Retained placenta and membranes without bleeding. Bleeding in the postpartum and early postpartum period Impaired discharge of placenta

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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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.

The measure used in a particular case depends on the reason that disrupted the normal course of the succession period. It is necessary to clearly distinguish between the delay in the process of detachment of the placenta from the bed and the delay in its release from the genital canal. As already mentioned, these processes occur depending on the contraction of the uterine muscles (retraction) and abdominal muscles, cessation of placental circulation, anatomical changes in the placenta, etc. Therefore, in each individual case, it is necessary, if possible, to accurately take into account all factors promoting the release of the uterus from its contents.

The cause of retained placenta is often an overflow of the bladder caused by the paretic state of the latter. In such cases, to release the placenta, it is enough to release urine with a catheter. The release of the placenta is often delayed due to poorly developed abdominal muscles. It must be emphasized once again that contractions of the abdominal press, as well as the muscles of the uterus, play a major role in the expulsion of the placenta.

Rice. 105. Abuladze method.

Abuladze's method is that it ensures the activation of the entire sum of expelling forces. This method is especially indicated for multiparous women with a flaccid abdominal wall. Abuladze’s method is technically simple and consists in grasping the abdominal wall along the midline with both hands, lifting it upward and asking the woman in labor to push; in this case, the afterbirth usually easily leaves the uterine cavity. We have used Abuladze's method many times, and therefore we can strongly recommend it. Its use gives success, according to the author, in 86%, and according to Mikeladze’s observations - in 97%.

Ya. F. Verbov, in order to speed up the exit of the placenta from the uterine cavity, recommended the sitting position of the woman in labor in a squatting position. In this position, the wire axis of the birth canal acquires a normal direction, which facilitates the birth of the placenta. In the lying position of a woman, the wire axis of the canal runs almost horizontally, and the force expelling the placenta has to overcome significant obstacles, in particular the resistance of the pelvic floor muscles; when squatting, the wire axis goes almost vertically, and expulsion of the placenta is easier.

Squeezing the placenta according to the Lazarevich-Crede method (Fig. 106). Squeezing the placenta in ordinary (uncomplicated) cases of retention of separated placenta is permissible only after 1/2-1 hour and after unsuccessful use of other methods of its release (emptying the bladder, Abuladze’s method).

In no case can we agree with the author of the method, who proposed squeezing out the placenta immediately after childbirth and not fear any complications.

Squeezing the placenta is permissible only in cases of significant blood loss when the placenta is separated; the use of this method when the placenta is not separated is violence, leading to crushing of the placenta and injury to the body of the uterus itself. If the placenta has not separated from the wall of the uterus and there is significant bleeding, the doctor is obliged to immediately go for manual separation and release of the placenta.

Technique of the Lazarevich-Crede method. The bladder is first emptied of its contents, then the uterus is placed along the midline of the abdomen and lightly massaged so that it contracts as much as possible. The palm is placed on the fundus of the uterus, with four fingers placed on the posterior surface of the uterus and the thumb on its anterior surface. The uterus is compressed and at the same time pressure is applied from top to bottom (Fig. 106). If these instructions are followed and there are no significant morphological changes in the placenta or in the walls of the uterus itself, squeezing the placenta according to Lazarevich-Crede gives positive results - the placenta can be brought out.

Rice. 106. Squeezing the placenta according to the Lazarevich-Crede method.

The method of pulling the umbilical cord proposed by Stroganov in combination with the Credet method should be used very carefully. This method is effective and safe only when the placenta is separated and is in the vagina.

When pulling the umbilical cord, you should press on the uterus in the direction of the pelvic cavity and do not massage it, since excessive contraction of the uterus prevents the release of the placenta.

M.V. Elkin and other clinicians used the following method of releasing the placenta: the operator stands between the spread legs of a woman in labor lying on the table, grabs the contracting uterus with both hands at the same time and tries to squeeze the placenta onto himself.

The method proposed by G. G. Genter is technically simple and quite effective. After emptying the bladder and moving the uterus to the midline, the operator places his hands, clenched into fists, with the back surface of the main phalanges on the bottom of the uterus in the area of ​​​​the tubal angles (obliquely) and applies gradually increasing pressure downwards and inwards. During the entire manipulation, the woman in labor should not push.

However, sometimes it is still not possible to squeeze out the afterbirth using these techniques. In some cases, this is explained by spasm of the circular muscles of the uterus in the area of ​​the internal os, caused by premature mechanical irritations, erroneous administration of ergot preparations, etc., in others, the reason for the retention of the placenta is the hypotonic state of the uterine muscles. In some cases, the retention of the placenta is associated with an abnormal location of the placenta in the tubal angle, which is revealed by external examination: one of the tubal angles of the uterus has the appearance of a separate protrusion of a hemispherical shape, separated from the rest of the body of the uterus by an interception. In this case, squeezing out the placenta is done under inhalation ether anesthesia, or it is even necessary to use manual separation and release of the placenta, especially in cases where there is a significant degree of blood loss.

Manual separation of the placenta (Separatio placentae manualis).

It is necessary to distinguish manual separation (detachment) of the placenta (Separatia placentae) from its removal (Extractio placentae) using internal techniques, although with both techniques it is equally necessary to insert the hand into the uterine cavity. The separation of the placenta is associated with a longer stay of the hand in the uterine cavity and is more unfavorable in terms of infection, while the removal of the separated placenta is a short-term manipulation.

