Genter's maneuver (Fig. 41) - pressure from the bottom along the ribs of the uterus downwards and inward (currently not used).

3. Reception Crede-Lazarevich (Fig. 42) empty the bladder with a catheter; bring the bottom of the uterus to the middle position;

make a light stroking (not massage!) of the uterus in order to reduce it; clasp the bottom of the uterus with the hand of the hand that the obstetrician is better at, so that the palmar surfaces of her four fingers are located on back wall uterus, the palm is at the very bottom of the uterus, and thumb- on its front wall; at the same time, they press on the uterus with the whole brush in two intersecting directions (fingers - from front to back, palm - from top to bottom) towards the pubis until the afterbirth is born.

The Krede-Lazarevich method is used without anesthesia. Anesthesia is necessary only when it is assumed that the separated placenta is retained in the uterus due to spastic contraction of the uterine os. In the absence of signs of separation of the placenta, apply manual separation placenta and excretion of the placenta. A similar operation is also performed when the postpartum period lasts more than 30 minutes, even in the absence of bleeding.

Rice. 40. Abuladze's reception

Rice. 41. Genter's reception

Rice. 42. Reception Krede-Lazarevich

After the birth of the fetus, intrauterine pressure increases to 300 mm Hg, which is many times higher than the blood pressure in the vessels of the myometrium and contributes to normal hemostasis. The placenta contracts, the pressure in the vessels of the umbilical cord rises to 50-80 mm Hg, and if the umbilical cord is not clamped, then 60-80 ml of blood is transfused to the fetus. Therefore, the clamping of the umbilical cord is shown after the cessation of its pulsation. During the next 2-3 contractions, the placenta separates and the placenta is released. After the birth of the placenta, the uterus becomes dense, rounded, located in the middle, its bottom is located between the navel and the womb.

The action taken in a particular case depends on the reason that violated normal flow subsequent period. It is necessary to clearly distinguish the delay in the process of detachment of the placenta from the bed from the delay in its release from the genital canal. As already mentioned, these processes occur depending on the contraction of the muscles of the uterus (retraction) and the muscles abdominals, cessation of placental circulation, anatomical changes in the placenta, etc. Therefore, in each individual case, it is necessary, if possible, to take into account all the factors that contribute to the release of the uterus from its contents.

The reason for the retention of the separated placenta is often the overflow of the bladder, caused by the paretic state of the latter. In such cases, to release the placenta, it is enough to release the urine with a catheter. The allocation of the placenta is often delayed due to poorly developed abdominal muscles. It must be emphasized once again that contractions of the abdominal press, as well as the muscles of the uterus, play a major role in the expulsion of the placenta.

Rice. 105. Abuladze's way.

Abuladze's method is that it ensures the activation of the entire amount of expelling forces. This method is especially indicated in multiparous women with a flaccid abdominal wall. Abuladze's method is technically simple and consists in the fact that the abdominal wall along the midline is captured with both hands, lifted up and the woman in labor is offered to push; in this case, the placenta usually easily leaves the uterine cavity. Abuladze's method has been repeatedly used by us, and therefore we can strongly recommend it. Its application gives success, according to the author, in 86%, and according to Mikeladze's observations, in 97%.

Ya. F. Verbov, in order to accelerate the exit of the afterbirth from the uterine cavity, recommended sitting position women in labor on their haunches. In this position, the wire axis of the channel birth canal acquires a normal direction, which facilitates the birth of the placenta. In the prone position of the woman, the wire axis of the canal runs almost horizontally, and the force that expels the placenta has to overcome significant obstacles, in particular muscle resistance. pelvic floor; when squatting, the wire axis goes almost vertically, and the expulsion of the placenta is facilitated.

Squeezing out the placenta according to the Lazarevich-Krede method (Fig. 106). Squeezing out the placenta in ordinary (uncomplicated) cases of retention of the separated placenta is permissible only after 1/2-1 hour and after the unsuccessful use of other methods of its isolation (bladder emptying, Abuladze's method).

