Manual separation of the placenta. Indications, technique. Tight attachment of the placenta: manual work Why do we need placental diagnostics

The successive or third stage of labor begins from the moment the baby is born and ends with the separation of the placenta, which consists of the placenta, umbilical cord and amniotic membrane.

As a rule, this process occurs independently within 10 - 30 minutes after the birth of the fetus. Contribute to the separation of the afterbirth of the contraction. If this process does not begin on its own, then doctors use the manual separation of the placenta. This technique is also necessary when the placenta began to separate from the uterine wall, but does not leave the birth canal. Continuing to remain in the uterine cavity, the placenta prevents its contraction and causes a number of problems.

outdoor tricks
Manual separation of the placenta and the allocation of the afterbirth is carried out mainly with the help of special external techniques. And here it is important to prevent the onset of bleeding, which is a sign of a violation of the placental separation process. Correct obstetrician manipulations should be carried out after emptying the bladder. The most effective and popular way to help a woman give birth to a “baby place” is the Abuladze technique, the meaning of which is that after a gentle massage, the woman is offered to push, while simultaneously holding her stomach between her hands in a longitudinal fold. If this method does not bring the desired results, then other methods of manual separation of the placenta are used.

Special cases
Manual separation of the placenta is necessary if the doctor suspects that particles of the “baby place” have remained in the uterine cavity or bleeding has begun in the absence of signs of separation. In addition, a direct indication for active action is the absence of an afterbirth after 30 minutes from the moment the fetus is born. The manual separation technique is used if there are defects in the placenta.

Technique of manual separation of the placenta
The so-called internal methods are less sparing, but sometimes the fate of a woman depends on them. For manual separation of the placenta, the obstetrician pushes the birth canal apart with one hand, and with the other hand separates the placenta in the uterine cavity. All manipulations are performed very carefully, slowly and according to a certain pattern.

The consequences of manual separation of the placenta
The consequences of manual separation of the placenta, provided there are no complications in the third stage of labor, may be completely absent. However, doctors note the possibility of similar problems in subsequent pregnancies and childbirth.

After the birth of a baby, a woman may have numerous complications. A fairly common occurrence is the rupture of the pubic articulation ...

Any bleeding during childbirth is a complication, which means it is dangerous for both the baby and the woman herself. Therefore, it is important to quickly and accurately establish ...

Indications:

1. Bleeding in the 3rd stage of labor due to abnormal separation of the placenta.
2. No signs of separation of the placenta and bleeding within 30 minutes after the birth of the fetus.
3. With the ineffectiveness of external methods for the allocation of the placenta.
4. With premature detachment of a normally located placenta.

Equipment: clip, 2 sterile diapers, forceps, sterile balls, skin antiseptic.

Preparation for manipulation:

1. Wash hands surgically, put on sterile gloves.
2. To carry out the toilet of the external genitalia.
3. Put sterile diapers under the pelvis of the woman in labor and on the stomach.
4. Treat the external genitalia with a skin antiseptic.
5. The operation is performed under intravenous anesthesia.

Performing manipulation:

1. The labia is spread with the left hand, and the right hand, folded in a cone, with the back side facing the sacrum, is inserted into the vagina, and then into the uterus, guided by the umbilical cord.
2. The edge of the placenta is found and the “sawing” movements of the hand gradually separate the placenta from the wall of the uterus. At this time, the outer hand helps the inner one by pressing on the fundus of the uterus.
3. After separation of the placenta, it is reduced to the lower segment of the uterus and removed with the left hand by pulling on the umbilical cord.
4. With the right hand, the inner surface of the uterus is once again carefully examined to exclude the possibility of retaining parts of the placenta.
5. Then the hand is removed from the uterine cavity.

