Impaired discharge of placenta. Bleeding in the postpartum and early postpartum period. Soft tissue injuries of the birth canal

1. Bleeding due to pathological attachment of the placenta

· dense attachment of the placenta - attachment of the placenta in the basal layer of the uterine mucosa;

· true placenta accreta - ingrowth of the placenta into the muscular layer of the uterus;

· anomalies, structural features and attachment of the placenta to the wall of the uterus.

2. Impaired discharge of placenta

· pinching of the placenta in the area of ​​the internal pharynx (spasm of the pharynx)

Pathological attachment of the placenta includes:

1) tight attachment of the placenta (placenta adhaerens);

2) accretion of the placenta to the muscle layer (placenta accreta);

3) ingrowth of the placenta into the muscle layer (placenta increta);

4) germination of the placenta (placenta percreta).

Pathological attachment of the placenta can be observed throughout (full) or in one place ( incomplete).

Etiology and pathogenesis. Normally, the placenta is formed in the functional layer of the mucous membrane, which transforms into the decidua and consists of a compact and spongy layer. The separation of the placenta from the uterine wall in the third stage of labor occurs at the level of the spongy layer of the decidua.

In case of inflammatory diseases or dystrophic changes in the endometrium, the spongy layer undergoes scar degeneration, as a result of which independent separation of the tissue along with the placenta in the third stage of labor is impossible. This condition is called tight attachment. With atrophy of the functional and basal layer of the mucous membrane, one or more cotyledons of the developing placenta reach the muscular layer or grow into it (true ingrowth).

Pathological attachment of the placenta is caused by either changes in the uterine mucosa or characteristics of the chorion. The following diseases lead to changes in the uterine mucosa that contribute to disruption of trophoblast formation:

ü nonspecific and specific inflammatory lesions of the endometrium (chlamydia, gonorrhea, tuberculosis, etc.);

ü excessive curettage during removal of the fertilized egg or diagnostic procedures;

ü postoperative scars on the uterus (CS and myomectomy).

Violation of trophoblast attachment or ingrowth also contributes to increased proteolytic activity of chorionic villi. The increased proteolytic ability of the chorion can lead to the ingrowth of villi into the compact layer of the falling membrane as a whole, and in some cases to growth into the muscular layer of the uterus up to the serous membrane.

Anomalies, structural features and attachment of the placenta to the wall of the uterus often contribute to the disruption of separation and discharge of the placenta. For separation of the placenta, the area of ​​contact with the surface of the uterus is important. With a large area of ​​attachment, a relatively thin or leathery placenta (placenta membranacea), the slight thickness of the placenta prevents physiological separation from the walls of the uterus. Placentas, shaped like lobes, consisting of two lobes, with additional lobules, are separated from the walls of the uterus with difficulty, especially with uterine hypotension.

Impaired separation of the placenta and placenta discharge may be due to the placenta insertion site: in the lower uterine segment (with a low location and presentation), in the corner or on the side walls of the uterus, on the septum, above the myomatous node. In these areas, the muscles are defective and cannot develop the contractile force necessary to separate the placenta.

CLINICAL PICTURE. The clinical picture of impaired separation of the placenta and discharge of the placenta depends on the presence of areas of separated placenta. Only with partial true accretion or partial tight attachment is bleeding possible.

The classification depends on the degree of penetration of chorionic villi into the layers of the uterine wall.

There are:

Dense attachment of the placenta (complete and partial)

· True placenta accreta (complete and partial).

Tight attachment of the placenta- a pathology in which the chorionic villi do not extend beyond the basal layer, but are tightly connected to it.

True placenta accreta a severe pathology in which chorionic villi penetrate the muscle layer, growing through it and reaching the serous membrane of the uterus.

If the placenta does not separate all the way ( complete pathological attachment), clinically determined no signs of placental separation and no bleeding.

