Manual separation of the placenta: methods and techniques. Manual separation of the placenta after childbirth - “No one is immune from this! THIS happened to me twice! Manual separation of the placenta, placenta accreta. Manual cleaning of the uterus." Manual examination of the walls

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

INDICATIONS

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

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

METHODS OF PAIN RELIEF

Intravenous or inhalational general anesthesia.

OPERATIONAL TECHNIQUE

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

After the end of the operation, before removing the arm from the uterine cavity, 1 ml of a 0.2% solution of methylergometrine is injected intravenously at the same time, and then intravenous drip administration of drugs that have a uterotonic effect (5 IU of oxytocin) is started, an ice pack is placed on the suprapubic area of the abdomen.

COMPLICATIONS

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

Examination of the birth canal in the postpartum period

Examination of the birth canal

After childbirth, the birth canal must be examined for ruptures. To do this, special spoon-shaped speculums are inserted into the vagina. First, the doctor examines the cervix. To do this, the cervix is taken with special clamps, and the doctor walks around its perimeter, interlocking the clamps. In this case, the woman may feel a pulling sensation in the lower abdomen. If there are cervical ruptures, they are sutured; no anesthesia is required, since there are no pain receptors in the cervix. Then the vagina and perineum are examined. If there are tears, they are sutured.

Suture of ruptures is usually carried out under local anesthesia (novocaine is injected into the area of the rupture or the genitals are sprayed with lidocaine spray). If manual separation of the placenta or examination of the uterine cavity was carried out under intravenous anesthesia, then the examination and suturing are also carried out under intravenous anesthesia (the woman is removed from anesthesia only after completion of the examination of the birth canal). If there was an epidural anesthesia, then an additional dose of pain relief is administered through a special catheter left in the epidural space from the time of birth. After the examination, the birth canal is treated with a disinfectant solution.

The amount of bloody discharge must be assessed. At the exit from the vagina, a tray is placed where all bloody discharge is collected; the blood remaining on napkins and diapers is also taken into account. Normal blood loss is 250 ml, up to 400-500 ml is acceptable. Large blood loss may indicate hypotension (relaxation) of the uterus, retained parts of the placenta, or an unsutured rupture.

Two hours after birth

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

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

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

Obstetric forceps are intended only for removing the fetus by the head, but not for changing the position of the fetal head. The purpose of the operation of applying obstetric forceps is to replace the labor expulsion forces with the attractive force of the obstetrician.

Obstetric forceps have two branches connected to each other using a lock; each branch consists of a spoon, a lock and a handle. The spoons of the forceps have a pelvic and cephalic curvature and are designed specifically for grasping the head; the handle is used for traction. Depending on the design of the lock, there are several modifications of obstetric forceps; in Russia, Simpson-Fenomenov obstetric forceps are used, the lock of which is characterized by a simple design and significant mobility.

CLASSIFICATION

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

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

INDICATIONS

· Severe gestosis, not amenable to conservative therapy and requiring exclusion of pushing.

· Persistent secondary weakness of labor or weakness of pushing, not amenable to drug correction, accompanied by prolonged standing of the head in one plane.

· PONRP in the second stage of labor.

· The presence of extragenital diseases in the woman in labor that require stopping pushing (diseases of the cardiovascular system, high myopia, etc.).

· Acute fetal hypoxia.

CONTRAINDICATIONS

Relative contraindications are prematurity and large fetuses.

CONDITIONS FOR THE OPERATION

· Live fruit.

· Complete opening of the uterine os.

· Absence of amniotic sac.

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

· Correspondence between the sizes of the fetal head and the mother's pelvis.

PREPARATION FOR OPERATION

It is necessary to consult an anesthesiologist and choose a method of pain relief. The woman in labor is lying on her back with her legs bent at the knees and hip joints. The bladder is emptied and the external genitalia and inner thighs of the woman in labor are treated with disinfectant solutions. A vaginal examination is performed to clarify the position of the fetal head in the pelvis. The forceps are checked, and the obstetrician's hands are treated as for performing a surgical operation.

METHODS OF PAIN RELIEF

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

OPERATIONAL TECHNIQUE

The general technique for applying obstetric forceps includes the rules for applying obstetric forceps, which are observed regardless of the plane of the pelvis in which the fetal head is located. The operation of applying obstetric forceps necessarily includes five stages: inserting spoons and placing them on the fetal head, closing the branches of the forceps, test traction, removing the head, removing the forceps.

