· Schroeder's sign: the uterus flattens, becomes narrower, its bottom rises above the navel, and often deviates to the right.

· Alfeld's sign: the separated placenta descends into the lower segment of the uterus or vagina. In this regard, the Kocher clamp, placed on the umbilical cord when ligating it, is lowered.

Dovzhenko's sign: retraction and descent of the umbilical cord with deep breathing indicates that the placenta has not separated, and vice versa - the absence of retraction of the umbilical cord during inhalation indicates the separation of the placenta.

· Klein's sign: the end of the umbilical cord protruding from the genital fissure lengthens when straining. If, after pushing, the protruding section of the umbilical cord does not retract, it means that the placenta has separated; if it retracts, it has not separated.

· Küstner-Chukalov sign: if, when pressing with the edge of the palm on the uterus above the symphysis pubis, the umbilical cord is not retracted into the birth canal, it means that the placenta has separated; if it is retracted, it means that it has not separated.

Methods for isolating separated placenta.

Preparatory period:

Make sure that the placenta has separated;

Empty your bladder;

Bring the uterus to the midline position.

· Abuladze's method: the anterior abdominal wall is grasped with both hands in a fold so that the rectus abdominis muscles are tightly clasped with the fingers. After this, the woman in labor is asked to push.

· Genter's method: The woman in labor should not push while performing this technique. Stand to the side of the woman in labor, facing her feet. The hands of both hands, clenched into fists, are placed with the dorsal surfaces of the main phalanges on the fundus of the uterus. Gradually increasing pressure on the fundus of the uterus in a downward and inward direction, the placenta is forced to slowly emerge from the genital slit.

· Crede-Lazarevich method: Isolation of the placenta according to Crede-Lazarevich should be resorted to as a last resort.

Cover the fundus of the uterus with the hand of the hand that is better controlled, so that the palmar surfaces of its 4 fingers are located on back wall, and the palm is at the bottom of the uterus;

Perform stroking to contract the uterus;

Simultaneously press on the uterus with the entire hand in two intersecting directions (fingers from front to back, palm from top to bottom) towards the pubis until the placenta is born from the vagina.

EXAMINATION TICKET No. 29

Task No. 1

1. Diagnosis: 12th day of the postpartum period, purulent mastitis.

Because high temperature, hyperemia of the mammary gland, pain and softening in the center.

2. Real problems: pain in the right mammary gland, temperature, tachycardia, anxiety about your condition.

Potential problems: surgical treatment, deterioration, sepsis, hypogalactia.

3. Midwife tactics: g hospitalization in a specialized maternity hospital for septic complications. It is necessary to open the abscess and proceed as purulent wound, treat with antibiotics, vitamins, and improve immunity.

4. Prevention - proper attachment to the breast of a newborn, pumping, prevention and treatment of cracked nipples.

Problem No. 2

Diagnosis: complete solid attachment or rotation of the placenta.

Tactics: call an anesthesiologist, release urine through the catheter, and begin manual separation of the placenta. When rotating, prepare for hysterectomy surgery.

Manipulation algorithm: manual release placenta and placenta discharge.

Indications:

No signs of placenta separation 30 minutes after birth;

Bleeding during the afterbirth period.

Preparing a woman in labor:

Get informed consent;

Psychological (calm);

The use of general (IV or inhalation anesthesia) is mandatory.

Action algorithm:

Perform catheterization bladder. Treat the external genitalia.

· Cover bottom part abdomen, inner thighs with sterile wipes.

· Spread the labia with 1 and 2 fingers of the left hand.

· Insert the right hand, folded in a cone shape, into the vagina, with the back surface facing the sacrum.

· Translate left hand to the fundus of the uterus, holding the uterus and helping with the right hand.

· Insert your right hand along the umbilical cord into the uterine cavity and reach the placenta.

· Find the edge of the placenta.

· Insert the fingertips of your right hand between the placenta and the wall of the uterus.

· Separate the placenta from the uterine wall using sawtooth movements of the ends of the fingers.

· Displace the separated placenta into the lower segment of the uterus.

· Remove the placenta with your left hand, pulling the umbilical cord outward.

· Leave your right hand in the uterus for manual control.

· Remove the hand from the uterus after manual control in the same way as inserted into the vagina.

· Place an ice pack on your lower abdomen.

EXAMINATION CARD No. 30

Task No. 1

1. Diagnosis: pregnancy 38 weeks, premature detachment of a normally located placenta. Hemorrhagic shock. 1 tbsp. gravity. Stillbirth.

