Manual removal of the placenta: methods and techniques for performing
The placenta is an organ that allows the baby to be carried in the womb. It supplies the fruit with useful substances, protects it from the internal environment of the mother's body, produces hormones necessary for maintaining pregnancy and many other functions that we can only guess about.
Formation of the placenta
The formation of the placenta begins with the moment when the fetal egg is attached to the wall of the uterus. Endometrium fuses with a fertilized egg, tightly fixing it to the wall of the uterus. In the place of contact of the zygote and mucous with time, the placenta grows. The so-called placentation begins already with the third week of pregnancy. Until the sixth week, the embryonic membrane is called chorion.
Until the twelfth week, the placenta does not have a clear histological and anatomical structure, but after, until the middle of the third trimester, it looks like a disc attached to the wall of the uterus. On the outside of it, the umbilical cord departs to the baby, and the inner side is a surface with villi that swim in the maternal blood.
Functions of the placenta
A child's place forms the connection between the fetus and the mother's body through the exchange of blood. This is called the hematoplacental barrier. Morphologically it is a young vessel with a thin wall, which form small villi on the entire surface of the placenta. They come in contact with lacunae located in the wall of the uterus, and between them circulates blood. This mechanism provides all the functions of the body:
- Gas exchange. Oxygen with a current of blood of the mother gets to the fetus, and carbon dioxide is transported back.
- Power and selection. It is through the placenta that the child receives all the substances necessary for growth and development: water, vitamins, minerals, electrolytes. And after the fetal body metabolizes them into urea, creatinine and other compounds, the placenta recovers everything.
- Hormonal function. The placenta secretes hormones that contribute to the preservation of pregnancy: progesterone, chorionic gonadotropin, prolactin. In the early stages, this role takes on a yellow body located in the ovary.
- Protection. The hematoplacental barrier does not allow antigens from the mother's blood to enter the blood of the child, in addition, the placenta does not miss many medications, own immune cells and circulating immune complexes. However, it is permeable to narcotic substances, alcohol, nicotine and viruses.
The degree of maturation of the placenta
The degree of maturation of the placenta depends on the gestational age of the woman. This organ grows with the fetus and dies after its birth. There are four degrees of maturity of the placenta:
- Zero - in the normal course of pregnancy lasts up to seven lunar months. It is relatively thin, constantly increasing and forming new lacunas.
- The first one corresponds to the eighth gestational month. The growth of the placenta stops, it becomes thicker. This is one of the critical periods in the life of the placenta, and even a minor intervention can provoke detachment.
- The second - lasts until the end of pregnancy. The placenta is already beginning to age, after nine months of hard work, she is ready to leave the uterus after the baby.
- Third - may be observed from the thirty-seventh week of gestation inclusive. It is the natural aging of the organ that performed its function.
Attaching the placenta
The placenta is most often located on the posterior wall of the uterus or passes to the side wall. But to find out this definitively it is possible, only when two thirds of pregnancy is already behind. This is due to the fact that the uterus increases in size and changes its shape, and the placenta moves along with it.
Usually, during the current ultrasound examination, the doctor notes the location of the placenta and the height of its attachment to the uterine throat. Normally, the placenta on the back wall is high. At least seven centimeters should be between the inner throat and the edge of the placenta to the third trimester. Sometimes she even crawls to the bottom of the uterus. Although experts believe that this arrangement is also not a guarantee of successful delivery. If this figure is lower, then obstetricians-gynecologists say that the placenta is low. If there are placental tissues in the throat area, then this is evidence of her presentation.
There are three types of presentation:
- Complete when the internal pharynx is blocked by the placenta. So in case of its premature detachment there will be massive bleeding, which will lead to the death of the fetus.
- Partial presentation means that the pharynx is blocked by no more than a third.
- A marginal presentation is established when the edge of the placenta reaches the pharynx, but does not go beyond it. This is the most favorable outcome of events.
Periods of delivery
Normal physiological birth begins at the time of occurrence of regular fights with equal intervals between them. In obstetrics distinguish three periods of childbirth.
The first period is the opening of the cervix. The ancestral ways should be prepared for the fact that the fetus will advance through them. They should expand, become more elastic and softer. At the beginning of the first period, the opening of the cervix is only two centimeters, or one finger of the obstetrician, and by the end it must reach ten or even twelve centimeters and let go of a whole fist. Only in this case the head of the child can be born. Most often at the end of the period of opening, there is a discharge of amniotic fluid. In all, the first stage lasts from nine to twelve hours.
