Algorithm for performing manual separation of the placenta. Manual separation of placenta. Manual separation of the placenta

The operation is performed under general anesthesia. With the left hand, the labia are spread wide apart, after which the cone-shaped hand of the right hand, dressed in a long glove, is inserted into the vagina. The left hand moves to the fundus of the uterus. The inner hand is inserted into the uterine cavity along the umbilical cord and, following along the umbilical cord, reaches the place of its attachment to the umbilical cord, then to the edge of the placenta. The inner hand then uses a sawing motion to peel the placenta away from its site until it is completely separated. The manipulation is performed with elongated fingers, tightly adjacent to each other, the palm surfaces of which are facing the placenta, and the back ones are facing the placental area. After the placenta is separated, the placenta is released by pulling the umbilical cord. The inner hand remains in the uterine cavity and promotes the release of the placenta; it is removed from the uterus only after the integrity of the removed placenta has been checked. Repeated insertion of the hand into the uterine cavity increases the risk of infection.

IX. METHOD FOR MANUAL EXAMINATION OF THE UTERINE CAVITY

X. METHOD FOR PROCESSING THE UMBILICAL CORD

The umbilical cord is tied in two stages 2-3 minutes after birth. At the first stage, with the cessation of pulsation of the umbilical cord, 2 sterile Kocher clamps are applied to it: one at a distance of 10 cm from the umbilical ring, the second 2 cm outward from the first clamp. The area of the umbilical cord between the clamps is treated with a 5% iodine solution, then cut with sterile scissors.

The second stage should be preceded by repeated treatment of the midwife's hands. The remainder of the umbilical cord is wiped with a sterile napkin, squeezed tightly between the thumb and forefinger, and Rogovin braces are applied. The remainder of the umbilical cord is cut off with sterile scissors, and the cut surface is treated with a 10% solution of potassium permanganate.

In case of Rh or ABO incompatibility between the blood of the mother and the fetus, the umbilical cord is clamped immediately after the birth of the child. The umbilical cord is tied at a distance of 5-10 cm from the umbilical ring (if a replacement blood transfusion is necessary through the umbilical cord vessels).

XI. METHOD FOR ASSESSING A NEWBORN ON THE APGAR SCALE

Apgar score- a system for assessing the condition of a newborn in the first minutes of life. This is a simple method for the initial assessment of the child's condition in order to determine the need for resuscitation procedures.

The scale involves a summary analysis of five criteria, each of which is assessed as an integer in points from zero to two inclusive. The score can range from 0 to 10. The score, recorded one minute after birth and recorded again 5 minutes later, reflects the overall condition of the newborn and is based on observations in five scoring categories.

Apgar SCALE

Criterion	0 points	1 point	2 points
Skin coloring	Generalized pallor or generalized cyanosis	Pink coloration of the body and bluish coloration of the limbs (acrocyanosis)	Pink coloring of the whole body and limbs
Heart rate	absent	<100	>100
Reflex excitability	Doesn't respond	The reaction is weakly expressed (grimace, movement)	Reaction in the form of movement, coughing, sneezing, loud screaming
Muscle tone	Missing, limbs hanging	Decreased, some limb flexion	Active movements are expressed
Breath	absent	Irregular, weak cry (hypoventilation)	Normal, loud scream

Children who score between 7 and 10 are considered good or excellent and usually require only routine care. Those who score between 4 and 6 are in fair condition and may require only some resuscitation procedures; and those whose score is less than 4 require immediate assistance to save their life.

PRACTICAL SKILLS IN GYNECOLOGY

I. Methodology for collecting anamnesis

First, the medical history is ascertained, then the life history. The latter includes information about past illnesses and operations, the menstrual cycle, pregnancy and childbirth, living and working conditions.

Then they move on to family history.

After collecting anamnesis, the doctor decides whether the patient requires consultation with other specialists.