Because the uterus is tense, painful at the site of bulging, shock index 1.1.

2. Real problems: abdominal pain, weakness, dizziness, dead fetus.

Potential problems: coagulopathic bleeding, Couveler's uterus, death of a woman.

3. Midwife tactics: start infusion therapy, call a doctor, open the operating room. Prepare for a cesarean section.

4. Causes of PONRP – sharp increase Blood pressure, gestosis, trauma, short umbilical cord, sharp decrease in uterine volume during rupture of water with polyhydramnios after the birth of 1 fetus. Diagnosis: the uterus is tense, painful, swelling on the uterus, signs internal bleeding, sudden pain.

Manipulation algorithm: examination of the cervix in the speculum after childbirth.

· Treat your hands using one of the following methods.

· Wear sterile gloves.

· Insert a spoon-shaped speculum or lift into the vagina.

· Dry the vagina with a cotton swab.

· Place windowed forceps on the neck and move them in opposite directions.

· Inspect the area of ​​the external pharynx.

· Transfer the forceps one at a time and go around the entire pharynx, inspecting each section.

· Remove the speculum from the vagina.

EXAMINATION CARD No. 31

Task No. 1

1. Diagnosis:premature birth at 34-35 weeks, longitudinal fetal position, cephalic presentation, 1st stage of labor, placenta previa, bleeding.

Because birth at 34 weeks fetal head high above the pelvic inlet if present labor activity, increased bleeding during contractions.

2. Real problems: premature birth, bleeding, fear of unsuccessful completion of labor.

Potential problems: fetal death, disseminated intravascular coagulation syndrome, maternal death, uterine rupture.

3. Midwife tactics: call a doctor, start infusion therapy, relieve labor by giving anesthesia, prepare for surgery C-section, as prescribed by the doctor, administer dexamethasone to prevent fetal distress syndrome.

4. Infusion-transfusion therapy for obstetric hemorrhage includes the administration of starches (infucol, refortan), 5% glucose, frozen plasma, and saline solutions.

Problem No. 2

Diagnosis: cephalic presentation, facial insertion, anterior dorsal view, 2nd stage of labor.

Prognosis of childbirth: spontaneous birth is impossible.

The body performs important role in gestation. Its separation normally occurs at the final stage of labor. However, this may happen prematurely. When signs of placenta separation appear ahead of time, they speak of an emergency onset of labor.

The term came from Greek language, translated as “flatbread”. The organ received its name due to its external resemblance to the product. The only difference is the extending “tail” in the form of an umbilical cord. The placenta plays an important role in a woman's life. It is needed for bearing and giving birth to a baby.

Formation begins from the moment the embryo attaches to the wall of the uterus. Full maturation occurs by 15–16 weeks. After 20, metabolism begins. 22 – 36 weeks are marked by an increase in size. By the beginning of labor, the weight is 500 - 600 g. Premature passage of the placenta before childbirth due to injury is possible.

Normally, the organ is born 10–15 minutes after the baby is born. The doctor examines you and sends you for examination. It is important to know whether she was born entirely, how the pregnancy progressed, and to identify the presence of infections.

The structure of the placenta resembles a tree with spreading branches. From the beginning of pregnancy, villi are formed, which branch throughout the organ. The child's blood flows through them inside, and the mother's blood flows through them outside. Thus, 2 circulatory systems are combined, thanks to which the child’s side is smooth, and the mother’s side is uneven, lobed.

1. exchange of gases;
2. passage of nutrients;
3. protection of the fetus at the immune level;
4. synthesis of hormones.

Oxygen passes from the mother's blood to the fetus. Carbon dioxide moves in the opposite direction. The nutritional elements transformed by the organ are needed for the development and growth of the child. The function of protection is to retain the cells of the mother immune system. She is capable of rejecting the baby if she takes it for a foreign object.

The blood of the fetus and mother do not mix. A unique membrane separates the 2 systems. It operates on the principle of selectivity. By letting in the nutrients and oxygen necessary for the baby, the placenta traps viruses and bacteria that rush into the mother’s blood cells.

Signs

Placental abruption occurred during childbirth, however, the organ still remains in the birth canal. Such cases do not occur often; uterine contractions are disrupted. Retention of tissue inside promotes infection.

Signs that help to understand the degree of separation:

• Schroeder;
• Alfeld;
• Küstner – Chukalov;
• Klein;
• Dovzhenko;
• Strassmann.