The second period is called the expulsion of the fetus. Contractions are replaced by attempts, the bottom of the uterus shrinks forcefully and pushes out the child. The fetus moves through the birth canal, turning according to the anatomical features of the pelvis. Depending on the presentation, the child may appear with a head or booty, but the obstetrician must be able to help him be born in any position.
The third period is called consecutive and begins with the birth of the child, and ends with the appearance of the afterbirth. Normally, it lasts half an hour, and after fifteen minutes the placenta separates from the uterus wall and is pushed out of the womb with the last attempt.
Post separation delay
The causes of delayed aftereffect in the uterine cavity may be its hypotension, placenta increment, anomalies of the structure or location of the placenta, adhesion of the placenta to the uterine wall. Risk factors in this case are inflammatory diseases of the uterus of the uterus, the presence of scars from caesarean section, fibroids, as well as miscarriages in the anamnesis.
The symptom of placental delay is bleeding in and after the third stage of childbirth. Sometimes the blood does not flow out at once, but accumulates in the uterine cavity. Such latent bleeding can lead to hemorrhagic shock.
Increment of the placenta
Increment of the placenta is called a tight attachment to the wall of the uterus. The placenta can lie on the mucosa, be immersed in the wall of the uterus to the muscle layer and grow through all layers, affecting even the peritoneum.
Manual removal of the placenta is possible only in the case of the first degree of increment, that is, when it has closely grown to the mucosa. But if the increment has reached the second or third degree, then surgical intervention is required. Usually, ultrasound can be distinguished, as a child's place is attached to the wall of the uterus, and in advance to discuss this moment with the future mother. If a doctor finds out about such anomaly of the placenta's location during childbirth, then he should make a decision to remove the uterus.
Methods for manual removal of the placenta
There are several ways to manually remove the placenta. This can be manipulations on the surface of the mother's abdomen when the latter is squeezed out of the uterus cavity, and in some cases doctors are forced to get the placenta with the membranes literally.
The most common method is Abuladze, when a midwife gently massages the anterior abdominal wall with her fingers, and then offers her to push. At the same time he himself keeps the stomach in the form of a longitudinal fold. So the pressure inside the uterine cavity increases, and there is a possibility that the placenta itself will be born. In addition, the puerperas are catheterized by the bladder, this stimulates the contraction of the uterine muscles. Introduce oxytocin intravenously to stimulate labor.
If manual removal of the placenta through the anterior abdominal wall is ineffective, then the obstetrician resorts to the inner compartment.
Post separation technique
Technique of manual removal of the placenta is the removal of it from the uterine cavity in pieces. The obstetrician inserts his hand into the uterus in a sterile glove. Fingers at the same time are brought to each other and stretched out. By touch, it reaches the placenta and gently, with light, cutting movements, separates it from the wall of the womb. Manual separation of the afterbirth should be very careful not to cut the wall of the uterus and not cause massive bleeding. The doctor gives a sign to the assistant so that he pulls the cord and pulls out the child's place and checks it for integrity. The midwife, meanwhile, continues to feel the walls of the uterus to remove all the excess tissue and make sure that there are no pieces of the afterburn inside, as this can trigger a postnatal infection.
Manual separation of the aftertreatment involves the massage of the uterus when one hand of the doctor is inside and the other gently presses from the outside. So the receptors of the uterus are stimulated, and it is reduced. The procedure is performed under general or local anesthesia in aseptic conditions.
Complications and consequences
Complications include bleeding in the postpartum period and hemorrhagic shock associated with massive blood loss from the vessels of the placenta. In addition, manual removal of the placenta can be dangerous by perforating the uterus and developing postpartum endometritis or sepsis. Under the most unfavorable circumstances, a woman risks not only her health and the opportunity to have children in the future, but also her life.
Prevention
In order to avoid problems in childbirth, it is necessary to properly prepare your body for pregnancy. First of all, the appearance of the child should be planned, because abortion violates to some extent the structure of the endometrium, which leads to a tight attachment of the child's place in subsequent pregnancies. It is necessary to diagnose and completely treat diseases of the genitourinary system in a timely manner, as they can affect reproductive function.
It is recommended to exclude casual sexual relations without the use of barrier methods of contraception, to observe the personal hygiene regime and to support the work of the immune system in the autumn-spring period.
An important role is played by timely registration for pregnancy. The earlier, the better for the child. Doctors of obstetrician-gynecologists insist on a regular visit to the women's consultation during the gestation period. Be sure to follow the recommendations, walks, proper nutrition, healthy sleep and exercise, as well as the rejection of bad habits.