Taking a medical history

1. First you need to give the patient the opportunity to express her complaints. They do not always correspond to the true picture of the disease, but they reflect how the patient perceives it. It is very important for the patient to express her complaints fully. It is useful to clarify how the patient felt before the complaints appeared. Sometimes it turns out that several days, months or even years before, other symptoms were observed that she did not attach importance to. In this way, it is possible to establish when the disease actually began.

It is better to give the patient the opportunity to talk about the course of the disease herself and not interrupt it. If necessary, you can ask clarifying questions, for example: “When did this start?” or “How did it start?” They will help the patient adhere to chronological order. After listening to the patient’s story, you need to ask what else is bothering her. At the same time, she may report symptoms that she did not mention before.

Thus, first the doctor receives information about the manifestations of the disease as interpreted by the patient. This eliminates errors that occur when the doctor himself asks questions, thereby imposing his opinion. In addition, this part of the conversation gives an idea of the importance of certain symptoms for the patient and her attitude towards the disease

2. In the second part of the history taking, the doctor asks in detail about each of the symptoms separately, adhering to chronological order.

You should ask in such a way as not to suggest an answer. This is especially true for questions that can be answered “yes” or “no.” The doctor must be sure that the patient's responses are not influenced. To do this, you can repeat questions, changing their form.

Then you should ask about those symptoms that are possible with this disease, but were not mentioned by the patient. Symptoms that the doctor asks about, but which the patient denies, are called negative. They can either confirm or reject the presumptive diagnosis.

3. The information obtained in the first two parts of the conversation makes it possible to make a presumptive diagnosis. If necessary, the doctor asks clarifying questions that will allow him to finally confirm the diagnosis.

4. Even with such a thorough survey, sometimes it is not possible to identify all the symptoms, especially those that have been observed for a long time and seem to the patient to be unrelated to the present disease. To identify them, you should ask about the condition of individual organs, and if violations are identified, conduct a more detailed survey

5. When collecting anamnesis of the disease, you need to remember the following

A. You should always try to establish the cause of the disease, for example mental stress, infection, malignant tumor

The patient's assumptions about the cause of the disease should not be ignored. If symptoms make you think of an infection, you need to find out

2. The hand is inserted into the uterine cavity.

3. Professor Akinints proposed a method - put a sterile sleeve on the hand and cover the fingers when inserted into the vagina; assistants pull the sleeve towards themselves and thus reduce infection.

4. The hand must get between the wall of the uterus and the fetal membranes, so that then, using sawing movements, they reach the placental area, separate it from the wall and release the placenta.

5. Examine the soft birth canal and repair the damage.

6. Reassess blood loss. If blood loss before surgery is 300-400, then during surgery it increases due to traumatic injuries.

7. Compensate for blood loss.

8. Continue intravenous administration of uterotonics.

With complete true growth and complete tight attachment, there is no bleeding (according to classical laws, wait 2 hours). In modern conditions, the rule is to separate the placenta 30 minutes after the birth of the fetus if there are no signs of placental separation and no bleeding. Performed: operation of manual separation of the placenta and release of the placenta.

Further tactics depend on the result of the operation:

1. if the bleeding has stopped as a result of the operation, then you need to:

Assess blood loss

2. If bleeding continues due to placenta accreta, attachment, etc. then this bleeding progresses into the early postpartum period.

Before the operation of manual separation of the placenta, no data can be used to make a differential diagnosis of dense attachment or true placenta accreta. Differential diagnosis is only during surgery.

1. When tightly attached, the hand can separate the decidua from the underlying muscle tissue

2. with true increment this is impossible. Do not overdo it as very heavy bleeding may develop.

In case of true accreta, the uterus must be removed - amputation, extirpation, depending on the location of the placenta, obstetric history, etc. this is the only way to stop the bleeding.

18. Manual examination of the walls of the uterine cavity

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.

