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Taking Lazarevich's creed. Methods for separating placenta

Childbirth is divided into three periods: opening of the cervix, pushing, during which the fetus is expelled, and the afterbirth. The separation and delivery of the placenta is the third stage of labor, which is the least lengthy, but no less responsible than the previous two. In our article we will look at the features of the placenta (how it is conducted), determining the signs of placental separation, the reasons for incomplete separation of the placenta and methods for separating the placenta and its parts.

After the birth of the child must be born. It is important to note that you should never pull on the umbilical cord to speed up this process. A good prevention of retained placenta is to put the baby to the breast earlier. Sucking at the breast stimulates the production of oxytocin, which promotes uterine contractions and separation of the placenta. Intravenous or intramuscular administration of small doses of oxytocin also accelerates the separation of the placenta. To understand whether separation of the placenta has occurred or not, you can use the described signs of placental separation:

  • Schroeder's sign: after separation of the placenta, the uterus rises above the navel, becomes narrow and deviates to the right;
  • Alfeld's sign: the detached placenta descends to the internal os of the cervix or into the vagina, while the outer part of the umbilical cord lengthens by 10-12 cm;
  • when the placenta is separated, the uterus contracts and forms a protrusion above the pubic bone;
  • Mikulich's sign: after the placenta separates and descends, the woman in labor feels the need to push;
  • Klein's sign: when the woman in labor strains, the umbilical cord lengthens. If the placenta has separated, then after pushing the umbilical cord does not tighten;
  • Küstner-Chukalov sign: when the obstetrician presses above the pubic symphysis when the placenta has separated, the umbilical cord will not retract.

If labor proceeds normally, then no later than 30 minutes after expulsion of the fetus.

Methods for isolating separated placenta

If the separated placenta is not born, then special techniques are used to speed up its release. Firstly, they increase the rate of administration of oxytocin and organize the release of the placenta externally. After emptying the bladder, the woman in labor is asked to push, and in most cases the placenta comes out after childbirth. If this does not help, use the Abuladze method, in which the uterus is gently massaged, stimulating its contractions. After which the woman in labor is taken with both hands in a longitudinal fold and asked to push, after which the placenta should be born.

Manual separation of the placenta is carried out if external methods are ineffective or if there is suspicion of placenta remains in the uterus after childbirth. The indication for manual separation of the placenta is bleeding in the third stage of labor in the absence of signs of placental separation. The second indication is the absence of separation of the placenta for more than 30 minutes when external methods of separation of the placenta are ineffective.

Technique for manual separation of the placenta

The birth canal is parted with the left hand, and the right hand is inserted into the uterine cavity, and, starting from the left rib of the uterus, the placenta is separated with sawing movements. The obstetrician should hold the fundus of the uterus with his left hand. Manual examination of the uterine cavity is also carried out in case of separated placenta with identified defects, and in case of bleeding in the third stage of labor.

After reading, it is obvious that, despite the short duration of the third stage of labor, the doctor should not relax. It is very important to carefully examine the released afterbirth and ensure its integrity. If parts of the placenta remain in the uterus after childbirth, this can lead to bleeding and inflammatory complications in the postpartum period.

29. Isolation of placenta according to Abuladze.
30. Isolation of placenta according to Genter.
31. Isolation of placenta according to Lazarevich - Crede.
32. A technique that facilitates the separation of membranes.

Heter method also technically simple and effective. When the bladder is empty, the uterus is positioned in the midline. Light massage of the uterus through the abdominal wall should cause its contraction.
Then, standing on the side of the woman in labor, facing her feet, you need to put your hands clenched into fists on the bottom of the uterus in the area of ​​the tubal angles and gradually increase the pressure on the uterus downwards, towards the exit from the pelvis. During this procedure, the woman in labor should completely relax (Fig. 30).

