External methods of allocation of the placenta. Management of the III stage of labor Signs of separation of the placenta Methods of isolation of the separated placenta

13.08.2020

MANAGEMENT OF THE III (PERMANENT) PERIOD OF BIRTH

PURPOSE: To prevent pathological blood loss.

After the baby is born, drain the urine with a catheter, separate the baby from the mother. Lower the maternal end of the umbilical cord into a clean tray for the placenta.

The third stage of labor is active and lasts up to 20 minutes (on average 5-10 minutes). The midwife monitors the condition of the woman in labor, signs of separation of the placenta and discharge from the genital tract.

SIGNS OF DEPARTMENT OF THE PLACENTA:

Schroeder's sign- change in the shape and height of the fundus of the uterus. After the birth of the fetus, the uterus has a rounded shape, the bottom is at the level of the navel after separation of the placenta, the uterus is extended in length, the bottom rises above the navel, and deviates to the right of the midline.

Alfeld's sign- lengthening the outer segment of the umbilical cord. After the separation of the placenta from the walls of the uterus, the afterbirth descends into the lower segment of the uterus, which leads to lengthening of the outer segment of the umbilical cord. The clamp applied to the umbilical cord at the level of the genital slit is lowered by 10-12 cm.

The appearance of a protrusion above the symphysis- when the separated placenta descends into the thin-walled lower segment of the uterus, the anterior wall, together with the abdominal wall, rises and a protrusion forms above the symphysis.

Dovzhenko's sign- retraction and lowering of the umbilical cord during deep breathing indicates that the placenta has not separated, and vice versa, the absence of retraction of the umbilical cord at the entrance indicates the separation of the placenta.

Küstner-Chukalov sign- when pressing with the edge of the palm on the uterus above the pubic articulation, the umbilical cord is not drawn into the vagina.

To establish the separation of the placenta, 2-3 signs are enough.

If the placenta has separated, they offer the woman in labor to push and the afterbirth is born, and if the attempts are ineffective, methods of isolating the separated placenta are used. After the expulsion of the placenta, the uterus is dense, rounded, its bottom is 2 transverse fingers below the navel.

The expulsion of the placenta is the final stage of physiological childbirth. The woman's health and the need for carrying out the delivery of the placenta and membranes depend on how quickly and "qualitatively" cleaning after childbirth.

Usually, the afterbirth is separated and born on its own within 30 minutes after the birth of the baby. Sometimes this process takes up to 1-2 hours. In this case, the obstetrician determines the signs of separation of the placenta.

The most important signs of separation of the placenta are:

Schroeder's sign.After the baby is born, the uterus becomes rounded and is located in the center of the abdomen, and its bottom is at the level of the navel. After the separation of the placenta, the uterus is stretched and narrowed, its bottom is defined above the navel, it often deviates to the right.

Dovzhenko's sign.If placentaseparated, then with a deep breath the umbilical cord is not drawn into the vagina.

Alfeld's sign.Once separated, the placenta descends into the lower part of the uterus or into the vagina. In this case, the clamp applied to the umbilical cord is lowered by 10-12 cm.

Klein's sign.The woman is straining. The placenta is detached from the wall of the uterus if, after the end of the pushing, the protruding end of the umbilical cord is not pulled into the vagina.

Küstner-Chukalov sign.The edge of the palm is pressed on the uterus above the pubis, if at the same time the protruding end of the umbilical cord is not drawn into the birth canal, then the placenta is separated.

Mikulich-Radetzky's sign.Having separated from the wall of the uterus, the placenta descends into the birth canal, at this moment an urge to push may appear.

Hohenbichler's sign.If the placenta has not separated, during contractions of the uterus, the umbilical cord protruding from the vagina may rotate around its axis, since the umbilical vein is full of blood.

