Indications for manual separation of the placenta. Manual separation of the placenta: methods and techniques. Rupture of the cervix

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

INDICATIONS

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

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

PAIN RELIEF METHODS

Intravenous or inhalation general anesthesia.

OPERATIONAL TECHNIQUE

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

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

COMPLICATIONS

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

Inspection of the birth canal in the postpartum period

Inspection of the birth canal

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

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

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

Two hours after birth

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

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

The imposition of obstetric forceps is a delivery operation, during which the fetus is removed from the mother's birth canal using special tools.

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

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

CLASSIFICATION

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

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

INDICATIONS

Severe gestosis, not amenable to conservative therapy and requiring the exclusion of attempts.

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

PONRP in the second stage of labor.

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

Acute fetal hypoxia.

CONTRAINDICATIONS

Relative contraindications - prematurity and large fetus.

CONDITIONS FOR THE OPERATION

Live fruit.

Full opening of the uterine os.

Absence of a fetal bladder.

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

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

PREPARATION FOR OPERATION

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

PAIN RELIEF METHODS

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

OPERATIONAL TECHNIQUE

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

Rules for the introduction of spoons

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

· The right spoon is held with the right hand and inserted into the right side of the mother's pelvis over the left spoon.

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

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

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

The branches are closed, but the handles of the forceps diverge strongly, which indicates the imposition of the forceps spoons not on the transverse size of the head, but on an oblique one, about the large size of the head or the location of the spoons on the head of the fetus too high, when the tops of the spoons rest against the head and the head curvature of the forceps does not fits her - it is advisable to remove the spoons, conduct a second vaginal examination and repeat the attempt to apply forceps;

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

After closing the branches of the forceps, it should be checked whether the soft tissues of the birth canal are captured by the forceps. Then a trial traction is carried out: the forceps handles are grasped with the right hand, they are fixed with the left hand, the forefinger of the left hand is in contact with the fetal head (if during traction it does not move away from the head, then the forceps are applied correctly).

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

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

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

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

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

Obstetric forceps.

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

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

Indications:

1. from the mother's side:

EGP in the stage of decompensation

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

high myopia

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

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

Conditions for application:

the pelvis should not be narrow

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

the amniotic sac must be opened, otherwise PONRP

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

the head should be in the outlet of the small pelvis

Training:

remove urine with a catheter

treatment of the doctor's hands and female genital organs

episiotomy - to protect the perineum

assistant

Anesthetize: intravenous anesthesia or pudendal anesthesia

Technique:

3 triple rules:

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

on obstetrician's socks

· to myself

on the obstetrician's face

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

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

putting spoons on the head:

tops facing the conductive head

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

the conductive point lies in the plane of the forceps

Stages:

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

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

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

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

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

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

Formation of the placenta

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

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

Functions of the placenta

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

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

Degrees of maturity of the placenta

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

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

Attachment of the placenta

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

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

There are three types of presentation:

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

Periods of childbirth

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

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

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

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

Delayed placenta separation

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

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

placenta accreta

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

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

Methods for manual separation of the placenta

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

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

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

Placenta separation technique

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

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

Complication and consequences

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

Prevention

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

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

Surgical interventions in the afterbirth period include manual separation and separation of the placenta when its separation is delayed (partial or complete dense attachment of the placenta) and removal of the separated placenta when it is infringed in the area of the internal os or tubal angle of the uterus.

In the postpartum period, surgical interventions include suturing ruptures of the soft tissues of the birth canal (cervix, vagina, vulva), restoration of the perineum (perineorrhaphy), manual reposition of the uterus during its eversion, as well as a control manual examination of the walls of the postpartum uterus.

SURGICAL INTERVENTIONS IN THE SUBSEQUENT PERIOD

MANUAL PLACENTA REMOVAL

Synonyms

Manual separation of the placenta.

