Gynecology

Sequential period: signs and ways of doing

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Among the many signs of separation of the placenta there are some of the most reliable that should be used.

Sign of Schroeder consists in the fact that after the separation of the placenta the body of the uterus is reduced, it becomes more dense, its contours are clearer, well visible by the eye. The uterus becomes narrower and flatter. Due to the fact that the placenta moves to the lower segment of the uterus or into the vagina, the bottom of the uterus rises and is 4-5 cm higher than the navel, slightly deflected to the right (Fig. 27). At the same time, a mild elevation appears over the bosom.


27. Sign of Schroeder.
I - the height of standing of the uterus after the birth of the baby, II - the height of the standing of the uterus after separation of the placenta, III - the height of the standing of the bottom of the uterus after the birth of the afterbirth.

Sign of Alfeld. After the detached placenta has descended into the lower segment of the uterus or into the vagina, the outer segment of the umbilical cord is extended. To observe this feature, it is necessary immediately after the birth of a baby to put a Kocher clamp or a ligature on the umbilical cord at the level of the genital slit. After separation of the placenta, the clamp is located at a distance of 10-12 cm from the confused gap.

Sign Dovzhenko checked on the deep breath of a woman. During deep inhalation, the diaphragm descends, and with it the uterus descends somewhat. When exhaling, on the contrary, the diaphragm and uterus are shifted upwards. If the placenta is not separated from the wall of the uterus, it moves along with the uterus, and the umbilical cord moves with the placenta, dropping when inhaling and drawing in as you exhale. After complete separation of the placenta, uterine movements during deep breathing of the mother are not transmitted to the umbilical cord.

Sign of Klein. It is necessary to ask the woman to give birth. In this case, the umbilical cord extends beyond the genital slit. If, after the termination of the attempts, the umbilical cord does not retract, then the placenta is separated.

Sign of Strassmann It is one of the most reliable and is verified as follows: when standing to the side of a woman in labor, it is necessary to take the umbilical cord above the superimposed clamp with one hand and slightly squeeze it. The second hand produces light tapping on the uterus in various parts of it. If the placenta is still connected to the wall of the uterus, then the beating of the uterus in the blood filling the intervillous spaces is transmitted to the contents of the capillaries of the villi, and from them to the blood filling the vein of the umbilical cord. The hand holding the umbilical cord, will feel at the same time a light push - fluctuation. When the placenta has separated, there is no fluctuation.

Sign Chukalov - Kyustner. If you press the edge of the palm on the anterior abdominal wall in the suprapubic area, then with the unseparated placenta the umbilical cord retracts into the vagina. When the placenta is separated, the umbilical cord does not retract (Fig. 28).


28. Sign of Chukalov-Kyustner.
a - the umbilical cord retracts - the placenta has not separated, b - the umbilical cord does not retract - the placenta has separated, 1 - the wall of the uterus, 2 - the placenta, 3 - the umbilical cord.

None of the listed signs is absolutely reliable, therefore, to diagnose the separation of the placenta, it is necessary to use a set of signs.

Methods for manual separation of the placenta in the postpartum period of labor

When a positive result of checking the given signs is found, the woman is offered to push, and the afterbirth separates on her own. If the separation of the placenta and the birth of the placenta themselves do not occur, then resort to its selection by hand. There are several ways of manual separation of the placenta.

The way of doing the follow-up period of labor according to Ambuladze.

It should be done after emptying the bladder. Perform the abdominal wall grip with both hands in the longitudinal fold, so that both rectus muscles are tightly covered with fingers. After that, the woman in labor is offered to get tighter, as a rule, the afterbirth is born easily, which is due to the elimination of divergence of the rectus abdominis muscles and a significant decrease in the volume of the abdominal cavity.

The way of conducting the follow-up period of the Creda – Lazarevich birth.

It is applied after the absence of effect from the application of the previous method of separation of the afterbirth. In order for the implementation of this method to be correct, you must follow a number of rules.

  • First - it is necessary to empty the bladder, which, as a rule, is always done immediately after the birth of the fetus.
  • Secondly, the uterus rejected to the right is shifted to the median line.
  • Third, it is necessary to perform a circular massage of the uterine floor in order to cause its reduction. This is necessary due to the fact that it is impossible to exert pressure on the relaxed uterus, since this can lead to its inversion.
  • Fourth, the girth of the uterus is performed in such a way that the thumb lies on the front surface of the uterus and the palm is located on the bottom of the uterus, while four fingers are on the back surface of the uterus.
  • The fifth is to perform simultaneous pressure on the uterus with the entire brush in two mutually intersecting directions (fingers from front to back and palm from top to bottom towards the pubis), thereby seeking the birth of the afterbirth. After the release of all the afterbirth, the pressure on the uterus ceases, and it is necessary to ensure that all the membranes completely come out of the uterus.

