Violations of separation of the placenta and discharge of the placenta. Retained placenta and membranes without bleeding. Topic: bleeding in the afterbirth and early postpartum period

In order to determine the cause of bleeding or the level of bleeding, it is necessary to identify signs of placental separation:

1) Schroeder's sign:

Shift of the uterine fundus up and to the right

2) Alfeld's sign:

Lengthening the umbilical cord by 10-12 cm

3) Kustner-Chukalov sign:

When pressing above the womb on the fundus of the uterus, the umbilical cord does not retract

If there is a violation of the separation of the separated placenta, all these signs are positive.

This occurs most often as a result of: spasm of the internal os; overflow of the bladder.

The placenta is a foreign body, so the contractile activity of the uterus is disrupted.

Bleeding develops, the source of which is the gaping vessels of the placental site.

Measures to stop bleeding if the separation of the separated placenta is impaired:

1) empty your bladder

2) bring the uterus to the midline position

3) consistently apply external methods of releasing the placenta.

External methods of releasing placenta.

1) Abuladze's technique:

The anterior abdominal wall is collected into a longitudinal fold and the woman in labor is asked to push.

This causes an increase in intra-abdominal pressure.

2) Genter's reception:

The doctor palpates the fundus of the uterus, clenches his hand into a fist and uses his back to press on the fundus of the uterus from top to bottom.

If there is no effect, proceed to the following procedure:

3) Credet-Lazarevich method:

The doctor palpates the fundus of the uterus and places 4 fingers through the anterior abdominal wall on the posterior surface of the uterus, and the thumb on the anterior surface and squeezes out the placenta.

If there is no effect from performing external openings, proceed to the operation of manual separation of the placenta.

The operation is performed under inhalation anesthesia - nitrous oxide, or under intravenous anesthesia - promedol, sombrevin, callipsol.

The lower third of the abdomen, inner thighs and genitals are treated with iodine tincture.

With one hand, the obstetrician spreads the vulvar ring, and with the other, the “obstetrician’s hand,” he enters inside.

With one hand, through a sterile napkin on the anterior abdominal wall, the fundus of the uterus is fixed.

A hand is turned into the vagina so that the axis coincides with the axis of the sacral cavity and uterus.

The obstetrician finds the placenta along the umbilical cord and, using a sawing motion with his hand between it and the uterus, separates the placenta from the wall of the uterus.

If the signs of placental separation are negative, then there is a violation of placental separation.

Violation of placental separation is caused by a more intimate than normal attachment of the placenta to the wall of the uterus.

There are 2 forms of violation of placental separation (based on different depths of penetration of placental villi into the uterine wall):

Placenta accreta True placenta accreta

Tight attachment of the placenta.

With this pathology, placental villi are fixed in the basal (compact, deep) layer of the endometrium.

In this case, excessive development of connective tissue and fibrosis of the intervillous space occur, which complicates the normal process of separation of the placenta.

If these changes occur over the entire area of ​​the placental site, this is a complete dense attachment of the placenta.

If these changes do not occur over the entire area of ​​the placental site, but only in a certain area, then they speak of partial tight attachment of the placenta.

In this case, bleeding occurs, the source of which is the unchanged areas of the placental site where the placenta was separated.

True placenta accreta.

Invasion of the placental villi occurs to one or another depth of the myometrium.

Depending on the depth of invasion, the following types of true placenta accreta are distinguished:

1) Placenta acraeta:

From the contact of villi with muscle cells to the growth of the myometrium by 1/3 of its thickness

2) Placenta incraeta:

Germination of placental villi to half the thickness of the myometrium

3) Placenta percraeta:

Growing of placental villi by more than half the thickness of the myometrium, up to the serous membrane.

If these changes occur over the entire area of ​​the placental site, this is complete true placenta accreta.

This does not cause bleeding.

If these changes do not occur over the entire area of ​​the placental site, but only in a certain area, then they speak of partial true placenta accreta.

In this case bleeding develops.

Reasons leading to the occurrence of pathological attachment of the placenta:

1) Reasons depending on the condition of the mother’s body

2) Reasons depending on the state of the ovum.

Reasons depending on the condition of the mother’s body:

Atrophic and degenerative changes in the endometrium (inflammatory or traumatic origin):

· chronic endometritis

intrauterine contraceptives

· scraping

multiparous women

Scars on the uterus:

· after caesarean section

· after myomectomy

Implantation of the fertilized egg in a place with insufficient secretory transformation of the endometrium:

· in the lower segment

· in the isthmus

Abnormalities of the uterus

Sexual infantilism

Tumors of the uterus

Deficiency of antitrophoblastic enzymes in the endometrium.

Reasons depending on the state of the ovum:

1) imbalance (functional imbalance) in the hyaluronic acid/hyaluronidase system

2) increased activity of trophoblast proteolytic enzymes.

Clinic of partial placenta accreta and partial true placenta accreta.