INDICATIONS

The normal afterbirth period is characterized by the separation of the placenta from the walls of the uterus and the expulsion of the placenta in the first 10-15 minutes after the birth of the child.
If there are no signs of separation of the placenta within 30–40 minutes after the birth of the child (with partial dense, complete dense attachment or placenta accreta), as well as in case of infringement of the separated placenta, the operation of manual separation of the placenta and allocation of the placenta is indicated.

PAIN RELIEF METHODS

Intravenous or inhalation general anesthesia.

OPERATIONAL TECHNIQUE

The delay of the parts is established when examining the released placenta and detecting a defect in the tissue, membranes or the absence of an additional lobule. A defect in the placental tissue is detected when examining the maternal surface of the placenta, spread out on a flat surface. The delay of the additional lobe is indicated by the detection of a torn vessel along the edge of the placenta or between the membranes. The integrity of the fruit membranes is determined after they are straightened, for which the placenta should be raised.

COMPLICATIONS

MANUAL UTERINE EXAMINATION

Manual examination of the uterus is an obstetric operation, which consists in the revision of the walls of the uterus with a hand inserted into its cavity.

INDICATIONS

Control manual examination of the postpartum uterus is carried out in the presence of:
uterine fibroids;
antenatal or intranatal fetal death;
malformations of the uterus (bicornuate uterus, saddle uterus);
bleeding in the postpartum period;
rupture of the cervix of the III degree;
a scar on the uterus.

Manual examination of the postpartum uterus is performed when parts of the placenta are retained in the uterus, uterine rupture is suspected, or with hypotonic bleeding.

PAIN RELIEF METHODS

Intravenous, inhalation or prolonged regional anesthesia.

OPERATIONAL TECHNIQUE

If a defect in the placental tissue is suspected, a control manual examination of the walls of the uterus is indicated, in which all the walls of the uterus are sequentially examined, paying special attention to the uterine angles.

The localization of the placental site is determined and, if retained placental tissue, remnants of membranes and blood clots are found, they are removed. At the end of the manual examination, it is necessary to perform a gentle external-internal massage of the uterus against the background of the introduction of contracting drugs.

Manual examination of the walls of the postpartum uterus has two tasks: diagnostic and therapeutic.

The diagnostic task is to revise the walls of the uterus with the determination of their integrity and the identification of a retained placental lobule. The therapeutic task is to stimulate the neuromuscular apparatus of the uterus by conducting a gentle external-internal massage of the uterus. In the process of performing external-internal massage, 1 ml of a 0.02% solution of methylergometrine or 1 ml of oxytocin is injected intravenously simultaneously, conducting a test for contractility.

SURGERY IN THE POSTPARTUM PERIOD

The postpartum period begins from the moment the placenta is born and lasts for 6–8 weeks. The postpartum period is divided into early (within 2 hours after birth) and late.

INDICATIONS

Indications for surgical intervention in the early postpartum period are:
rupture or incision of the perineum;
rupture of the walls of the vagina;
rupture of the cervix;
rupture of the vulva
the formation of hematomas of the vulva and vagina;
uterine inversion.

In the late postpartum period, indications for surgical intervention are:
fistula formation;
formation of hematomas of the vulva and vagina.

Rupture of the cervix

According to the depth of ruptures of the cervix, three degrees of severity of this complication are distinguished.
I degree - tears no more than 2 cm long.
· II degree - gaps exceeding 2 cm in length, but not reaching the fornix of the vagina.
III degree - deep ruptures of the cervix, reaching the arches of the vagina or passing to it.

PAIN RELIEF METHODS

Restoration of the integrity of the cervix with a rupture of I and II degrees is usually performed without anesthesia. At the III degree of rupture, anesthesia is indicated.