Schroeder. Signs of placental separation according to Schroeder include finding changes in shape, fundal height reproductive organ. At the end of the birth process, the uterus is round. The bottom is located at the level of the navel. When the placenta is separated, the uterus takes on a flat appearance and the bottom rises. There is a deviation to the right. More complex signs include all except Schroeder; this one is the simplest and most effective.

Alfelda. The outer part of the umbilical cord lengthens. The placenta moves down the uterus. To see this sign, after the baby is born, a ligature is applied. The action takes place at the genital slit. When the release is triggered, the instrument moves 10 - 12 cm.

Kustner - Chukalov. Detachment of the placenta from the uterus during childbirth is determined by palm pressure. By pressing the edge on the area above the pubic area, retraction of the umbilical cord is noted. The fact is that there was no separation. Otherwise there would be no movement inward.

Klein. When a woman pushes, the end of the umbilical cord lengthens. Klein's sign is based on the protruding part of the genital fissure. The placenta is successfully separated if it does not go inside when pushing. When I get involved, additional manipulations are needed.

Dovzhenko. Also, the separation of the placenta can be judged by Dovzhenko’s sign. The test is carried out on the deep breathing process of the woman in labor. The diaphragm moves down when you inhale. When you exhale, it rises. If the placenta separation mechanisms do not work, movement occurs simultaneously with the uterus. The umbilical cord lowers as you inhale, and stretches out as you exhale. When the final detachment occurs, the actions of the uterus are not transferred to it.

Strassmann. The doctor is at the mother's side. With one hand, he takes the umbilical cord above the clamp and squeezes. Another taps the reproductive organ in different areas. When the connection is not interrupted, the limb holding the umbilical cord will feel a fluctuation. Otherwise it is not observed.

Assessment of signs of placental separation showed that no method is absolutely reliable. To get an accurate result, diagnostics are carried out based on 2 - 3 determination methods. When an organ is retained, external removal techniques are used.

Methods

IN in rare cases the placenta separates early stages pregnancy. If there is a threat of not carrying the child to term, an artificial termination is performed. When placental abruption occurs before childbirth, the woman is prepared for the birth of the baby.

Postpartum period of childbirth in good condition lasts 15 – 20 minutes. You need to make sure that the placenta has come out, otherwise the process needs to be accelerated. The obstetrician asks the woman in labor to push. When the action does not help, other methods of separating the placenta are used.

Abuladze method. The doctor grabs with both hands abdominal wall along the midline. Forms a fold and lifts slightly. After this, the woman pushes hard, the placenta comes out during the push.

Genter's method. The actions are simple, effective, and are carried out if the placenta does not come out during childbirth. When the bladder is empty, the uterus takes a position in the middle. The obstetrician uses massage movements to induce contractions through the abdominal wall. Next, he sits on the side of the woman in labor and places his hands on the place where the fundus of the uterus is located. As you press, the downward pressure increases.

Lazarevich's method. Having emptied the bladder, the reproductive organ is brought to the middle, causing contraction with massage manipulations. If this preparation is not carried out, it will not relax, can easily be injured, and will not be able to contract. Bleeding may begin one day after birth.

When the preparatory steps have been completed, the obstetrician is positioned on the side of the woman and grasps the fundus of the uterus with her hand. He squeezes the organ, pressing down. There is no need to push. Removal is easy.

Placenta separation methods are used when there is no spontaneous rejection. At the end of the process, a thorough examination of the organ is carried out. You need to make sure that all the slices come out. The retained part can cause bleeding, a source of endomyometritis, and sepsis.

Manual release

The placenta is not always separated by the indicated methods. The reason is muscle spasm isthmus, hypotension, erroneous administration of ergot. The difficulty is caused by incorrect placement.

It is necessary to distinguish between manual separation, removal internal ways. In the first case, the hand lingers in the uterine cavity. This indicates the possibility of introducing infection inside. The second appointment goes faster. Manual separation is used for urgent intervention when bleeding begins in the postpartum period, the placenta did not come out within 2 hours.

Algorithm of actions:

1. the obstetrician washes his hands thoroughly;
2. the genitals of the woman in labor are disinfected;
3. the bladder is emptied by a catheter;
4. the protruding end of the umbilical cord is cut off;
5. the obstetrician’s hands are lubricated with sterile vegetable oil;
6. one upper limb is inserted into the cavity of the reproductive organ, the second is placed on the bottom;
7. the one that is placed inside moves along the umbilical cord to the root;
8. you need to find the gap between the wall;
9. separation occurs with sawtooth movements of the fingertips;
10. the hand on the outside controls the process;
11. the detached placenta is captured and removed;
12. the outside hand can help by tugging on the umbilical cord;
13. having fully examined internal cavity after separation, the hand is removed.