The separation of the placenta is diagnosed by 2-3 signs. The most reliable are the signs of Alfeld, Schroeder and Küstner-Chukalov. If the afterbirth is separated, the woman in labor is offered to push. As a rule, this is enough for the birth of the placenta and membranes.

If the placenta is delayed, there are no signs of its separation, with external and internal bleeding, manual separation of the placenta is performed.

MANAGEMENT OF THE III (PERMANENT) PERIOD OF BIRTH

TARGET:Prevent pathological blood loss.

After the baby is born, drain the urine with a catheter, separate the baby from the mother. Lower the maternal end of the umbilical cord into a clean tray for the placenta.

SIGNS OF DEPARTMENT OF THE PLACENTA:

Alfeld's sign - lengthening the outer segment of the umbilical cord. After the separation of the placenta from the walls of the uterus, the afterbirth descends into the lower segment of the uterus, which leads to lengthening of the outer segment of the umbilical cord. The clamp applied to the umbilical cord at the level of the genital slit is lowered by 10-12 cm.

The appearance of a protrusion above the symphysis - when the separated placenta descends into the thin-walled lower segment of the uterus, the anterior wall, together with the abdominal wall, rises and a protrusion forms above the symphysis.

Dovzhenko's sign - retraction and lowering of the umbilical cord during deep breathing indicates that the placenta has not separated, and vice versa, the absence of retraction of the umbilical cord at the entrance indicates the separation of the placenta.

Küstner-Chukalov sign- when pressing with the edge of the palm on the uterus above the pubic articulation, the umbilical cord is not drawn into the vagina.

To establish the separation of the placenta, 2-3 signs are enough.

METHODS FOR ISOLATION OF SEPARATED AFTER

TARGET: Highlight the separated afterbirth

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

TECHNICS:

ABULADZ'S METHOD:

1. Make a gentle massage of the uterus, with the aim of its contraction.

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

METHOD OF CREDE-LAZAREVICH: (used when Abuladze's method is ineffective).

1. Bring the fundus of the uterus to the median position, cause the uterus to contract with a light external massage.

2. Stand to the left of the woman in labor (facing the legs), grasp the bottom of the uterus with your right hand, so that the thumb is on the front wall of the uterus, the palm is on the bottom, and four fingers are on the back of the uterus.

3. Carry out squeezing of the placenta: squeeze the uterus in the anteroposterior dimension and at the same time press on its bottom downward and forward along the axis of the pelvis. The separated afterbirth with this method easily comes out. With the ineffectiveness of the Krede-Lazarevich method, manual isolation of the placenta is carried out according to general rules.

If the next check reveals positive signs of separation of the placenta, the woman in labor is offered to push, and the afterbirth is born independently. If the afterbirth is not independently born, then they resort to manual isolation.

Methods for manual selection of the placenta.

Abuladze's way. After emptying the bladder, the anterior abdominal wall is grasped with both hands in a longitudinal fold so that both rectus abdominis muscles are tightly covered with fingers. The woman in labor is offered 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.

Genter's way . The doctor stands to the side of the woman in labor, facing her legs. The uterus is also moved to the middle position. Hands, clenched into a fist, with the back surface of the main phalanges are placed on the fundus of the uterus in the area of \u200b\u200bthe tubal corners. Then proceed to the actual squeezing of the placenta. At first, weakly, and then, gradually increasing the pressure, press on the uterus in the direction of the top and bottom. The afterbirth is born from the genital crevice.

The Crede-Lazarevich method and. If the afterbirth was not born after the Abuladze method was applied, they resort to the Crede-Lazarevich method. This method is quite traumatic and must be done with great care. For its correct implementation, you should adhere to the following rules, dividing the entire manipulation into 5 points:

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

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

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

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

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

To do this, Jacob suggested, taking the placenta in his hands, rotate it clockwise so that the shells curl up into a "cord" and come out unbreakable.