Rules for introducing spoons

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

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

To control the position of the spoon, all fingers of the obstetrician’s hand are inserted into the vagina, except for the thumb, which remains outside and is moved to the side. Then, like a writing pen or bow, take the handle of the forceps, with the top of the spoon facing forward and the handle of the forceps parallel to the opposite inguinal fold. The spoon is inserted slowly and carefully using pushing movements of the thumb. As the spoon moves, the handle of the tongs is moved to a horizontal position and lowered down. After inserting the left spoon, the obstetrician removes his hand from the vagina and passes the handle of the inserted spoon to the assistant, who prevents the spoon from moving. Then the second spoon is introduced. The spoons of the forceps rest on the fetal head in its transverse dimension. After inserting the spoons, the handles of the tongs are brought together and an attempt is made to close the lock. This may cause difficulties:

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

· one spoon is located higher than the other and the lock does not close - under the control of fingers inserted into the vagina, the overlying spoon is shifted downwards;

· the branches are closed, but the handles of the forceps diverge greatly, which indicates that the spoons of the forceps are placed not on the transverse size of the head, but on the oblique one, about the large size of the head or the position of the spoons on the head of the fetus is too high, when the tops of the spoons rest against the head and the head curvature of the forceps is not fits it tightly - it is advisable to remove the spoons, conduct a repeated vaginal examination and repeat the attempt to apply forceps;

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

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

Next, the actual traction is carried out, the purpose of which is to extract the fetal head. The direction of traction is determined by the position of the fetal head in the pelvic cavity. When the head is in the wide part of the pelvic cavity, the traction is directed downwards and backwards; when traction is from the narrow part of the pelvic cavity, the traction is directed downwards, and when the head is located at the outlet of the small pelvis, it is directed downwards, towards oneself and anteriorly.

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

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

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

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

Obstetric forceps.

Parts: 2 curvatures: pelvic and head, apexes, spoons, lock, Bush hooks, ribbed handles.

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

Indications:

1. from mother's side:

EGP in the stage of decompensation

· Severe PTB (BP = 200 mm Hg - you can’t push)

High myopia

2. from labor: weakness of pushing

3. from the fetus: progression of fetal hypoxia.

Conditions for use:

· the pelvis should not be narrow

· The BL must be fully opened (10 – 12 cm) – otherwise the BL may be damaged by separation

· the amniotic sac must be opened, otherwise PONRP

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

the head should be at the outlet of the pelvis

Preparation:

remove urine with a catheter

· treatment of the doctor’s hands and female genital organs

episiotomy – to protect the perineum

· assistant

· anesthetize: intravenous anesthesia or pudendal anesthesia

Technique:

3 triple rules:

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

· on the obstetrician's socks

· to myself

· on the obstetrician's face

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

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

· placing spoons on the head:

· the tops are facing towards the conducting head

· spoons cover the head with the largest circumference (from the chin to the small fontanelle)

· the conducting point lies in the plane of the forceps

Stages:

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

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

Test traction - will the head move behind the forceps? Place the 3rd finger of the right hand on the lock, 2 and 4 fingers on the Bush hooks, and 5 and 1 on the handle. Test traction +3 finger of the left hand on the sagittal suture.

Traction itself: on top of the right hand - the left hand.

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

A woman’s body is created by nature so that she can conceive, bear and give birth to healthy offspring. Every step along the path of this miracle is “thought out” to the smallest detail. So, to provide the baby with everything necessary for 9 months, a special organ is formed - the placenta. She grows, develops and is born just like a baby. Many women who are just about to give birth to a child ask about what an afterbirth is. It is this question that will be answered below.

Development of the placenta

The fertilized egg travels from the fallopian tube to the uterus before becoming an embryo and then a fetus. Approximately 7 days after fertilization, it reaches the uterus and implants into its wall. This process involves the release of special substances - enzymes, which make a small area of the uterine mucosa loose enough so that the zygote can settle there and begin its development as an embryo.

A feature of the first days of embryo development is the formation of structural tissues - chorion, amnion and allantois. Chorion is villous tissue that connects to the lacunae formed at the site of destruction of the uterine mucosa and filled with maternal blood. It is with the help of these outgrowths-villi that the embryo receives from the mother all the substances important and necessary for its full development. The chorion develops over 3-6 weeks, gradually degenerating into the placenta. This process is called "placentation".

Over time, the tissues of the embryonic membranes develop into important components of a healthy pregnancy: the chorion becomes the placenta, the amnion becomes the fetal sac (vesicle). By the time the placenta is almost completely formed, it becomes like a cake - it has a fairly thick middle and thinner edges. This important organ is fully formed by the 16th week of pregnancy, and together with the fetus it continues to grow and develop, properly providing for its changing needs. Experts call this entire process “maturation.” Moreover, it is an important characteristic of pregnancy health.

The maturity of the placenta is determined by performing an ultrasound examination, which shows its thickness and the amount of calcium in it. The doctor correlates these indicators with the duration of pregnancy. And if the placenta is the most important organ in the development of the fetus, then what is the placenta? This is a mature placenta that has fulfilled all its functions and is born after the child.

Structure of the containment shell

In the vast majority of cases, the placenta forms along the posterior wall of the uterus. Tissues such as cytotrophoblast and endometrium take part in its origin. The placenta itself consists of several layers that play a separate histological role. These membranes can be divided into maternal and fetal - between them there is the so-called basal decidua, which has special depressions filled with the mother's blood and is divided into 15-20 cotyledons. These components of the placenta have a main branch formed from the umbilical blood vessels of the fetus, connecting with the chorionic villi. It is thanks to this barrier that the child’s blood and the mother’s blood do not interact with each other. All metabolic processes occur according to the principle of active transport, diffusion and osmosis.