End of manipulation:

1. Inform the patient of the completion of the manipulation.
2. Disinfection of reusable equipment: mirror, lifting forceps according to OST in 3 stages (disinfection, pre-sterialization cleaning, sterilization). Disinfection of used gloves: (O cycle - rinse, I cycle - immerse at 60 /) with subsequent disposal class "B" - yellow bags.
3. Disinfection of used dressings with subsequent disposal in accordance with SanPiN 2.1.7. – 2790-10..
4. Treat the gynecological chair with rags soaked in disinfectant. solution twice with an interval of 15 minutes.
5. Wash hands in the usual way and dry. Treat with moisturizer.
6. Help the patient get up from the chair.

Date added: 2014-11-24 | Views: 2167 | Copyright infringement

It is necessary to distinguish between: a) manual separation of the placenta (separatio placentae manualis); b) manual selection of the placenta (extractio placentae manualis); c) manual examination of the uterus (revisio uteri manualis). In the first case, we are talking about the separation of the placenta, which has not yet separated (partially or completely) from the walls of the uterus; in the second case - about the removal of an already separated, but not released placenta due to hypotension of the uterus, abdominal integuments or spastic contraction of the walls of the uterus. The first operation is more difficult and is accompanied by a known danger of infection of the woman in labor compared to manual examination of the uterus. The operation of manual examination of the uterus is understood as an intervention undertaken to locate, separate and remove the retained part of the placenta or to control the uterine cavity, which is usually necessary after difficult rotation, application of obstetric forceps or embryotomy.

Indications for manual removal of the placenta

1) bleeding in the third stage of labor, which affects the general condition of the woman in labor, blood pressure and pulse; 2) a delay in the release of the placenta for more than 2 hours and the failure of the use of pituitrin, taking Crede without anesthesia and under anesthesia. With manual separation of the placenta, inhalation anesthesia or intravenous administration of epontol is used. The woman in labor is placed on the operating table or on a transverse bed and carefully prepared. The obstetrician washes his hands up to the elbow with diocide or according to Kochergin - Spasokukotsky. Operation technique. The obstetrician lubricates one hand with sterile vaseline oil, folds the brush of one hand cone-shaped and, spreading the labia with fingers I and II of the other hand, inserts his hand into the vagina and into the uterus. For orientation, the obstetrician leads his hand along the umbilical cord, and then, approaching the placenta, goes to its edge (usually already partially separated).

Manual examination of the uterine cavity

Indications for surgery: I) retention of lobules or parts of the lobules of the placenta, doubts about its integrity, regardless of the presence or absence of bleeding; 2) bleeding in the presence of a delay of all membranes; 3) after such obstetric operations as embryotomy, external-internal rotation, application of cavity forceps, if the last two operations were technically difficult. and infection. The prognosis is the worse the later after childbirth the intervention is performed. Manual examination of the uterus (as well as examination of the cervix with the help of mirrors) is indicated after all difficult vaginal operations in order to timely establish (or exclude) uterine rupture, vaginal fornix, cervix. When manually examining the uterus, it is necessary to remember the possibility of error due to the fact that the obstetrician poorly examines that side of the uterus that is adjacent to the back surface of his hand (left - with the introduction of the right hand, right - with the introduction of the left hand). To prevent such a very dangerous mistake and a detailed examination of the entire inner surface of the uterus, it is necessary to make an appropriate circular rotation of the hand during the operation. decreased. However, the huge danger that threatens the puerperal not only when she refuses this operation, but also when she delays with the manual separation of the afterbirth, requires the mastery of it by every doctor and midwife. Obstetric bleeding refers to the pathology in which emergency care is the responsibility of not only every doctor regardless of his length of service and specialty, but also midwives.

Instrumental examination of the uterine cavity

An indication for curettage of the uterus is a delay in the lobule or doubts about the integrity of the placenta. This operation has some supporters. However, our data on its immediate and long-term results indicate the need for a more careful manual examination of the uterine cavity. If you suspect a delay in the lobule in the uterus in those days of the postpartum period, when the uterus has already sharply decreased in size, it is shown to be scraped.

All this is very unpleasant and painful for the mother. When you have already given birth to a wonderful child, find out that the end is not yet, that intervention is required, and even under general anesthesia! Each mother then, subsequently, is looking for reasons why this happened to me.