Methods for complete selection of shells in the sequence

One of the methods for achieving a complete separation of the shells during a sequential period was suggested by Jacobs. According to his method, it is necessary, having taken the placenta in hands, to rotate it clockwise, as a result of which the shells collapse into a cord and come out unbroken.

Another method suggested by Genter: after the birth of the placenta, the woman must, leaning on the feet, raise the pelvis, while the placenta hangs down and its weight contributes to the detachment and excretion of fetal membranes.

The position of the doctor on the side of the woman in labor, facing her legs. The uterus, as in the first method, is brought to the middle position. Hands doctor squeezes into fists and their back surface (main phalanges) lays on the bottom of the uterus in the area of ​​the pipe corners. Next is the immediate squeezing of the afterbirth. The pressure exerted on the uterus is weak at first, and then gradually increases, and it is directed in the direction downwards and inwards. In this case, the afterbirth should be born from the genital slit. This method is more traumatic, and it must be carried out with great care.

Ways to accelerate the follow-up period

Independent detachment of the afterbirth in the afterbirth wait no more than 30 minutes, despite the absence of bleeding and the good condition of the woman in labor. Further delay can lead to the development of complications and the loss of a large amount of blood, so it is more expedient to resort to manual separation of the placenta.

A follow-up period is also actively conducted with the development of bleeding, if blood loss has reached 250–300 ml, and there are no signs of separation of the placenta. Active measures (manual separation of the placenta) in the afterbirth period are also necessary in case of a small blood loss, but due to the presence of a pronounced deterioration of the parturient woman (a fall or increase in blood pressure, etc.).

With a normally flowing period, attempts to speed up the expulsion of the afterbirth by massaging the uterus, pulling on the umbilical cord are unacceptable. This violates the physiological process of placental detachment from the uterine wall, changes the rhythm of its reduction and only contributes to increased bleeding.

Examination of the placenta in the postpartum period

After birth, the doctor carefully examines. Its maternal surface spread on a smooth surface and reveal the presence or absence of damage or violation of the integrity of tissues. The surface of the placenta should be smooth, covered with a thin layer of decidual membrane and have a grayish-blue color.

Pay special attention to the edges of the placenta, as the pieces of tissue often come off in the peripheral parts of the placenta. It should be noted the presence or absence of changes in the tissue of the afterbirth - calcification, areas of fatty rebirth, old blood clots. Having ascertained the integrity of the placenta, it is necessary to trace whether its vessels are moving away from the edges in the afterbirth into the membranes.

If a vessel is broken in the membranes, it can be concluded that there is an additional lobe remaining in the uterine cavity. This pathology is an indication for immediate manual examination of the uterine cavity, which removes the delayed lobe of the placenta.

After inspecting the placenta, shells are no less carefully inspected. Determine the presence and location of the gap, as well as find out whether all the shells were born. The regularity was determined that the closer to the edge of the placenta there was a rupture of the membranes, the lower it was located in the uterine cavity. Manual examination is necessary when there is a shortage of a large number of membranes, since they must be removed from the uterus. If the missing shells are small and there is no bleeding in the afterbirth period, they, as a rule, are not artificially removed. They themselves stand out in the first days of the postpartum period.

In the end, after researching the placenta, it is weighed and its dimensions are measured. This data is recorded in the history of childbirth.

Ways to isolate the separated afterbirth

If the separated placenta is not born, then use special techniques to accelerate its release. First, they increase the rate of oxytocin injection and organize the excretion of the afterbirth by external methods. After the bladder is emptied, the woman in labor is offered to have a rest, while in most cases after delivery the placenta comes out. If this does not help, use the Abuladze method, in which the uterus is gently massaged, stimulating its contractions. After that, the pregnant women take the stomach with both hands in a longitudinal crease and offer to tighten, after which the afterbirth should be born.

Manual selection and separation of the afterbirth

Manual separation of the placenta is carried out with the ineffectiveness of external methods or suspected residues of the placenta in the uterus after childbirth. Indications for manual separation of the placenta is bleeding in the third stage of labor with no signs of separation of the placenta. The second indication is the absence of separation of the placenta for more than 30 minutes with the ineffectiveness of external methods of separation of the placenta.