The development of bleeding is typical with negative signs of placental separation.

In order to clarify the nature of the pathology (tight attachment or true accretion), the operation of manual separation of the placenta is used.

The use of external methods for releasing the placenta in the presence of negative signs of placental separation is categorically unacceptable!

If during the operation of manual separation of the placenta, its separation occurs without effort, the uterus contracts and bleeding stops, then this is a partial tight attachment of the placenta.

The operation of manual separation of the placenta is both a diagnostic and therapeutic manipulation - an adequate measure to stop bleeding.

If during a manual separation operation the placenta tissue is torn, the doctor’s fingers penetrate the muscle layer, and the bleeding intensifies, then this is a partial true placenta accreta.

In this case, it is necessary to immediately stop the manipulation; in this case, it is only diagnostic in nature.

An adequate measure to stop bleeding with partial true placenta accreta is supravaginal amputation of the uterus,

and if the volume of blood loss is more than 1.5 liters - hysterectomy (since the risk of developing disseminated intravascular coagulation syndrome is high).

The separation of the placenta begins after the birth of the fetus and the rupture of water. This happens a sharp decrease in the volume of the uterus, intramyometrial pressure and basal tone increase significantly (it increases 2-3 times). Intrauterine pressure decreases sharply. Active retraction of the inner layers of the uterus begins.

The area of ​​the placental area decreases, the local progesterone block is removed. arise afterbirth contractions, and the placenta separates in the center or along the edge. Signs of placental separation appear and the amount of blood loss is determined.

Physiological blood loss– its volume does not exceed 0.3% of the mother’s body weight. Physiological blood loss does not require replacement.

Borderline blood loss- its volume is 0.3% -0.5% of the mother’s body weight. It is necessary to replace borderline blood loss if a woman has:

· hypotension.

Pathological blood loss - its volume exceeds 0.5% of the mother’s body weight. It is necessary to replace the volume of blood loss.

The release of the placenta occurs due to:

1) afterbirth contractions

Causes of bleeding that occurs in the third stage of labor:

1. trauma to the soft birth canal

2. violation of placenta discharge

3. placental separation disorder(its pathological attachment)

Partial tight attachment of the placenta

· partial true placenta accreta.

VIOLATION OF PLACENTA SEPARATION.

In order to determine the cause of bleeding or the level of bleeding, it is necessary to identify signs of placental separation:

1) Schroeder's sign- displacement of the uterine fundus up and to the right

2) Alfeld sign- umbilical cord lengthening by 10-12 cm

3) Küstner-Chukalov sign- when pressing above the womb on the fundus of the uterus, the umbilical cord does not retract

If there is a violation of the separation of the separated placenta, all these signs positive.

This happens most often as a result of:

1. spasm of the internal pharynx

2. bladder overflow.

The placenta is a foreign body Therefore, the contractile activity of the uterus is disrupted. Bleeding develops, the source of which is gaping vessels of the placental site.

Measures to stop bleeding if the separation of the separated placenta is impaired:

1) empty your bladder

2) bring the uterus to the midline position

3) consistently apply external methods of releasing the placenta.

External methods of releasing placenta.

1) Abuladze's reception - the anterior abdominal wall is collected into a longitudinal fold and the woman in labor is asked to push. This causes an increase in intra-abdominal pressure. If there is no effect, proceed to the following procedure:

2) Genter's reception - the doctor palpates the fundus of the uterus, clenches his hand into a fist and presses the bottom of the uterus from top to bottom with his back. If there is no effect, proceed to the following procedure:

3) Credet-Lazarevich method - the doctor palpates the fundus of the uterus and places 4 fingers through the anterior abdominal wall on the posterior surface of the uterus, and the thumb on the anterior surface and squeezes out the placenta. If there is no effect from performing external openings, proceed to the operation of manual separation of the placenta. Operation in progress under inhalation anesthesia– nitrous oxide, or under intravenous anesthesia – promedol, sombrevin, calypsol. The lower third of the abdomen, inner thighs and genitals are treated with iodine tincture. With one hand the obstetrician spreads the vulvar ring, and with the other "by the hand of an obstetrician" goes inside. With one hand, through a sterile napkin on the anterior abdominal wall, the fundus of the uterus is fixed. A hand is turned into the vagina so that the axis coincides with the axis of the sacral cavity and uterus.

The obstetrician finds the placenta using the umbilical cord and with a sawing movement of the hand between it and the uterus, the placenta is separated from the wall of the uterus. If signs of placental separation negative, then it occurs placental separation disorders. Violation of placental separation is caused by a more intimate than normal attachment of the placenta to the wall of the uterus.

Highlight 2 forms of placental separation disorder (based on different depths of penetration of placental villi into the uterine wall):

1. Tight attachment of the placenta

2. True placenta accreta

Observed when:

A. pathological attachment of the placenta;

b. anomalies and features of the structure and attachment of the placenta to the wall of the uterus.