When it all happened, probable reasons immediately fell from friends and relatives:

• you didn't move much!
• you moved a lot!
• you caught a cold during pregnancy!
• you went to the bath during pregnancy! You were overheating!
• You must have been drinking alcohol!

Oh, what nonsense .. I moved as usual, never got sick, did not visit baths, beaches, and certainly did not drink any alcohol. I had no abortions and no scarring on my uterus!

But it happened.

I don't remember those births at all.. Everything was so terrible and painful, and when the son finally got out, it was a relief! Right every second! It hurts, it hurts, it hurts! it doesn't hurt! Hooray! Happiness! Well, show me this happiness!

And something as small as a placenta, didn't really interest me at all. The main thing is that THIS HELL is over, and my child is healthy and next to me.

But half an hour has passed, and there is no placenta. I don't care, but the doctors look at each other, make me "work with my stomach", then they pulled the umbilical cord, and .. pooook! - the umbilical cord came off, and I was left with the placenta inside.

It was a long time ago. More than 13 years have passed. Time has erased the memories. I don’t even remember if the doctors warned me about what would happen to me now. Did they give me something to sign? I don't remember!

They took my child away from me and gave it to my father.

They put me on a drip. And that's it, complete break. A dream, just a dream. No hallucinations. I slept and woke up. There was no pain anywhere.

According to dad (which was right there, in the generic): "I held Sasha, he was sleeping, they put a hand up to your elbow in you, you yelled so that my ears were blocked, the child, oddly enough, did not wake up"

- I? Orala? Well, it didn't hurt at all, I was asleep. Am I really yelling? What did I yell? Mat? I'm a mom!!? Are not you lying?

Extremely heavy "otkhodnyak" after all this business.

For more than a day I just slept, woke up for some feedings, changing clothes, forced myself to drink something and sleep again, sleep ..

Three days later - a control ultrasound of the uterus, everything is clear.

At home, in the future, for about a month, I could not recover. Sleeping until noon is common. If you suddenly need to get up early - a terrible dizziness. Perhaps this is a consequence not only of this procedure, but also of childbirth in general. I dont know..

I read about the reasons, and even reproached myself. I also read that if this happened once, then with a high degree of probability it will happen again. I haven't been pregnant in 10 years. I did not want to repeat the horror of childbirth again.

When I got pregnant again, I tortured the doctor with the placenta at every ultrasound, is it visible or not? Did she grow up again? Doctors said in a voice that this could not be determined by ultrasound and everything would be known only on the day of birth.

Well, then we will wait for a miracle. Suddenly it will pass.

The second birth was much easier and faster, I was so happy with my daughter that I even forgot that it was time to start " worry about the placenta".

Therefore, for me, the words of the doctor were a complete surprise: "the placenta is whole, everything is fine." How is everything good? She went out? Herself? When? I didn't even notice!!!

And there were also third births.

Inspired by the success of the placenta during the second birth, I forced myself to believe that everything would be fine, that the placenta would not accrete, that it would come out on its own, just like the last time.

And she really came out! Herself. Not immediately, I had to work and push her to the exit, she came out after 40 minutes.

But anyway, third births are also related to this topic. Unfortunately.

In the ward, a few hours after the birth, I began to have severe uterine bleeding. I was taken back to the rodblok, saying that now I would be doing a manual cleaning of the uterus.

Remembering my terrible "waste", I was very upset, right to tears. But there is nothing to do, this is a dangerous business, and the doctors know better.

They put me on a drip. The whole procedure does not take long. 15 minutes.

I don’t know what kind of drug they gave me for anesthesia, but it seemed to me that eternity has passed. The brightest impressions of the third birth are this general anesthesia.

I still remember everything so clearly.

I, a small part of a large kaleidoscope, twist and turn, make various beautiful patterns for the delight of someone's invisible eyes. So I poured into a blue stream as a droplet, so I turned into a petal of a beautiful flower .. And everything would be fine, but I (a small particle) are oppressed by the feeling "what, this is my life? After all, I came here for something important!? I don’t remember why, but I definitely had another goal! why am I spinning around where I took a wrong turn.

and all this for a very, very, very long time, until finally there was a bright light, and people began to speak in low drawling voices, like in slow motion, and then everything finally fell into place, and then I remembered about your newborn a truly great goal, and the realization of this was simply unreal happiness!