Lazarevich-Crede method, like both previous ones, is applicable only for separated placenta. At first it is similar to Genter's method. After emptying the bladder, the uterus is brought to the midline and its contraction is caused by a light massage. This point, as when using the Genter method, is very important, since pressure on the relaxed wall of the uterus can easily injure it, and the injured muscle is not able to contract. As a result of an incorrectly applied method of releasing the separated placenta, serious postpartum hemorrhage can occur. In addition, strong pressure on the fundus of a relaxed, hypotonic uterus easily leads to inversion.
After achieving contraction of the uterus, standing on the side of the woman in labor, the fundus of the uterus is grasped with the strongest hand, in most cases the right. In this case, the thumb lies on the front surface of the uterus, the palm is on the bottom of it, and the remaining four fingers are located on the back surface of the uterus. Having thus captured the well-contracted dense uterus, it is compressed and at the same time pressed downwards on the bottom (Fig. 31). The woman in labor should not push. The separated afterbirth is easily born.

Sometimes after the birth of the placenta it turns out that the membranes have not yet separated from the uterine wall. In such cases, it is necessary to ask the woman in labor to raise her pelvis, leaning on her lower limbs bent at the knees (Fig. 32). The placenta, with its weight, stretches the membranes and promotes their separation and birth.

Another technique that facilitates the birth of retained membranes is to take the born placenta with both hands and twist the membranes, turning the placenta in one direction (Fig. 33).

33. Twisting of shells.
34. Examination of the placenta.
35. Inspection of shells. a - inspection of the site of rupture of shells; b - examination of the membranes at the edge of the placenta.

It often happens that immediately after the birth of the placenta, the contracted body of the uterus sharply tilts anteriorly, forming an inflection in the area of ​​the lower segment that interferes with the separation and birth of the membranes. In these cases, it is necessary to move the body of the uterus upward and somewhat posteriorly, pressing on it with your hand.

10 question. Manual examination of the uterine cavity

1. Preparation for surgery: cleaning the surgeon’s hands, treating the external genitalia and inner thighs with an antiseptic solution. Place sterile pads on the anterior abdominal wall and under the pelvic end of the woman.

2. Anesthesia (nitrous-oxygen mixture or intravenous administration of sombrevin or calypsol).

3. With the left hand, the genital slit is spread, the right hand is inserted into the vagina, and then into the uterus, the walls of the uterus are inspected: if there are remains of the placenta, they are removed.

4. With a hand inserted into the uterine cavity, the remains of the placenta are found and removed. The left hand is located at the fundus of the uterus.

Manual examination of the uterine cavity is an operation performed by an obstetrician-gynecologist after childbirth. The doctor inserts his hand into the uterine cavity and examines it. The woman in labor is given general anesthesia before the operation.

Indications for manual examination of the uterine cavity

  • bleeding after childbirth
  • the placenta was not delivered after the baby was born
  • violation of the integrity of the placenta or doubts about its integrity
  • spontaneous childbirth if you previously had a cesarean section or other uterine surgery
  • 3rd degree cervical rupture
  • doubt about the integrity of the uterine walls
  • fetal death during childbirth
  • uterine malformations
  • application of obstetric forceps

Preparing for surgery

  • midwife removes urine with a catheter
  • anesthesiologist administers general anesthesia
  • An obstetrician-gynecologist treats a woman’s external genitalia and inner thighs

Treatment after surgery

  • uterotonic drugs (improve uterine contractions)
  • antianemic drugs (iron, in case of large blood loss)
  • Ultrasound of the uterus in the postpartum period
  • antibacterial therapy
  • drugs to improve immunity

Manual separation and release of placenta. Operation technique

The obstetrician lubricates one hand with sterile Vaseline oil, folds the hand of one hand into a cone and, spreading the labia with fingers I and II of the other hand, inserts the hand into the vagina and 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 starting to separate it, the obstetrician massages the uterus with the outer hand to contract it, and with the inner hand, going from the edge of the placenta, separates the placenta with a sawtooth movement. Having separated the placenta, the obstetrician, without removing his hand, with the other hand, carefully pulling the umbilical cord, removes the placenta.

Secondary insertion of the hand into the uterus is highly undesirable, as it increases the risk of infection. The hand should be removed from the uterus only when the obstetrician is convinced that the removed placenta is intact. Manual removal of the already separated placenta (if external methods are unsuccessful) is also performed under deep anesthesia; this operation is much simpler and gives better results.