OPERATIONAL TECHNIQUE

The sewing technique does not present great difficulties. The vaginal part of the cervix is exposed with wide long mirrors and the anterior and posterior uterine lip are carefully grasped with bullet forceps, after which they begin to restore the cervix. From the upper edge of the gap towards the external pharynx, separate catgut sutures are applied, and the first ligature (provisional) is slightly higher than the gap. This allows the doctor to easily, without injuring the already damaged cervix, reduce it when necessary. In some cases, a provisional ligature allows you to avoid the imposition of bullet forceps. In order for the edges of the torn neck to properly fit together when sewing, the needle is injected directly at the edge, and the puncture is made 0.5 cm away from it. Moving to the opposite edge of the gap, the needle is pierced 0.5 cm away from it, and the right at the edge. The seams do not erupt with such an overlay, since the cervix serves as a gasket. After fusion, the suture line is a thin, even, almost imperceptible scar.

In case of rupture of the cervix of the III degree, a control manual examination of the lower uterine segment is additionally performed to clarify its integrity.

RUPTURE OF THE VULVA

Damage to the vulva and vaginal vestibule during childbirth, especially in primiparas, is often noted. With cracks and slight tears in this area, usually no symptoms are noted and the intervention of a doctor is not required.

OPERATIONAL TECHNIQUE

For ruptures in the clitoral region, a metal catheter is inserted into the urethra and left there for the entire duration of the operation.
Then the tissues are deeply chipped with a solution of novocaine or lidocaine, after which the integrity of the tissues is restored with a separate and nodal or continuous superficial (without underlying tissues) catgut suture.

RUPTURE OF THE VAGINA WALL

The vagina can be damaged during childbirth in all parts (lower, middle and upper). The lower part of the vagina is torn at the same time as the perineum Tears of the middle part of the vagina, as less fixed and more extensible, are rarely noted. Vaginal ruptures usually go longitudinally, less often - in the transverse direction, sometimes penetrating quite deep into the perivaginal tissue; in rare cases, they also capture the intestinal wall.

OPERATIONAL TECHNIQUE

The operation consists in the imposition of separate interrupted catgut sutures after the wound is exposed using vaginal mirrors. In the absence of an assistant to expose and suture vaginal ruptures, you can open it with two fingers spread apart (index and middle) of the left hand. As the wound is sutured in the depths of the vagina, the fingers that expand it are gradually pulled out. Suturing sometimes presents significant difficulties.

HEMATOMA OF THE VULVA AND VAGINA

Hematoma - a hemorrhage due to rupture of blood vessels in the fiber below and above the main muscle of the pelvic floor (the muscle that lifts the anus) and its fascia. More often, a hematoma occurs below the fascia and spreads to the vulva and buttocks, less often - above the fascia and spreads through the paravaginal tissue retroperitoneally (up to the perirenal region).

Symptoms of hematomas of considerable size are pain and a feeling of pressure at the site of localization (tenesmus with compression of the rectum), as well as general anemization (with extensive hematoma). When examining puerperas, a tumor-like formation of a blue-purple color is found, protruding outward towards the vulva or into the lumen of the entrance to the vagina. On palpation of the hematoma, its fluctuation is noted.

If the hematoma spreads to the parametric tissue, a vaginal examination determines the uterus pushed aside and between it and the pelvic wall a motionless and painful tumor-like formation. In this situation, it is difficult to differentiate a hematoma from an incomplete rupture of the uterus in the lower segment.

Urgent surgical treatment is necessary with a rapid increase in hematoma in size with signs of anemia, as well as with a hematoma with heavy external bleeding.

PAIN RELIEF METHODS

The operation is performed under anesthesia.

OPERATIONAL TECHNIQUE

The operation consists of the following steps:
tissue incision over the hematoma;
removal of blood clots;
ligation of bleeding vessels or stitching with 8-shaped catgut sutures;
closure and drainage of the hematoma cavity.

With hematomas of the broad ligament of the uterus, a laparotomy is performed; the peritoneum is opened between the round ligament of the uterus and the infundibular ligament, the hematoma is removed, ligatures are applied to the damaged vessels. If there is no uterine rupture, the operation is completed.