One of the most unpleasant and often unexpected situations for a woman in labor: the child has already been safely born, but instead of a quiet rest and congratulations from relatives, there is anesthesia and surgery.

Why is the placenta not separated, how does manual separation of the placenta occur, and what consequences will this have?

What is the placenta attached to: the decidua

The embryo enters the uterus at the blastocyst stage. This is no longer just a fertilized egg, but several hundred cells, divided into an outer and inner layer. But even the blastocyst is too small to easily attach itself to the wall of the uterus. This requires special conditions and a “particularly hospitable” internal environment.

That is why on the 25-27th day of the cycle, the endometrium - the inner layer of the uterus - begins to change dramatically. Cells become larger, glycogen accumulates in them - this is the main way our body stores nutritious glucose, it is this that the embryo will eat in the first days after implantation. The increase in the level of the hormone progesterone in the blood, which occurs with successful fertilization, spurs the change in endometrial cells - they form the so-called decidual layer. After implantation of the embryo, it is literally everywhere: between the wall of the uterus and the embryo (basal membrane), around the embryo (capsular membrane) and on the entire surface of the uterus (parietal membrane).

” The last two, with the growth of the baby, gradually become thinner and merge with each other, but the basal membrane, located under the placenta, grows, thickens and becomes two-layered. A compact layer (stratum compactum) faces inside the uterine cavity, in which the excretory ducts of the glands pass. Behind it is a spongy (porous) layer (stratum spongiosum), which consists of many hypertrophied glands.

The basal decidua is not smooth: by the third month of pregnancy, outgrowths-partitions (septa) appear on it, which form a kind of "calyx" where maternal blood enters. The villi of the chorion are immersed in these cups (the chorion is the embryonic part of the placenta, and its villi are structures formed by the blood vessels of the fetus). They seem to “line” the cups from the inside.

Why does the placenta separate or not separate?

You may have noticed that there is no rigid connection between the placenta and the uterine wall. They are adjacent to each other, but normally the chorionic villi do not grow deep into the basal sheath: its inner porous layer becomes an insurmountable barrier. In the subsequent (third) period of childbirth, after the birth of the baby, the uterus begins to shrink. In this case, the placenta exfoliates easily and relatively painlessly.

” To better imagine what is happening, imagine a balloon to which a thin plasticine cake has been attached. As long as the balloon is inflated and retains its dimensions, the design is stable. However, if you deflate the balloon, the plasticine cake will peel off.

Unfortunately, this does not always happen. If the basal layer is thinned and deformed, then the chorionic villi grow directly into it in search of food. Now, if we return to our analogy and "deflate the balloon", the plasticine cake will stretch the rubber, and you will have to make an effort to unstick this design. The placenta will not allow that part of the uterus to which it is attached to contract, and, accordingly, it will not separate itself.

” So there is a dense attachment (or false increment) of the placenta. This is a relatively rare pathology - 0.69% of all cases of childbirth.

It happens even worse - if the decidual layer is not developed at all, which usually happens at the site of scars after surgical interventions and inflammations, chorionic villi adhere to the muscular layer of the uterus, grow into it and even grow through the walls of the uterus! This is how true placenta accreta appears - an extremely rare and dangerous pathology, due to which the uterus is amputated immediately after the birth of a child. We discussed this situation in detail in the article. « » .

Why does placental attachment occur?

The causes of false and true placenta accreta are the same - this is local dystrophy of the endometrium (the inner layer of the uterus), which occurs for a number of reasons.

Scars on the wall of the uterus. They can occur after any surgical intervention: caesarean section, abortion, removal of neoplasms, and even diagnostic curettage.

Inflammatory process in the uterus- endometritis. It can be caused by chlamydia, gonorrhea, other sexually transmitted diseases, and bacterial infections, such as complications from a medical procedure.