V. strangulation of the placenta in the uterus

d. hypotension of the uterus

Pathological attachment of the placenta includes:

Dense attachment of the placenta in the basal layer of the uterine mucosa (placenta adhaerens);

Placenta accreta to the muscle layer (placenta accreta);

Placenta increta into the muscle layer;

Germination of the placenta into the muscular layer and serous layer of the uterus (placenta percreta).

Pathological attachment of the placenta can be throughout its entire length (complete) or locally in one place (incomplete).
The term placenta adhaerens is not used in foreign literature. The term placenta accreta implies ingrowth and combines increta and percreta.
Etiology and pathogenesis
Normally, the placenta is formed in the functional layer of the mucous membrane, which is transformed into the decidual layer. At the level of the spongy layer of the decidua, the placenta is separated from the uterine wall in the third stage of labor.
With inflammatory diseases or dystrophic changes in the endometrium, the functional layer degenerates into scars, which is why its independent separation along with the placenta does not occur in the third stage of labor. This condition is called tight attachment. With atrophy of not only the functional, but also the basal layer of the mucous membrane, the Nitabuch layer (zone of embryonic degeneration), one or more cotyledons of the developing placenta directly reach the muscular layer (placenta accreta) or grow into it (placenta increta), or grow into it (placenta percreta ) (true ingrowth).
Pathological attachment of the placenta is caused by either changes in the mucous membrane uterus, or features of the chorion.
Changes in the uterine mucosa before pregnancy, which contribute to disruption of trophoblast formation, can be observed in the following diseases:

Nonspecific and specific inflammatory (chlamydia, gonorrhea, tuberculosis, etc.) endometrial lesions;

Excessive curettage of the uterus during removal of the fertilized egg or diagnostic procedures;

Postoperative scars on the uterus (caesarean section and myomectomy).

An increase in the proteolytic activity of the chorionic villus also contributes to disruption of the attachment or ingrowth of the trophoblast.
Anomalies and features of the structure and attachment of the placenta to the wall of the uterus often contribute to the disruption of its separation and excretion. For separation of the placenta, the area of ​​its contact with the surface of the uterus is important. With a large area of ​​attachment, which is more often observed with a relatively thin placenta, its insignificant thickness prevents physiological separation from the walls of the uterus. Placentas, shaped like blades, consisting of two lobes, with additional lobules, are separated from the walls of the uterus with difficulty, especially with uterine hypotension.[ Violation of separation and discharge of the placenta may determined by the place of attachment of the placenta: 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 places, the muscles are less complete, so the contractile activity of the uterus, necessary for the separation of the placenta, cannot develop sufficient strength.
Infringement of the placenta after its separation occurs when it is retained in one of the uterine angles or in the lower segment of the uterus, which is most often observed during discoordinated contractions in the placenta period.
As a rule, this pathology is observed with improper management of the afterbirth period. An untimely attempt to release the placenta, massage of the uterus, including according to Crede-Lazarevich, pulling on the umbilical cord, and the administration of large doses of uterotonic drugs disrupt the physiological course of the third stage of labor and the correct sequence of contractions of various parts of the uterus.
One of the reasons for the violation of the separation of the placenta and the discharge of the placenta is uterine hypotension. With uterine hypotension, afterbirth contractions are either weak or absent for a long time after the birth of the fetus. As a result, both the separation of the placenta from the uterine wall and the release of the placenta are disrupted, and the placenta may be strangulated in one of the uterine angles or in the lower segment of the uterus. The succession period is characterized by a protracted course.
Diagnostics.
It is possible to accurately determine the type of pathological attachment of the placenta with targeted ultrasound and manual separation of the placenta. On ultrasound, the following are characteristic of placenta accreta:

the distance between the serous membrane of the uterus and the retroplacental vessels is less than 1 cm;

the presence of a large number of intraplacental hyperechoic inclusions/cysts.

The most reliable data can be obtained using three-dimensional Doppler color mapping.
At Manual separation of the placenta and the presence of a tight attachment of the placenta (placenta adhaerens) makes it possible, as a rule, to remove all lobes of the placenta by hand. With true chorionic villus ingrowth, it is impossible to separate the placenta from the wall without violating its integrity. Often, placenta accreta is established only by histological examination of the uterus, which was removed due to its suspected hypotension and massive bleeding in the postpartum period.

Clinic for violation of placental separation and placenta discharge determined by the presence or absence of areas of separated placenta. If the placenta is not separated along its entire length (complete pathological attachment), then the main symptoms characterizing the clinical picture of the disease are:

No signs of placental separation;

No bleeding.

More often, partial separation of the placenta (incomplete attachment) is observed, when one or another section is separated from the wall, and the rest remains attached to the uterus. In this situation, when the placenta remains in the uterine cavity, muscle contraction, in particular at the level of the separated placenta, is not sufficient to compress the vessels and stop bleeding from the placental site. As a result, the main symptoms of partial separation of the placenta are:

No signs of placental separation;

Bleeding.