In no case can we agree with the author of the method, who proposed to apply the squeezing of the placenta immediately after childbirth and not be afraid of any complications.

Squeezing out the afterbirth is permissible only in cases of a significant degree of blood loss with a separated afterbirth, the use of this method with an unseparated afterbirth is violence, entailing crushing of the placenta and trauma to the body of the uterus itself. If the placenta has not separated from the wall of the uterus and there is significant bleeding, the doctor must immediately go for manual separation and removal of the placenta.

Technique of the Lazarevich-Krede method. The bladder is first freed from the contents, then the uterus is placed in the midline of the abdomen and gently massaged so that it shrinks as much as possible. The palm is placed on the bottom of the uterus, with four fingers placed on the back of the uterus, and the thumb on its front surface. The uterus is compressed and at the same time pressed down on it (Fig. 106). Subject to these instructions and the absence of any significant morphological changes in the placenta or in the walls of the uterus itself, squeezing the placenta according to Lazarevich - Crede gives positive results- the placenta can be brought out.

Rice. 106. Squeezing out the placenta according to the Lazarevich-Krede method.

The method of umbilical cord pulling proposed by Stroganov in combination with the Crede method should be used very carefully. This method is effective and safe only when the separated placenta is located in the vagina.

When pulling the umbilical cord, one should press on the uterus in the direction of the pelvic cavity and do not massage it, since excessive contraction of the uterus prevents the release of the placenta.

M. V. Elkin and other clinicians used next way discharge of the afterbirth: the operator stands between the divorced legs of the woman in labor lying on the table, grabs the contracted uterus with both hands at the same time and tries to squeeze the afterbirth onto herself.

The method proposed by G. G. Genter is technically simple and quite effective. After emptying the bladder and shifting the uterus to the midline, the operator puts his hands, clenched into fists, with the back surface of the main phalanges on the bottom of the uterus in the area of ​​the tubal angles (obliquely) and produces gradually increasing pressure on it down and inwards. During the entire manipulation, the woman in labor should not push.

However, sometimes it is still not possible to squeeze out the placenta using these methods. In some cases, this is due to a spasm of the circular muscles of the uterus in the area of ​​​​the internal os, caused by premature mechanical irritations, erroneous administration of ergot preparations, etc., in others, the reason for the delay in the placenta is the hypotonic state of the muscles of the uterus. In some cases, retention of the placenta is associated with an abnormal location of the placenta in the tubal angle, which is detected during an external examination: one of the tubal angles of the uterus has the form of a separate hemispherical protrusion, separated from the rest of the uterine body by interception. In this case, the squeezing of the placenta is performed under inhalation ether anesthesia or even manual separation and removal of the placenta must be used, especially in cases where there is a significant degree of blood loss.

Manual Separation of placenta placenta (Separatio placentae manualis).

It is necessary to distinguish between manual separation (abstraction) of the placenta (Separatia placentae) from its removal (Extractio placentae) internal tricks, although with both benefits it is equally necessary to insert a hand into the uterine cavity. Separation of the placenta is associated with a longer stay of the hand in the uterine cavity and is more unfavorable in terms of infection, while the removal of the separated placenta is a short-term manipulation.

Manual separation of the placenta (Fig. 107) is usually performed as an emergency intervention for bleeding in consecutive period exceeding the permissible degree of blood loss, as well as in the absence of signs of separation of the placenta within 2 hours and if it is impossible to extract it outward using the above methods.

Rice. 107. Manual separation of the placenta.