More often observed partial separation of the placenta (incomplete attachment), when one or another section is separated from the wall, and the rest remains attached to the uterus. In this situation, muscle contraction at the level of the separated placenta is not enough to compress the vessels and stop bleeding from the placental site.

The main symptoms of partial separation of the placenta are: no signs of placental separation and bleeding.

Clinic for partial separation of the placenta. Bleeding 10-15 minutes after the birth of the baby. There are no signs of separated placenta. The blood is liquid, mixed with clots of various sizes, and flows out in spurts and unevenly. On external examination there are no signs of separation of the placenta. The fundus of the uterus is located at the level of the navel or above. The general condition of the woman in labor depends on the degree of blood loss and changes quickly. In the absence of timely assistance, hemorrhagic shock occurs.

DIAGNOSTICS. It is possible to accurately determine the type of pathological attachment of the placenta with targeted ultrasound and manual separation of the placenta.

Determine true accretion or fetal attachment It is possible only with manual separation of the placenta. During manual separation of the placenta when it's tight attachment (placenta adhaerens), as a rule, can be removed by hand all shares placenta. At true ingrowth chorionic villi impossible separate the placenta from the wall without violating its integrity.

SCREENING. Ultrasound of patients with a burdened obstetric history.

PREVENTION. Prevention of pathological attachment of the placenta consists of reducing the frequency of abortions and inflammatory diseases leading to degenerative changes in the uterine mucosa.

INFRINGEMENT OF THE SEPARATE PLACENTA . Bleeding 10-15 minutes after the baby is born. Presence of signs of placenta separation. If the internal os is spasmed or blocked by the detached placenta and the outflow of blood to the outside stops, the uterus increases in volume, takes on a spherical shape and is sharply tense. Help. Under anesthesia, try to extract the placenta using external methods; if that fails, then manually extract the placenta.

SEQUENCE OF MEASURES FOR DELAYED PLACENTA AND NO BLOOD DISCHARGE FROM THE GENITAL ORGANS.

1) Catheterization of the bladder (often causes increased contractions of the uterus and separation of the placenta).

2) Puncture or catheterization of the ulnar vein, intravenous administration of crystalloids in order to adequately correct possible blood loss.

3) Administration of uterotonic drugs 15 minutes after expulsion of the fetus (oxytocin intravenously 5 units in 500 ml of 0.9% sodium chloride solution). In order to prevent bleeding in women with advanced pregnancy, the administration of oxytocin should begin in the second stage of labor.

4) If signs of placenta separation appear, release the placenta using one of the accepted methods (Abuladze, Genter, Crede-Lazarevich)

5) If there are no signs of separation of the placenta within 30 minutes against the background of the introduction of reducing agents, the placenta is manually separated and the placenta is released.

6) After removal of the placenta, the uterus usually contracts; if the tone of the uterus is not restored, additional uterotonic drugs are administered intravenously and methylergometrine is administered simultaneously (2 ml in 20 ml of isotonic solution).

7) If true placenta accreta is suspected, it is necessary stop the attempt to secede to avoid massive bleeding and perforation of the uterus. Preparing a woman for emergency surgery.

8) Examine the soft birth canal and repair the damage.

9) Assess the general condition of the woman in labor and the amount of blood loss.

10) Compensate for blood loss by administering blood substitutes and blood products (depending on the volume of blood loss, hemoglobin and hematocrit).

11) Continue intravenous drip administration of uterotonics for at least 1 hour after surgery.

12) Carry out constant monitoring of the height of the uterine fundus, its tone and the volume of external blood loss.

13) Transfer the postpartum woman to the postpartum department after normalization of hemodynamic parameters and replenishment of blood loss.

Violation when:

Hypotonicity of the uterus

spasm of the internal pharynx

Spasm can occur if contractile agents are used incorrectly in the afterbirth period.

TACTICS OF FOLLOW-UP PERIOD.

Principle: hands off the uterus!