Neoplasms in the uterus such as large submucosal fibroids.

High chorion activity: due to enzymatic imbalance, chorionic villi penetrate into the deep layers of the basal membrane.

Preeclampsia caused by nephritis(kidney inflammation) during pregnancy.

Dense attachment of the placenta: how to determine

Unlike true placental accreta, firm attachment is rarely detected during antenatal ultrasound. Suspicion may arise if changes appear in the placenta itself. It is thickened or, on the contrary, thinned (leathery placenta), it has additional lobules, sometimes remote from the main placental site. But more often the obstetrician makes a diagnosis already during childbirth, if:

within 30 minutes after the birth of the child, there are no signs of separation of the placenta, and there is no bleeding;

blood loss exceeded 250 ml, and there are no signs of placental separation.

” Although it is believed that spontaneous separation of the placenta can be expected within two hours, this rule only applies if there are no signs of bleeding; the loss of 400 ml of blood is considered critical, and the loss of a liter of blood already carries the risk of developing hemorrhagic shock.

If separation of the placenta does not occur, the obstetrician has two tasks. First, understand whether the placenta is still attached to the wall of the uterus or simply cannot leave its cavity. There are a number of clinical tests for this. If the placenta is still attached to the uterine wall, then:

sign of Alfeld- the outer part of the umbilical cord does not lengthen;

sign of Dovzhenko- the umbilical cord is pulled into the vagina with a deep breath;

sign of Klein- the umbilical cord lengthens when straining, but after attempts it is pulled back;

sign of Kyustner-Chukalov- when pressing the edge of the palm on the abdominal wall slightly above the pubis, the umbilical cord does not retract into the vagina, but, on the contrary, goes out even more.

Secondly, the doctor must determine whether it is a true placental accreta, which was not noticed at the stage of prenatal observation, or a false one. Unfortunately, this is only possible when trying to manually separate the placenta.

Manual separation of a tightly attached placenta: procedure and consequences

Manual separation of the placenta is carried out, as the name implies, by hand. The obstetrician fixes the fundus of the uterus with one hand from the outside (that is, presses on it from above, from the side of the chest), and inserts the other hand directly into the uterine cavity.

” It sounds, of course, creepy, but, firstly, you just had a whole baby in your uterus - in comparison with it, the obstetrician's hand has a very modest size. Secondly, you will not feel anything - this procedure is performed only under full intravenous anesthesia.

What does an obstetrician do? He gently gropes for the edge of the placenta and makes “sawing” movements with his fingertips. If the placenta is not accreted, the chorionic villi have not sprouted through the basal membrane, then it is relatively easy to separate from the uterine wall. To speed up this process, medications are administered intravenously that cause spasm of the muscles of the uterus.

The doctor does not withdraw his hand from the uterine cavity immediately after this: first he conducts a manual examination - is there an additional lobe left somewhere, has the placenta itself torn?

If the chorionic villi have grown tightly into the body of the uterus, then when trying to manually separate the placenta, the doctor will inevitably injure the muscle layer. Difficulties in separation, and most importantly, profuse bleeding when trying to act on the placenta (after all, the muscle is damaged!) Says that doctors are dealing with true placental accreta. Unfortunately, in this case, the uterus will most likely have to be removed immediately.

Of course, after such an intervention, complications of varying severity may occur.

Profuse bleeding and hemorrhagic shock(critical state of the body associated with acute blood loss). The likelihood of developing complications is especially high with partial dense attachment of the placenta.

Perforation of the uterus- rupture of the uterine wall can occur when an obstetrician tries to separate the accrete placenta.

Inflammation of the uterus (endometritis) and sepsis (blood poisoning). After childbirth, the uterus is practically a continuous wound surface. The probability of accidentally introducing an infection, even with all precautions, is quite high. That is why women after manual separation of the placenta are prescribed a course of antibiotics.

Unfortunately, the likelihood of a firm attachment or even true accreta of the placenta, as well as its presentation, will only increase during subsequent pregnancies.

Prepared by Alena Novikova