The placenta, and, therefore, the placenta that is rejected after childbirth, has a multilayer structure. It consists of a layer of fetal vascular endothelial cells, then there is a basement membrane, connective pericapillary tissue with a loose structure, the next layer is the trophoblast basement membrane, as well as layers of syncytiotrophoblast and cytotrophoblast. Experts define the afterbirth and placenta as a single organ at different stages of its development, formed only in the body of a pregnant woman.

Functions of the placenta

The afterbirth, which is born some time after the birth of the child, carries an important functional load. After all, the placenta is precisely the organ that protects the fetus from negative factors. Experts define its functional role as a hematoplacental barrier. The multilayer structure of this “cake”, connecting the growing, developing fetus and the mother’s body, makes it possible to successfully protect the baby from pathologically dangerous substances, as well as viruses and bacteria, but at the same time, through the placenta, the child receives nutritional components and oxygen and through it gets rid of products of their vital activity. From the moment of conception and a little longer after childbirth - this is the “life path” of the placenta. From the very beginning, it protects future life, going through several stages of development - from the chorionic membrane to the placenta.

The placenta exchanges not only useful, but also waste substances between mother and child. The baby's waste products first enter the mother's blood through the placenta, and from there they are excreted through the kidneys.

Another functional responsibility of this pregnancy organ is immune defense. In the first months of a fetus’s life, the mother’s immunity is the basis of its health. nascent life uses the mother's antibodies for protection. At the same time, maternal immune cells, which can react to the fetus as a foreign organism and cause its rejection, are retained by the placenta.

During pregnancy, another organ appears in a woman’s body that produces enzymes and hormones. This is the placenta. It produces hormones such as human chorionic gonadotropin (hCG), progesterone, estrogens, mineralocorticoids, placental lactogen, somatomammotropin. They are all important for the proper development of pregnancy and childbirth. One of the regularly checked indicators throughout all months of bearing a child is the level of the hormone estriol; its decrease indicates problems with the placenta and a potential threat to the fetus.

Placental enzymes are necessary for many functions, according to which they are divided into the following groups:

respiratory enzymes, which include NAD and NADP diaphorases, dehydrogenases, oxidases, catalase;
enzymes of carbohydrate metabolism - diastase, invertase, lactase, carboxylase, cocarboxylase;
aminopeptidase A, involved in reducing the vascular pressor response to angiotensin II during chronic intrauterine fetal hypoxia;
cystine aminopeptidase (CAP) is an active participant in maintaining the blood pressure of the expectant mother at a normal level throughout the entire period of pregnancy;
cathepsins help the fertilized egg implant into the uterine wall and also regulate protein metabolism;
aminopeptidases are involved in the exchange of vasoactive peptides, preventing the narrowing of placental blood vessels and participating in the redistribution of fetoplacental blood flow during fetal hypoxia.

The hormones and enzymes produced by the placenta change throughout pregnancy, helping the woman’s body withstand serious stress and the fetus to grow and develop. A natural birth or cesarean section will always be fully completed only when everything that helped the baby grow is removed from the woman’s body - the placenta and membranes, in other words, the afterbirth.

Where is the children's seat located?

The placenta can be located on the wall of the uterus in any way, although its location in the upper part (the so-called fundus of the uterus) of the posterior wall is considered classic and absolutely correct. If the placenta is located below and even almost reaches the os of the uterus, then experts speak of a lower location. If an ultrasound showed a low position of the placenta in the middle of pregnancy, this does not mean at all that it will remain in the same place closer to childbirth. Placenta movement is recorded quite often - in 1 out of 10 cases. This change is called placental migration, although in fact the placenta does not move along the walls of the uterus, since it is tightly attached to it. This shift occurs due to the stretching of the uterus itself, the tissues seem to move upward, which allows the placenta to take the correct upper position. Those women who undergo regular ultrasound examinations can see for themselves that the placenta is migrating from the lower to the upper location.

In some cases, with ultrasound it becomes clear that it is blocking the entrance to the uterus, then the specialist diagnoses placenta previa, and the woman is taken under special control. This is due to the fact that the placenta itself, although it grows in size along with the fetus, its tissues cannot stretch much. Therefore, when the uterus expands for the growth of the fetus, the baby's place may detach and bleeding will begin. The danger of this condition is that it is never accompanied by pain, and a woman may not even notice the problem at first, for example, during sleep. Placental abruption is dangerous for both the fetus and the pregnant woman. Once started, placental bleeding can recur at any time, which requires placing the pregnant woman in a hospital under the constant supervision of professionals.

Why is placental diagnosis needed?

Since the correct development of the fetus, as well as the condition of the pregnant woman, largely depend on the placenta, close attention is paid to it during examinations. An ultrasound examination of pregnancy allows the doctor to assess the location of the placenta and the features of its development throughout the entire period of gestation.

Also, the condition of the placenta is assessed by conducting laboratory tests on the amount of placental hormones and the activity of its enzymes, and Doppler ultrasound helps determine the blood flow of each vessel of the fetus, uterus and umbilical cord.

