Methods for isolating the separated placenta. Management of the III stage of labor by a midwife

After the baby is born, childbirth continues, the third period begins. The successful completion of the stage is very important, since unnecessary tissues remain inside, they need to be removed outside. Fine children's place comes out with an effort, but if there are no signs of separation of the placenta, manual intervention is necessary. The untimely rejection of the placenta with membranes is fraught with the development of inflammation, heavy bleeding.

The afterbirth is an organ that is formed specifically for carrying the embryo. At 40 weeks, it provides the baby with a protective "house" that is connected to circulatory system mothers. Necessity and functional significance are completed by the end of pregnancy.

  1. placenta;
  2. umbilical cord;
  3. enveloping membranes.

Placenta outside attached to the uterus, inside adjacent to fertilized egg. On the inside placenta - the base of the umbilical cord, it contains blood vessels that conduct maternal plasma, oxygen, and nutrients to the fetus.

The placenta and the umbilical canal are enveloped by an aqueous membrane, it forms the amniotic sac, with fluid inside. FROM outside this sac is connected to the uterus by chorionic villi that penetrate into slime layer uterine tissues. Thus, a child's place for the period of pregnancy is fixed in the internal reproductive system of a woman, ensuring the normal development of the fetus.

  • carrying oxygen, removing carbon dioxide;
  • intake of food, removal of metabolic products;
  • hormone synthesis;
  • protection against infections, chemical compounds.

The formation of the afterbirth begins from the first days after the attachment of the egg and ends by the end of the 4th month of pregnancy. The dimensions of the organ are 20-25 cm in circumference, the thickness of the shells is 4-5 cm, and the weight is 400-600 grams.

The discharge of the placenta means the completion of the final stage of childbirth, the cleansing of the uterus. The behavior of a woman is controlled by an obstetrician, it is important to push in a timely manner, to reject the remaining tissues. If the shells did not come out on their own, manual methods are used.

signs

In most cases, obstetricians use active-expectant management tactics. subsequent period. Before you start manual separation placenta, the doctor must be convinced of the need for intervention. Perhaps the woman was simply pushing incorrectly, or physically exhausted. For this, in obstetrics, a classification of signs is used that determines the state of the placenta in the 3rd stage of childbirth.

Methods of determination:

  • Mikulich - Radetsky;
  • Schroeder;
  • Alfeld;
  • Klein;
  • Kostner-Chukalov;
  • Dovzhenko;
  • Strassmann.

According to Mikulich-Radetsky. The separated placental tissue goes down, presses on the bottom of the uterus. There are urges to push. The method works in half the cases, since the pressure is not always sufficient for the neck to react.

According to Schroeder. The technique determines the unattached placenta according to the state of the uterus. If the tissues are still aligned, the uterine fundus does not change its position, and the walls of the organ are softened, wide, and the contours are blurred. After separation of the placenta, the uterus is well palpable, it becomes dense, narrow, with wide walls. The lower part rises, deviating in right side.

By Alfeld. The basis of the method is the observation of the umbilical cord. When the placenta is separated, it becomes longer if measured from the external genitalia. Immediately after the birth of the fetus, the umbilical canal is clamped at the exit site, from the outside. If the clamp during the 3rd stage of labor is lowered, the distance between it and the genital slit has increased (normally up to 12 cm), the child's place will soon appear.

By Klein. The obstetrician monitors the umbilical cord during the patient's efforts. On exhalation, the tip should appear outside, but if it is pulled inward during relaxation, it means that the afterbirth has not separated. You need a manual method.

According to Kostner-Chukalov. With non-separated tissues, if you press the edge of the palm on the suprapubic part, the umbilical cord will be pulled inward. In no case should you strongly compress the channel with your fingers.

According to Dovzhenko. The mother is asked to take a deep breath and exhale. When the lungs are filled with air, the diaphragmatic part rises, followed by the uterus, while inhaling the organs return to their original position. If the umbilical cord moves up and down during breathing, it means that the placenta is attached, motionless - you still need to push, the afterbirth will soon come out.

According to Strassmann. The obstetrician stands on the right side, facing the woman in labor. Sets the clamp on the umbilical cord, holds it lower with the fingers of the left hand, at the same time weakly beats the uterus along the entire length. The uterine tissues react, the blood moves intensively through the arteries, if the placenta is not detached, then plasma shocks will be felt in the doctor's left hand. The umbilical cord does not respond - it means that the placenta has detached.

More often than others, when determining the signs of separation of the placenta in women, the methods of Strassmann and Alfeld are used, which are recognized as the most informative. But, each doctor who conducts childbirth has his own “working” signs. For example, the second place, according to polls, is occupied by the Costner-Chukalov method, as simple and fast.