Question

The born placenta must be carefully examined, measured and weighed. The placenta should be subjected to a particularly thorough examination, for which it is laid with the maternal surface up on a flat plane, most often on an enamel tray, on a sheet or on your hands (Fig. 34). The placenta has a lobular structure, the lobules are separated from each other by grooves. When the placenta is located on a horizontal plane, the lobules are closely adjacent to each other. The maternal surface of the placenta has a grayish color, as it is covered with a thin superficial layer of the decidua, which peels off along with the placenta.

The purpose of examining the placenta is to make sure that not the slightest piece of placenta remains in the uterine cavity, since the retained part of the placenta can cause postpartum hemorrhage immediately after birth or in the long term. In addition, placental tissue is an excellent breeding ground for pathogenic microbes and, therefore, the placental lobule remaining in the uterine cavity can be a source of postpartum endomyometritis and even sepsis.
When examining the placenta, it is necessary to pay attention to any changes in its tissue (degeneration, heart attacks, depressions, etc.) and describe them in the birth history.
After making sure that the placenta is intact, you need to carefully examine the edge of the placenta and the membranes extending from it (Fig. 35). In addition to the main placenta, there are often one or more additional lobules connected to the placenta by vessels that pass between the aqueous and villous membranes. If upon examination it turns out that a vessel has separated from the placenta onto the membranes, it is necessary to trace its course. The breakage of a vessel on the membranes indicates that the lobule of the placenta to which the vessel went remained in the uterus.

Measuring the placenta makes it possible to imagine what the conditions were for intrauterine development of the fetus and what size the placental area in the uterus was. The usual average dimensions of the placenta are as follows: diameter -18-20 cm, thickness 2-3 cm, weight of the entire placenta - 500-600 g. With larger placental areas, greater blood loss from the uterus can be expected.
When inspecting the shells, it is necessary to pay attention to the place of their rupture. By the length of the membranes from the edge of the placenta to the place of their rupture, one can to a certain extent judge the location of the placenta in the uterus. If the rupture of the membranes occurred along the edge of the placenta or at a distance of less than 8 cm from its edge, there was low attachment of the placenta, which requires increased attention to the condition of the uterus after childbirth and blood loss.

Question 15 TERMINAL APPLICATION ACCORDING TO BAKSHEEV

Indications:

Hypotonic bleeding in the early postpartum period.

Equipment:

Gynecological chair (Rakhmanov bed), obstetric phantom, postpartum uterus phantom, obstetric speculum (2 pcs.), fenestrated clamps (6 - 8 pcs.), tweezers and forceps (2 - 3 pcs.), sterile swabs, skin antiseptic, tray for blood collection, sterile pad, sterile gloves.

Preparation for manipulation:

  1. Toilet the external genitalia, dry it, treat it with a skin antiseptic.
  2. The midwife washes her hands 2 times with soap, dries them, and puts on sterile gloves.

Technique:

  1. The cervix is ​​exposed using speculums;
  2. The front and rear lips are captured by clamps, and are brought down and then alternately retracted to the right and left;
  3. On the lateral sections of the lower segment of the uterus, 3 to 4 fenestrated clamps are applied on each side as follows: one branch of the clamp is inserted into the uterus and is located on the inner surface of the side wall of the uterus, and the other is applied from the side of the lateral vaginal vault;
  4. After applying the clamps, they are slightly pulled downwards, as a result of which the border of the external uterine pharynx is reduced to the entrance to the vagina;
  5. All blood flowing from the uterus should be collected in a tray (basin, vessel) placed under the pelvis of the mother in labor.
  6. 30 - 40 minutes (maximum 1.5 - 2 hours) after stopping bleeding and replenishing blood loss, the clamps are removed.

Question 19 Curettage of the uterine cavity during postpartum hemorrhage

After disinfection of the external genitalia and vagina, the cervix is ​​exposed using spoon-shaped mirrors, the anterior lip is grabbed with a forceps or fenestrated clamp. A Bumm curette is carefully inserted into the uterine cavity, then the handle of the curette is pressed so that its loop slides along the wall of the uterus and is brought out from top to bottom to internal os. to scrape the posterior wall, without removing the curette from the uterine cavity, carefully turn it 180°. Curettage is carried out in a certain order, first the anterior then the left lateral, posterior, right and corners of the uterus.

equipment: phantom, uterus, tweezers, forceps or window clamp, Bumm curette, spoon-shaped mirrors.