The condition of the placenta also plays an important role in the most crucial period - the period of childbirth, because it remains the only opportunity for the baby passing through the birth canal to receive all the substances and oxygen he needs. And that is why natural childbirth must end with the birth of a placenta that has fulfilled its functions.

Natural childbirth in three stages

If a woman gives birth naturally, then specialists divide such childbirth into three stages:

period of contractions;
period of pushing;
birth of placenta.

The placenta is one of the most important biological elements throughout pregnancy until the birth of a new person. The baby was born, a “cake” of several layers of different types of tissue and blood vessels played its role. Now the woman’s body needs to get rid of it in order to continue functioning normally in its new status. That is why the birth of the placenta and membranes is separated into a separate, third stage of labor - the departure of the placenta.

In the classic version, this stage is almost painless; only weak contractions can remind the woman that childbirth has not yet completed completely - the postpartum placenta has separated from the walls of the uterus and must be pushed out of the body. In some cases, contractions are not felt at all, but the separation of the placenta can be determined visually: the fundus of the uterus rises above the navel of the woman in labor, shifting to the right side. If the midwife presses with the edge of her hand just above the womb, the uterus is raised higher, but the umbilical cord, which is still attached to the placenta, is not retracted. The woman needs to push, which leads to the birth of the placenta. Methods for isolating the placenta during the postpartum period help to complete the pregnancy correctly, without pathological consequences.

What does the afterbirth look like?

So what is afterbirth? It is a rounded flat formation of a spongy structure. It has been noted that with the body weight of a born child being 3300-3400 grams, the weight of the placenta is half a kilogram, and the dimensions reach 15-25 centimeters in diameter and 3-4 centimeters in thickness.

The afterbirth after childbirth is the object of careful study, both visual and laboratory. A doctor examining this vital organ of the fetus in the womb should see a solid structure with two surfaces - maternal and fetal. The placenta on the fetal side has an umbilical cord in the middle, and its surface is covered with amnion - a grayish membrane with a smooth, shiny texture. Upon visual inspection, you can notice that blood vessels radiate from the umbilical cord. On the reverse side, the afterbirth has a lobed structure and a dark brown tint of the shell.

When childbirth is completed completely, no pathological processes have opened, the uterus contracts, decreasing in size, its structure becomes denser, and its location changes.

Pathologies of the placenta

In some cases, at the last stage of labor, the placenta is retained. The period when a doctor makes such a diagnosis lasts from 30-60 minutes. After this period, medical personnel attempt to release the placenta by stimulating the uterus with massage. Partial, complete accretion or tight attachment of the placenta to the wall of the uterus does not allow the placenta to separate naturally. In this case, specialists decide to separate it manually or surgically. Such manipulations are performed under general anesthesia. Moreover, complete fusion of the placenta and the uterus can be resolved in the only way - removal of the uterus.

After childbirth, the placenta is examined by a doctor, and if damage or defects are found, especially if the woman in labor continues to have uterine bleeding, then a so-called cleaning is carried out to remove the remaining parts of the placenta.

Massage for the placenta

In natural childbirth, it is not such a rare problem - the placenta did not come out. What to do in this case? One of the effective and safe methods is massage to stimulate the uterus. Experts have developed many techniques to help a woman in labor get rid of the placenta and membranes without external intervention. These are methods such as:

Abuladze's method is based on gentle massage of the uterus with the aim of contracting it. Having stimulated the uterus until it contracts, the doctor with both hands forms a large longitudinal fold on the peritoneum of the woman in labor, after which she must push. The placenta comes out under the influence of increased intra-abdominal pressure.
Genter's method allows the placenta to be born without any effort on the part of the woman in labor due to manual stimulation of the uterine fundus in the direction from top to bottom, to the center.
According to the Crede-Lazarevich method, the placenta is squeezed out by pressing the doctor on the fundus, anterior and posterior walls of the uterus.

Manual manipulation

Manual separation of the placenta is carried out through internal manipulation - the doctor inserts his hand into the vagina and uterus of the woman in labor and tries to separate the placenta by touch. If this method does not help to remove it, then we can only talk about surgical intervention.

Is there a way to prevent placental pathologies?

What is afterbirth? Gynecologists often hear this question from women. planning motherhood. The answer to this question is both simple and complex at the same time. After all, the placenta is a complex system for maintaining life, health and proper development of the fetus, as well as the health of the mother. And although it appears only during pregnancy, the placenta is still a separate organ, potentially susceptible to various pathologies. And disturbances in the vital functions of the placenta are dangerous for the baby and his mother. But very often the occurrence of placental complications can be prevented by fairly simple, natural methods:

thorough medical examination before conception;
treatment of existing chronic diseases;
a healthy lifestyle with cessation of smoking and alcohol, normalization of work and rest schedules;
introduction of a balanced diet for the expectant mother;
maintaining a positive emotional background in life;
moderate exercise;
walks in the open air;
preventing infection with viral, bacterial and fungal infections;
taking vitamin and mineral complexes recommended by a specialist.

Following these natural tips will help you avoid many problems during pregnancy and childbirth.

So, what is afterbirth? This is a special part of the pregnant woman’s body that ensures conception, gestation and the birth of a new life. This word, which speaks for itself, refers to the placenta and fetal membranes that were born after the child or were forcibly removed and served the most important role - helping in the formation of a new life.