The placenta is separated after thorough disinfection of the operator's hands and the external genitalia of the woman in labor. After disinfection of the outer opening urethra emptying the urinary bladder of the woman in labor with a catheter. The end of the umbilical cord hanging from the vagina is again intercepted with a clamp and cut off. After that, one hand, the back surface of which is abundantly lubricated with sterile vegetable oil, the doctor inserts into the uterine cavity, and places the other (outer) hand on the bottom of the uterus. He runs his inner hand along the umbilical cord to its root, and then, with sawtooth movements of the ends of the fingers, carefully separates the tissue of the placenta from the uterine wall under the control of the hand supporting the fundus of the uterus from the outside. The operating hand should be facing the palmar surface of the placenta, and the back - to the wall of the uterus. The separated placenta is captured inner hand and brought out by pulling the outer hand on the end of the umbilical cord. The hand should be removed from the uterine cavity only after the final examination of the latter and examination of the extracted placenta. It is desirable to remove the placenta under general anesthesia.

With manual separation of the placenta, it is important to get into the gap between it and the wall of the uterus; otherwise, significant difficulties are inevitable.

Manual separation of the placenta is carried out with strict observance asepsis and prophylactic administration penicillin. In some cases, a blood transfusion is performed.

The frequency of using manual separation of the afterbirth ranges from 0.13 (P. A. Guzikov) to 2.8% (Schmidt).

After removing the placenta from the uterine cavity, it is necessary to immediately carefully examine the placenta and membranes to make sure they are intact. At the same time, the hand is not removed from the uterine cavity; the integrity of the placenta can never be accurately determined either by the degree of contraction of the uterus, or by the absence (or rather, cessation) of bleeding. Literature data and personal experience show that there are cases when the retention of significant parts of the placenta was not accompanied by bleeding.

To determine the integrity of the placenta, a number of tests were proposed (air, milk, swimming, scalding with boiling water according to Shcherbak, etc.), none of which gives reliable results. From modern methods fluorescent is recommended to detect placental tissue defects.

A PRK mercury-quartz lamp can serve as a light source that excites luminescence. Its rays are passed through a Wood filter (glass tinted with nickel oxide).

The specified filter has the ability to absorb the rays of the visible part of the spectrum and transmit invisible ultraviolet rays, the length of which is 3650-3660 Å (angstrom).

The placenta, well washed from blood clots, is placed in these ultraviolet rays.

When examining the placenta in ultraviolet rays, it is noted that the decidua covering the maternal part of the placenta has its own grayish-green glow. To enhance the glow on the maternal part of the placenta, a few drops of a 0.5% fluorescein solution are applied with a pipette, which is evenly distributed by hand over its surface. After that, the excess fluorescein is washed off with water, and the placenta is again placed in ultraviolet rays, where it is finally examined. For a brighter glow, it is better to inspect in a darkened room, at room temperature.

When examining the placenta in the light of luminescence, it was noted that the undisturbed decidual tissue glows with a golden-green light. If there is a defect on the surface of the placenta, then no glow is observed in this area; the location of the defect looks like dark spots sharply demarcated from the intact surface of the placenta.

However, in the context of widespread practice, the use of this method is difficult.

Therefore, all of the above obliges the practitioner to make a thorough examination of the placenta and membranes ad oculos.

If, when examining the placenta, a defect is found in it or a delay in the membranes is detected, then it is necessary to immediately remove the remaining parts without removing the hand from the uterine cavity, since the secondary entry of the hand into the uterine cavity (some time after childbirth) is not indifferent to the condition of the woman (infection) .

Sometimes residual placenta can be removed with a large blunt curette; however, only a qualified obstetrician-gynecologist can perform this operation.

Recognition of a delay in the uterine cavity of the placenta, its parts and additional lobules often presents significant difficulties. Washing the uterus after manual separation of the placenta is not performed.

In cases suspected of infection, antibiotics or sulfa drugs. To reduce the uterus, injections of 0.5-1 ml of Sol are made. Adrenalini (1: 1000) or ergotine, or pregnantol in the amount of 1 ml, etc.