With small sizes of hematomas and their localization in the wall of the vulva or vagina, their instrumental opening (under local anesthesia), emptying and suturing with X-shaped or Z-shaped catgut sutures is indicated.

PERINE RUPTURE

Perineal rupture is the most common type of birth injury to the mother and complications of the birth act; more often noted in primiparas.

There are spontaneous and violent rupture of the perineum, and in terms of severity, three degrees of it are distinguished:
I degree - the integrity of the skin and subcutaneous fat layer of the posterior commissure of the vagina is violated;
II degree - in addition to the skin and subcutaneous fat layer, the muscles of the pelvic floor (bulbospongiform muscle, superficial and deep transverse muscles of the perineum), as well as the posterior or lateral walls of the vagina, suffer;
III degree - in addition to the above formations, there is a rupture of the external sphincter of the anus, and sometimes the anterior wall of the rectum.

PAIN RELIEF METHODS

Pain relief depends on the degree of perineal tear. For ruptures of the perineum of I and II degrees, local anesthesia is performed, for suturing tissues with a rupture of the perineum of the III degree, anesthesia is indicated.

Local infiltration anesthesia is carried out with a 0.25–0.5% solution of novocaine or 1% trimecaine solution, which is injected into the tissues of the perineum and vagina outside the birth injury; the needle is injected from the side of the wound surface in the direction of intact tissue.

If regional anesthesia was used during childbirth, then it is continued for the duration of suturing.

OPERATIONAL TECHNIQUE

Restoration of perineal tissues is carried out in a certain sequence in accordance with the anatomical features of the pelvic floor muscles and perineal tissues.

Treat the external genital organs and hands of the obstetrician. The wound surface is exposed with mirrors or fingers of the left hand. First, sutures are placed on the upper edge of the rupture of the vaginal wall, then sequentially from top to bottom, knotted catgut sutures are placed on the vaginal wall, 1–1.5 cm apart from each other until the posterior commissure is formed. The imposition of knotted silk (lavsan, letilan) sutures on the skin of the perineum is performed at the I degree of rupture.

At II degree of rupture, before (or as far as) suturing the posterior wall of the vagina, the edges of the torn pelvic floor muscles are sutured together with separate nodal submerged sutures with catgut, then silk sutures are applied to the skin of the perineum (separate nodal ones according to Donati, according to Jester). When suturing, the underlying tissues are picked up so as not to leave pockets under the suture, in which subsequent accumulation of blood is possible. Separate heavily bleeding vessels are tied up with catgut. Necrotic tissue is pre-cut with scissors.

At the end of the operation, the suture line is dried with a gauze swab and lubricated with a 3% solution of iodine tincture.

With a rupture of the perineum of the III degree, the operation begins with disinfection of the exposed area of the intestinal mucosa (ethanol or chlorhexidine solution) after removal of fecal residues with a gauze swab. Then sutures are placed on the intestinal wall. Thin silk ligatures are passed through the entire thickness of the intestinal wall (including through the mucous membrane) and tied from the side of the intestine. The ligatures are not cut off and their ends are brought out through the anus (in the postoperative period, they depart on their own or they are pulled up and cut off on the 9th–10th day after the operation).

Gloves and tools are changed, after which the separated ends of the external sphincter of the anus are connected with a knotted suture. Then the operation is carried out, as with a rupture of the II degree.

Eversion of the uterus

The essence of the eversion of the uterus is that the bottom of the uterus from the side of the abdominal cover is pressed into its cavity until it is completely everted. The uterus is located in the vagina with the endometrium outward, and from the side of the abdominal cavity, the wall of the uterus forms a deep funnel lined with a serous cover, into which the uterine ends of the tubes, round ligaments and ovaries are drawn.

Distinguish between complete and incomplete (partial) eversion of the uterus. Sometimes a complete eversion of the uterus is accompanied by eversion of the vagina. Eversion can be acute (rapid) or chronic (slow). Acute inversions are more often observed, and 3/4 of them occur in the afterbirth period and 1/4 - on the first day of the postpartum period.