Surgical interventions in the placenta include manual separation and isolation of the placenta when its separation is delayed (partial or complete tight attachment of the placenta) and removal of the separated placenta if it is strangulated in the area of the internal os or tubal angle of the uterus.

In the postpartum period, surgical interventions include suturing ruptures in the soft tissue of the birth canal (cervix, vagina, vulva), restoration of the perineum (perineorrhaphy), manual reposition of the uterus when it is inverted, as well as control manual examination of the walls of the postpartum uterus.

SURGICAL INTERVENTIONS IN THE FOLLOW-UP PERIOD

MANUAL SEPARATION OF THE PLACENTA

Synonyms

Manual removal of the placenta.

INDICATIONS

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

METHODS OF PAIN RELIEF

Intravenous or inhalational general anesthesia.

OPERATIONAL TECHNIQUE

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

COMPLICATIONS

MANUAL EXAMINATION OF THE UTERUS

Manual examination of the uterus is an obstetric operation that involves examining the walls of the uterus with a hand inserted into its cavity.

INDICATIONS

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

Manual examination of the postpartum uterus is carried out if parts of the placenta are retained in the uterus, uterine rupture is suspected, or if there is hypotonic bleeding.

METHODS OF PAIN RELIEF

Intravenous, inhalation or prolonged regional anesthesia.

OPERATIONAL TECHNIQUE

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

The location of the placental site is determined and if retained placental tissue, remnants of membranes and blood clots are detected, they are removed. At the end of the manual examination, it is necessary to perform a gentle external-internal massage of the uterus while administering contractile drugs.

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

The diagnostic task is to inspect the walls of the uterus to determine their integrity and identify the retained lobule of the placenta. The therapeutic goal is to stimulate the neuromuscular apparatus of the uterus by performing a gentle external-internal massage of the uterus. During external internal massage, 1 ml of 0.02% solution of methylergometrine or 1 ml of oxytocin is simultaneously injected intravenously, conducting a test for contractility.

OPERATIVE INTERVENTIONS IN THE POSTPARTUM PERIOD

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

INDICATIONS

Indications for surgical intervention in the early postpartum period are:
· rupture or incision of the perineum;
· rupture of the vaginal walls;
· cervical rupture;
vulvar rupture;
· formation of hematomas of the vulva and vagina;
· inversion of the uterus.

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

CERVICAL RUPTURE

Based on the depth of cervical ruptures, three degrees of severity of this complication are distinguished.
· I degree - tears no more than 2 cm long.
· II degree - tears exceeding 2 cm in length, but not reaching the vaginal vault.
· III degree - deep ruptures of the cervix, reaching the vaginal vaults or extending to it.

METHODS OF PAIN RELIEF

Restoring the integrity of the cervix in cases of I and II degree rupture is usually performed without anesthesia. For grade III rupture, anesthesia is indicated.

OPERATIONAL TECHNIQUE

The sewing technique does not present any great difficulties. They expose the vaginal part of the cervix with wide, long speculums and carefully grasp the anterior and posterior uterine lips with bullet forceps, after which they begin to restore the cervix. Separate catgut sutures are applied from the upper edge of the rupture towards the outer pharynx, with the first ligature (provisional) slightly above the rupture site. This allows the doctor to easily, without injuring the already damaged cervix, lower it when necessary. In some cases, a provisional ligature allows one to avoid the application of bullet forceps. To ensure that the edges of the torn neck are correctly adjacent to each other when suturing, the needle is injected directly at the edge, and the puncture is made at a distance of 0.5 cm from it. Moving to the opposite edge of the tear, the needle is injected at a distance of 0.5 cm from it, and the puncture is made directly at the edge. With this application, the sutures do not cut through, since the cervix serves as a gasket. After fusion, the suture line is a thin, even, almost invisible scar.

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

VULVA RUPTURE

Damage to the vulva and vaginal vestibule during childbirth, especially in primigravidas, is often noted. With cracks and slight tears in this area, usually no symptoms are noted and there is no need for medical intervention.

OPERATIONAL TECHNIQUE

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

RUPTURE OF THE VAGINAL WALL

The vagina can be damaged during childbirth in all parts (lower, middle and upper). The lower part of the vagina ruptures simultaneously with the perineum. Ruptures of the middle part of the vagina, as less fixed and more extensible, are rarely noted. Vaginal ruptures usually go longitudinally, less often - in the transverse direction, sometimes penetrating quite deeply into the peri-vaginal tissue; in rare cases, they also invade the intestinal wall.

OPERATIONAL TECHNIQUE

The operation consists of applying separate interrupted catgut sutures after exposing the wound using vaginal speculum. If there is no assistant for exposing and suturing vaginal tears, you can open it with two fingers (index and middle) of the left hand spread apart. As the wound in the depths of the vagina is sutured, the fingers that expand it are gradually pulled out. Suturing sometimes presents significant difficulties.