Manual separation of the placenta (Fig. 107) is usually performed as an emergency intervention in case of bleeding in the placenta period that exceeds the permissible degree of blood loss, as well as in the absence of signs of separation of the placenta within 2 hours and if it is impossible to separate it out using the above methods.

Rice. 107. Manual separation of the placenta.

Separation of the placenta is carried out after thorough disinfection of the operator’s hands and the external genitalia of the woman in labor. After disinfection of the external opening of the urethra, the bladder of the woman in labor is emptied with a catheter. The end of the umbilical cord hanging from the vagina is again intercepted with a clamp and cut off. After this, the doctor inserts one hand, the back surface of which is generously lubricated with sterile vegetable oil, into the uterine cavity, and places the other (outer) hand on the fundus of the uterus. He runs his inner hand along the umbilical cord to its root, and then, using a sawtooth motion of the ends of his fingers, carefully separates the placental tissue from the wall of the uterus under the control of the hand supporting the fundus of the uterus from the outside. The operating hand should be facing the placenta with the palm of the hand and the back facing the uterine wall. The separated placenta is grasped with the inner hand and brought out by pulling the end of the umbilical cord with the outer hand. The hand should be removed from the uterine cavity only after a final examination of the latter and examination of the removed placenta. It is advisable to remove the placenta under general anesthesia.

When manually separating the placenta, it is important to get into the gap between it and the uterine wall; otherwise significant difficulties are inevitable.

Manual separation of the placenta is carried out with strict adherence to asepsis and prophylactic administration of penicillin. In some cases, blood transfusion is performed.

The frequency of use of manual separation of the placenta ranges from 0.13 (P. A. Guzikov) to 2.8% (Schmidt).

After removing the placenta from the uterine cavity, it is necessary to immediately carefully examine the placenta and membranes to ensure their integrity. In this case, the hand is not removed from the uterine cavity; the integrity of the placenta can never be accurately determined either by the degree of uterine contraction or by the absence (or rather, cessation) of bleeding. Literary data and personal experience show that there are often cases when retention of significant parts of the placenta is not accompanied by bleeding.

To determine the integrity of the placenta, a number of tests have been proposed (air, milk, swimming, scalding with boiling water according to Shcherbak, etc.), none of which gives reliable results. Of the modern methods for identifying defects in placental tissue, fluorescent is recommended.

The light source that excites luminescence can be a PRK mercury-quartz lamp. Its rays are passed through a Wood filter (glass colored with nickel oxide).

This filter has the ability to absorb rays of the visible part of the spectrum and transmit invisible ultraviolet rays, the length of which is 3650-3660 Å (angstroms).

The placenta, well washed from blood clots, is placed in these ultraviolet rays.

When examining the placenta in ultraviolet rays, it is noted that the decidua covering the maternal part of the placenta has its own grayish-green glow. To enhance the glow, a few drops of a 0.5% fluorescein solution are applied with a pipette to the maternal part of the placenta, which is evenly distributed by hand over its surface. After this, the excess fluorescein is washed off with water, and the placenta is again placed under ultraviolet rays, where it is finally examined. For a brighter glow, it is better to carry out the inspection in a darkened room, at room temperature.

When examining the placenta in the light of luminescence, it was noted that undisturbed decidual tissue glows golden-green. If there is a defect on the surface of the placenta, then no glow is observed in this area; the site of the defect looks like dark spots, sharply demarcated from the intact surface of the placenta.

However, in conditions of widespread practice, the use of this method is difficult.

Therefore, all of the above obliges the practitioner to conduct a thorough examination of the placenta and membranes ad oculos.

If, upon examination of the placenta, a defect is found in it or retention of the membranes is detected, then it is necessary to immediately, without removing the hand from the uterine cavity, remove the remaining parts, since the second entry of the hand into the uterine cavity (some time after childbirth) is not indifferent to the woman’s condition (infection) .

Sometimes the remnants of the placenta can be removed using a large, blunt curette; however, only a qualified obstetrician-gynecologist can perform this operation.

Recognizing retention of the placenta, its parts and additional lobules in the uterine cavity often presents significant difficulties. The uterus is not washed after manual separation of the placenta.

In cases of suspected infection, after removing the placenta and checking the uterine cavity, it is recommended to prescribe antibiotics or sulfonamide drugs. To contract the uterus, injections of 0.5-1 ml of Sol are made. Adrenalini (1: 1000) or ergotine, or pregnanthol in an amount of 1 ml, etc.

Douching or washing the vagina before using manual separation of the placenta should not be done, since the outpouring of amniotic fluid and then the passage of the fetus sufficiently thin out the vaginal flora. In addition, the blood constantly flowing from the uterus has good bactericidal properties. Washing the vagina only promotes the introduction of bacteria into the crushed tissue. But it is mandatory to prepare the external genitalia and use sterile underwear.

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).

^ MECHANISM OF HEMOSTASIS IN THE UTERUS.

1. 
   Myometrial retraction - the most important factor is the contractility of the uterus.
2. 
   Hemocoagulation factor - processes of thrombosis of blood vessels of the placental site (they do not apply to other organ systems). Provide thrombosis processes:

1. 
   plasma factors
2. 
   blood cells
3. 
   biologically active substances

1. 
   Tissue factors
2. 
   Vascular factors.

These assumptions are correct because violations occur when:

1. 
   antenatal fetal death (stillbirth) if the fetus is born more than 10 days after death, disseminated intravascular coagulation may develop. Therefore, in case of antenatal death, they strive to end the birth as quickly as possible.
2. 
   Amniotic fluid embolism (mortality rate 80%) also leads to disseminated intravascular coagulation.