Question 20 External uterine massage

Putting your hand on the bottom of the uterus, begin to make light massaging movements until the uterus becomes dense.

Purpose of manipulation: increasing uterine tone due to mechanical stimulation of uterine contractions.

Indications:

Hypotony of the uterus in the early postpartum period

Conditions:

1. Early postpartum period

2. Preservation of blood coagulation properties

Technique:

1. Explain to the patient the purpose and significance of the study and obtain consent.

2.Empty your bladder.

3. Place the patient on the Rakhmanov bed in the “supine” position, legs bent at the hip and knee joints and apart.

4. Wear gloves.

5. Find the fundus of the uterus (with hypotonic and atonic bleeding, sometimes the fundus of the uterus is so soft that at first it is difficult to palpate.

6. Place your right hand on the fundus of the uterus so that four fingers lie on the back wall, the palm is on the fundus, and the thumb is on the front wall of the uterus.

7.Make light intermittent circular stroking movements with your right hand. Under no circumstances should you vigorously rub the wall of the uterus, because this does not help much.

8. Therapeutic gentle external massage of the uterus through the anterior abdominal wall for 20-30 seconds with breaks of 1 minute. (imitation of natural contraction of the uterus in the postpartum period)

9. As soon as the uterus becomes hard, stop external massage of the uterus.

21 questionsVAGINAL EXAMINATION and 13 question

During pregnancy and childbirth, internal (vaginal) examination is of great importance. It is a mandatory part of the obstetric examination and is carried out after appropriate treatment of hands with sterile gloves. The doctor is located to the right of the pregnant or laboring woman. The woman's thighs are spread wide apart and her feet rest on the bed or footrests. A thick pad can be placed under the sacrum if the examination is carried out on a soft bed. Using the thumb and index finger of the left hand, open the entrance to the vagina. With a cotton ball with a disinfectant solution in the right hand, wipe the external opening of the urethra and the vestibule of the vagina. First, the middle finger of the right hand is inserted into the vagina, they press it on the back wall of the vagina and the index finger is inserted on top of it, then both fingers are pushed together deep into the vagina. After this, the left hand ceases to hold the entrance to the vagina open. Before inserting the fingers, pay attention to the nature of the vaginal discharge, the presence of pathological processes in the vulva area (condylomas, ulcerations, etc.). The condition of the perineum deserves special attention: its height, the presence or absence of scars after injuries in previous births are assessed. During a vaginal examination, attention is paid to the entrance to the vagina (of a woman who has given birth or a nulliparous woman), the width of the vagina (narrow, wide), the presence of septa in it, and the condition of the pelvic floor muscles.

During a vaginal examination in the first trimester of pregnancy, the size, consistency, and shape of the uterus are determined. In the second half of pregnancy, and especially before childbirth, the condition of the vaginal part of the cervix (consistency, length, location in relation to the pelvic axis, patency of the cervical canal), and the condition of the lower segment of the uterus are assessed. During childbirth, the degree of opening of the external pharynx is determined, and the condition of its edges is assessed. The amniotic sac is determined if the cervical canal is passable for the examining finger. The entire amniotic sac is palpated as a thin-walled, fluid-filled sac.

The presenting part is located above the amniotic sac. It may be the head or the pelvic end of the fetus. In the case of a transverse or oblique position of the fetus during vaginal examination, the presenting part is not determined, and the fetal shoulder can be palpated above the plane of the entrance to the small pelvis.