Instrumental examination of the postpartum uterine cavity

A Sims speculum and a lift are inserted into the vagina. The vagina and cervix are treated with an antiseptic solution, the cervix is fixed by the front lip with bullet forceps. A blunt large (Bumon) curette is used to inspect the walls of the uterus: from the fundus of the uterus towards the lower segment. The removed material is sent for histological examination (Fig. 1).

Rice. 1. Instrumental examination of the uterine cavity

TECHNIQUE FOR MANUAL EXAMINATION OF THE UTERINE CAVITY

General information: retention of parts of the placenta in the uterus is a serious complication of childbirth. Its consequence is bleeding, which occurs soon after the birth of the placenta or at a later date. Bleeding can be severe, threatening the life of the postpartum mother. Retained pieces of the placenta also contribute to the development of septic postpartum diseases. In case of hypotonic bleeding, this operation is aimed at stopping the bleeding. In a clinical setting, before surgery, inform the patient about the need and essence of the operation and obtain consent for surgery.

Indications:

1) defect of the placenta or fetal membranes;

2) monitoring the integrity of the uterus after surgical interventions, long labor;

3) hypotonic and atonic bleeding;

4) childbirth in women with a uterine scar.

Workplace equipment:

1) iodine (1% solution of iodonate);

2) cotton balls;

3) forceps;

4) 2 sterile diapers;

6) sterile gloves;

7) catheter;

9) consent form for medical intervention,

10) anesthesia machine,

11) propafol 20 mg,

12) sterile syringes.

Preparatory stage of performing the manipulation.

Execution sequence:

Remove the foot end of Rakhmanov's bed.

Perform bladder catheterization.

Place one sterile diaper under the woman in labor, the second on her stomach.

Treat the external genitalia, inner thighs, perineum and anal area with iodine (1% iodonate solution).

The operations are performed under intravenous anesthesia against the background of inhalation of nitrous oxide and oxygen in a 1:1 ratio.

Put on an apron, sanitize your hands, put on a sterile mask, gown, and gloves.

The main stage of the manipulation.

The labia are spread with the left hand, and the right hand, folded in the shape of a cone, is inserted into the vagina and then into the uterine cavity.

The left hand is placed on the anterior abdominal wall and the wall of the uterus from the outside.

The right hand, located in the uterus, controls the walls, placental area, and uterine angles. If lobules, fragments of the placenta, membranes are found, they are removed by hand

If defects in the walls of the uterus are detected, the hand is removed from the uterine cavity and transection, suturing of the rupture or removal of the uterus (doctor) is performed.

The final stage of the manipulation.

11.Remove gloves, immerse in a container with disinfectant

means.

12.Place an ice pack on your lower abdomen.

13. Conduct dynamic monitoring of the condition of the postpartum woman

(control of blood pressure, pulse, skin color

integument, condition of the uterus, discharge from the genital tract).

14.As prescribed by the doctor, begin antibacterial therapy and administer

uterotonic drugs.

Since the normal duration of the placenta is 15-20 minutes, after this time, if the placenta has not yet been born, it is necessary, making sure that the placenta has been separated, to speed up its birth. First of all, the woman in labor is asked to push. If the force of the attempt does not produce the placenta, they resort to one of the methods of isolating the separated placenta. Abuladze's method: the abdominal wall is grabbed along the midline into a fold with both hands and raised, after which the woman in labor must push (Fig. 29). In this case, the afterbirth is easily born. This simple-to-implement technique is almost always effective.

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.