Bleeding from the placental site begins a few minutes after the birth of the baby. The flowing blood is liquid, mixed with clots of various sizes, flows out in portions, temporarily stopping, only to resume with renewed vigor after a minute or two. Retention of blood in the uterus and vagina often creates a false impression of the absence of bleeding, as a result of which measures aimed at diagnosing and stopping it may be delayed. Sometimes blood initially accumulates in the uterine cavity and vagina, and then is released in the form of clots, intensifying when external methods are used to determine the separation of the placenta. An external examination of the uterus shows no signs of placental separation. The fundus of the uterus is at the level of the navel or above, deviating to the right. The general condition of the woman in labor is determined by the amount of blood loss and can change quickly. In the absence of timely assistance, hemorrhagic shock develops.
The clinical picture of impaired discharge of the placenta does not differ from that of impaired separation from the uterine wall and is manifested by bleeding.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Retained placenta without bleeding (O73.0)

general information

Short description

Retention of the placenta and membranes in the uterine cavity without bleeding is a complication of the third stage of labor, which is not accompanied by bleeding, but requires emergency treatment. The incidence of these complications is about 10%.

Protocol code: H-O-005 "Retained placenta and membranes without bleeding"
For obstetrics and gynecology hospitals

ICD-10 code(s):

O73 Retained placenta and membranes without bleeding

O73.0 Retained placenta without bleeding

O73.1 Retention of parts of the placenta or membranes without bleeding

Classification

1. Defect of the placental tissue or its additional lobule.

2. Retention of membranes in the uterus.

3. Tight attachment of the placenta - no signs of separation of the placenta and bleeding within 30 minutes after the birth of the fetus.

4. True placenta accretion - germination of placenta tissue into the muscular layer of the uterus, can only be diagnosed by attempting to manually separate and isolate the placenta.

Risk factors and groups

1. Defect of placenta during childbirth.

2. True increment of placenta.

3. Tight attachment of the placenta.

4. Previous cesarean section or other surgical interventions on the uterus.

5. Multiparous women.

6. Anomalies in the development of the placenta.

7. Excessive traction on the umbilical cord in the third stage of labor, especially when it is attached to the fundus of the uterus.

8. Hyperthermia during childbirth.

9. Long water-free period (more than 24 hours).

Diagnostics

Diagnostic criteria

Complaints and anamnesis: none.

Physical examination:

1. When examining a newborn placenta, a defect in the placental tissue or membranes is noted.

2. No signs of separation of the placenta within 30 minutes after the birth of the fetus.

3. No signs of external or internal bleeding.

Laboratory tests: not specific.

Instrumental studies: not specific.

Indications for hospitalization, specialists: according to indications.

Differential diagnosis: no.

List of main diagnostic measures:

1. Blood type and Rh factor of the postpartum mother.

2. Complete blood count (hemoglobin, hematocrit, platelet concentration).

3. Serological examination for syphilis.

4. If surgical treatment is necessary (manual separation and isolation of the placenta or its parts, curettage of the walls of the uterine cavity, laparotomy) and the risk of bleeding increases, the following studies are additionally carried out: re-determination of blood type and Rh factor, hemoglobin concentration, hematocrit, platelets, coagulogram ( prothrombin, thrombin time, prothrombin index, fibrinogen concentration, fibrinogen degradation products), blood clotting time, ultrasound examination of the abdominal organs, heart rate, blood pressure level; assessment of urine output through an indwelling Foley catheter.

List of additional diagnostic measures:

1. HIV testing.

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Treatment

Treatment tactics

Retention of the placenta or its parts is a common cause of postpartum hemorrhage. This diagnosis is made if there is no spontaneous expulsion of the placenta from the uterine cavity 30 minutes after the birth of the fetus.

Treatment Goals
Active tactics for managing the third stage of labor (includes early clamping and crossing of the umbilical cord, control traction on the umbilical cord, prophylactic administration of oxytocin), careful examination of the separated placenta.

If a defect in the placental tissue and/or membranes is detected, and there are no signs of separation of the placenta within 30 minutes after the birth of the fetus, promptly decide on further labor management tactics.

Prevention of possible postpartum hemorrhage.

Non-drug treatment: no.

Drug treatment

If the placenta or its parts are retained in the uterine cavity in the absence of bleeding, treatment is aimed at stimulating the contractility of the uterus when the bladder is emptied. In case of placental tissue defect, surgical curettage of the uterine cavity is allowed against the background of adequate anesthesia and saline infusion.

In the absence of uterotonic prevention of postpartum hemorrhage in women in labor with signs of placenta retention, it is necessary to administer 5 units of oxytocin intravenously. In this case, the administration of ergometrine is contraindicated, since the drug causes spasms of the lower segment of the uterus, and therefore difficulties in the independent expulsion of the placenta from the uterine cavity. Control traction of the umbilical cord is performed if there are no signs of separation of the placenta within 30 minutes during the administration of oxytocin.