During pregnancy and childbirth, the height of the head in relation to the planes of the small pelvis is determined. The head can be movable or pressed against the entrance to the pelvis, fixed by a small or large segment in the plane of the entrance to the small pelvis, and can be located in a narrow part of the pelvic cavity or on the pelvic floor. Having gained an idea of ​​the presenting part and its location in relation to the planes of the small pelvis, landmarks are determined on the head (sutures, fontanelles) or the pelvic end (sacrum, lin, intertrochanterica); assess the condition of the soft birth canal. Then they begin to palpate the walls of the pelvis. The height of the symphysis, the presence or absence of bony protrusions on it, the presence or absence of deformations of the lateral walls of the pelvis are determined. Carefully palpate the anterior surface of the sacrum. The shape and depth of the sacral cavity are determined. By lowering the elbow, they strive to reach the cape with the middle finger of the examining hand, i.e., measure the diagonal conjugate. Diagonal conjugate - this is the distance between the lower edge of the symphysis and the prominent point of the promontory (Fig. 31). The easy accessibility of the cape indicates a decrease in the true conjugate. If the middle finger reaches the promontory, then press the radial edge of the second finger to the lower surface of the symphysis, feeling the edge of the arcuate ligament of the pubis (lig.arcuatumpubis). After this, the index finger of the left hand marks the place of contact of the right hand with the lower edge of the symphysis. The right hand is removed from the vagina, and another doctor (or midwife) measures the distance between the tip of the middle finger and the mark on the right hand with a pelvis. With a normally developed pelvis, the size of the diagonal conjugate is 13 cm. In these cases, the cape is unattainable. If the cape is reached, the diagonal conjugate is 12.5 cm or less. By measuring the size of the diagonal conjugate, the doctor determines the size of the true conjugate. To do this, subtract 1.5-2.0 cm from the size of the diagonal conjugate (this figure is determined taking into account the height of the symphysis, the level of the promontory, and the angle of inclination of the pelvis).

The true conjugate, diagonal conjugate and the posterior surface of the symphysis form a triangle in which the diagonal conjugate is the hypotenuse of an isosceles triangle, and the symphysis and true conjugate are legs. The magnitude of the hypotenuse could be calculated according to the Pythagorean theorem. But in the practical work of an obstetrician, such mathematical calculations are not necessary. It is enough to take into account the height of the symphysis. The higher the symphysis, the greater the difference between the conjugates, and vice versa. When the symphysis height is 4 cm or more, 2 cm is subtracted from the diagonal conjugate value; when the symphysis height is 3.0-3.5 cm, 1.5 cm is subtracted.

If the cape is high, then the subtracted value should be greater (2 cm), since in a triangle composed of the pubic joint and two conjugates (true and diagonal), the true one will be significantly less than the diagonal one. If the cape is low, then the triangle will be almost isosceles, the true conjugate approaches the diagonal conjugate, and should be subtracted from the latter by 1.5 cm.

When the pelvic inclination angle exceeds 50°, to determine the true conjugate, subtract 2 cm from the diagonal conjugate value. If the pelvic inclination angle is less than 45°, then subtract 1.5 cm.

Question 22 Determination of signs of placenta separation

The following signs of separation of the placenta from the uterine wall are most often used in practice.

Schroeder's sign. If the placenta has separated and descended into the lower segment or into the vagina, the fundus of the uterus rises up and is located above the right umbilicus; The uterus takes on an hourglass shape.

Chukalov-Kustner sign. When pressing with the edge of the hand on the suprapubic area when the placenta is separated, the uterus rises up, the umbilical cord does not retract into the vagina, but, on the contrary, comes out even more.

Alfeld sign. The ligature placed on the umbilical cord at the genital slit of the woman in labor, when the placenta is separated, falls 8-10 cm below the Boulevard Ring.

Dovzhenko sign. The woman in labor is asked to breathe deeply: if, when exhaling, the umbilical cord does not retract into the vagina, the umbilical cord has separated.

Klein's sign. The woman in labor is asked to push: if the placenta is separated, the umbilical cord remains in place; if the placenta has not yet separated, the cord is pulled into the vagina.

In the absence of bleeding, the determination of signs of placental separation begins 15-20 minutes after the birth of the baby.

After the baby is born, labor continues and the third period begins. Successful completion of this stage is very important, since unnecessary tissue remains inside and needs to be removed out. Normally, the baby's place comes out with an effort, but if there are no signs of separation of the placenta, manual intervention is necessary. Untimely rejection of the placenta with membranes is fraught with the development of inflammation and heavy bleeding.

General information

The placenta is an organ that is formed specifically for bearing an embryo. For 40 weeks, it provides the baby with a protective “house”, which is connected to the mother’s circulatory system. The necessity and functional significance are completed by the end of pregnancy.

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

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

The placenta and umbilical canal are surrounded by a water membrane, it forms the amniotic sac, with fluid inside. From the outside, this sac is connected to the uterus by chorionic villi, which penetrate the mucous layer of the uterine tissue. Thus, the baby's place during pregnancy is fixed in the woman's internal reproductive system, ensuring normal development of the embryo.