Manual separation is performed under general anesthesia. Asepsis is observed. Antibiotics are administered for prevention. If necessary, a blood transfusion is given.

Complications

The birth of the placenta is the 3rd stage of labor. The step is no less important. In case of deviations, emergency intervention of medical personnel will be required.

Complications in stages:

1. the first period faces weak activity, premature detachment placenta during childbirth;
2. on the second, fetal hypoxia and ruptures may occur;
3. the third is marked by incomplete tissue release.

Part of the tissue is retained in the uterus, and blood flow occurs. Endometritis may occur. When the determination of signs of incomplete separation has been completed, manual examination is used.
Another complication is poor contraction. As a result, it begins profuse bleeding. Large blood loss requires the placement of an IV. Any complications that appear during the birth process can be dangerous and have consequences for the child and mother.

A serious complication is premature placental abruption. Will be required emergency assistance. Changes are manifested by the flow of blood. The causes of placental abruption during childbirth are vascular pathology. The permeability of the wall of the reproductive organ increases. Capillaries become fragile and brittle. Blood circulation is disrupted. Premature process is facilitated by adoption alcoholic drinks, smoking. Possible repeated births after placental abruption. You just need to give female body time for rest.

Symptoms of placental abruption before childbirth can gradually increase and develop suddenly. A slight deviation does not manifest itself in any way; it becomes visible after the end of the birth process. After birth, the placental area becomes epithelialized, and a small blood clot can be found on the surface.

The birth of the placenta completes the normal birth process. The health of the woman in labor and the need for cleaning depend on the time it takes place. If separation does not occur within 2 hours, signs are determined.

Plan:

1. 
   Management of the third stage of labor
2. 
   Signs of placenta separation
3. 
   Inspection of the placenta.

Management of the third stage of labor

Remember the existence in practical obstetrics catchphrase: "Hands off the afterbirth uterus." This, of course, does not mean that the uterus cannot be touched during the afterbirth period. It is possible and necessary to clarify the signs of separation of the placenta. But this must be done carefully, without causing indiscriminate pressure on the uterus, so as not to cause untimely contractions in it, which can lead to dangerous bleeding.

The basic rule in managing this period of labor is careful observation:

for the woman in labor (general condition, coloring skin, visible mucous membranes, pulse, blood pressure, inquire about your health),

for blood loss (a kidney-shaped tray or a boiled vessel is placed under the pelvis of the woman in labor),

for the separation of the placenta (observe the shape of the uterus, the height of its fundus)

monitor the condition of the bladder (prevent it from overflowing - an overfilled bladder is a reflex, preventing uterine contractions and the birth of the placenta)

At good condition Women in labor, if there is no bleeding, must wait for spontaneous abruption and birth of the placenta within 30 minutes. Active measures to remove it are required in case of pathological blood loss and deterioration of the woman’s condition, as well as long delay placenta in the uterus for more than 30 minutes.

Actions medical personnel in such cases, they are determined by the presence or absence of signs of placental separation:

if there are positive signs of placenta separation, the woman is asked to push. If the woman in labor is pushing, but the placenta is not born, they proceed to methods of isolating the separated placenta;

in the absence of signs of separation of the placenta, or the presence of signs of external or internal bleeding, an operation is performed to manually separate the placenta and release the placenta. If the separated placenta lingers in the vagina, it is removed externally, without waiting for the above period.

Signs of placenta separation

Schroeder's sign. Changes in the shape and height of the fundus of the uterus. Immediately after the birth of the fetus, the uterus takes on a rounded shape and is located in the midline. The fundus of the uterus is at the level of the navel. After the placenta is separated, the uterus stretches (becomes narrower), its bottom rises above the navel, and often deviates to the right

Dovzhenko's sign. The woman in labor is asked to breathe deeply. If, when you inhale, the umbilical cord does not retract into the vagina, then the placenta has separated from the wall of the uterus; if the umbilical cord retracts into the vagina, the placenta has not separated

Alfeld's sign. The separated placenta descends into the lower segment of the uterus or vagina. In this regard, the Kocher clamp, applied to the umbilical cord when ligating it, lowers by 8-10 cm or more.