If control traction on the umbilical cord is ineffective, it is necessary to perform manual separation and release of the retained placenta or its parts with adequate anesthesia and contact with the vein. Before carrying out this surgical intervention, it is necessary to determine the hemoglobin concentration, blood group and Rh affiliation. After the placenta is isolated, a thorough examination of its fruiting and maternal surfaces is carried out.

If it is impossible to separate the placenta during manual examination of the uterine cavity, true accretion of the placenta should be suspected. In this case, surgical treatment including laparotomy and hysterectomy is indicated.

Maintenance stages:

1. Active management of the third stage of labor:

10 units of oxytocin intramuscularly within the first minute after the birth of the child;

Early clamping and cutting of the umbilical cord one minute after birth;

Controlled cord traction.

2. If a defect in the placental tissue or fetal membranes is identified, manual separation and release of retained parts of the placenta is indicated under the following conditions:

Adequate anesthetic care;

Intravenous infusion of saline;

Laboratory testing of hemoglobin concentration, hematocrit, platelets, blood clotting, blood group and Rh factor.

3. In the absence of independent discharge of the placenta within 30 minutes after the birth of the fetus and the ineffectiveness of control traction on the umbilical cord, manual separation and isolation of retained parts of the placenta are indicated for the purpose of differential diagnosis of dense attachment of the placenta and true accretion.

4. If signs of true accretion of the placenta are detected, surgical treatment through laparotomy or hysterectomy is indicated.

Preventive actions:

1. Routine prevention of PPH with oxytocin 10 units intramuscularly immediately after birth.

2. Emptying the bladder.

3. Active management of the placenta (early clamping and crossing of the umbilical cord, controlled traction of the umbilical cord, careful examination of the separated placenta and birth canal).

Sources and literature

1. Protocols for diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Scottish Obstetric Guidelines and Audit Project: The Management of Postpartum Haemorrhage.- 2000.-p.29 2. Department of Health, NSW: Framework for Prevention, Early Recognition and Management of Postpartum Haemorrhage.- Policy Directive.- 2005.- www.health.nsw.gov.au 3. SOGC Clinical Practice Guidelines: Prevention and Management of Postpartum Haemorhage.- #88, 2000, p.11 4. Institute for Clinical Systems Improvement. Health Care Guideline. Routine Prenatal Care, 2005, p.80 5. National Collaborating Center for Women’s and Children’s Health. Antenatal Care: Routine Care for the Healthy Pregnant Women. Clinical Guideline, 2003, p.286

Information

Raeva R.M. Candidate of Medical Sciences, Senior Researcher Republican Research Center for Maternal and Child Health (RNICMHMR).

Attached files

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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 a high-risk group, a combination of intravenous drip administration of oxytocin and 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.

72. Demonstration on a phantom of a classic aid for breech presentation.

breech presentation classified based on the position of the legs and buttocks of the fetus.

Pure breech presentation. The buttocks are presented, the legs of the fetus are bent at the hip joints, extended at the knee joints and extended along the body. Observed in 60-65% of cases of breech presentation.

Mixed breech presentation. The legs are completely bent at the knee joints and pressed against the fetal abdomen. Observed in 25-35% of cases of breech presentation.

Leg presentation. One or both feet or (extremely rarely) the knees of the fetus are presented. There are complete and incomplete leg presentations. With a complete breech presentation, both legs are presented; with an incomplete breech presentation, one leg or knees of the fetus are presented. Observed in 5% of cases of breech presentation. Frequency - 2.7-5.4% of all pregnancies, in 15-30% of cases it ends in the birth of a child with low body weight (less than 2,500 g). Risk factors Fetal malformations, such as anencephaly, hydrocephalus, Down syndrome Placenta previa Uterine atony, multiple births in history Low fetal weight or prematurity.

Etiology

Organic causes Narrowing of the pelvis, abnormal shape of the pelvis Malformations of the uterus Excessive mobility of the fetus with polyhydramnios Myomatous nodes in the lower segment of the uterus

Functional reasons. Discoordination of labor, leading to redistribution of myometrial tone between the fundus, body and lower segment of the uterus; in such cases, the large dense part of the fetus (the head) is pushed away from the entrance to the pelvis, and the fetus turns over.

Clinical picture

High standing of the uterine fundus, due to the location of the pelvic end of the fetus above the entrance to the pelvis. When palpating the pregnant woman’s abdomen, it is determined that the fetal head (a round dense voting formation) is located in the fundus of the uterus, and the buttocks (a large, irregularly shaped, non-balloting presenting part) is located above the entrance to the small pelvis The fetal heartbeat is heard above the navel or at its level.