Before checking contact signs, you need to check non-contact signs: look at the umbilical cord, which is lengthening (positive Alfeld sign). The uterus deviates to the right, upwards and flattens (Schroeder's sign), the umbilical cord retracts with a deep breath (Dovzhenko's sign).

IT IS NECESSARY TO START SEPARATION OF THE AFTERMISSION IMMEDIATELY AS SOON AS SIGNS OF ITS SEPARATION APPEAR.

· Or physiologically (pushing)

· external techniques (Abuladze, Genter, Crede-Lazarevich) - these techniques can only separate the separated placenta.

IF BLEEDING OCCURS DURING THE SUBSEQUENT PERIOD, THE FIRST TASK OF THE OBSTETRIC IS TO DETERMINE IF THERE ARE SIGNS OF SEPARATION OF THE PLACENTA.

OPERATION OF MANUAL SEPARATION OF THE PLACENTA AND DISCHARGE OF THE AFTERMISSION.

1. The hand is inserted into the uterine cavity.

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

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

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

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

6. Compensate for blood loss.

7. Continue intravenous administration of uterotonics.

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

Further tactics depend on the result of the operation:

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

Assess blood loss

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

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

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

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

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

BLEEDING IN THE EARLY POSTPARTUM PERIOD.

Most often it is a continuation of complications in all stages of labor.

The main reason is the hypotonic state of the uterus.

RISK GROUP.

1. Women with weak labor.

2. Childbirth with a large fetus.

3. Polyhydramnios.

4. Multiple births.

PATHOGENESIS. Impaired thrombus formation due to the exclusion of the muscle factor from the mechanisms of hemostasis.

Also causes of bleeding in the early postpartum period may be:

1. injuries to the uterus, cervix, vagina

2. blood diseases

Variants of hypotonic bleeding.

1. Bleeding immediately, profusely. In a few minutes you can lose 1 liter of blood.

2. After taking measures to increase the contractility of the uterus: the uterus contracts, bleeding stops after a few minutes - a small portion of blood - the uterus contracts, etc. and so gradually, in small portions, blood loss increases and hemorrhagic shock occurs. With this option, the vigilance of personnel is reduced and they often lead to death since there is no timely compensation for blood loss.

The main operation that is performed for bleeding in the early postpartum period is called MANUAL EXAMINATION OF THE UTERINE CAVITY.

Objectives of the ROPM operation:

1. determine whether there are any retained parts of the placenta left in the uterine cavity and remove them.

2. Determine the contractile potential of the uterus.

3. Determine the integrity of the uterine walls - whether there is a uterine rupture (clinically it is sometimes difficult to diagnose).

4. Determine whether there is a malformation of the uterus or a tumor of the uterus (a fibromatous node is often the cause of bleeding).

SEQUENCE OF PERFORMING THE OPERATION OF MANUAL EXAMINATION OF THE UTERINE CAVITY.

1. Determine the amount of blood loss and the general condition of the woman.

2. Treat hands and external genitalia.

3. Give intravenous anesthesia and begin (continue) the administration of uterotonics.

5. Empty the uterine cavity from blood clots and retained parts of the placenta (if any).

6. Determine the tone of the uterus and the integrity of the uterine walls.

7. Inspect the soft birth canal and suturing damage, if any.

8. Re-evaluate the woman’s condition for blood loss and compensate for blood loss.

SEQUENCE OF ACTIONS IN STOPING HYPOTONIC BLEEDING.

1. Assess the general condition and volume of blood loss.

2. Intravenous anesthesia, start (continue) administration of uterotonics.

3. Proceed with the operation of manual examination of the uterine cavity.

4. Remove clots and retained parts of the placenta.

5. Determine the integrity of the uterus and its tone.

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

7. Against the background of ongoing intravenous administration of oxytocin, simultaneously inject 1 ml of methylergometrine intravenously and 1 ml of oxytocin can be injected into the cervix.