Normal blood loss is no more than 400 ml, anything higher is pathology (no more than 0.5% of body weight).

Separation of the placenta occurs from the center (formation of a retroplacental hematoma) or from the edge, hence the clinical difference during the period:

1. 
   if the placenta separates from the center, the blood will be in the membranes and there will be no spotting before the birth of the placenta.
2. 
   If it separates from the edge, then when signs of placenta separation appear, bleeding appears.

^ GROUPS AT RISK FOR BLEEDING (IN GENERAL).

I. If we assume that muscle retraction is the main mechanism of hemostasis, then we can distinguish 3 risk groups:

1. 
   violation of uterine contractility before the onset of labor:

1. 
   abnormalities of the uterus
2. 
   uterine tumors (fibroids)
3. 
   if there were inflammatory diseases of the uterus (endometritis, metroendometritis).
4. 
   Dystrophic disorders.

1. 
   Women who have overstretched myometrium:

1. 
   large fruit
2. 
   polyhydramnios
3. 
   multiple births

1. 
   Women who have somatic and endocrine pathologies.

Women whose contractility of the uterus is impaired during childbirth.

1. 
   Childbirth complicated by labor anomalies (excessive labor, weakness of labor).
2. 
   With excessive use of antispasmodic drugs.
3. 
   Women with traumatic injuries (uterus, cervix, vagina).

III risk group. These are women who have disrupted processes of attachment and separation of the placenta and abnormalities in the location of the placenta:

1. 
   placenta previa complete and incomplete
2. 
   PONRP develops during childbirth
3. 
   firm placenta attachment and true placenta accreta
4. 
   retention of parts of the placenta in the uterine cavity
5. 
   spasm of the internal os with separated placenta.

That is, risk groups are women with extragenital pathology, with complications of pregnancy, with complications of childbirth.

^ BLEEDING IN THE FOLLOW-UP PERIOD.

Caused by disruption of the processes of separation of the placenta and discharge of the placenta.

There are 2 phases during the period:

1. 
   separation of the placenta
2. 
   discharge of placenta

1. 
   in women with weak labor
2. 
   with tight attachment and true increment

True accretion - villi penetrate the muscular lining of the uterus up to the serosa and sometimes cause uterine rupture. Occurs in 1/10,000 births. It can be complete or incomplete depending on the length.

If there is complete true accretion and complete tight attachment, then there will never be bleeding, that is, when the entire placental area adjoins or grows into the muscle wall.

With true partial accreta, part of the placenta separates and bleeding occurs in the afterbirth period.

Bleeding in the placenta can develop when parts of the placenta are retained, when part of the placenta is separated and released, but several lobules remain or a piece of the membrane remains and interferes with the contraction of the uterus.

^ Impaired discharge of placenta.

Violation when:

1. 
   hypotonicity of the uterus
2. 
   spasm of the internal pharynx

^ 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.

1. 
   Or physiologically (pushing)
2. 
   external techniques (Abuladze, Genter, Crede-Lazarevich) - these techniques can only separate the separated 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 - a sterile sleeve is put on the hand and the fingers are covered when inserted into the vagina; the 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 with sawing movements they reach the placental area, separate it from the wall and release the afterbirth.
4. 
   
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:

1. 
   estimate blood loss
2. 
   compensate for blood loss and continue to act as during normal childbirth

1. 
   If bleeding continues due to placenta accreta, attachment, etc. then this bleeding progresses into the early postpartum period.

1. 
   If attached tightly, 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.

^ 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 weakness of labor.
2. 
   Delivery of a large fetus.
3. 
   Polyhydramnios.
4. 
   Multiple births.

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

1. 
   injuries of the uterus, cervix, vagina
2. 
   blood diseases

Variants of hypotonic bleeding.

1. 
   Bleeding immediately and 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.

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 difficult to diagnose sometimes).
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).

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.
4. 
   Insert your hand into the vagina and then into the uterine cavity.
5. 
   Empty the uterine cavity of 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 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. 
   Inspect the soft birth canal and suture 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 for 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 occurs 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.

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

^ PREVENTION OF BLEEDING.

Bleeding can and should be predicted based on risk groups:

1. 
   extragenital pathology
2. 
   pregnancy complications
3. 
   gestosis (chronic stage of disseminated intravascular coagulation)
4. 
   multiparous
5. 
   large fetus, polyhydramnios, multiple births
6. 
   weakness of labor during childbirth

1. 
   blood platelet test
2. 
   blood coagulation potential
3. 
   skilled labor management

Administration of uterotonics depending on the risk group.

1. 
   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)
2. 
   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.
3. 
   In a high-risk group, a combination of intravenous drip administration of oxytocin + simultaneous administration of methylergometrine.

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.

^ LECTURE No. 17.

TOPIC: BIRTH INJURIES.

Uterine rupture.

Uterine rupture during pregnancy and childbirth is the most severe manifestation of obstetric trauma. Its frequency is 0.015-0.1% of the total number of births. The mortality rate for uterine rupture is high - 12.8-18.6%. This is associated with extensive trauma, massive blood loss, shock, purulent-septic complications, which always requires qualified surgical intervention, targeted resuscitation measures and long-term intensive care.

The classification of uterine ruptures, developed by L.S. Persianinov in 1964, has now been refined and modified by M.A. Repina, taking into account the features of modern obstetrics.

1. By pathogenesis.

Spontaneous uterine rupture: 1) with morphological changes in the myometrium; 2) with mechanical obstruction to the birth of the fetus; 3) with a combination of morphological changes in the myometrium and mechanical obstacles to the birth of the fetus.