Special studies

Vaginal examination during childbirth With a breech presentation, the presenting part is softer than with a cephalic presentation. You can palpate the groove between the buttocks, the sacrum, the genitals of the fetus. In a purely breech presentation, you can find the inguinal fold. In a mixed breech presentation, the foot is palpated next to the buttocks. With the help of palpation of the sacrum, the position and appearance are clarified. In case of leg presentation, in order not to mistakenly mistake the leg for a dropped arm (for example, in transverse positions), it is necessary to remember the distinctive features of the fetal limbs. By the location of the popliteal fossa, you can determine the position of the fetus. In the first position, the popliteal fossa faces to the left, in the second - to the right. Ultrasound easily diagnoses breech presentation.

Mechanism of labor
The first point is the descent of the pelvic end. When the buttocks enter the small pelvis, their transverse size (intertrochanteric line) coincides with one of the oblique dimensions of the pelvis. In the anterior view of the first position, the gluteal line runs in the left oblique dimension, in the second position - in the right. In an oblique size, the buttocks descend into the small pelvis, the wire point is the buttock, facing anteriorly and standing below the back, a birth tumor is formed on it.

The second point is the internal rotation of the buttocks, which occurs as they move forward. The anterior buttock approaches the symphysis, the posterior one approaches the sacrum, the intertrochanteric line corresponds to the direct size.

The third point is cutting in and cutting through the buttocks. After eruption of the anterior buttock, the fetal ilium rests on the symphysis (fixation point). Strong lateral flexion of the fetal trunk occurs, then the posterior buttock is born. If the fetal presentation was mixed breech, the legs are born along with the buttocks. With a pure breech presentation, the legs are born along with the body. After the birth of the pelvic end, the torso straightens and is born to the navel, and then, slightly turning the back to the front, to the lower angle of the shoulder blades.

The fourth moment is the birth of the shoulder girdle. At the outlet of the pelvis, the shoulders change from an oblique size of the pelvis to a straight one. The anterior shoulder abuts the symphysis and the posterior shoulder is born. If after this the hands are not born on their own, they are released with the help of a manual aid.

The fifth moment is the birth of the head. The bent head from the oblique size of the pelvis, perpendicular to the one through which the buttocks and shoulders passed, turns into a straight one (the back of the head to the symphysis). After the appearance of the neck in the genital slit, the head rests on the lower edge of the pubic arch with the suboccipital fossa, which becomes the point of fixation - the birth of the head occurs from the chin to the back of the head.

With a breech presentation, the legs are born first. In front there is a leg facing the symphysis. The buttocks enter the small pelvis after the birth of the legs up to the knee. The further course of labor is the same as with breech presentation.

Lead tactics
Prenatal care From 35 weeks of pregnancy, it is recommended to engage in therapeutic corrective gymnastics. Some doctors recommend external obstetric rotation to transform a breech presentation into a cephalic presentation, however, obstetric rotation is unsafe - placental abruption, compression and entanglement of the umbilical cord, and premature birth may occur. whether to give birth naturally or to resort to caesarean section.

Management of childbirth
Disclosure period. Prevent premature rupture of the membranes. Strict bed rest is indicated. After the discharge of amniotic fluid - vaginal examination (clarification of the diagnosis, exclusion of umbilical cord prolapse).

Second stage of labor. After the birth of the fetus, the head presses the umbilical cord to the level of the navel. If labor does not end within 10 minutes, the fetus dies from asphyxia. There is also a risk of placental abruption. Therefore, prompt obstetric care is necessary after the birth of the lower torso.

Manual aid for purely breech presentation using the Tsovyanov method is used to prevent complications. The method is based on maintaining the normal position of the fetus.

After eruption, the buttocks are grabbed as follows: the thumbs are placed on the legs pressed to the stomach, and the remaining fingers of both hands are placed along the sacrum to prevent premature loss of the legs. As the body is born, the arms are moved towards the genital opening of the woman in labor, continuing to press the outstretched legs to the stomach until the birth of the shoulder girdle. If after the birth of the shoulders the arms do not fall out on their own, the shoulder girdle is set in the direct size of the pelvis and the fetal body is tilted downwards (posteriorly). This creates the front handle. The body is then tilted upward (anteriorly), after which the posterior arm and legs (heels) of the fetus are born. When the head is born, the fetal body is also directed upward.

Manual aid for foot presentations using the Tsovyanov method. The method is based on holding the legs in the vagina until the opening is completely dilated. Technique. The woman's external genitalia is covered with a sterile napkin. A palm is placed on the vulva, delaying the birth of the legs, which leads to full opening of the pharynx. Thus, the fetus moves from a leg presentation to a mixed breech presentation. After complete opening of the throat, childbirth is carried out as in a breech presentation.

Sometimes, when using the Tsovyanov manual, premature loss of legs still occurs. In such cases, a classic manual manual is used.

If the birth of the head is delayed, it is released using the Morisde-Levreux maneuver.