8. Insertion of tampons with ether into the posterior fornix.

9. Re-assessment of blood loss and general condition.

10. Reimbursement of blood loss.

Obstetricians also distinguish atonic bleeding (bleeding in the complete absence of contractility - Couveler's uterus). They differ from hypotonic bleeding in that the uterus is completely inactive and does not respond to the administration of uterotonics.

If hypotonic bleeding does not stop with ROPM, then further tactics are as follows:

1. Apply a suture to the posterior lip of the cervix with a thick catgut ligature - according to Lositskaya. Mechanism of hemostasis: reflex contraction of the uterus as a huge number of interoreceptors are located in this lip.

2. The same mechanism when introducing a tampon with ether.

3. Applying clamps to the cervix. Two fenestrated clamps are inserted into the vagina, one open branch is located in the uterine cavity, and the other in the lateral vaginal fornix. The uterine artery departs from the iliac artery in the area of ​​the internal os and is divided into descending and ascending parts. These clamps compress the uterine artery.

These methods sometimes help stop bleeding, and sometimes are steps in preparation for surgery (as they reduce bleeding).

Massive blood loss is considered to be blood loss during childbirth of 1200 - 1500 ml. Such blood loss dictates the need for surgical treatment - removal of the uterus.

When starting the hysterectomy operation, you can try another reflex method to stop bleeding:

1. ligation of vessels according to Tsitsishvili. Vessels passing through the round ligaments, the ligament proper of the ovary, the uterine tube, and the uterine arteries are ligated. The uterine artery runs along the rib of the uterus. If it doesn’t help, then these clamps and vessels will be preparatory for removal.

2. Electrical stimulation of the uterus (now they are moving away from it). Electrodes are placed on the abdominal wall or directly on the uterus and a shock is delivered.

3. Acupuncture

Along with stopping bleeding, blood loss is compensated.

PREVENTION OF BLEEDING.

Bleeding can and should be predicted based on risk groups:

extragenital pathology

pregnancy complications

· gestosis (chronic stage of disseminated intravascular coagulation)

multiparous

· large fetus, polyhydramnios, multiple births

weakness of labor during childbirth

This requires examination of the woman during pregnancy:

blood platelet test

coagulation potential of blood

· qualified childbirth management

Prevention of bleeding in the afterbirth and early postpartum period:

Administration of uterotonics depending on the risk group.

· Minimum risk group: women with no medical history. Bleeding may occur because childbirth is a stressful situation, and the body’s reaction may be different. Administration of uterotonics intramuscularly after the birth of the placenta: oxytocin, pituitrin, hyfotocin 3-5 units (1 unit = 0.2 ml)

· higher risk group. Intravenous drip of oxytocin, which begins in the second stage of labor and ends within 30-40 minutes after birth. Or according to the scheme: methylergometrine 1 mg in 20 ml of physiological solution (5% glucose solution) intravenously in a stream at the moment of eruption of the head.

· In the high-risk group, a combination of intravenous drip administration of oxytocin + simultaneous administration of methylergometrine.

Violation of hemostasis during childbirth is identified as follows:

1. Lee-White test (blood is taken from a vein into a test tube and seen when the blood clots).

2. You can determine the coagulation potential on a glass slide using the Folia method: 2-3 drops from your finger and determine how many minutes the blood will clot.

The first stage of labor is 3-5 minutes.

The second stage of labor is 1-3 minutes.

Third period 1-3 minutes.

NORM ACCORDING TO LEE-WHITE.

The first period is 6-7 minutes.

Third period 5 minutes.

Early postpartum period 4 minutes.

A woman at risk should be provided with blood substitutes and blood before going into labor.

If there are signs of placental separation, the placenta is not born. Must be applied:

1) reception of Abuladze, Crede-Lazarevich;

2) taking Credet-Lazarevich under anesthesia;

3) manual separation of the placenta.