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

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

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

The birth of a little man is a slow process, within which one stage successively replaces another. When the two most painful and difficult stages are behind, the turn of the last phase of childbirth begins, which is easier for the young mother, but no less responsible: the phase, the successful completion of which depends to a greater extent not on the woman, but on the doctors.

What is afterbirth?

The afterbirth is a very important temporary organ consisting of a baby seat, an amnion and an umbilical cord. The main functions of the child's place or placenta are the nutrition of the embryo and gas exchange between the mother and the fetus. Also, the child's seat is a barrier that protects the child from harmful substances, drugs and toxins. The amnion (fetal membranes) performs the function of both mechanical and chemical protection of the fetus from external influences, regulates the exchange of amniotic fluid. The umbilical cord acts as a highway connecting the fetus and the placenta. Such important organs during pregnancy immediately after childbirth lose their need and must leave the uterine cavity in order to allow it to fully contract.

Signs of separation of the placenta

The process when the baby's place with the umbilical cord and fetal membranes begins to slowly exfoliate from the walls of the uterus is called the separation of the placenta. Isolation or birth of the placenta is the moment it leaves the uterus through the birth canal. Both of these processes occur sequentially in the last, third stage of labor. This period is called successive.

Normally, the third period lasts from several minutes to half an hour. In some cases, in the absence of bleeding, obstetricians recommend waiting up to an hour before starting to take action.

There are several very ancient, like the science of obstetrics itself, signs of separation of the placenta from the walls of the uterus. All of them are named after famous obstetricians:

Schroeder's sign. The symptom is based on the fact that a completely separated placenta allows the uterus to contract and shrink in size. After the separation of the afterbirth, the body of the uterus becomes smaller in size, denser, acquires a narrow long shape and deviates from the midline.
Alfred's sign is based on lengthening the free end of the umbilical cord. After childbirth, the umbilical cord is crossed at the baby's umbilical ring, its other end goes into the uterine cavity. The obstetrician puts a clamp on her at the entrance to the vagina. As it separates under the force of gravity, the placenta descends into the lower segment of the uterus and further into the birth canal. As the placenta descends, the clamp on the umbilical cord goes lower and lower from its original position.
Klein's sign. If you ask a woman in labor to push with an unseparated placenta, then when pushing, the free end of the umbilical cord goes into the birth canal.
The Kyustner-Chukalov sign is the most commonly used in obstetrics. When pressing with the edge of the palm on the lower segment of the uterus with an unseparated afterbirth, the end of the umbilical cord is pulled into the birth canal. Once the placenta is detached, the umbilical cord remains motionless.

Methods of separation and isolation of the placenta

The third, successive, period of labor is the fastest in time, but far from the easiest. It is in this period that postpartum hemorrhages, life-threatening to women, occur. If the placenta is not separated in time, the uterus is unable to contract further, and numerous vessels do not close. There is profuse bleeding that threatens the woman's life. It is in such cases that obstetricians urgently use methods of separation and isolation of the placenta.

There are a number of ways to isolate, that is, birth, an already separated placenta:

Abuladze's method. With both hands, the obstetrician grasps the anterior abdominal wall together with the uterus into a longitudinal fold and lifts it. The woman at this time should push. It is painless and simple, but effective.
Crede-Lazarevich method. The technique is similar to the previous technique, but the fold of the abdominal wall is not longitudinal, but transverse.
Genter's method is based on the massage of the corners of the uterus with two fists, in which the obstetrician, as it were, squeezes the afterbirth towards the exit.

All these methods are effective when the placenta has moved away from the walls of the uterus on its own. The doctor only helps her out. Otherwise, doctors proceed to the next stage - manual separation and allocation of the placenta.

Manual separation and isolation of the placenta: indications and technique

The main principle of conducting normal childbirth, including the last period, is expectant. Therefore, the indications for such serious manipulations are quite specific:

uterine bleeding in the third stage of labor in the absence of signs of placental separation.
no signs of placenta separation within an hour after the baby is born.