Geter 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 shell rupture; 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. 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, you need to pay attention to the location 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, then there was a low attachment of the placenta, which requires increased attention to the condition of the uterus after childbirth and to blood loss. Considering the fact that the afterbirth period for every woman is accompanied by blood loss, the task of the midwife leading the birth is to prevent pathological blood loss. Meanwhile, bleeding is the most common complication of the afterbirth period. In order to be able to anticipate and prevent pathological blood loss, it is necessary to know the causes that cause it. The amount of blood loss depends primarily on the intensity of uterine contraction in the afterbirth period. The stronger and longer the contractions, the faster the placenta separates. Blood loss is small if the placenta is separated in one contraction and can reach pathological sizes in those births when the process of separation of the placenta occurs during three, four or more contractions of weak strength. Insufficiency of contractile activity of the uterus in the afterbirth period can be observed in the following situations: 1 ) in labor that lasted a long time due to the primary weakness of labor; 2) due to hyperextension of the uterus during the birth of a large fetus (more than 4 kg), with multiple pregnancy and polyhydramnios; 3) with a pathologically altered uterine wall, especially in the presence of fibroid nodes; 4) after violent labor, observed in the first two stages of labor, and rapid labor; 5) with the development of endometritis during childbirth; 6) with a full bladder. The speed of placenta separation and the amount of blood loss is affected by the size of the baby's place. The larger the placenta, the longer it takes to separate and the larger the area of the placental area with bleeding vessels. The place of attachment of the placenta in the uterus is essential. If it is located in the lower segment, where the myometrium is poorly defined, separation of the placenta occurs slowly and is accompanied by large blood loss. Also unfavorable for the course of the succession period is the attachment of the placenta in the fundus of the uterus with the capture of one of the tubal angles. The cause of pathological blood loss may be improper management of the afterbirth period. Attempts to speed up the separation of the placenta by pulling the umbilical cord, premature (before the placenta is separated) use of the Genter and Lazarevich-Crede methods lead to disruption of the process of placenta separation and to increased blood loss. The course of the afterbirth period certainly depends on the nature of the placenta’s attachment. Normally, chorionic villi do not penetrate deeper than the compact layer of the uterine mucosa, therefore, in the third stage of labor, the placenta is easily separated at the level of the loose spongy layer of the mucosa. In cases where the uterine lining is altered and there is no decidual reaction, a more intimate attachment of the placenta to the uterine wall, called placenta accreta, may occur. In this case, independent separation of the placenta cannot occur. Placenta accreta is observed more often in women who have had abortions in the past, especially if the operation of artificial termination of pregnancy was accompanied by repeated curettage of the uterus, as well as in women who have had inflammatory diseases of the uterus and operations on it in the past. There are true and false placenta accreta. With a false accretion (placenta adhaerens), which occurs much more often than a true one, the chorionic villi can grow throughout the entire thickness of the mucous membrane, but do not reach the muscle layer. In such cases, the placenta can be separated from the uterine wall by hand. True placenta accreta (placenta accreta) is characterized by the penetration of villi into the muscular layer of the uterus, sometimes even by the germination of the entire uterine wall (placenta percreta). With true placenta accreta, it is impossible to separate it from the uterine wall. In these cases, supravaginal amputation of the uterus is performed. Placenta accreta, both false and true, can be observed throughout its entire length, but partial accretion is more common. Then part of the placenta separates from the uterus, after which bleeding begins from the vessels of the placental area. To stop bleeding in case of false placenta accreta, it is necessary to manually separate its attached part and remove the placenta. If during the operation it turns out that the villi are deeply embedded in the wall of the uterus, i.e. there is a true