In the absence of signs of placental separation and the appearance of bleeding, an operation is indicated - manual separation of the placenta and release of the placenta:

Tight attachment of the placenta - easily separated;

Placenta accreta - does not separate from the wall of the uterus and causes heavy bleeding; attempts to separate the placenta must be stopped; laparotomy and supravaginal amputation of the uterus or its extirpation.

With partial placenta accreta, atonic bleeding, shock, and disseminated intravascular coagulation often develop. Transportation of women in labor during the afterbirth period is unacceptable. The duration of the third stage of labor is 5-15 minutes. If within 30 min. there are no signs of placental separation and no bleeding, then manual separation of the placenta and release of the placenta with intravenous administration of oxytocin is indicated.

Bleeding in the early postpartum period

The early postpartum period lasts 24 hours;

1) retention of parts of the placenta in the uterine cavity;

2) hypotension and atony of the uterus;

3) hereditary or acquired hemostasis defects;

4) rupture of the uterus and soft birth canal.

Frequency - 2.5%.

1. If there are defects in the placenta, membranes, torn placenta, as well as vessels located along the edge of the placenta and doubts about the integrity of the placenta, an urgent manual examination of the uterine cavity is indicated.

Hypotony of the uterus indicates weakness of uterine contractility and insufficient tone.

Causes of hypo- and atonic bleeding:

violation of the functional ability of the myometrium to the onset of labor (preeclampsia, somatic diseases, endocrinopathies, scar changes in the myometrium, uterine tumors, hyperextension of the uterus - large fetus, polyhydramnios);

overexcitation with subsequent depletion of the central nervous system, leading to dysfunction of the myometrium during labor (prolonged labor, surgical termination of labor, prolonged use of contractile agents, hypoxia due to improper provision of anesthesia, use of drugs that reduce uterine tone).

The clinical course of hypotonic bleeding is characterized by waves.

There are two clinical variants of early postpartum hemorrhage:

1. Bleeding from the very beginning takes on a profuse, massive character. The uterus remains flabby, atonic, and does not respond to uterotonics. Hypovolemia rapidly progresses, hemorrhagic shock develops, then disseminated intravascular coagulation.

2. The initial blood loss is small - alternation of repeated bleeding with temporary restoration of uterine tone is typical.

It is important not only to recognize the cause of bleeding, but also to determine the amount of blood lost and the woman’s reaction to blood loss:

compensated;

decompensated;

hemorrhagic collapse.

Determination of the amount of blood loss:

collecting blood from the genital tract;

Algover's "shock index" definition

PS/ sist blood pressure - 10% bcc -< 0,5

20% bcc - 0.9-1.2

30% bcc - 1.3-1.4

40% BCC - 1.3 and >

Blood density and hematocrit.

Title Bleeding in the afterbirth and early postpartum period
_Author
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Previously, people died from these bleedings.

The normal afterbirth period lasts 2 hours (within 2 hours the afterbirth should separate from the walls of the uterus). The placenta is normally located along the posterior wall of the uterus with a transition to the side (or bottom). Separation of the placenta occurs in the first 2-3 contractions after the birth of the fetus, although it can separate from the walls during the birth of the fetus.

In order for the placenta to separate, the contractility of the uterus must be high (that is, equal to that in the 1st period).

The placenta is separated due to the fact that there is a discrepancy between the volume of the uterine cavity and the placental site. Separation most often occurs in the first 10-15 minutes after the birth of the fetus (in classical obstetrics, the placenta can separate within 2 hours after birth).