Klein's sign. The woman in labor is asked to push. If the placenta has separated from the wall of the uterus, the umbilical cord remains in place after the effort stops. If the placenta has not separated, the umbilical cord is retracted into the vagina.

Küstner-Chukalov sign. If, when pressing with the edge of your palm on the uterus above the symphysis pubis, the umbilical cord is not retracted into the birth canal, it means that the placenta has separated; if it retracts, it means it has not separated

Mikulicz-Radetzky sign. The separated placenta descends into the vagina, and the urge to push appears (not always).

Strassmann's sign. When the placenta has not separated, the swaying along the bottom of the uterus is transmitted to the blood-filled umbilical vein. This wave can be felt with the fingers located on the umbilical cord above the clamping point. If the placenta has separated from the wall of the uterus, this symptom is absent.

Hohenbichler's sign. If the placenta has not separated, during contraction of the uterus, the umbilical cord hanging from the genital slit can rotate around its axis due to the overflow of the umbilical vein with blood.

Note: the separation of the placenta is judged not by one sign, but by a combination of 2-3 signs. The most reliable are the signs of Schroeder, Alfeld, and Kustner-Chukalov.

Methods for isolating separated placenta

If there are positive signs of separation of the placenta and the absence of spontaneous birth of the placenta, they resort to its isolation manually. To deliver the placenta, sufficient intra-abdominal pressure must be created. To do this, the woman in labor is asked to push. If artificial pushing does not lead to the birth of the placenta, which occurs when the abdominal muscles are overstretched, the anterior abdominal wall should be folded (reduce the volume abdominal cavity) according to Abuladze's method. After this, in one or two attempts the placenta is born.

Abuladze's method

Emptying the bladder.

Gentle massage of the uterus through the anterior abdominal wall.

Stand to the right, to the side of the woman in labor.

Grasp the anterior abdominal wall in a longitudinal fold with both hands.

Invite the woman to push.

Genter's method

Emptying the bladder.

Stand to the side of the woman in labor, facing her feet.

Clench both hands into fists.

Put back surface fists to the bottom of the uterus in the area of ​​​​the tubal angles.

Forbid the woman in labor to push.

Press the uterus with your fists down towards the sacrum.

Crede-Lazarevich method

Emptying the bladder.

Gentle massage of the uterus through the anterior abdominal wall.

Bringing the uterus to a midline position.

Stand to the left of the woman in labor, facing her feet.

Cover the fundus of the uterus with your right hand so that thumb was on the anterior wall of the uterus, the palm was on the fundus, and 4 fingers were on the posterior surface of the uterus.

Simultaneously pressing on the uterus with the entire hand in two mutually intersecting directions (fingers from front to back and palm from top to bottom in the direction of the pubis) to achieve the birth of the placenta.

Stop putting pressure on the uterus and make sure that the membranes come out completely.

At the birth of the placenta, the midwife grabs it with her hands and arms and twists the membranes in the form of a cord with rotational movements (Jacobs method). This simple technique prevents the shells from coming off.

The Jacobs method is to take the placenta in your hands, rotate it clockwise so that the membranes curl into a cord and come out unbroken

The woman in labor enters the maternity room after initial sanitary treatment. Pubic hair removal is mandatory.

If labor does not end within the next few hours after the woman in labor is admitted to maternity ward, then the external genitalia is toileted twice a day.

During vaginal examination, the skin of the external genitalia is thoroughly disinfected and inner surface upper third of the thighs.

The hands of the obstetrician performing a vaginal examination are treated in the same way as for abdominal surgery.

During labor and delivery postpartum period it is necessary to create conditions to prevent pathogens from entering the birth canal from outside infectious process. After a vaginal examination, some obstetricians recommend leaving upper section vagina 3-4 tablets of tetracycline or other antibiotic.

When the antibiotic slowly dissolves in the vagina, an environment is created that has antibacterial effect on the microflora if it was brought by the hand of the examiner from the lower part of the vagina to the cervical area. Accumulated material from vaginal use of antibiotics with for preventive purposes, after internal research, indicates that this method almost completely eliminates the possibility of infection birth canal even with multiple studies. This event is even more important in case of premature and early discharge of water.

When the birth canal becomes infected, antibiotics should be used in accordance with the identified sensitivity of the infectious agent to them. Modern methods make it possible to obtain this data in 18-24 hours.

ABSTRACT

On the topic: Childbirth, duties of a paramedic during the introduction of the 3rd stage of labor.

Completed by: Diana Salakhova

Checked by: Zakirova I.A.