HEMATOMA OF THE VULVA AND VAGINA

Hematoma is a hemorrhage due to rupture of blood vessels in the tissue below and above the main pelvic floor muscle (levator ani muscle) and its fascia. More often, a hematoma occurs below the fascia and spreads to the vulva and buttocks, less often - above the fascia and spreads along the peri-vaginal tissue retroperitoneally (up to the perinephric region).

Symptoms of hematomas of significant size are pain and a feeling of pressure at the site of localization (tenesmus due to compression of the rectum), as well as general anemia (with an extensive hematoma). When examining postpartum women, a tumor-like formation of a blue-purple color is discovered, protruding outward towards the vulva or into the lumen of the vaginal opening. When palpating the hematoma, its fluctuation is noted.

If the hematoma spreads to the parametrial tissue, vaginal examination reveals the uterus pushed to the side and between it and the pelvic wall a fixed and painful tumor-like formation. In this situation, it is difficult to differentiate a hematoma from an incomplete uterine rupture in the lower segment.

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

METHODS OF PAIN RELIEF

The operation is performed under anesthesia.

OPERATIONAL TECHNIQUE

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

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

If the hematomas are small in size and localized in the wall of the vulva or vagina, their instrumental opening (under local anesthesia), emptying and suturing with shaped or Z-shaped catgut sutures is indicated.

CROTCH RUPTURE

Perineal rupture is the most common type of maternal birth injury and complications of childbirth; more often noted in primiparous women.

A distinction is made between spontaneous and violent rupture of the perineum, and according to its severity, three degrees are distinguished:
· I degree - the integrity of the skin and subcutaneous fat layer of the posterior vaginal commissure is compromised;
· II degree - in addition to the skin and subcutaneous fat layer, the pelvic floor muscles (bulbspongiosus muscle, superficial and deep transverse muscles of the perineum), as well as the posterior or lateral walls of the vagina, are affected;
· III degree - in addition to the above formations, there is a rupture of the external anal sphincter, and sometimes the anterior wall of the rectum.

METHODS OF PAIN RELIEF

Pain relief depends on the degree of perineal rupture. For ruptures of the perineum of the 1st and 2nd degrees, local anesthesia is performed; for suturing the tissues for ruptures of the perineum of the 3rd degree, anesthesia is indicated.

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

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

OPERATIONAL TECHNIQUE

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

The external genitalia and the hands of the obstetrician are treated. The wound surface is exposed with mirrors or fingers of the left hand. First, sutures are placed on the upper edge of the tear in the vaginal wall, then sequentially from top to bottom, knotted catgut sutures are placed on the vaginal wall, spaced 1–1.5 cm apart until a posterior adhesion is formed. The application of knotted silk (lavsan, letilan) sutures to the skin of the perineum is carried out in the first degree of rupture.

In case of II degree of rupture, before (or as) suturing the posterior wall of the vagina, the edges of the torn pelvic floor muscles are sewn together with separate interrupted submersible sutures using catgut, then silk sutures are placed on the skin of the perineum (separate interrupted ones according to Donati, according to Shuta). When applying sutures, the underlying tissues are picked up so as not to leave pockets under the suture, in which subsequent accumulation of blood is possible. Individual heavily bleeding vessels are tied with catgut. Necrotic tissue is first cut off with scissors.

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

In case of a third-degree perineal rupture, the operation begins with disinfection of the exposed area of the intestinal mucosa (with ethanol or chlorhexidine solution) after removing feces with a gauze swab. Then sutures are placed on the intestinal wall. Thin silk ligatures are passed through the entire thickness of the intestinal wall (including through the mucosa) and tied from the intestinal side. The ligatures are not cut off and their ends are removed through the anus (in the postoperative period they come off on their own or they are tightened and cut off on the 9–10th day after surgery).

Gloves and instruments are changed, and then the separated ends of the external anal sphincter are connected using a knotted suture. Then the operation is performed as for a II degree rupture.

EVERION OF THE UTERUS

The essence of uterine inversion is that the fundus of the uterus from the abdominal covering is pressed into its cavity until it is completely inverted. The uterus turns out to be located in the vagina with the endometrium facing outwards, and from the side of the abdominal cavity the wall of the uterus forms a deep funnel, lined with a serous covering, into which the uterine ends of the tubes, round ligaments and ovaries are drawn.

There are complete and incomplete (partial) inversion of the uterus. Sometimes complete inversion of the uterus is accompanied by inversion of the vagina. Eversion can be acute (fast) or chronic (slowly occurring). Acute inversions are observed more often, with 3/4 of them occurring in the afterbirth period and 1/4 in the first day of the postpartum period.

PREPARATION FOR OPERATION

Antishock therapy is carried out.

The external genitalia and the hands of the obstetrician are treated. 1 ml of 0.1% atropine solution is injected subcutaneously to prevent cervical spasm. Empty the bladder.

OPERATIONAL TECHNIQUE

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

Pressing on the uterus with the whole hand, first the inverted vagina is inserted into the pelvic cavity, and then the uterus, starting from its bottom or isthmus. The left hand is placed on the lower part of the abdominal wall, going towards the screwed-in uterus. Then contractile agents are administered (at the same time oxytocin, methylergometrine).