The afterbirth period (third stage of labor) begins with the birth of the fetus and ends with the birth of the placenta. The placenta includes the placenta, membranes and umbilical cord. Usually the placenta separates on its own within 5–20 minutes after the birth of the fetus. You should not try to isolate the placenta before the placenta is separated. The succession period is characterized by the appearance of afterbirth contractions, which lead to the gradual separation of the placenta from the walls of the uterus. Separation of the placenta from the walls of the uterus can occur in two ways - from the center (central placenta compartment) and from the peripheral parts of the placenta (marginal placenta compartment). With the central separation of the placenta, blood released from the uteroplacental vessels accumulates between the placenta and the uterine wall, forming a retroplacental hematoma. The formation of a retroplacental hematoma, together with afterbirth contractions increasing in strength and frequency, contributes to the separation of the placenta and membranes from the walls of the uterus and the birth of the placenta. The marginal separation of the placenta begins from its peripheral parts, as a result of which the blood released from the uteroplacental vessels does not form a hematoma, but immediately flows between the wall of the uterus and the amniotic membranes to the outside. By the time the placenta and membranes are completely separated from the walls of the uterus and the placenta is lowered into the lower uterine segment and uterine vagina, the woman in labor begins to struggle, as a result of which the placenta is born within 2–3 minutes. When the placenta is separated from the center, the placenta is born with the fetal surface facing outward; when separated from the periphery, the maternal surface of the placenta will be located on the outside. In some cases, the placenta may separate from the wall of the uterus, but not be released from the birth canal. The separated placenta continues to remain in the uterus, thereby preventing its contraction. The separated placenta should be removed using external techniques, but it is first necessary to determine whether the placenta has separated.

Tactics for managing the afterbirth period. The basic principle: “hands off the uterus!”

Signs of placental separation. Before checking contact signs, you need to check non-contact signs:

1) the umbilical cord lengthens (positive Alfeld sign);

2) the umbilical cord is retracted with a deep breath (Dovzhenko’s sign);

3) the fundus of the uterus takes on a rounded shape, becomes denser to the touch and rises higher and to the right of the navel (Schroeder’s sign);

4) bloody discharge from the genital tract appears;

5) the outer section of the umbilical cord lengthens;

6) when pressing with the edge of the palm on the abdominal wall slightly above the pubis, the umbilical cord does not retract into the vagina, but, on the contrary, comes out even more.

After separation of the placenta, a gentle massage of the uterine fundus is performed while simultaneously pulling the umbilical cord. It is recommended to use the Brandt-Andrews maneuver: after emptying the bladder through the catheter, pull the umbilical cord with one hand, and with the other move the anterior wall of the uterus in the opposite direction (to prevent uterine inversion).

Bleeding in the afterbirth period may occur as a result of a violation of the separation of the placenta and the discharge of the placenta.

Violation of the process of separation of the placenta. It may be associated with weakness of labor, with tight attachment and true placenta accreta.

The placenta is considered to be firmly attached if the chorionic villi do not extend beyond the compact layer of the decidua. It can be complete or incomplete depending on the length.

With true accretion, the villi penetrate the muscular lining of the uterus up to the serous lining and sometimes cause uterine rupture. Occurs in 1 case per 10,000 births. It can be complete or incomplete depending on the length.

With complete true accretion and complete tight attachment, no bleeding is observed, since the entire placental area adjoins or grows into the muscle wall.

With true partial placenta accreta, part of it can separate, and then bleeding occurs in the afterbirth period.

When parts of the placenta are retained, bleeding may also develop in the postpartum period, when part of the placenta is separated and released, but several lobules or a piece of the membrane remain, which interferes with the contraction of the uterus.

Violation of placenta discharge occurs with spasm of the internal pharynx, hypotonicity of the uterus. Spasm may be the result of irrational use of contractile agents in the afterbirth period.

If bleeding occurs during the postpartum period, the first task of the obstetrician is to determine whether there are signs of placental separation.

If there are signs of placental separation, it is necessary to immediately isolate the placenta externally, assess blood loss, introduce or continue administration of uterotonics, put ice and weight on the stomach, clarify the condition of the woman in labor and the amount of blood loss; examine the afterbirth and the integrity of its tissues.

If blood loss remains within normal limits, it is necessary to monitor the condition of the woman in labor and administer uterotonics for another 30–40 minutes.