Believe me, the doctors themselves absolutely do not want to give a woman anesthesia and go for serious manipulation, but obstetric bleeding is one of the most dangerous conditions in medicine. So:

The procedure takes place under intravenous or, less commonly, mask anesthesia.
After the woman in labor has completely fallen asleep and the genital tract has been processed, the doctor enters the uterine cavity with his hand. The obstetrician finds the edge of the placenta with his fingers and, with the so-called "sawing" movements, begins to peel it from the walls of the uterus, while simultaneously pulling the free end of the umbilical cord with the other hand.
After complete separation of the placenta, gently pulling on the umbilical cord, the placenta with the membranes is removed and given to the midwife for examination. At this time, the doctor re-enters the uterus with his hand to inspect its walls for additional lobules of the child's place, remnants of the membranes and large blood clots. If such formations are found, the doctor removes them.
After the uterine cavity is treated with an antiseptic, special drugs are injected to reduce the uterus and antibiotics to prevent the development of infection.
After 5-10 minutes, the anesthesiologist wakes up the woman, they show her the baby, and after that the mother is left under supervision for two hours in the delivery room. An ice pack is placed on the stomach, and every 20-30 minutes the midwife checks how the uterus has contracted, whether there is profuse bleeding.
A woman is periodically measured pressure, followed by breathing and pulse. All this time, a urinary catheter will be in the urethra to control the amount of urine.

This technique is effective in the case of the so-called "false" placenta accreta. However, in rare cases, a true increment of the placenta occurs, when the villi of the placenta, for some reason, grow into the uterus to the full depth of its wall. It is absolutely impossible to predict this before the end of labor. Fortunately, such unpleasant surprises are rare. But when confirming the diagnosis: "True placenta accretion", unfortunately, there is only one way out: in this case, the operating room is urgently deployed and to save the woman it is necessary to remove the uterus together with the ingrown placenta. It is important to understand that the operation is designed to save the life of a young mother.

Usually, the operation takes place in the amount of supravaginal amputation of the uterus, that is, the body of the uterus is removed with an afterbirth. The cervix, fallopian tubes, and ovaries remain. After such an operation, a woman will no longer be able to have children, menstruation will stop, but the hormonal background will remain unchanged due to the ovaries. Contrary to popular belief, it does not occur. The anatomy of the vagina and pelvic floor is preserved, the sex drive and libido remain the same and the woman can live a sex life. No one, except for a gynecologist, during examination, will be able to find out that a woman does not have a uterus.

Of course, it is a huge stress and unhappiness for any woman to hear the verdict: "You will no longer have children!" But the most precious thing is life, which must be saved at any cost, because a child who has just seen the light of day must have a mother.