Methods

If there are positive signs of separation of the placenta from the uterus, you need to get it with the help of the patient's attempts and special equipment. Depending on the location of the shells and physical condition women in labor, several methods of stimulation are used.

Placenta separation methods:

  • Abuladze;
  • Lazarevich-Krede;
  • Hetera.

Abuladze. outdoor reception separation of the separated placenta according to the Abuladze method works by creating inside abdominal cavity pressure concentration. First emptied bladder, the uterus is massaged with light pressure, brought to a median location. Then, the obstetrician captures outer fabrics the abdomen of the woman in labor, along the body. At this time, on command, an attempt is made 1-2 times. The method is the most efficient and simple. If the placenta is separated, the placenta appears immediately.

Lazarevich-Krede. When carrying out the method of isolating the separated placenta, according to the Krede-Lazarevich method, pressure on the uterus is used. After emptying the bladder and bringing the uterus to the middle position, the woman in labor breathes calmly for 1-2 minutes. Then, the doctor embraces lower part uterus so that thumb turned out to be on its front wall, the palm clogged the bottom.

The upper phalanges of the remaining 4 fingers should press on the back wall. In such a girth, the afterbirth stretches down, the other hand makes pressing longitudinal movements from the navel to the pubis. The woman in labor remains in a calm position, does not push.

The Geter method is similar to the previous technique, it is also done on an empty bladder, on the uterus in the middle position. Only pressure occurs with fists, smoothly from the uterine fundus, down to the small pelvis. Mom's assistance is not required, she is resting.

When the placenta is poorly separated from the uterine wall, it is possible to stimulate it independent exit. The patient raises the pelvis, while remaining on the shoulder blades, with emphasis on the feet. The weight of the placenta stretches the tissue of the placenta, the remnants are detached under pressure. If the method does not work, the doctor resorts to emergency measures.

Manual separation

The method is used in complicated situations, if they do not help traditional methods or the placenta is completely attached to the uterus. There must be indications for the procedure, the woman in labor signs the document in advance for the consent of the intervention.

Indications:

  • there are no signs of discharge of the placenta 30 minutes after the birth of the child;
  • profuse bleeding;
  • operative complicated delivery;
  • cervicitis of uterine tissues.

Manual separation is permissible with tightly fused tissues, but in half the cases it is ineffective if the membranes of the placenta have grown into the uterus. Then the organ is removed completely or partially.

Technique:

  1. indications are evaluated;
  2. using a dropper (intravenously, jet), an electrolyte solution is introduced;
  3. intravenous anesthesia is placed;
  4. the obstetrician tightens the umbilical cord on the clamp;
  5. a hand is inserted into the uterus along the umbilical cord;
  6. the edge of the placenta is found;
  7. the tissue is gently separated from the surface of the uterus with a palm (sawing movement);
  8. the palm remains inside the organ;
  9. the placenta is pulled out with the second hand;
  10. a manual examination of the uterus after childbirth is carried out for integrity, the absence of remnants of the membranes;
  11. if necessary, the walls are massaged, toned;
  12. drugs are introduced that are used to separate the placenta after childbirth (antibacterial, oxytocin);
  13. the hand is carefully reached.

In case of bleeding after separation of the placenta, the plasma volume is monitored. If the loss exceeds 800 ml, urgent surgical intervention, DIC is excluded, hemorrhagic shock etc. In 10% of cases uterine bleeding in the third stage of labor, ends with the removal of the organ.

Manual examination of the uterine cavity is carried out only under sterile conditions, with clean pads under the thighs of the woman in labor, under anesthesia. One hand is used, the second is at the bottom of the organ.

Examination and complications

The technique for examining the placenta has a strict sequence, since the integrity of the torn membranes should normally be 90%. The rest comes out with lochia within 2 months from the date of birth.

The algorithm for examining the placenta:

  1. after extraction, the child's place is placed on a sterile plane;
  2. the maternal side of the organ looks up;
  3. the placenta is examined for integrity;
  4. need to make sure there is no blood vessels on shells;
  5. if a torn vessel is found, then an additional slice of the placenta remains inside.

Often the cause of complications in the third stage of labor is a true accreta of the placenta. The villi of the membranes grow deep into the tissue of the uterus, it is impossible to separate the afterbirth, even manually.

Particles will remain on the walls, this is fraught with development severe infections, decompensated blood loss, death of a woman in labor. Therefore, in order to avoid lethal outcome patient, the uterus is removed. The neck remains the fallopian tubes, ovaries. After the operation, the woman's quality of life does not change, there is only one significant minus.

Consequences of removal:

  • loss of reproductive function;
  • the hormonal background will not be disturbed;
  • menstruation stops;
  • sex drive will continue.