Antibiotics

Based on their ability to have embryotoxic and teratogenic effects, drugs are divided into 3 groups.

Group I. Medicines With high risk development of teratogenic and embryotoxic effects. The prescription or use of this group of drugs during pregnancy requires its termination. - Antifungal antibiotics. - Antitumor antibiotics (for example, rubomycin).

II group. Medicines, the use of which in the first 3-10 weeks of pregnancy in a significant percentage of cases can cause the death of the embryo and/or spontaneous miscarriage. - Antibiotics (aminoglycosides, tetracyclines, rifampicin). - Antimalarial drugs (plaquenil, hingamine, quinine preparations).

III group. Medicinal products of moderate risk. - Sulfonamides (including biseptol). - A drug for the treatment of protozoal infections - metronidazole.

So, absolutely contraindicated: doxycycline; norfloxacin; ofloxacin; tetracycline; ciprofloxacin, relatively contraindicated: aminoglycosides; isoniazid; itraconazole; ketoconazole ( systemic use); miconazole (systemic use); pentamidine; pyrazinamide; rifampicin; TMP/SMK (Contraindicated in last weeks pregnancy); fluconazole; ethambutol, Relatively safe: azithromycin; aztreonam; acyclovir; vancomycin; imipenem/cilastatin; clarithromycin; clindamycin; metronidazole (Contraindicated in the first trimester); chloramphenicol (Contraindicated in the last weeks of pregnancy)

Tetracycline V large doses, prescribed in late pregnancy, can cause acute yellow dystrophy of the liver (impaired liver function as a result of the damaging effects of antibiotics, characterized by a decrease in its size; in this case, the liver on the cut has yellow). In addition, even small doses of tetracycline taken during this period can cause staining of the fetal teeth, their hypoplasia (underdevelopment), and slower skeletal development. Streptomycin, prescribed to a pregnant woman, may cause the development of lesions in the fetus nervous system, in particular, defeat auditory nerve, micromyelia (underdevelopment /small size/ spinal cord), violation of skeletal development. TO aminoglycosides include gentamicin, kanamycin, netilmicin, streptomycin, amikacin, tobramycin and a number of other drugs. Due to oto- and nephrotoxicity, drugs in this group are prescribed to pregnant women only in exceptional cases. Sulfonamides. It is not advisable to use sulfonamides in the third trimester of pregnancy, especially long acting, since they intensively bind to blood plasma proteins and displace bilirubin (bile pigment), which can lead to the development of jaundice in newborns. In addition, sulfonamides, as well as nitrofurans can cause hemoglobin anemia in newborns (a decrease in hemoglobin content in the blood due to increased breakdown of red blood cells). Not recommended for pregnant women biseptol, since it can disrupt the exchange folic acid both in the body of the mother and the fetus. Chloramphenicol. The fetal liver is not able to metabolize this drug. As a result, the newborn develops gray syndrome. Macrolides Since erythromycin estolate is hepatotoxic and causes a transient increase in serum aminotransferase activity, it is not prescribed in late dates pregnancy. Clarithromycin is toxic to the fetus. It is better not to prescribe this drug to pregnant women. TMP/SMK during pregnancy is prescribed only according to absolute indications. According to experimental studies, this drug has a teratogenic effect. In addition, the substances included in its composition serve as folic acid antagonists, which can cause anemia. Rifampicin There is information about abnormalities in the development of limbs in the fetus while taking it. Pyrimethamine Contraindicated in the first and second trimesters of pregnancy, as it has a teratogenic effect. In the third trimester of pregnancy, the drug is prescribed only for absolute indications. Zidovudine used to treat HIV infection. Side effect- inhibition of hematopoiesis. Metronidazole not prescribed in the first trimester of pregnancy due to the embryotoxicity (the ability of the drug to cause death or pathological changes in the embryo when it enters the mother’s body).

Determination of cervical maturity for childbirth (from 37 weeks)

D.b behind from the wire. pelvic axis, shortening, softening, opening of wires. channel.

1. deviation: posterior - 0b, anterior - 1b, center - 2b.

2. Length: > 2cm-0b, 1-2cm-1b,< 1 см/сглаженная-2б.

3. consistency: dense - 0b, not completely softened - 1b, soft - 2b.

4. cross-country ability cervical canal: nar.pharynx closed/pass fingertip-0b, pass for 1 finger –1b, > than for 1 finger –2b.

If the total is 0-2b – immature, 3-4b – ripening, 5-8b – mature.