placenta accreta, you must immediately stop trying to separate the placenta, as this will lead to increased bleeding, immediately call a doctor and prepare for surgery for supravaginal amputation or hysterectomy . In very rare cases, true accreta develops throughout the entire placenta. In this case, there is no bleeding in the afterbirth period - the placenta does not separate. Contractions of the uterus, clearly visible to the eye, follow one after another for a long time, and separation of the placenta does not occur. In these conditions, first of all, it is necessary to call a doctor and, about an hour after the birth of the child, having prepared everything for the operation of supravaginal amputation of the uterus, attempt to manually separate the placenta. Once you are convinced of complete true placenta accreta, you should immediately begin the transection operation. Even when meeting a woman in labor for the first time, collecting her anamnesis and performing a detailed examination of the woman, it is necessary, based on the data obtained, to make a forecast of possible complications of the subsequent period and reflect it in the plan for the management of childbirth. The following women should be included in the high-risk group for bleeding in the afterbirth period: 1) multiparous women, especially with short intervals between births; 2) multiparous women with a burdened course of the placenta and postpartum period during previous births; 3) those who had abortions before the onset of this pregnancy with aggravated post-abortion course (repeated uterine curettage, edomyometritis); 4) have had uterine surgery in the past; 5) with an overstretched uterus (large fetus, multiple births, polyhydramnios); 6) with uterine fibroids; 7) with anomalies of labor in the first two stages of labor (weakness of contractions, excessively strong contractions, discoordinated labor); 8) with the development of endometritis during childbirth. For women who are expected to have a complicated course of the third stage of labor, for prophylactic purposes, in addition to releasing urine, uterine contractions can be used. In recent years, the use of methylergometrine or ergotamine has proven itself very well. Intravenous administration of these drugs reduced the incidence of pathological blood loss by 3-4 times. The drug should be administered slowly, over 3-4 minutes. To do this, 1 ml of methylergometrine is drawn into a syringe along with 20 ml of 40% glucose. At the moment when the head begins to extend and the woman in labor does not push, the second midwife or nurse begins to slowly inject the solution into the cubital vein. The administration ends shortly after the baby is born. The purpose of intravenous methylergometrine is that it intensifies and prolongs the contraction that expels the fetus, and the placenta is separated during this same prolongation contraction. 3-5 minutes after the birth of the baby, the placenta is already separated and it is only necessary to speed up the birth of the placenta. A negative quality of ergot preparations, including methylergometrine, is their reducing effect not only on the body of the uterus, but also on the cervix. Therefore, if the separated placenta is not removed from the uterus within 5-7 minutes after the administration of methylergometrine into the vein of the woman in labor, it may be strangulated in a spastically contracted pharynx. In this case, you must either wait until the spasm of the pharynx passes, or apply 0.5 ml of atropine intravenously or subcutaneously. A strangulated placenta is already a foreign body for the uterus, preventing its contraction, and can cause bleeding, so it must be removed. After the birth of the placenta, the uterus, under the influence of methylergometrine, remains well contracted for another 2-3 hours. This property of methylergometrine also helps to reduce blood loss during childbirth. Among other means that contract the uterus, oxytocin or pituitrin M are widely used. However, the latter, when administered internally, disrupts the physiology of the placenta, since, unlike methylergometrine, it does not enhance muscle retraction, but causes contractions of small amplitude at a high tone of the uterus. Oxytocin is destroyed in the body within 5-7 minutes, and therefore the uterine muscle may begin to relax again. Therefore, instead of oxytocin and pituitrin “M” in the afterbirth period, it is better to use methylergometrine for prophylactic purposes. In cases where blood loss in the afterbirth period exceeded the physiological one (0.5% in relation to the body weight of the woman in labor), and there are no signs of placental separation, it is necessary to proceed with the operation of manual separation of the placenta. Every independent midwife should be able to perform this operation.