  • conduction of oxygen, removal of carbon dioxide;
  • supply of food, removal of metabolic products;
  • synthesis of hormones;
  • protection against infections, chemical compounds.

The formation of the placenta begins in 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 membranes is 4-5 cm, weight is 400-600 grams.

The passing of the placenta means the completion of the final stage of childbirth, the cleansing of the uterus. The woman’s behavior is controlled by the obstetrician; it is important to push in a timely manner and tear away the remaining tissue. If the shells do not come out on their own, manual methods are used.

Signs

In most cases, obstetricians use active expectant management of the afterbirth period. Before manual removal of the placenta begins, the doctor must be sure that the intervention is necessary. Perhaps the woman was simply pushing incorrectly, or was physically exhausted. For this purpose, obstetrics uses a classification of signs that determine the state of the placenta in the 3rd stage of labor.

Determination methods:

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

According to Mikulich-Radetsky. The separated placental tissue descends and presses on the fundus of the uterus. There is an urge to push. The method works in half of the cases, since the pressure is not always sufficient for the cervix to react.

According to Schroeder. The technique determines the unattached placenta based on the condition of the uterus. If the tissues are still combined, the uterine fundus does not change its position, and the walls of the organ are softened, wide, and the contours are blurred. After the placenta is separated, the uterus can be easily palpated; it becomes dense, narrow, with wide walls. The lower part rises, deviating to the right.

According to Alfeld. The basis of the method is observation of the umbilical cord. When the placenta is separated, it becomes longer when 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 drops during the 3rd stage of labor, the distance between it and the genital opening increases (normally up to 12 cm), the baby's place will soon appear.

According to Klein. The obstetrician monitors the umbilical cord while the patient is pushing. As you exhale, the tip should appear outside, but if upon relaxation it retracts inward, it means that the afterbirth has not separated. A manual method is needed.

According to Kostner-Chukalov. If the tissues are not separated, if you press the edge of your palm on the suprapubic part, the umbilical cord will be pulled inward. Under no circumstances should you squeeze the canal too hard with your fingers.

According to Dovzhenko. The woman in labor is asked to take a deep breath and exhale. When the lungs are filled with air, the diaphragm part rises up, followed by the uterus; as you inhale, the organs return to their original position. If the umbilical cord moves up and down when breathing, it means that the placenta is attached and motionless - you need to push further, the placenta will soon come out.

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

More often than others, when determining signs of placenta separation in women, the Strassmann and Alfeld methods are used, which are recognized as the most informative. But each doctor leading the birth has his own “working” signs. For example, second place, according to polls, is occupied by the Kostner-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 out using the patient’s efforts and special equipment. Depending on the location of the membranes and the physical condition of the woman in labor, several methods of stimulation are used.

Methods for separating the placenta:

  • Abuladze;
  • Lazarevich-Crede;
  • Getera.

Abuladze. The external method of releasing separated placenta using the Abuladze method works by creating a pressure concentration inside the abdominal cavity. First, the bladder is emptied, the uterus is massaged with light pressure, and brought to the midline position. Then, the obstetrician grabs the outer tissue of the mother's abdomen, along the body. At this time, on command, an attempt is made 1-2 times. The method is the most effective and simple. If the placenta is separated, the placenta appears immediately.

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

The upper phalanges of the remaining 4 fingers should press on the back wall. In this girth, the placenta is pulled down, the other hand makes pressing longitudinal movements from the navel to the pubis. The woman in labor remains in a calm position and 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 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 its independent release. The patient raises the pelvis, while remaining on the shoulder blades, with emphasis on the feet. The weight of the placenta pulls on the tissue of the placenta, and the remnants are detached under pressure. If the method does not work, the doctor resorts to emergency measures.

Manual release

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

Indications:

  • there are no signs of placenta discharge 30 minutes after the birth of the child;
  • heavy bleeding;
  • surgical complicated delivery;
  • cervicitis of uterine tissue.