PREPARATION FOR OPERATION

Carry out antishock therapy.

Treat the external genital organs and hands of the obstetrician. 1 ml of a 0.1% solution of atropine is injected subcutaneously to prevent cervical spasm. Empty the bladder.

OPERATIONAL TECHNIQUE

The uterus is repositioned with preliminary manual removal of the placenta.
The inverted uterus is grasped with the right hand so that the palm is at the bottom of the uterus, and the ends of the fingers are near the cervix, resting against the cervical annular fold.

Pressing on the uterus with the whole hand, first the everted vagina is pushed into the pelvic cavity, and then the uterus, starting from its bottom or isthmus. The left hand is placed on the lower part of the abdominal wall, going towards the screwed uterus. Then, contracting agents are administered (simultaneously oxytocin, methylergometrine).

FEATURES OF THE POSTOPERATIVE PERIOD

Within a few days after the operation, the administration of drugs that have a uterotonic effect is continued.

obstetric fistula

Obstetric fistulas occur as a result of severe birth trauma, lead to permanent disability, violations of the sexual, menstrual and generative functions of a woman. According to the nature of the occurrence, fistulas are divided into spontaneous and violent. According to localization, vesicovaginal, cervicovaginal, urethrovaginal, ureterovaginal, enterovaginal fistulas are distinguished.

For genitourinary fistulas, the outflow of urine from the vagina of varying intensity is characteristic, for entero-genital fistulas - the release of gas and feces. The time of occurrence of these symptoms is of diagnostic importance: the appearance of these symptoms in the first hours after operative delivery indicates the injury of adjacent organs. With the formation of a fistula as a result of tissue necrosis, these symptoms appear on the 6-9th day after delivery. The final diagnosis is made when examining the vagina with the help of mirrors, as well as urological and radiological diagnostic methods.

OPERATIONAL TECHNIQUE

When adjacent organs are injured with instruments and in the absence of tissue necrosis, the operation is performed immediately after childbirth; in case of fistula formation as a result of tissue necrosis - 3–4 months after childbirth.

Small fistulas sometimes close as a result of conservative local treatment.

The operation of manual separation of the placenta must be performed under the strictest asepsis under general anesthesia. Anesthesia is not only a method of anesthesia, but also prevents spasm of the uterine pharynx, which sometimes does not allow the hand to be inserted into the uterine cavity, or it squeezes the operating hand inserted into the uterus so strongly that it makes it impossible to carry out further manipulations.

Manual separation and isolation of the placenta best done with thin rubber gloves (Fig. 57). Having penetrated into the uterine cavity, the operator, sliding his hand along the umbilical cord, reaches the edge of the placenta and with sawtooth movements of the fingers, holding them with the palm side to the placenta, separates the child's place from the uterine wall. At this time, the left hand, pressing from the side of the abdominal wall on the bottom of the uterus, helps with the operation. After the placenta is separated, it is removed by pulling on the umbilical cord and pushing with the fingers of the hand inserted into the uterus. Then the uterine cavity is carefully checked, the remnants of placental tissue and blood clots are removed. It should be borne in mind that the placental site is a somewhat elevated rough surface, different from the smooth surface of the rest of the uterus. M. S. Malinovsky (1967), warning against attempts to "separate" the placental site, indicates that with paralysis of it, that is, with thinning and poor contractility of the placental site, which occurs in old primiparas, or repeated increments of the placenta, it is easy to perforate the uterine wall .

Rice. 57. Manual separation of the placenta.

With a true increment of the placenta during its manual separation, it is possible to drill the wall of the uterus.

In addition, separation of the placenta with its true increment is accompanied by severe bleeding. Therefore, as soon as a true placental accreta is established, the operation of manual separation of a child's place ingrown into the muscular layer of the uterus is immediately stopped and they switch to abdominal surgery with removal of the uterus by amputation or extirpation. If it is impossible to immediately start a celiac surgery and heavy bleeding, tamponation of the uterus is used, pressing the aorta to the spine.