Douching or washing the vagina before using the manual removal of the placenta should not be done, since the outflow of amniotic fluid, and then the passage of the fetus, is sufficiently rarefied vaginal flora. In addition, the blood constantly flowing from the uterus has good bactericidal properties. Washing the vagina only promotes the introduction of bacteria into the crushed tissues. But in without fail the preparation of the external genital organs is carried out and sterile underwear is used.

If the next check reveals positive signs of placental separation, the woman in labor is offered to push, and the placenta is born on its own. If the placenta is not born on its own, then they resort to its allocation by manual methods.

Methods for manual selection of the placenta.

Abuladze method. After emptying the bladder, the anterior abdominal wall is grasped with both hands in a longitudinal fold so that both rectus abdominis muscles are tightly grasped by the fingers. The woman in labor is offered to push. The separated placenta is easily born due to the elimination of the divergence of the rectus abdominis muscles and a significant decrease in the volume of the abdominal cavity.

Genter's method . The doctor stands on the side of the woman in labor, facing her feet. The uterus is also transferred to the middle position. Hands, clenched into a fist, with the back surface of the main phalanges are placed on the bottom of the uterus in the area of ​​the tube corners. Then proceed to the actual squeezing of the placenta. At first, weakly, and then, gradually increasing the pressure, they press on the uterus in the downward and inward direction. The afterbirth is born from the genital gap.

Crede-Lazarevich method A. If the placenta was not born after applying the Abuladze method, they resort to the Krede-Lazarevich method. This method is quite traumatic, and it must be performed with great care. For his correct execution the following rules should be followed, dividing the entire manipulation into 5 points:

1st moment- emptying of the bladder (it was performed immediately after the birth of the fetus);

2nd moment- the uterus deviated to the right is shifted to the midline;

3rd moment- produce a circular massage of the bottom of the uterus to cause its contraction, since it is impossible to put pressure on a flaccid relaxed uterus due to its possible eversion;

4th moment- the uterus is clasped with a hand so that the thumb lies on the front surface of the uterus, the palm is on the bottom of the uterus, and 4 fingers are on its back surface;

5th moment- simultaneously pressing on the uterus with the whole brush in two mutually intersecting directions (fingers from front to back and palm from top to bottom, in the direction towards the pubis), they achieve the birth of the placenta. After the placenta, shells are stretched, folded into a tourniquet. The pressure on the uterus is stopped and care is taken that the membranes come out completely.

To do this, Yakobe suggested, taking the placenta in his hands, rotate it clockwise so that the shells curl up into a “cord” and come out unexploded.

If, when observing a woman in labor, it is not possible to detect signs of separation of the placenta, then the expectant management of the III period should not exceed 30 minutes, despite the absence of bleeding and the good condition of the woman in labor. In order to avoid possible complications leading to a large loss of blood, one has to resort to manual separation of the placenta and removal of the placenta.

Active management of the afterbirth period is also started in cases where bleeding has begun, blood loss has reached 250-300 ml, and there are no signs of placental separation. Active measures (manual separation of the placenta) are also necessary with a small external blood loss, but with a deterioration in the condition of the woman in labor.

Attempts to speed up the process of expulsion of the placenta by massaging the uterus, pulling on the umbilical cord are unacceptable, as they disrupt the physiological process of placental abruption from the uterine wall, change the rhythm of its contractions and only contribute to increased bleeding.

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 angles) 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. Technique this method is as follows: a) empty the bladder; b) bring the bottom of the uterus to the middle position; V) light massage trying 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 placenta according to Krede-Lazarevich Failure to follow these rules can lead to spasm of the pharynx and infringement of the placenta 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 more late dates postpartum period. Bleeding can be very heavy life threatening puerperas. 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 exit along 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. Inspection of the cervix with the help of mirrors is performed in all primiparas, and in multiparous at birth large fruit and after surgical interventions. All non-sutured 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. Ruptures of the cervix 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. If there are no complaints, the condition of the puerperal is good, the pulse normal filling and not speeded up, the uterus is dense and 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.