If the blood loss is pathological, then it is necessary:

1) clarify the woman’s condition;

2) compensate for blood loss:

a) if blood loss is 400–500 ml, administer gelatinol, saline solution, oxytocin intravenously;

b) if blood loss exceeds 500 ml, hemodynamic disturbances occur and blood transfusion is necessary.

If there are no signs of placental separation, you must:

1) assess the general condition of the woman in labor and the amount of blood loss;

2) give intravenous anesthesia and begin or continue the administration of uterotonics, having previously performed an external massage of the uterus;

3) proceed with the operation of manual separation of the placenta and release of the placenta.

Manual separation of the placenta and placenta release performed in the absence of signs of placental separation within 30 minutes after anesthesia. Infectious complications after this intervention are quite rare.

Operation technique. Holding the body of the uterus with one hand, with the other gloved hand they penetrate the uterine cavity and carefully separate the placenta from its walls, then remove the placenta and massage the fundus of the uterus through the anterior abdominal wall to reduce bleeding.

Inspection of the placenta. The placenta is examined for the presence of all its lobules and the membranes are examined. If broken vessels are present, there may be additional lobules that remain in the uterine cavity. The umbilical cord is examined in cases where one umbilical artery is missing; other anomalies are possible. In cases of pathological changes, the placenta is sent for histological examination.

Further tactics depend on the result of the operation.

When stopping bleeding during surgery, it is necessary to assess the amount of blood loss and begin to replace it, acting as in normal childbirth.

In cases of continued bleeding due to accreta, placenta attachment, etc., this bleeding continues into the early postpartum period.

Before manual separation of the placenta, no diagnosis can be made - dense attachment or true placenta accreta. A definitive diagnosis can only be made through surgery.

In cases of tight attachment of the placenta, you can separate the decidua from the underlying muscle tissue by hand; with true accreta, this is impossible. You must be very careful to avoid severe bleeding.

With true accreta, there is a need to remove the uterus by amputation or extirpation, depending on the location of the placenta and obstetric history. Surgery is the only option to stop bleeding.

Prevention of hypotonic bleeding. The causes of bleeding in the postpartum period can be hypotension and uterine atony. To prevent hypotension and atony, gentle massage of the uterus and the administration of oxytocin are used, the latter is administered either at the birth of the anterior shoulder (10 units intramuscularly), or, better, after the birth of the placenta (20 units in 1000 ml of 5% glucose solution intravenously, with at a rate of 100 drops per minute). When administered intravenously, oxytocin can cause severe arterial hypotension. In cases of ineffectiveness of oxytocin, methylergometrine is administered - 0.2 mg intramuscularly. Methylergometrine is contraindicated in arterial hypertension, as well as in arterial hypotension (constriction of peripheral vessels during hypovolemic shock can be accompanied by severe complications). If bleeding continues, carboprost promethamine is prescribed - 0.25 mg intramuscularly.

Restoring the integrity of the soft tissues of the birth canal

Soft tissue ruptures. To diagnose soft tissue ruptures, the lateral walls and vaults of the vagina, as well as the labia minora and the external opening of the urethra are examined. The palm of one hand is inserted into the vagina and the cervix and anterior lip are examined, which is then pulled up and the rest of the cervix is ​​examined. Soft tissue ruptures are repaired by suturing with continuous or interrupted sutures.

Absorbable suture material 2/0 or 3/0 is applied to the perineum after perineo- or episiotomy. Interrupted sutures are placed on the perineal muscles. The vaginal mucosa is sutured with a continuous suture, capturing the apex of the tear, after which an intradermal cosmetic suture is applied.

If the external anal sphincter ruptures, which is the third degree of perineal rupture, interrupted sutures are applied. A double-row intestinal suture must be applied to the rupture of the anterior wall of the rectum (fourth degree rupture of the perineum), after which the perineum is sutured.

Surgical delivery. Surgical delivery can be performed by caesarean section, forceps or vacuum extraction if spontaneous vaginal delivery is not possible.