Forced uterine rupture: 1) clean (during vaginal delivery operations, external trauma); 2) mixed (with different combinations of a violent factor, morphological changes in the myometrium, mechanical obstacles to the birth of a child). 2. According to the clinical course. Risk of uterine rupture. Threatening uterine rupture. Completed uterine rupture. 3. By the nature of the damage. Incomplete uterine rupture (not penetrating into the abdominal cavity).

Complete uterine rupture (penetrating into the abdominal cavity). 4. By localization.

Rupture in the lower segment of the uterus: 1) rupture of the anterior wall; 2) lateral tear; 3) rupture of the posterior wall; 4) separation of the uterus from the vaginal vault.

Rupture in the body of the uterus: 1), rupture of the anterior wall, 2) rupture of the posterior wall. Rupture in the fundus of the uterus.

The practical significance of the above classification dictates the need to identify a risk group for the occurrence of uterine rupture. It is formed:

Pregnant women with scars on the uterus after a cesarean section, conservative myomectomy, uterine perforation during an induced abortion;

Pregnant women with a burdened obstetric history (multiparous, had several abortions, complicated course of the post-abortion period);

Pregnant women and women in labor who are at risk due to a clinical discrepancy between the fetal head and the mother’s pelvis (large fetus, narrow pelvis, incorrect insertion of the fetal head, fetal hydrocephalus);

Pregnant women with multiple pregnancy, polyhydramnios, transverse position of the fetus;

Women in labor with labor anomalies and unreasonable use of labor-stimulating therapy.

Features of uterine ruptures at the present stage include a decrease in the frequency of spontaneous uterine ruptures due to mechanical reasons. Violent ruptures (severe trauma, illiterate obstetric interventions, inappropriate use of birth-stimulating drugs) are rare. However, the role of uterine ruptures caused by cicatricial changes in its wall has grown. This is due to an increase in the frequency of cesarean sections to 9-10% in our country and up to 20% abroad, a large number of abortions, often complicated by uterine perforation, in the inflammatory process of the uterus, as well as an increase in the number of conservative plastic surgeries for fibroids in young people women.

Etiology and pathogenesis. Structural changes in the uterus will be considered as a predisposing factor,

And a mechanical obstacle is a revealing factor. The clinical picture of uterine rupture depends on the relationship of these factors and the predominance of one or the other.

According to Bandl's theory, uterine rupture is a consequence of hyperextension of its lower segment, associated with the presence of a mechanical obstacle to the passage of the fetal head (narrowing of the pelvis, large fetus, hydrocephalus, incorrect insertion of the fetal head, incorrect position of the fetus, cicatricial changes in the cervix or vagina, exostoses tumors of the ovary or uterus fixed in the pelvis).

The histopathic nature of the ruptures is due to the inferiority of the myometrium due to scars on the uterus, infantilism, malformations, damage to the myometrium during abortion, and metroendometritis.

In recent years, new factors have been identified, called “biochemical trauma of the uterus.” This condition occurs during prolonged labor, discoordinated labor, when, due to disruption of energy metabolism and the accumulation of under-oxidized compounds, the muscle becomes flabby and easily tears.

Clinic and diagnostics. The clinical picture of uterine rupture will depend on the cause leading to the rupture, stage, location, and nature of the damage. The speed and severity of the development of hemorrhagic shock (the main cause of death of patients) is influenced by the background against which the uterine rupture occurred: concomitant chronic diseases of parenchymal organs, toxicosis of pregnant women, depletion of the physical and spiritual strength of the woman in labor, and the addition of infection.

Clinic for threatening uterine rupture.

The mechanical rupture of the uterus described by Bandle is called typical and is characterized by the following symptoms: the woman in labor is very restless, screams in pain, which hardly decreases between contractions, the face is hyperemic and expresses fear. Tachycardia, slightly elevated temperature, dry tongue. The contractions are violent, taking on the character of pushing. The uterus does not relax between contractions, is elongated, the contraction ring is located at the level of the navel, or above the uterus has an unusual hourglass shape, palpation

Tense, painful in the lower parts, round ligaments are sharply stretched. Parts of the fetus, as a rule, cannot be felt. Fetal heart rate is measured or absent. There is swelling of the external genitalia due to pinching of the anterior lip of the cervix, which, due to the inexperience of the doctor, can be regarded as incomplete dilatation. The birth tumor on the fetal head is pronounced, making it difficult to determine the nature of the insertion of the head.

The current widespread use of anesthesia during childbirth and antispasmodic drugs can lead to delayed diagnosis of impending uterine rupture, since the symptoms of the rupture become unclear. Therefore, the basis for the diagnosis of impending uterine rupture should be signs of disproportion between the fetus and the mother’s pelvis, risk factors for uterine incompetence.

Diagnosis of threatening uterine rupture of a histopathic nature in the presence of a scar on the uterus is greatly facilitated by knowledge of the fact of the operation and the condition of the scar based on anamnesis. Signs of a defective scar are as follows:

Caesarean section was performed less than 2 years before the actual pregnancy;

Postoperative course with fever;

Suppuration of the sutures of the anterior abdominal wall in the postoperative period;

Scar after corporal caesarean section;

The presence of abdominal pain and scanty bleeding long before childbirth, diagnosis is facilitated by ultrasound.