Alexandra Pechkovskaya, obstetrician-gynecologist, specially for the site

Abuladze's way. After emptying the bladder, a gentle massage of the uterus is performed in order to reduce it. Then, with both hands, they take the abdominal wall into a longitudinal fold and offer the woman in labor to push ( fig. 110). The separated afterbirth is usually born easily. Fig. 110. Isolation of the placenta according to Abuladze Genter's way... The bladder is emptied, and the fundus 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 \u200b\u200bthe tube corners) and gradually press downward and inward ( fig. 111); the woman in labor should not push. Fig. 111. Genter's reception The Crede - Lazarevich method... It is less careful than the methods of Abuladze and Genter, therefore, they resort to it after the unsuccessful application of one of these methods. The technique of this method is as follows: a) the bladder is emptied; b) bring the bottom of the uterus to the middle position; c) they try to cause contraction of the uterus with a light massage; d) become to the left of the woman in labor (facing her legs), the bottom of the uterus is wrapped around the right hand so that the 1st finger is on the front wall of the uterus, the palm is at the bottom, and 4 fingers are on the back of the uterus ( fig. 112); e) squeeze the placenta: squeeze the uterus in the anteroposterior size and simultaneously press on its bottom down and forward along the axis of the pelvis. The separated afterbirth with this method easily comes out. Fig. 112. Squeezing the placenta according to Krede-Lazarevich Failure to follow these rules can lead to spasm of the pharynx and infringement of the placenta in it. In order to eliminate the spastic contraction of the pharynx, 1 ml of a 0.1% solution of atropine sulfate or noshpu, aprofen or anesthesia is administered. Usually, the latter is born immediately; sometimes, after the birth of the placenta, it is found that the membranes connected to the baby's place are retained in the uterus. In such cases, the placenta is taken in the palms of both hands and slowly rotated in one direction. In this case, twisting of the membranes occurs, contributing to their gradual detachment from the walls of the uterus and removal to the outside without breaking ( fig. 113, a). There is a Genter method for selecting shells; after the birth of the placenta, the woman in labor is offered to lean on her feet and raise the pelvis; while the placenta hangs down and, with its weight, contributes to the detachment of the membranes ( fig. 113, b).Fig. 113. Isolation of the shells a - twisting into a cord; b - the second method (Genter). The woman in labor raises the pelvis, the placenta hangs down, which facilitates the separation of the membranes The afterbirth is carefully examined to make sure 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 ( fig. 114) and carefully examine it, one slice after another. Fig. 114. Examination of the maternal surface of the placenta It is necessary to very carefully examine the edges of the placenta; the edges of the whole placenta are smooth and do not have broken vessels extending from them. After examining the placenta, they proceed to inspect the membranes. The placenta is turned over with the mother's side down, and the fruit side up ( fig. 115, a). The edges of the rupture of the membranes are taken with fingers and straightened, trying to restore the egg chamber ( fig. 115, b), which contained the fruit along with the waters. At the same time, they pay attention to the integrity of the water and fleecy membranes and find out if there are any torn vessels between the membranes extending from the edge of the placenta. Fig. 115 a, b - inspection of the shells The presence of such vessels ( fig. 116) indicates that there was an additional 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 to the edge of the placenta is the place of rupture of the membranes, the lower it was attached to the uterine wall. Determining the integrity of the placenta is essential. Retention of parts of the placenta in the uterus is a formidable complication of childbirth. Its consequence is bleeding, which occurs soon after the birth of the placenta or at a later date in the postpartum period. Bleeding can be very severe, life-threatening for the parturient woman. 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 - a curette) immediately after the defect is established. The retained part of the membranes does not require intrauterine intervention: they necrotize, disintegrate and go out along with the secretions flowing from the uterus. The placenta is measured and weighed after examination. 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). Then the total amount of blood lost in the successive period and immediately after childbirth is measured. After the birth of the placenta, the external genitalia, the perineal region and the inner surfaces of the thighs are washed with a warm weak disinfectant solution, dried with a sterile napkin and examined. First, the external genitals and the perineum are examined, then the labia are pushed apart with sterile tampons and the entrance to the vagina is examined. Examination of the cervix with the help of mirrors is performed in all primiparous, and in multiparous at the birth of a large fetus and after surgical interventions. All non-sewn soft tissue ruptures of the birth canal are the entrance gate for infection. In addition, tears in the perineum further contribute to the prolapse and prolapse of the genitals. Ruptures of the cervix can lead to cervical eversion, chronic endocervicitis, erosions. All these pathological processes can create conditions for the occurrence of cervical cancer. Therefore, tears in the perineum, vaginal walls and cervix must be carefully sutured immediately after childbirth. Suturing the tears of the soft tissues of the birth canal is the prevention of postpartum infectious diseases. The postpartum woman is observed in the delivery room for at least 2 hours. At the same time, they pay attention to the general condition of the woman, count the pulse, inquire about her health, 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, which is most often associated with a decreased tone of the uterus. h are transported to the postpartum department. Together with the postpartum woman, they send her birth history, where all records must be made in a timely manner.