53. Manual separation and release of placenta

The birth of a little person is a slow process, in which one stage successively replaces another. When the two most painful and difficult stages are over, the last phase of labor begins, easier for the young mother, but no less responsible: a phase, the successful completion of which largely depends not on the woman, but on the doctors.

What is afterbirth?

The placenta is a very important temporary organ consisting of the baby's place, amnion and umbilical cord. The main functions of the baby's place or placenta are nutrition of the embryo and gas exchange between the mother and the fetus. Also, the child's place 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 and 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 to allow it to fully contract.

Signs of placenta separation

The process when the baby's place with the umbilical cord and membranes begins to slowly peel off from the walls of the uterus is called separation of the placenta. The discharge 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 the successive period.

Normally, the third period lasts from several minutes to half an hour. In some cases, if there is no bleeding, obstetricians recommend waiting up to an hour before taking active steps.

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 sign is based on the fact that the completely separated placenta gives the uterus the opportunity to contract and decrease in size. After separation of the placenta, the body of the uterus becomes smaller in size, denser, acquires a narrow, long shape and deviates away from the midline.
Alfred's sign is based on elongation of the free end of the umbilical cord. After birth, the umbilical cord is crossed at the baby's umbilical ring, the second end goes into the uterine cavity. The obstetrician places 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 moves lower and lower from its original position.
Klein's sign. If you ask a woman in labor to push when the placenta has not separated, then when pushing, the free end of the umbilical cord goes into the birth canal.
The Küstner-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 the placenta not separated, the end of the umbilical cord is pulled into the birth canal. Once the placenta has separated, the umbilical cord remains motionless.

Methods for separating and isolating the placenta

The third, subsequent, period of childbirth is the fastest in time, but far from the easiest. It is during this period that life-threatening postpartum hemorrhages occur. If the placenta is not separated in time, the uterus is not able to contract further, and numerous vessels do not close. Heavy bleeding occurs, threatening the woman’s life. It is in such cases that obstetricians urgently use methods of separating and releasing the placenta.

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

Abuladze method. With both hands, the obstetrician grabs the anterior abdominal wall along with the uterus in a longitudinal fold and lifts it. The woman should push at this time. This is a painless and simple but effective technique.
Credet-Lazarevich method. The technique is similar to the previous technique, but the fold of the abdominal wall is not longitudinal, but transverse.
The Genter method is based on massaging the corners of the uterus with two fists, in which the obstetrician seems to squeeze the placenta 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 get out. Otherwise, doctors move on to the next stage - manual separation and release of the placenta.

Manual separation and release of placenta: indications and technique

The basic principle of managing normal labor, including the last stage, 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 undergo serious manipulation, but obstetric hemorrhage 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 treated, the doctor enters the uterine cavity with his hand. Using his fingers, the obstetrician finds the edge of the placenta and, using so-called “sawing” movements, begins to peel it off from the walls of the uterus, while simultaneously pulling the free end of the umbilical cord with his other hand.
After complete separation of the placenta, by gently pulling the umbilical cord, the placenta with membranes is removed and given to the midwife for examination. At this time, the doctor re-enters the uterus with his hand to examine its walls for additional lobules of the baby's place, remnants of the membranes and large blood clots. If such formations are found, the doctor removes them.
Afterwards, the uterine cavity is treated with an antiseptic, special drugs are administered to contract the uterus and antibiotics to prevent the development of infection.
After 5-10 minutes, the anesthesiologist wakes the woman up, she is shown the baby, and then the postpartum woman 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 and whether there is heavy bleeding.
The woman's blood pressure is periodically measured, her breathing and pulse are monitored. During this time, a urinary catheter will be placed in the urethra to monitor the amount of urine.

This technique is effective in the case of so-called “false” placenta accreta. However, in rare cases, true placenta accreta occurs, when placental villi for some reason grow into the uterus to the entire depth of its wall. It is absolutely impossible to predict this before the end of childbirth. Fortunately, such unpleasant surprises are quite rare. But when the diagnosis is confirmed: “True placenta accreta,” there is, unfortunately, 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 along with the accreta placenta. It is important to understand that the operation is designed to save the life of the young mother.

Typically, the operation involves supravaginal amputation of the uterus, that is, the body of the uterus with the placenta is removed. The cervix, fallopian tubes and ovaries remain. After such an operation, the woman will no longer be able to have children, menstruation will stop, but the hormonal levels 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, sexual desire and libido remain the same and the woman can be sexually active. No one except a gynecologist during an examination will be able to find out that a woman does not have a uterus.

Of course, it is a huge stress and misfortune for any woman to hear the verdict: “You will no longer have children!” But the most precious thing is life, which must be preserved at any cost, because a child who has just been born must have a mother.

Alexandra Pechkovskaya, obstetrician-gynecologist, especially for the site