During childbirth, characteristic signs are: 1) pain in the area of ​​the postoperative scar, on the uterus or in the lower abdomen, persisting beyond the contraction; 2) soreness of the entire uterine scar or its sections, thinning, presence of niches; 3) the mother’s anxiety, which is not adequate to the strength of the contraction; 4) ineffective labor; 5) the appearance of unproductive attempts with a high-standing head.

Clinical manifestations of the threat of uterine rupture with other structural changes in the wall are similar to those with ruptures along the scar. In such cases, uterine rupture is preceded by weakness of labor, which is a functional reflection of morphological changes in the uterus, and labor stimulation (intravenous drip administration of oxytocin and the unreasonable prescription of labor stimulation are especially dangerous).

Clinic of completed uterine rupture.

With a typical uterine rupture, a “calm” occurs after a stormy clinical picture: contractions suddenly stop, pain subsides. Before our eyes, the shape of the abdomen and the contours of the uterus change (irregular shape), bloating of the intestines gradually develops, and the abdomen becomes painful, especially in the lower sections. When the uterus is completely ruptured and the fetus is expelled into the abdominal cavity, its parts are easily palpated, the fetus becomes mobile, and the fixed head moves upward. A contracted uterus can be felt next to the fetus. The fetal heartbeat disappears. Symptoms of shock and anemia as a result of bleeding increase.

In the pathogenesis of shock during uterine rupture, blood loss, pain and traumatic components are important. Bleeding can be external, internal or combined. With incomplete ruptures, a subperitoneal hematoma is formed, located on the side of the uterus, displacing it upward and in the opposite direction. In some cases, hematomas spread far upward, involving the perinephric area. In this case, the hematoma is palpated as a painful tumor of doughy consistency, with uneven contours merging with the walls of the pelvis.

Increased bleeding is associated with a hypotonic state of the uterus and the development of disseminated intravascular coagulation syndrome. Blood loss can immediately be very significant and lead to the rapid death of the patient. More often, blood loss and hemorrhagic shock increase slowly, since the source of bleeding is often small-caliber vessels feeding this area of ​​the uterus. Less commonly, the source of bleeding is the uterine artery or its branches.

Uterine rupture may occur at the end of labor, and its symptoms may be erased. The following symptoms will help to suspect a uterine rupture: bleeding during childbirth of unknown origin, signs of fetal hypoxia, deterioration of the mother's condition immediately after the birth of the child. In this case, a manual examination of the uterine cavity should be performed. In order to exclude uterine rupture, this operation must also be performed after fetal destruction operations, combined obstetric rotation of the fetus, after childbirth in a woman with a scar on the uterus. Clinical signs of a completed uterine rupture along the scar are as follows: 1) rapid increase in existing pain in the scar and soreness; 2) bloody discharge from the vagina; 3) the addition of pain and a feeling of heaviness in the epigastrium, nausea, vomiting 4) short-term fainting, slight intestinal paresis, vague symptoms of peritoneal irritation; 5) changes in the fetal heartbeat.

The clinical picture may not be burdened by shock and anemia if the rupture is limited to the area of ​​the old scar or may be erased due to the adhesive process in the scar area, with only minor pain in the lower abdomen.

Treatment of uterine rupture depends on the stage of the process (threatened or completed), but it is always immediate transection.

If there is a scar on the uterus, the tactics are the same - immediate abdominal surgery, since it is impossible to reliably distinguish between the clinic of a threatening rupture and a completed rupture. First, the contractile activity of the uterus is removed.

In case of uterine rupture of mechanical origin, medical tactics are somewhat different for threatening and completed uterine rupture. Thus, if there is a threat of uterine rupture, the doctor’s task is to prevent the onset of rupture, which is achieved in the following ways:

Immediate removal of contractile activity of the uterus. For this purpose, inhalation anesthesia with ftorotan is used, which must be quite deep (an overdose of ftorotan can provoke atonic uterine bleeding);

Urgent delivery by abdominal cesarean section or by fetal-destroying surgery (if the fetus is dead or its viability is questionable) if conditions exist for its implementation.

Treatment of a completed uterine rupture consists of the simultaneous implementation of the following measures: 1) surgical intervention, 2) adequate anesthesia, 3) infusion-transfusion therapy, adequate blood loss and the severity of the patient’s condition, 4) correction of hemocoagulation disorders.

Surgery is performed immediately after diagnosis using endotracheal anesthesia with mechanical ventilation. Purpose of surgical treatment:

a) elimination of the source of bleeding, b) restoration of anatomical relationships disturbed by injury, c) elimination of the entrance gate for the introduction of infection into the abdominal cavity and retroperitoneal space. Only a lower median laparotomy is performed, the fetus, placenta and blood and amniotic fluid are removed from the abdominal cavity using electric suction, the nature of the damage is determined and hemostasis is performed.

The scope of the operation is strictly individual and is selected depending on the severity of the patient’s condition, the location of the damage, the size of the damage, the presence of infection, etc. In the absence of contraindications and the presence of appropriate conditions, one should strive to preserve menstrual and reproductive function.

The minimum scope of the operation is suturing the rupture. It can be performed under the following conditions: no signs of infection, a short anhydrous interval, the presence of a fresh linear rupture (especially along an old scar), and preservation of uterine contractility. First, the edges of the wound are refreshed.

Expanding the scope of the operation to supravaginal amputation of the uterus or its extirpation is necessary in the presence of an extensive wound with torn, crushed edges, a complex rupture, significant hemorrhage into the uterine wall,

The maximum volume of surgery - hysterectomy - is selected in cases of: gross damage to the lower segment, transition of the rupture to the cervix, separation of the uterus from the vaginal vault, peritonitis. In addition to hysterectomy, drainage of the retroperitoneal space is carried out in case of extensive hematomas reaching the perinephric region, and the abdominal cavity after its thorough sanitation in case of peritonitis.