Only in the presence of an increment of a small area, the placenta and a relatively shallow ingrowth of the villi into the muscle layer, manual separation is possible, after which it is permissible to resort to the careful use of a blunt curette. If the separation of the accrete placenta occurred perforation of the uterus, you have to immediately resort to abdominal surgery and removal of the uterus (resection, amputation, extirpation).

The smooth course of the postoperative period after manual removal of the placenta is now quite common in the presence of antibiotics, and severe complications are rare. So, according to the obstetric clinic of the Minsk Medical Institute for 1952-1956. 455 (1.7%) manual separations of the placenta were used for 25736 births, after which there was not a single severe septic disease in the postpartum period and death. Before the introduction of antibiotics into practice, manual separation of the placenta according to M. S. Malinovsky was accompanied in 50% of cases by morbidity and 11% mortality. M. S. Romanov (1933), citing data from the clinic of V. S. Gruzdev for 18 years, with manual separation of the placenta, notes the incidence in 42.8% of cases, and in 13.8% there was severe postpartum sepsis; deaths were observed in 2.6%.

Manual separation of the placenta is one of the most frequent obstetric operations, and, despite modern advances in the prevention and treatment of infection, one should not forget about the dangers associated with this surgical intervention, one should try to avoid them (infection, trauma to the uterine wall).

Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983

Indications for manual separation of the placenta:

- bleeding in the third stage of labor, which is a danger to the life of a woman;

The delay in the separation of the afterbirth for more than 15-20 minutes against the background of the use of pituitrin and the administration of Crede;

Partial separation of the placenta with bleeding from the placental site (in this case, it is necessary to establish exactly whether there is a true accretion of the placenta, in which an attempt at manual separation is prohibited, it is necessary to remove the uterus).

Operation technique:

Inhalation or intravenous anesthesia,

The woman in labor is on the operating table or transverse bed.

The obstetrician lubricates one hand with sterile vaseline oil, folds the fingers of the other hand conically, spreading the labia with 1 and 2 fingers of the other hand, inserts the 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),

having determined the edge of the placenta and proceeding to its separation, the obstetrician massages the uterus with the outer hand in order to reduce it, and with the inner hand, going from the edge of the placenta, separates the placenta with sawtooth movements;

having separated the placenta, the obstetrician, without removing his hand, carefully pulling the umbilical cord with the other hand, removes the placenta; the hand should be removed from the uterus only when the obstetrician is convinced of the integrity of the extracted afterbirth (re-introduction of the hand into the uterine cavity increases the likelihood of identification).

24. Fruit-destroying operations (types, indications, conditions of use).

Fruit-destroying operations are used for rapid delivery and alleviation of the mother's condition in case of fetal death before childbirth. On a living fetus, these operations are used in cases where a woman's life is in immediate danger, and delivery in another way is impossible.

Types of fruit-destroying operations:

1) embryotomy - a group of operations on the trunk and neck,

2) decapitation - separation of the head of the fetus from its body, followed by removal of the body and head;

3) cleidotomy - dissection of the clavicles to reduce the volume of the shoulder girdle,

4) spondylotomy - separation of the spine and trunk in the lumbar region,

5) eventration - removal of the entrails from the chest and abdominal cavities of the fetus to extract it in a reduced volume,

6) craniotomy - perforation of the fetal head, destruction and removal of the brain, followed by extraction of the fetus.

Indications:

A threat to the life and health of a woman,

A sharp discrepancy between the size of the fetus and the size of the pelvis of the woman in labor,

Fetal death during childbirth

Inability to extract the fetal head after the birth of the trunk,

Unfavorable presentation (posterior view of the front, front view of the frontal presentation). Operation conditions:

The opening of the pharynx is not less than 5 - 6 cm,

The pelvis should not be absolutely narrow,

Opened fetal bladder.