Technique. The body of the fetus is placed astride the forearm of the hand, the second or third finger of the same hand is inserted into the vagina of the woman in labor, following its back wall, and then into the mouth of the fetus. With the second hand, grasp the fruit by the shoulders and release the head. The third stage of labor with breech presentation is carried out as usual.

After birth, it is necessary to determine the gas composition of the blood in the vessels of the umbilical cord.

Surgery
Extraction of the fetus by the pelvic end is considered not an aid, but an obstetric operation, because in the process of manipulation all four stages of labor are artificially reproduced by applying drag force. The fruit is removed from the heels to the crown.

Indications for surgery

The need for urgent vaginal delivery due to severe somatic illness of the woman in labor (for example, cardiovascular disease) Threatening fetal hypoxia and lack of conditions for cesarean section Previous classic rotation of the fetus.

Conditions

Full dilatation of the cervix. Discharge of amniotic fluid. Correspondence between the sizes of the fetus and the woman's pelvis.

Operation technique
First point. There are 2 ways to extract the fetus by the inguinal fold. The index finger of the hand grasps the front leg of the fetus by the inguinal fold; attraction is produced during pushing. To grasp the pelvic end, the thumbs are placed on the buttocks, the index fingers are placed on the groin fold, and the rest are placed on the hips of the fetus. The fetus is removed up to the umbilical ring. The fetus is removed by the stem. The leg is grabbed with the whole hand in the area of ​​the knee joint and pulled down. The second leg is born independently.

Second point. The fruit is removed to the level of the lower corner of the shoulder blades. This moment is highlighted for two reasons. The release of the arms can only begin after the birth of the fetus to the level of the lower angle of the shoulder blades. After the birth of the fetus to the level of the navel, the head, entering the small pelvis, can pinch the umbilical cord, which threatens hypoxia. The third and fourth moments. The arms and head of the fetus are released as with classic manual assistance. Caesarean section Indications for cesarean section for breech presentation (in addition to absolute indications for any presentation) Combination of breech presentation with a burdened obstetric and gynecological history (infertility, stillbirth, birth of a child with trauma), uterine fibroids, uterine malformations, narrowing of the pelvis , gestosis, post-term pregnancy, primipara age 30 years or more Scar on the uterus Large fetus Umbilical cord presentation Partial placenta previa Posterior view of breech presentation Contraindications Intrauterine fetal death Terminal condition Deformity or extreme prematurity of the fetus Acute infectious disease in a woman Prolonged labor (more than 24 hours) Large number of vaginal examinations The use of obstetric forceps for breech presentation is contraindicated Conditions for cesarean section The fetus is alive and viable (not always feasible with absolute indications) The woman agrees to the operation (if there are no vital indications) The pregnant woman has no signs of infection Preparing the patient If Ht is less than 30%, perform infusion therapy to compensate for fluid deficiency It is necessary to prepare for a possible blood transfusion during surgery The woman's bladder must be emptied Anesthesia can be inhalational (general) or regional (spinal or epidural). General anesthesia often leads to depression of the newborn’s vital functions, therefore, when performing general anesthesia, the time interval from the onset of anesthesia to the moment of extraction of the fetus should not exceed 10 minutes. Progress of the operation Dissection of the abdominal wall Opening and separation of the vesicouterine fold of the peritoneum, exposure of the myometrium Dissection of the myometrium (Kerr incision -Rusakov, according to Sellheim or according to Sanger) The child is carefully removed by hand, using forceps, a vacuum extractor. The uterus is often removed from the abdominal cavity for the purpose of massaging the fundus, examining the appendages and visualizing the incision when applying sutures. To reduce blood loss, uterine contracting agents (oxytocin, methylergometrine, etc.) are injected into the uterine muscle. After separation of the placenta, a manual examination of the uterine cavity is necessary to diagnose submucosal fibroids or to remove remnants of the fertilized egg. Double-layer suturing of the wound. The vesicouterine fold of the peritoneum is sutured with thin absorbable suture material, and the incision of the abdominal wall is sutured in the usual way. After the operation, it is necessary to determine the gas composition of the blood in the vessels of the umbilical cord.

Information for the patient

Hospitalization must be carried out as planned 2-3 weeks before birth. If a decision is made to perform a caesarean section, the woman must be informed about the nature of the operation, possible complications and give consent to the operation (with the exception of surgery for health reasons). Observation During childbirth, constant monitoring of the fetal heart rate should be carried out. Observation of the postpartum woman is carried out for 6 weeks (as after other births).

Prevention

Therapeutic corrective gymnastics (indicated from 35 weeks of pregnancy), external obstetric rotation (see Management tactics).

Complications

Throw back the arms Untimely rupture of amniotic fluid Abnormalities of labor Prolapse of the umbilical cord and small parts of the fetus Spasm of the uterine pharynx with pinching of the fetal torso or neck Extension of the head Injuries to the head and soft tissues, brachial plexus and spinal cord of the fetus Asphyxia of the fetus.