During all operations for uterine rupture, it is advisable to leave nipple drains in the abdominal cavity for the administration of antibiotics.

Adequate anesthetic care must be provided at all stages: during transportation of the patient, during manual examination of the uterine cavity if a uterine rupture is suspected - and continue when the diagnosis of uterine rupture is confirmed. When changing combined general anesthesia.

Infusion-transfusion therapy is adequate to the blood loss and the severity of the patient's condition. Carrying out correction of hemocoagulation disorders.

Cervical ruptures (CC).

The incidence of cervical cancer is 25% among all complications of childbirth. Cervical cancer requires suturing, since this can be followed by: immediately after a rupture - bleeding (sometimes profuse), and in the long term - cervicitis, spread of inflammation to the internal genitalia, formation of ectropion of the cervix, erosion and other precancerous diseases.

ETIOLOGY AND PATHOGENESIS. Cervical cancer can be spontaneous during normal spontaneous labor and violent during forced or operative delivery in case of incomplete dilatation of the uterine pharynx.

The risk group includes pregnant women and women in labor if they have:

1. 
   large fruit,
2. 
   extensor insertions of the fetal head,
3. 
   post-term pregnancy,
4. 
   wide shoulder girdle and breech presentation of the fetus;
5. 
   during rapid labor,
6. 
   cervical dystocia;
7. 
   morphological changes in the tissues of the cervix in cases of prolonged pressing by the fetal head with a clinically narrow pelvis
8. 
   infantilism
9. 
   in elderly primiparas
10. 
    in inflammatory processes
11. 
    scar changes after surgical interventions on the cervix (diathermocoagulation, diathermoexcision, surgical amputation of the cervix, plastic surgery for fistulas, old ruptures)
12. 
    placenta previa.

CLASSIFICATION.

There are 3 degrees of cervical cancer on one or both sides:

1st degree - a rupture up to 2 cm long, 2nd degree - a rupture more than 2 cm long and not reaching 1 cm from the vaginal vault, 3rd degree - a rupture reaching the vault or involving the vault.

In most cases, cervical cancer is linear in shape, corresponding to the longitudinal axis, and in location it is lateral, one- or two-sided.

^ CLINIC AND DIAGNOSTICS.

The main symptom of cervical cancer is bleeding from the birth canal of varying intensity with a well-contracted uterus. The final diagnosis is established after examining the cervix in a speculum: after completion of the succession period, subject to the rules of asepsis and antisepsis, without prior anesthesia, a sequential examination of the cervix is ​​performed clockwise. Inspection is carried out by alternately applying hemorrhoidal or bullet forceps to the edges of the pharynx, stretching the edges of the pharynx with them.

It consists of suturing grade 1-3 tears with separate catgut sutures (catgut No. 3-4), without involving the mucous membrane of the cervical canal. The first suture is placed above the apex of the tear to ligate the bleeding vessel. Next, the seams are placed from top to bottom at a distance of 1.5 - 2 cm, the injection and puncture are done at a distance of 1 - 1.5 cm from the edge of the tear.

Prevention of cervical cancer consists of rational management of labor (use of antispasmodics, regulation of labor) and competent surgical delivery.

^ LECTURE No. 18. PART 2.

CROTCH RUPTURE.

This is the most common type of maternal birth trauma and complications of childbirth, more often found in first-time mothers. Consequences of perineal rupture:

1. 
   bleeding
2. 
   inflammation of the vagina, cervix and generalization of infection
3. 
   prolapse and prolapse of the cervix and vagina
4. 
   incontinence of gases and feces (with a 3rd degree rupture)
5. 
   sexual dysfunction

The causes of perineal tears are:

1. 
   anatomical and functional state of the perineum
2. 
   tall with well muscled crotch
3. 
   inflexible, poorly extensible in elderly primigravidas
4. 
   scar changes after trauma in previous births and after plastic surgery
5. 
   swollen perineum
6. 
   features of the bony pelvis (narrow pubic arch, small pelvic inclination angle);
7. 
   improper management of labor (rapid and rapid labor, operative delivery, incorrect obstetric care during the removal of the fetal head and shoulders).

The RP mechanism (sequence of changes) is as follows.

1. 
   As a result of compression of the venous plexus, the outflow of blood is disrupted;
2. 
   cyanosis of the skin of the perineum (venous stagnation), swelling of the skin (sweating of the liquid part of the blood from the vessels into the tissue) appears; a peculiar shine and pallor of the skin (compression of the arteries);
3. 
   decreased tissue strength due to metabolic disturbances; rupture of perineal tissue.

The sequence of tissue damage during spontaneous ruptures (from outside to inside):

posterior commissure, skin, perineal muscles, vaginal wall. When obstetric forceps are applied, the rupture begins from the vaginal side, but the skin may remain intact.

CLASSIFICATION.

There are spontaneous and violent ruptures, and according to degree - 3 degrees of perineal rupture:

1. 
   1st degree - rupture of the posterior commissure, part of the posterior vaginal wall and perineal skin.
2. 
   2nd degree - the pelvic floor muscles (levators) are additionally involved in the rupture.
3. 
   3rd degree - rupture of the sphincter (sphincter) of the anus, and sometimes part of the anterior wall of the rectum.

^ CLINIC AND DIAGNOSTICS.