A woman after a complicated birth is stressed, especially if the reproductive organ. But it's important to understand that cardinal decision taken by doctors to save the mother's life.

Timely independent separation of the placenta depends on the quality of obstetric care and the adequate behavior of the woman in labor. Complications requiring removal of the uterus occur in 0.01% of cases. Incorrect placenta previa is determined even during pregnancy, doctors are preparing tactics in advance for successful delivery reducing the risk of severe consequences.

General information: for the management of the afterbirth period, it is important to know the signs indicating that the placenta has separated from the walls of the uterus, and then apply external techniques for isolating the placenta.

Indications: 3rd stage of childbirth. The presence of signs of separation of the placenta.

Equipment: bladder catheter, tray, umbilical cord clamp.

Performing a manipulation

Preparatory stage:

1. Empty the bladder with a catheter

2. Invite the woman to push. If the placenta is not born, the following external methods are used to remove the separated placenta.

Main stage:

1. Abuladze method. front abdominal wall grasp with both hands in the fold so that both rectus abdominis muscles are tightly clasped with fingers. After that, they offer the woman to push. the separated afterbirth 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.

2. Crede-Lazarevich method. It is performed in a certain sequence:

a/ empty the bladder with a catheter

b/ bring the bottom of the uterus to the middle position

c/ make light stroking /not massage!/ of the uterus in order to reduce it

g / clasp the bottom of the uterus with the hand of the hand that the obstetrician has a better command of, 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 the thumb is on its front wall d / simultaneously press on the uterus with the whole brush in two intersecting directions (fingers - from front to back, palm from bottom to top towards the pubis until the afterbirth is born from the vagina

3. Genter's method.

a) the bladder is emptied with a catheter

b/ the bottom of the uterus leads to the midline

c / the midwife stands 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 down and inward

d/ the woman in labor should not push

Genter's method is used relatively rarely.

The final stage:

1. Sometimes, after the birth of the placenta, it is found that the membranes are retained 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, contributing to their gradual detachment from the walls of the uterus and removal to the outside without breakage.

2. Method for isolating 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



3. After the placenta is isolated, it is carried out outdoor massage uterus.

4. Put cold on the lower abdomen

5. Inspect the last.

Filling in the passport part individual card pregnant and puerperal No.

General information: Primary documentation is filled out for each pregnant woman when registering with antenatal clinic.

Indications:When taking a pregnant woman for dispensary registration in the antenatal clinic

Equipment: an individual card of a pregnant woman and a puerperal, form 111 / U.

Filling sequence:

1. Date of registration

2. Passport data in the history of childbirth are entered from the passport indicating the number of surname, name, patronymic

3. Age - date, month, year of birth. Age matters for pregnant women (the first pregnancy before the age of 18 is "young" primigravida, over 30 years old "age" - accompanied by a number of complications during pregnancy and childbirth). The most favorable age for the first pregnancy is 18-25 years

4. Marital status: marriage registered, not registered, single (underline)

5. Address, phone, registered, lives. Place of residence, especially living in areas contaminated with radionuclides, can adversely affect both the woman's body and the fetus

6. Place of work, telephone, profession, position. Profession or position, working conditions have great importance for the health of the pregnant woman and the development of the fetus. Education: primary secondary, higher (underline)

7. Surname and place of work of the husband, phone.

Survey of a pregnant woman:

General.

Special.

Examination at the 1st turnout: height, weight, blood pressure in both arms, special obstetric research external (pelvic examination), internal (examination of the external genitalia, cervix in the mirrors, bimanual examination), taking smears for gonorrhea, for oncocytology, laboratory examination(an. blood general, biochemical, glucose, protombin index, RW, Rhesus and group, an. urine, an. feces for eggs of the worm), referrals to a general practitioner, dentist, ENT doctor, ophthalmologist, endocrinologist, ultrasound.

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. The bladder is emptied, 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. Technique this method is as follows: a) empty the bladder; b) bring the bottom of the uterus to the middle position; in) 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 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 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 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. 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 soft tissue tears birth canal are entry gates 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. 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.

The measure applied in this or that case depends on the reason that violated the normal course of the 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 birth canal channel 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 region 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 afterbirth (Fig. 107) is usually performed as an emergency intervention for bleeding in the afterbirth period that exceeds the permissible degree of blood loss, and also in the absence of signs of separation of the afterbirth within 2 hours and if it is impossible to extract it outward by 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 separation 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.

Follow-up principles:

Emptying the bladder immediately after the birth of the fetus;

Control of hemodynamic parameters of the mother;

Control of blood loss;

At normal course childbirth 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 the back wall of the uterus, the palm is on the very bottom of the uterus, and the thumb is 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 placental separation, manual separation of the placenta and the allocation of the placenta are used. 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.

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