Signs of placenta separation

The most important signs The compartments of the placenta are as follows:

1. Change in the shape and height of the uterine fundus (Schröder sign). Immediately after the birth of the fetus, the shape of the uterus is rounded, its bottom is at the level of the navel. After separation of the placenta, the uterus flattens, becomes narrower, its bottom rises (above the detached placenta) above the navel (sometimes to the costal arch); The uterus often deviates to the right.

2. Lengthening the outer section of the umbilical cord. The detached placenta descends into the lower segment of the uterus or into the vagina. In this regard, the ligature placed on the umbilical cord at the genital fissure (during transection) drops 10-15 cm in 10-15 minutes (sign Alfeld).

3. 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 of this segment, together with the abdominal wall, rises and forms a protrusion above the symphysis.

4. The separated placenta descends into the vagina, and a urge to push appears (not always) (a sign Mikulich-Radetsky).

5. When the woman in labor strains, the end of the umbilical cord protruding from the genital slit lengthens. If, after pushing, the protruding section of the umbilical cord does not retract, then the placenta has separated, but if it retracts, it has not separated (Klein’s sign).

6. Sign Kustner - Chukalov. If you press with the edge of your palm on the suprapubic area, the umbilical cord, with the placenta not separated, is retracted into the vagina; When the placenta separates, the umbilical cord does not retract.

7. Strassmann's test- tapping on the bottom of the uterus, if the placenta has not separated - vibrations are transmitted.

8. Fader's sign- they pull the umbilical cord; if the uterus moves, it means it has not yet separated.

9. Klein's sign– push, if it doesn’t pull back, it means it’s separated.

10. Dovzhenko sign- breathes deeply with her stomach, if she does not fluctuate in rhythm with her breathing - she has separated.

The separation of the placenta is usually judged not by one, but by a combination of the described signs (at least 3 signs). During the normal course of the pre-explant period, the separated placenta is released from the genital tract on its own, in most cases within 5-10 minutes after the birth of the fetus. If the birth of the placenta is delayed, check for signs of separation; if the afterbirth has not separated, they begin to isolate it. In cases where, during testing, the signs of separation of the placenta are positive, measures are immediately taken to separate it. First of all, the bladder is emptied and the woman in labor is asked to push. Under the action of the abdominal press, the separated placenta is easily born. If this method is unsuccessful, they resort to extracting the placenta externally.

Succession period- begins after the birth of the fetus and ends with the birth of the placenta. This is the shortest period of labor. The average duration of the third period in primiparous women is 20-30 minutes, in multiparous women - 10 minutes. Maximum duration this period is up to 1 hour. In the afterbirth period, the mother's tachycardia disappears; blood pressure, which increases in the second stage of labor, decreases and reaches the initial level; the feeling of chills stops; body temperature, color of the skin and visible mucous membranes are normal; subsequent contractions, as a rule, do not cause discomfort, they are less intense, moderately painful, on average the placenta is separated after 2-3 contractions.

After the birth of a child, the uterus contracts, acquires a rounded shape, its bottom is located at the level of the navel; after a few minutes, afterbirth contractions begin, which contribute to further contractions of the uterus, including at the placenta attachment site (placental platform). The placenta itself does not have the ability to contract, so with each contraction it is displaced and gradually detached, and the uteroplacental vessels rupture.

The separation of the placenta from the uterus occurs in two ways:

1. Central (according to Schultz)- first, the central part of the placenta is exfoliated, and a retroplacental hematoma is formed between the separated areas of the placenta and the wall of the uterus, which contributes to further placental abruption; the placenta is born with the fetal surface facing outward, that is, the membranes of the placenta are turned inside out; retroplacental hematoma is released along with the placenta;

2. Regional (according to Duncan)- separation of the placenta begins from the periphery, the placenta is born with the maternal surface outward, i.e., the location of the placenta membranes is preserved the same as in the uterine cavity; a retroplacental hematoma does not form, so the placenta takes longer to separate and the blood loss in this case is greater; part of the blood is released before the birth of the placenta, and part - along with it. The second method is less common than the first.

The type of detachment can be determined after its birth by the location of the blood vessels.

Thus, the separation of the placenta from the walls of the uterus is facilitated by:

a) contractions; b) pushing; c) the heaviness of the placenta itself; d) retroplacental hematoma with central separation of the placenta.

After separation of the placenta, the uterus contracts, which leads to compression of the blood vessels and stops bleeding.

Physiological (average) blood loss- 250 ml.