Any rupture of the perineum is accompanied by bleeding. Diagnosed by examining the soft birth canal. If a third degree perineal rupture is suspected, it is necessary to insert a finger into the rectum. An intact sphincter creates resistance when a finger is inserted into the rectum. A rupture of the intestinal wall is easily determined by the specific appearance of the inverted intestinal mucosa.

If there is significant bleeding from the perineal tissue, a clamp is applied to the bleeding tissue without waiting for the birth of the placenta.

TREATMENT. Treatment of all ruptures consists of suturing them after the birth of the placenta.

^ SEQUENCE OF URGENT ACTIONS.

1. 
   Treatment of external genitalia, obstetrician's hands.
2. 
   Anesthesia with general anesthetic drugs (1 ml of 2% promedol solution), local infiltration anesthesia with 0.25 - 0.5% novocaine solution or 1% trimecaine solution, 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.
3. 
   Stitching of a perineal rupture when the wound surface is exposed with mirrors or fingers of the left hand. Sutures are placed on the upper edge of the tear in the vaginal wall, then sequentially from top to bottom, knotted catgut sutures (No. 2-4) are applied to the vaginal wall, spaced 1-1.5 cm apart until a posterior adhesion is formed. The injection and puncture of the needle are carried out at a distance of 1 -1.5 cm from the edge.
4. 
   Application of knotted silk (lavsan, letilan) sutures to the skin of the perineum - with 1st degree of rupture.
5. 
   In case of 2nd degree rupture, before (or as) suturing the posterior wall of the vagina, the edges of the torn pelvic floor muscles are sewn together with knotted catgut sutures, then silk sutures are placed on the skin of the perineum. When applying sutures, the underlying tissues are picked up so as not to leave pockets under the suture where blood will accumulate. Individual heavily bleeding vessels are tied with catgut under a clamp. Deflated, necrotic tissues are first cut off with scissors.
6. 
   At the end of the operation, the suture line is dried with a gauze swab and lubricated with a 3% solution of iodine tincture.
7. 
   When suturing a central perineal rupture, the remaining tissue in the area of ​​the posterior commissure is first cut with scissors, that is, it is first turned into a 2nd degree perineal rupture, and then the wound is sutured layer-by-layer in 2-3 layers in the usual way.

^ SEQUENCE OF MEASURES FOR 3 DEGREE PERINEAL RUPTURE.

1. 
   Preparation of the surgical field and the surgeon’s hands according to the rules adopted for obstetric operations.
2. 
   General anesthesia.
3. 
   Disinfection of the exposed area of ​​the intestinal mucosa (with alcohol or chlogexidine solution after removing feces with a gauze swab).
4. 
   Suturing 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 are tightened and cut off on days 9-10 after surgery).
5. 
   Change of gloves and tools.
6. 
   Connection of the separated ends of the sphincter using a knotted suture.
7. 
   The operation continues as for a 2nd degree tear.

Prevention of perineal ruptures consists of rational management of labor, qualified delivery, and timely perineotomy in case of threat of perineal ruptures.

^ UTERUS EVERION.

The frequency of this complication is 1 in 45 - 450 thousand births. The essence of uterine inversion is that the fundus of the uterus from the side of the abdominal covering is pressed into its cavity more and more, but complete inversion of the uterus will not occur. 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.

CLASSIFICATION.

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 more common, with 3/4 of them occurring in the afterbirth and 1/4 in the first day of the postpartum period. According to the etiological factor, uterine inversion is divided into forced and spontaneous, although at the end of the 19th century it was proven that uterine inversion is always spontaneous and is associated with uterine pathology. Violent is understood as an inversion that occurs when the umbilical cord is pulled or the Lazarevich-Crede maneuver is roughly applied - with a relaxed uterus.

ETIOPATHOGENESIS.

The main reason is relaxation of all parts of the uterus, loss of elasticity of its myometrium. In this condition, even an increase in intra-abdominal pressure during pushing, coughing, or sneezing can lead to inversion of the uterus. The predisposing factor is the fundal attachment of the placenta, as well as large submucosal fibroids arising from the fundus of the uterus.

CLINIC. Clinic of acute uterine inversion: sudden severe pain in the lower abdomen, shock, uterine bleeding. It can begin before uterine inversion due to atony and continues after its occurrence.

Complete inversion of the uterus may or may not be accompanied by vaginal inversion. In the first case, the uterus and placenta are located outside the vulva. In the second, the uterus is determined in the vagina when examined in the speculum. In both cases, upon palpation there is no uterus above the womb.

With incomplete uterine reversal, the general condition does not change so quickly and severely. For differential diagnosis with other complications (for example, uterine rupture), a bimanual examination is performed, which determines the unusually low location of the upper edge of the uterus for the placenta and early postpartum period and the presence of a funnel-shaped depression at the site of the uterine fundus.

The prognosis if emergency assistance is not provided is the patient’s death from shock and blood loss, and in the following days from infection (peritonitis, sepsis). Spontaneous correction of inversion does not occur.

Reduction of the uterus under anesthesia with preliminary manual removal of the placenta.