Manual separation of the placenta

The left hand moves the birth canal, and the right hand is introduced into the uterine cavity, and, starting from the left uterine rib, the placenta is separated by sawing movements. The obstetrician must hold the bottom of the uterus with his left hand. Manual examination of the uterus is also carried out with the separated afterbirth with identified defects, with bleeding in the third stage of labor.

After reading it is obvious that, despite the short duration of the third period of labor, the doctor should not relax. It is very important to carefully examine the excreted afterbirth and ensure its integrity. If parts of the placenta in the uterus remain after delivery, this can lead to bleeding and inflammatory complications in the postpartum period.

12. Determination of the sign of separation of the afterbirth

CONDUCT OF THE III (LAST) PERIOD OF CHILDBIRTH

OBJECTIVE: To prevent pathological blood loss.

After giving birth, remove the urine with a catheter, separate the baby from the mother. Place the mother end of the umbilical cord in a clean tray for the afterbirth.

The third period of labor is active and lasts up to 20 minutes (on average 5-10 minutes). A midwife observes the condition of the woman in labor, signs of separation of the afterbirth and discharge from the genital tract.

SIGNS OF PLACENTA DEPARTMENT:

Sign of Schroeder - changing the shape and height of the bottom of the uterus. After the birth of the fetus, the uterus is rounded, the bottom is at the level of the navel after the placenta is removed, the uterus is stretched out in length, the bottom rises above the navel, and deviates to the right from the middle line.

Sign of Alfeld- lengthening of the outer segment of the umbilical cord. After separation of the placenta from the walls of the uterus, the placenta descends into the lower segment of the uterus, which leads to lengthening of the external segment of the umbilical cord. The clip placed on the umbilical cord at the level of the genital slit is lowered by 10-12 cm.

The appearance of protrusion over the symphysis- when the separated placenta descends into the thin-walled lower segment of the uterus, the anterior wall along with the abdominal wall rises and a protrusion forms above the symphysis.

Sign Dovzhenko- retraction and lowering of the umbilical cord during deep breathing indicates that the placenta is not separated, and vice versa, the absence of umbilical cord retraction upon entry indicates the separation of the placenta.

Sign of Kyustner - Chukalov - when pressing the edge of the palm on the uterus above the pubic joint, the umbilical cord does not retract into the vagina.

2-3 signs are enough to establish the separation of the placenta.

If the placenta is separated, a woman in labor is suggested to be squeezed and the latter is born, and with ineffectiveness, attempts are made to isolate the separated placenta. After the expulsion of the afterbirth, the uterus is dense, rounded, its bottom is 2 transverse fingers below the navel.

Expulsion of the afterbirth - the final stage of physiological childbirth. On how quickly and “qualitatively” the delivery of the placenta and membranes will take place, depends on the health of the woman and the need for cleaning after childbirth.

Usually, the afterbirth is separated and born independently within 30 minutes after the birth of a baby. Sometimes this process takes up to 1-2 hours. In this case, the obstetrician determines the signs of separation of the placenta.

The most important signs of the separation of the afterbirth are:

Sign of Schroeder. After giving birth, the uterus becomes round and is located in the center of the abdomen, and its bottom is at the level of the navel. After separation of the placenta, the uterus is stretched and narrowed, its bottom is defined above the navel, often it deviates to the right.

Sign Dovzhenko.If aplacentaseparated, then with a deep breath, the umbilical cord does not retract into the vagina.

Sign of Alfeld.Separated, the placenta descends into the lower part of the uterus or into the vagina. In this case, the clip applied to the umbilical cord is lowered by 10-12 cm.

Sign of Klein.The woman is straining. The placenta is separated from the wall of the uterus, if after the end of the attempt, the protruding end of the umbilical cord does not retract into the vagina.

Sign of Kyustner-Chukalov.The edge of the palm pressure on the uterus above the pubis, if at the same time the protruding end of the umbilical cord is not drawn into the birth canal, the placenta is separated.

Sign of Mikulich-Radetsky.Separated from the wall of the uterus, the afterbirth descends into the birth canal, at this moment there may be a desire for a parrot.

Sign of HohenbichlerIf the placenta is not separated, with contractions of the uterus, the umbilical cord protruding from the vagina can rotate around its axis, since the umbilical vein is filled with blood.

The placenta is diagnosed according to 2-3 signs. The signs of Alfeld, Schroeder and Kyustner-Chukalov are considered the most reliable. If the afterbirth is separated, the woman in labor is offered to be pulled. As a rule, this is enough for the birth of the placenta and fetal membranes.

When delaying the afterbirth, the absence of signs of its separation, with external and internal bleeding, manual separation of the afterbirth is carried out.

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