Course and prognosis

Perinatal morbidity and mortality are higher in breech births. For fetal weights less than 1,500 g, the risk of cerebral hemorrhage, as well as perinatal mortality, is significantly higher in cases of vaginal delivery than after cesarean section.

032.1 Breech presentation of the fetus requiring maternal medical care

082 Singleton birth, delivery by caesarean section

083.0 Removing the fetus by the pelvic end

083.1 Other obstetric aid for breech delivery

Notes Absolute indications for cesarean section Complete placenta previa Absolutely narrow pelvis Clinical discrepancy between the size of the woman’s pelvis and the fetal head Incomplete placenta previa with unprepared birth canal and severe bleeding Premature abruption of a normally located placenta with unprepared birth canal and bleeding Tumors of the pelvic organs that prevent the birth of a child Coarse cicatricial changes in the cervix and vagina Threatened or incipient uterine rupture Severe gestosis with ineffective conservative treatment and unprepared birth canal Incompetent scar on the uterus Extragenital cancer and cervical cancer Serious extragenital pathology (for example, retinal detachment, complicated myopia, severe cardiovascular diseases) Techniques Leopold First reception. The palms of both hands are placed on the fundus of the uterus, the fingers are brought together, the height of the fundus of the uterus is assessed and the part of the fetus adjacent to the fundus of the uterus is determined.

Second appointment. Both hands are moved downwards from the fundus of the uterus, placed on its lateral surfaces and the position and type of position of the fetus are determined. The third technique is used to determine the presenting part of the fetus. The hand is placed above the symphysis so that the first finger is on one side, and the remaining 4 fingers are on the other side of the lower segment of the uterus. Cover the presenting part. The head is palpated in the form of a dense round part with distinct contours, and the pelvic end is palpated in the form of a large, but less dense and less rounded formation. The fourth technique is an addition and continuation of the third technique. The examiner stands on the right, facing the legs of the pregnant woman, places the palms of both hands on the lower segment of the uterus on the right and left, reaches the symphysis with his fingertips and determines the presenting part and the height of its standing. The Moriso-Levre technique is a method of extracting the fetal head in a breech presentation, in which the head is bent inserted into the fetal mouth with the index finger of one hand, followed by traction of the body with the other hand. Distinctive features of the fetal limbs. The leg has a calcaneus, the fingers are straight, short, the thumb is not set back. The big toe of the leg cannot be pressed against the sole, unlike the thumb of the handle, which is easily pressed. to the palm; You can say hello to the pen. The knee differs from the elbow in that it has a movable patella; the foot meets the shin at a right angle. Myometrial incisions.

Kerr-Gusakova (low transverse) is currently used most widely. The incision is made on the non-contracting part of the uterus (lower segment), which reduces the likelihood of rupture or divergence of the edges of the scar during subsequent pregnancies. Disadvantage - danger of damage to nearby vessels Sanger incision (classical, or corporal, now rarely used, according to indications) - longitudinal incision on the anterior surface of the uterine fundus Sellheim incision (low vertical) begins in the non-contractile part of the uterus and continues to the body of the uterus.

74. List the sequence of performing perineal protection during the birth of the fetal head.

The technique of removing the head and torso of the fetus during childbirth is called perineal protection. To gradually stretch the tissue, the head should move slowly and in the smallest size.

It is necessary to restrain excessively rapid advancement of the head. To do this, three fingers of the right hand are placed on the head and prevent its rapid advancement and extension. With strong attempts, help with the left hand, for which the hand is placed on the pubis and the palm or thumb and forefinger gently press on the head, bending it towards the perineum. In the pauses between attempts, a “tissue loan” is performed, for which the tissue of the clitoris and labia minora is lowered from the nascent nape. The less stretched tissues of the anterior part of the Boulevard ring are brought back, eliminating excessive stretching of the perineum.

When the head is removed, when the area of ​​the suboccipital fossa approaches the lower edge of the symphysis, the woman in labor is prohibited from pushing (the woman in labor breathes through her mouth, her hands lie on her chest). After the birth of the occipital tubercle, the parietal tubercles are released, the head is grabbed with the left hand and carefully straightened. During extension, the perineal tissues are pulled away from the head with the right hand. After birth, the head is released from the shoulder girdle, after which the body is born without difficulty. To cut through the shoulder girdle, the following assistance is provided: the front shoulder is pressed against the pubic arch and the perineum is carefully pulled away from the back shoulder. If the shoulders are not born on their own, the head is grabbed so that the midwife's palms rest on the ear area (without touching the fetal neck), then the head is pulled down until the front shoulder fits under the pubic arch. After the front shoulder is removed, the head is lifted upward and the back shoulder is rolled out over the perineum. After the birth of the fetus, the umbilical cord is tied (see Toilet of the newborn), the eyes are treated (see Blennorrhea of ​​the eyes of the newborn) and the baby is taken to the changing table.

78. The use of oxytocin in obstetrics. Recipes, doses, administration methods.