^ SEQUENCE OF EMERGENCY MEASURES WHEN REPOSITION OF THE UTERUS BY MANUAL TECHNIQUES:

1. 
   administer general anesthesia and antishock therapy
2. 
   disinfect the genitals and hands of the surgeon
3. 
   inject subcutaneously 1 ml of 0.1% atropine to prevent cervical spasm.
4. 
   Empty your bladder
5. 
   grab the inverted uterus with your right hand so that the palm is at the bottom of the uterus, and the ends of the fingers are near the cervix, resting on the cervical-uterine ring fold.
6. 
   Adjust the uterus; pressing on the uterus with your whole hand, first straighten the inverted vagina 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, moving towards the screwed-in uterus. With recently occurring uterine inversion, its reduction is performed without much difficulty. Massage of the uterus with a fist should not be performed, since against the background of shock and blood loss, squeezing thromboplastic substances from the uterus into the general bloodstream can lead to impaired blood clotting and continued uterine bleeding;
7. 
   introduce contractile agents (simultaneously oxytocin, methylergometrine), continuing to administer them for several days.

PREVENTION.

Prevention of uterine inversion consists of proper management of the placenta, releasing the placenta externally if there are signs of placental separation without pulling on the umbilical cord.

^ HEMATOMA OF THE VULVA AND VAGINA.

Localization - below and above the main pelvic floor muscle (mm. Levator ani) 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 paravaginal tissue retroperitoneally up to the perinephric region.

Etiopathogenesis. The main cause of hematomas is changes in the vascular wall. Occurs with varicose veins of the external genitalia and pelvis, hypovitaminosis C, hypertension, chronic glomerulonephritis, gestosis in pregnant women. Against this background, a hematoma is formed not only as a result of complicated labor (long or rapid, with a narrow pelvis, application of obstetric forceps, extraction by the pelvic end), but also during spontaneous uncomplicated labor.

Hematomas are more often formed on the left, which is associated with the asymmetry of the development of the venous system and the more frequent formation of 1 position with the longitudinal position of the fetus.

Clinic and diagnostics. The size of hematomas can vary, and the severity of clinical manifestations depends on this. Symptoms of a hematoma of significant size: pain and a feeling of pressure at the site of localization (tenesmus due to compression of the rectum), as well as 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, deforming it. On palpation, the hematoma fluctuates. Diagnosis of vaginal hematoma is more difficult. It is necessary to use vaginal examination, speculum examination and rectal examination to determine the size and topography of the hematoma. If the hematoma spreads to the parametrial tissue vaginally, a vaginal examination reveals the uterus pushed to the side and between it and the pelvic wall an immobile and painful tumor-like formation. In this situation, it is difficult to differentiate a hematoma from an incomplete uterine rupture in the lower segment.

Treatment of hematoma - conservative or surgical; it depends on its location, size and clinical course. Small, non-progressive hematomas of the vagina and vulva, which gradually resolve, are treated conservatively. Emergency surgical treatment is required if the hematoma rapidly increases in size with signs of anemia; with a hematoma that produces profuse external bleeding; with a large hematoma that occurred before the onset of labor and in the first period. The latter will create an obstacle to the birth of a child and contribute to additional trauma and crushing of tissues.

The operation is performed under general anesthesia and consists of the following stages: incision of tissue above the tumor; removing blood clots; ligation of bleeding vessels or stitching with 8-shaped catgut sutures; closing and draining the hematoma cavity. A hematoma of the broad uterine ligament requires transection, opening of the peritoneum between the round ligament of the uterus and the infundibulopelvic ligament, removal of the blood tumor, and ligation of damaged vessels. The operation is limited to this unless the uterus ruptures.

Prevention of vaginal hematomas consists of the treatment of diseases that affect the condition of the vascular wall, as well as the qualified management of labor and delivery operations.

^ OBSTETRIC FISTULAS.

This concept includes genitourinary and enterogenital fistulas. They arise as a result of severe birth trauma and lead to permanent loss of ability to work, disorders of a woman’s sexual, menstrual and generative functions. Fistulas contribute to the development of ascending infection of the genital organs and urinary system.

Classification. Based on the nature of their occurrence, fistulas are divided into spontaneous and violent. According to localization, vesicovaginal, cervicovaginal, urethrovaginal, ureterovaginal, and enterovaginal fistulas are distinguished.

Etiology and pathogenesis. Spontaneous fistulas are more common, and according to localization - vesicovaginal. The formation of fistulas is associated with necrosis of a section of the walls of the bladder or rectum when blood circulation in them is impaired as a result of prolonged (more than 3-4 hours) compression of tissues by the fetal head. This is observed with a functionally narrow pelvis or with severe weakness of labor. Fistulas of a violent nature are rarely formed and occur during childbirth operations (fetal destruction operations, obstetric forceps, cesarean section). Rectovaginal fistulas can form as a result of unsuccessful suturing of a 3rd degree perineal tear.

^ CLINIC AND DIAGNOSTICS.

With genitourinary fistulas, urine leaks from the vagina of varying intensity, and with entero-genital fistulas, gas and feces are released. 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 6-9 days after birth. The final diagnosis is made by examining the vagina in a speculum, as well as using urological and radiological diagnostic methods.

TREATMENT.

Treatment of fistulas is only surgical. If adjacent organs are injured by instruments and there is no 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.

PREVENTION.

1. 
   Identification of a risk group for clinical discrepancy between the fetal head and the mother’s pelvis, early hospitalization of these pregnant women in the antenatal department to resolve the issue of a planned caesarean section.
2. 
   Rational management of childbirth
3. 
   timely diagnosis and treatment of clinical discrepancy between the fetal head and the mother’s pelvis, treatment of weakness of labor, preventing the fetal head from standing in one plane for more than 2-3 hours,
4. 
   monitoring bladder and bowel function
5. 
   competent performance of delivery operations

^ LECTURE No. 20.

Title Bleeding in the afterbirth and early postpartum period
_Author
_Keywords

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).