FEATURES OF MANAGEMENT IN THE POSTOPERATIVE PERIOD

For several days after surgery, the administration of drugs that have a uterotonic effect is continued.

OBSTETRIC FISTULAS

Obstetric fistulas occur as a result of severe birth trauma and lead to permanent loss of ability to work and disorders of a woman’s sexual, menstrual and generative functions. Based on the nature of their occurrence, fistulas are divided into spontaneous and violent. Based on localization, they distinguish between vesicovaginal, cervicovaginal, urethrovaginal, ureterovaginal, and intestinal-vaginal fistulas.

Genitourinary fistulas are characterized by the leakage of urine from the vagina of varying intensity, while entero-genital fistulas are characterized by the release of gas and feces. The time at which these symptoms appear is of diagnostic importance: injury to adjacent organs is indicated by the appearance of these symptoms in the first hours after surgical delivery. When a fistula forms as a result of tissue necrosis, these symptoms appear on the 6th–9th day after birth. The final diagnosis is made by examining the vagina using speculum, as well as urological and x-ray diagnostic methods.

OPERATIONAL TECHNIQUE

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

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

The placenta is responsible for ensuring the life and breathing of the unborn child and protects against harmful substances. Tight attachment of the baby's place to the tissues affects the woman's condition after childbirth and promotes bleeding. Manual separation of the placenta is carried out when the organ adheres to the walls of the uterus or is attached to scars.

The placenta, an organ that helps in the development of the fetus during pregnancy, appears on the 7th day after the egg attaches to the walls of the uterus. Full formation of the organ is completed at 16 weeks.
When carrying a fetus, the weight of the placenta, its size and density increase. Maturation allows you to fully provide the unborn child with the necessary vitamins and minerals.

Structure:

villi are responsible for the supply of oxygen and nutrients through the umbilical cord to the fetus;
the membrane divides the vascular systems into maternal and child ones. The membrane retains harmful substances, acting as a natural barrier.

How much does the placenta weigh after birth? The average weight of the placenta is 600 grams. The normal thickness reaches 3 cm, width - from 18 to 25 cm.

The placenta performs the following functions:

fetal nutrition;
gas exchange;
hormone production;
protective function.

The location of the organ in the uterus is important. If the pregnancy progresses correctly, the placenta is attached in the upper part of the cavity. Low position or abnormal presentation is a pathology.

Indications for manual separation of the placenta are identified during pregnancy using ultrasound or during childbirth. Normally, it comes out after the baby is born. If after half an hour the baby's place is not born, or heavy bleeding begins, the placenta is removed manually.

Causes

Manual separation of the placenta is carried out in cases of complete accretion, improper attachment to the uterus, or hypotension. Untimely assistance will lead to inflammation, scars, and bleeding.

Why the placenta does not separate after childbirth:

the afterbirth is tightly attached to the uterus;
the organ has grown entirely into the female organs.

Dense increment is divided into full and partial. Placental villi do not penetrate into the deep layers of the epidermis and do not cause severe bleeding. Pathologies can be determined during pregnancy using ultrasound or during labor. Tight attachment occurs in 4% of multiparous women, and in 2% of mothers expecting their first child.

Placenta accretion into the uterus has more dangerous consequences for women. The cause of the pathology is surgical interventions, inflammatory processes, scars on the female organs, and a previous caesarean section.

Reasons for manually separating the placenta:

determining the presence of an anomaly during pregnancy;
after the birth of the child there was severe bleeding;
when pushing, the baby's place does not appear;
the shape of the uterus has changed, it has become denser;
The umbilical cord is pulled into the vagina when pressure is applied to the abdomen.

Manual release of the placenta 30 minutes after birth allows you to avoid subsequent complications for the woman. Surgery is performed immediately, as bleeding often leads to the removal of reproductive organs.

In the case when the placenta does not appear and there is no discharge, hemorrhoidal shock is possible. The accumulation of blood in the uterine cavity leads the body to a serious condition that threatens the life of the mother during childbirth.

Technique of the operation

The discharge of the placenta normally occurs with the help of contractions and pushing. If the placenta does not come out within the first 30 minutes, you will need to manually separate it from the uterus. This will avoid negative consequences such as blood loss and organ removal.

Types of techniques for manual separation of the placenta:

Abuladze's reception. It is performed by increasing pressure in the abdominal cavity during pushing;
Genter's method. The obstetrician clenches his hand into a fist and presses on the fundus of the uterus. Due to palpation, the baby's place is separated and comes out;
Credet-Lazarevich method. The afterbirth is squeezed out by hand.

If these methods are ineffective, surgery is used. The procedure after childbirth is performed under general anesthesia.

Algorithm for manual separation of placenta:

manipulations are carried out under sterile conditions;
general anesthesia is administered;
empty your bladder;
the doctor inserts one hand into the vagina to the level of the fundus of the uterus;
Use the edge of your palm to separate the placenta from the walls so that no parts remain;
gently pull the umbilical cord so that the afterbirth comes out;
check the uterine cavity, there should be no accumulation of blood and remains of placental tissue;
the afterbirth is checked for integrity and, if necessary, sent for laboratory testing;
The mother is given drugs to speed up uterine contractions.