Manual separation is acceptable for tightly fused tissues, but in half of 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 assessed;
  2. an electrolyte solution is administered using a dropper (intravenously, jet);
  3. intravenous anesthesia is given;
  4. the obstetrician tightens the umbilical cord using a clamp;
  5. A hand is inserted into the uterus along the umbilical cord;
  6. the edge of the placenta is detected;
  7. gently use your palm to separate the tissue from the surface of the uterus (sawing motion);
  8. the palm remains inside the organ;
  9. with the second hand the placenta is pulled out;
  10. a manual examination of the uterus after childbirth is carried out for integrity and the absence of remnants of membranes;
  11. if necessary, the walls are massaged and toned;
  12. drugs used to separate the placenta after childbirth are administered (antibacterial, oxytocin);
  13. the hand is carefully removed.

In case of bleeding after separation of the placenta, the plasma volume is monitored. If the loss exceeds 800 ml, urgent surgical intervention is used to exclude disseminated intravascular coagulation syndrome, 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 in 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 rejected membranes should normally be 90%. The remains come out with lochia within 2 months from the date of birth.

Algorithm for examining the placenta:

  1. after removal, the baby seat is placed on a sterile plane;
  2. the maternal side of the organ faces upward;
  3. the placenta is inspected for integrity;
  4. you need to make sure that there are no blood vessels on the membranes;
  5. if a torn vessel is found, it means that an additional placenta lobe remains inside.

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

The particles will remain on the walls, this is fraught with the development of severe infections, decompensated blood loss, and death of the woman in labor. Therefore, to avoid the death of the patient, the uterus is removed. What remains is the cervix, fallopian tubes, and ovaries. After the operation, the woman’s quality of life does not change; there is only one significant disadvantage.

Consequences of deletion:

  • loss of reproductive function;
  • hormonal levels will not be disrupted;
  • menstruation will stop;
  • sexual desire will remain.

A woman after a complicated birth experiences stress, especially if her reproductive organ has been removed. But it is important to understand that the cardinal decision is made by doctors to save the mother’s life.

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

The third stage of labor is defined from the moment of birth of the child until the separation of the placenta and the discharge of the placenta. Duration 5-20 minutes. During this period, it is necessary to monitor the nature and amount of blood discharge from the uterus and signs of placental separation. When signs of separation of the placenta appear, the woman is recommended to push to give birth to the separated placenta, or begin to release it externally.

Signs of placenta separation:

- Chukalov-Kustner – when pressing with the edge of the palm on the uterus above the pubic symphysis, the umbilical cord does not retract into the vagina;

- Alfeld – a ligature placed on the umbilical cord at the genital slit of the woman in labor, with the separated placenta, lowers 8–10 cm from the vulvar ring;

- Schroeder – change in the shape and height of the uterine fundus. The fundus of the uterus rises up and is located above and to the right of the navel.

- Dovzhenko – the woman in labor is asked to take a deep breath and if, when inhaling, the umbilical cord does not retract into the vagina, then the placenta has separated.

Application of external methods for removing separated placenta:

- Abuladze's method – grab the abdominal wall in a longitudinal fold with both hands and offer to push. The separated afterbirth is easily born.

- Genter's method – the fundus of the uterus is brought to the midline. The doctor stands on the side of the woman in labor, facing her feet. The hands, clenched into a fist, are placed with the dorsal surfaces of the main phalanges on the bottom of the uterus, in the area of ​​its corners, and gradually press on it downward and inward. With this method of releasing the placenta, the woman in labor should not push.

- Crede-Lazarevich method - the uterus is brought to the middle position, with a light massage they try to cause its contraction and then the fundus of the uterus is grasped with the 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 wall of the uterus. After this, the placenta is squeezed out - the uterus is compressed in the anteroposterior direction and at the same time pressure is applied to its bottom downward and forward along the axis of the pelvis.

During the normal course of the afterbirth period, blood loss averages no more than 0.5% of body weight. This blood loss is physiological, since it does not have a negative effect on the body of the postpartum woman. The maximum permissible blood loss during physiological childbirth is no more than 500 ml.

After the birth of the placenta, you should perform an external massage of the uterus and make sure there is no bleeding. After which they begin to inspect the placenta to ensure its integrity.

Having ensured the integrity of the placenta, determine its mass and the size of the maternal surface area of ​​the placenta. The weight of the placenta during full-term pregnancy is 1/6-1/7 of the fetal weight; on average 400-600 g. The mature placenta has the form of a disk with a diameter of 15*20 cm and a thickness of 2-3 cm. The surface of the lobules of the maternal part of the placenta is smooth and shiny.