Borderline blood loss- 300-400 ml.

Pathological blood loss - >. 400 ml.

Acceptable blood loss- 0.5% of a woman’s body weight.

After the birth of the placenta, the woman is called maternity mother.

Management of childbirth in the afterbirth period.

1. Tactics for managing the afterbirth period expectant(“hands off the uterus” is the slogan of obstetricians in the third stage of labor).

2. Immediately after the birth of the child, it is necessary to release the woman’s urine with a catheter, and use the mammary reflex to accelerate the contraction of the uterus. In the future, it is necessary to monitor the function of the bladder, preventing it from overflowing, as this inhibits the afterbirth contractions and disrupts the process of placental abruption and expulsion of the placenta.

3. Constantly monitor general condition the woman in labor, her state of health, pulse, blood pressure, color of the skin and visible mucous membranes, the nature and amount of discharge from the genital tract.

4. If the woman in labor is in good condition and there is no bleeding, she should wait for spontaneous abruption of the placenta and birth of the placenta. Moreover, it is constantly necessary to monitor signs of placenta separation, the most important of which are:

a) Schroeder's sign- change in the shape and height of the fundus of the uterus - the uterus rises up, above the navel, flattens, becomes narrower and deviates to the right (the round ligament on the right is shorter);

b) Alfeld's sign- lengthening the outer segment of the umbilical cord - a clamp placed on the umbilical cord at the genital slit is lowered by 10-12 cm;

c) Kustner-Chukalov sign- when pressing with the edge of the palm on the suprapubic area when the placenta has separated, the umbilical cord does not retract;

d) Dovzhenko’s sign- when a woman breathes deeply, the umbilical cord does not retract;

e) Klein's sign- when the woman in labor strains, the end of the umbilical cord lengthens and after the end of the strain, the umbilical cord does not retract;

f) Mikulicz's sign- urge to push - the separated placenta descends into the vagina, the urge to push appears (the sign is not permanent);

g) the appearance of a protrusion above the symphysis as a result of the separated placenta descending into the thin-walled lower segment, and the anterior wall of this segment, together with the abdominal wall, rises.

During the physiological course of the afterbirth period, the separated afterbirth is released independently. If there are signs of placental separation, it is necessary to empty the bladder and ask the woman to push;

under the action of the abdominal press, the separated placenta is easily born.

5. If there are signs of separation of the placenta, but the placenta does not stand out, then use ways to isolate separated afterbirth:

a) Abuladze’s method – performed after emptying the bladder. Massage the uterus to contract it. Then, with both hands, they gather the anterior abdominal wall into a longitudinal fold and invite the woman to push. The separated afterbirth is easily born.

b) Genter's method - the uterus is brought to the median position. They stand on the side of the woman, facing her feet. The hands, clenched into fists, are placed on the fundus of the uterus in the area pipe angles and slowly press inward and downward.

c) Crede-Lazarevich method - used when other methods are unsuccessful. The fundus of the uterus is brought to the midline position and causes its contraction light massage. Right hand cover the fundus of the uterus, placing the thumb on its anterior surface and the rest on the posterior surface. The placenta is released by squeezing the uterus between the fingers in an anteroposterior direction and pressing on its bottom downward and anteriorly.

d) manual separation of the placenta. indications: 1) absence of signs of placenta discharge within 30 minutes; 2) beginning blood loss (250-300 ml) without signs of placenta discharge; 3) external blood loss when the mother’s condition worsens.

Indications for manual examination of the uterus after the birth of the placenta: 1) defect of placental tissue or doubt about its integrity; 2) the presence of an additional lobule of placenta retained in the uterus; 3) complete or almost complete breakage and retention of the chorionic membrane in the uterus; 4) ongoing bleeding, reaching more than 250-300 ml.

6. After the birth of the placenta, it is carefully examined to ensure the integrity of the placenta and membranes, since retention of parts of the placenta or membranes in the uterus can lead to severe complications(bleeding, septic postpartum diseases). Remaining parts of the placenta and membranes are necessary.

delete. After examination, the placenta is measured and weighed, and the data is entered into the birth history.

7. After the birth of the placenta, the external genitalia, perineal area and internal genitalia (vagina and cervix) must be examined. If there are ruptures, they must be sutured, this is a preventative measure. postpartum hemorrhage And infectious diseases, as well as prolapse and prolapse of the internal genital organs.

8. The postpartum woman is observed for 2 hours in maternity ward, and then transferred to the postpartum ward.