If blood loss is more than 0.5% of the mother's body weight, she is given a transfusion. General anesthesia helps during manipulations, relieves pain and spasms, relaxing the female organs.

The remaining parts of the placenta can cause inflammation. Symptoms include abdominal pain, bleeding, and increased body temperature. In this case, vacuum cleaning and antibiotic treatment are carried out.

Consequences

After the operation to remove the placenta, doctors conduct an examination. Checking the birth canal allows you to assess the condition of the cervix. The amount of blood loss in the woman in labor is determined. Retention of parts of the placenta in the uterus will require additional manipulations.

How long does the discharge last after manual separation of the placenta? If the operation is performed correctly, uterine bleeding lasts up to 14 days. Early termination of discharge indicates the presence of pathology, for example, endometritis.

Complications after manual separation of the placenta:

heavy bleeding;
the appearance of defects in the uterus due to the influence of a doctor;
hemorrhagic shock;
sepsis – blood poisoning during the procedure;
endometritis – inflammation of the reproductive organs;
death, most often due to blood loss.

The consequences of manual separation of the placenta can lead to the removal of organs or the death of the woman in labor. With proper treatment, the woman will recover quickly and will subsequently be able to have children.

What may hurt after manual separation of the placenta:

nagging pain in the uterine area. They are associated with contraction of the organ and the return of its previous shape;
discomfort in the vagina. Appear due to muscle strain during surgery;
headaches may be associated with the use of general anesthesia.

To avoid complications after manual removal of the placenta, you must carefully monitor your well-being, personal hygiene and medication intake. If you have symptoms such as increased discharge, fainting and severe pain, you should seek help from a doctor.

Preventive measures

To avoid accretion of a child's place, it is necessary to take preventive measures before planning a pregnancy. They will help maintain the health of the reproductive organs and give birth to a healthy child.

Prevention:

plan conception, undergo the necessary tests to exclude uterine pathologies;
cure infectious diseases of the reproductive system;
do an ultrasound during pregnancy;
visit a gynecologist regularly;
eat a balanced diet, exclude unhealthy foods;
give up alcoholic beverages and smoking;
lead an active lifestyle, attend gymnastics for pregnant women.

If a woman has previously had a cesarean section, she should pay special attention to the scar on the uterus. Timely examination will help to identify incorrect accretion in time and immediately use manual separation of the placenta during childbirth.

After natural childbirth, scars also form if the uterus ruptures. In this place, the mucous membrane is damaged, and the placenta is able to form and attach to the damaged area.

Surgeries on the genital organs affect a woman’s health. After separation of the placenta, it is recommended to maintain personal hygiene to avoid infection of the genitals. In the first few months, you should not lift weights or engage in physical activity.

During subsequent pregnancy, it is necessary to monitor the condition of the placenta. The operation affects the gestation of the fetus, as it affects the uterine cavity.

Placenta accreta affects not only the health of the baby, but also the course of labor. The appearance of bleeding and failure of the placenta to leave the uterine cavity indicate the presence of a life-threatening pathology for the woman. Manual separation of the placenta is carried out immediately after identifying the main signs. The operation allows you to preserve the reproductive organs and avoid their removal.

METHODS FOR ISOLATING SEPARATED AFTERMISSION

PURPOSE: To isolate the separated placenta

INDICATIONS: Positive signs of placenta separation and ineffective pushing

ABULADZE METHOD:

Perform a gentle massage of the uterus in order to contract it.

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

CREDET–LAZAREVICH METHOD: (used when Abuladze’s method is ineffective).

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

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

Squeeze the placenta: squeeze the uterus anteroposteriorly and at the same time press on its bottom downward and forward along the pelvic axis. With this method, the separated afterbirth easily comes out. If the Credet-Lazarevich method is ineffective, manual separation of the placenta is carried out according to the general rules.

Indications:

no signs of placenta separation within 30 minutes after birth of the fetus,

blood loss exceeding the permissible level

third stage of labor,

· the need for rapid emptying of the uterus in case of previous difficult and operative labor and the histopathic condition of the uterus.

2) start intravenous crystalloid infusion,

3) provide adequate pain relief (short-term intravenous anesthesia (anesthesiologist!

4) tighten the umbilical cord on the clamp,

5) insert a sterile gloved hand along the umbilical cord into the uterus to the placenta,

6) find the edge of the placenta,

7) using a sawing motion, separate the placenta from the uterus (without using excessive force),

8) without removing your hand from the uterus, use your outer hand to remove the placenta from the uterus,

9) after removing the placenta, check the integrity of the placenta,

10) control the walls of the uterus with the hand in the uterus, make sure that the walls of the uterus are intact and that there are no elements of the fertilized egg,

11) do a light massage of the uterus if it is not dense enough,

12) remove the hand from the uterus.

Assess the condition of the postpartum woman after surgery.

In case of pathological blood loss it is necessary:

· replenish blood loss.

· carry out measures to eliminate hemorrhagic shock and DIC syndrome (topic: Bleeding in the afterbirth and early postpartum period. Hemorrhagic shock and DIC syndrome).

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.