Management of the postpartum period.

Immediately after childbirth, early postpartum hemorrhage may occur, most often associated with uterine hypotension. Therefore, for the first 2 hours, the postpartum woman is in the maternity ward, where the condition of the uterus, the amount of discharge from the genital tract, and hemodynamics are monitored.

To prevent bleeding in the early postpartum period, all postpartum women need timely emptying of the bladder with a catheter, external reflex massage of the uterus, and cold on the lower abdomen. Active management of the third period childbirth is indicated at an increased risk of postpartum hemorrhage and in women with complications (severe anemia). Currently, for prophylactic purposes, intravenous administration of oxytotic drugs (oxytocin, ergometrine, methylergometrine, syntometrine, syntocinon) is recommended for primiparas when the head erupts, and for multiparas - when the head is cut into the head. If there are no signs of placental separation 10-15 minutes after the birth of the child, even if methylergometrine was administered intravenously for prophylactic purposes, intravenous drip administration of oxytocin is indicated. If, despite the administration of oxytocin, there are no signs of placental separation and external bleeding, then 30-40 minutes after the birth of the fetus, manual separation and release of the placenta is indicated.

Anomalies of contractile activity of the uterus. Reasons. Classification. Diagnostic methods

Anomalies of contractile activity of the uterus include variants in which the nature of at least one of its indicators is disrupted (tone, intensity, duration, interval, frequency and coordination of contractions).

Classification.

Genter's method

The bladder is emptied, the fundus 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, place the back surface of the main phalanges on the bottom of the uterus (in the area of ​​​​the tubal angles) and gradually press downward and inward, the woman in labor should not push.

Currently, the Genter method is used relatively rarely.

Credet-Lazarevich method

It is less gentle than the methods of Abuladze and Genter, so they resort to it after the unsuccessful use of one of these methods.

The technique of this method is as follows:

  • empty the bladder;
  • bring the fundus of the uterus to the midline position;
  • with a light massage they try to cause contractions of the uterus;
  • stand to the left of the woman in labor (facing her legs), grasp the fundus of the uterus with the right hand so that the first finger is on the front wall of the uterus, the palm is on the bottom, and 4 fingers are on the back surface of the uterus;
  • The placenta is squeezed out: the uterus is compressed anteroposteriorly and at the same time pressure is applied to its bottom downward and forward along the pelvic axis.

With this method, the separated afterbirth easily comes out. Failure to follow these rules can lead to spasm of the pharynx and strangulation of the placenta in it. In order to eliminate spastic contraction of the pharynx, 1 ml of a 0.1% solution of atropine sulfate or no-shpu, aprofen is administered, or anesthesia is used. Usually the placenta is born completely at once, sometimes after the birth of the placenta it is discovered that the membranes connected to the baby's place 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 become twisted, facilitating their gradual detachment from the walls of the uterus and removal outside without breaking.

There is a method for isolating the membranes according to Genter; after the birth of the placenta, the woman in labor is asked to lean on her feet and raise her pelvis, while the placenta hangs down and with its weight contributes to the detachment of the membranes.

The afterbirth is carefully examined to ensure the integrity of the placenta and membranes.

The placenta is laid out on a smooth tray or on the palms with the maternal surface facing up and carefully examined, one lobe at a time. It is necessary to examine the edges of the placenta very carefully; the edges of the whole placenta are smooth and do not have broken vessels extending from them.

Having examined the placenta, they move on to examining the membranes. The placenta is turned over with the maternal side down and the fetal side up.

The edges of the ruptured membranes are taken with fingers and straightened, trying to restore the egg chamber in which the fetus was located along with the waters.

At the same time, pay attention to the integrity of the aqueous and villous membranes and find out whether there are torn vessels between the membranes extending from the edge of the placenta.

The presence of such vessels indicates that there was an additional lobule of placenta that remained in the uterine cavity.

When examining the membranes, the location of their rupture is determined, this allows, to a certain extent, to judge the place of attachment of the placenta to the wall of the uterus.

The closer to the edge of the placenta is the place where the membranes rupture, the lower it was attached to the wall of the uterus.

“Obstetrics”, V.I. Bodyazhina