AFTERBIRTH PERIOD — the third, completing, the period of childbirth, in Krom occurs placental detachment and allocation of an afterbirth. The pct begins with the moment of the birth fruit (see) also comes to the end with allocation afterbirth (see) then childbirth comes to an end and there comes early puerperal period (see). In Pct allocate three phases: from the moment of the birth of a fruit before emergence clinical (or radio telemetric) signs of placental detachment; 2) from the first signs of placental detachment to its full amotio; 3) from full department of a placenta before exile of an afterbirth. Clinically beginning of amotio placentae (see) the termination — emergence of clinical signs of placental detachment is characterized by emergence of blood allocations, and.
Mechanism of placental detachment it is based that under the influence of reductions uterus (see) its wall exfoliates from a placenta. At reductions of a uterus the area - placental platform (see) decreases. The placenta has no ability to reduction therefore begins to exfoliate, at first partially, and then completely. Placental detachment can begin or with its edge, or with the center. If the placenta exfoliates from edge, then she usually is born the bottom edge, the maternal surface at the same time is turned outside, fruit — inside (Duncan's way). At this way of the birth of a placenta the blood following from the vessels of a uterus which are broken off in the place of amotio begins to stream outside (between a placenta and a wall of a uterus) from the moment of the beginning of amotio. If placental detachment begins with its center, then the retroplapentarny hematoma promoting further amotio is formed. The placenta is born the fruit surface (a way to Shulttsa), edges are delayed for itself by a fetal bag the clots which accumulated in it. At this way outside bleeding during placental detachment happens smaller, than at regional amotio. The clinical option of placental detachment not always corresponds to a way of its birth. It is possible to establish option of placental detachment after its birth in the location of blood clots — a retroplacental hematoma. At regional department the hematoma is located at edge of a placenta (at the same time it can often not be), at central — in the center of a maternal surface of a placenta.
The most reliable and standard a wedge, signs of ended placental detachment is the following. 1. Change of position of a uterus and its form (Schröder's sign). Right after the birth of a fruit the uterine fundus is defined at the level of a navel. In process of department of a placenta and omission of an afterbirth in patrimonial ways the uterine fundus rises and deviates to the right hypochondrium (an afterbirth, falling to patrimonial ways, pushes aside a body of the womb up and to the right). At the same time a body of the womb, being exempted from an afterbirth, it is flattened in perednezadny and in side the directions. Thus, high standing of an uterine fundus and its flattening demonstrate that the afterbirth separated and fell to the bottom of patrimonial ways. If at the same time the woman in labor feels a desire on a bottom (Mikulich's sign), then it usually demonstrates that the afterbirth is in a vagina. 2. Lengthening of an outside part of an umbilical cord (Alfeld's sign): if after the birth of a fruit to impose on umbilical cord (see) a ligature (or a clip) directly at a vulva, after department of a placenta and its omission in a genital tract the ligature departs on 10 — 15 cm from initial situation. 3. Kyustner's sign — Chukalova: an edge of a palm make pressure upon an abdominal wall directly over a pubic symphysis and thus push aside a body of the womb up; if the placenta is still attached to a body of the womb, then it rises together with it, and an outside (visible) part of an umbilical cord is involved in a sexual crack (fig. 1, a). After placental detachment at this reception the umbilical cord is not involved, and sometimes in addition acts from a vagina (fig. 1, 6) more (if the placenta lies in a vagina and pushes aside it from top to bottom). Set of the specified three signs with a bigger share of probability demonstrates that process of placental detachment is complete.
Auxiliary signs of placental detachment are: Shtrassmann's sign — at not separated placenta easy effleurage on an uterine fundus is transferred to an umbilical cord and felt as fingers of the obstetrician above the place of its bandaging; Klein's sign — the woman in labor ask - to be to sweat, at the same time an outside (visible) part of an umbilical cord is extended and after the termination of an attempt is not involved back if the placenta separated (at not separated placenta of it does not occur — the umbilical cord is not extended and involved after an attempt); Dovzhenko's sign — transfer of respiratory movements on an umbilical cord at not separated placenta; Fabr's sign — at not separated placenta of twitching for an umbilical cord are transferred to a uterus and are felt as the hand lying in the area of an uterine fundus (it is undesirable to use this method since it can break process of placental detachment); Rossye's sign — formation of «crest» in an uterine fundus (due to rapprochement of walls of a uterus after emptying of her cavity).
On a radio telemetric tokogramma at the beginning of placental detachment at height of a fight short-term falling of intraplacental pressure (in the form of a tooth) with bystry return to initial level is visible. End of amotio is demonstrated by emergence on toko-gram of «step» at rasslaole-. scientific research institute of a uterus. If the placenta separates at the time of reduction of a uterus, then the flat («cut-off») or rounded-off top of a fight * and also falloff of amplitude of pains, their duration and a tone is noted. There are a wedge, signs of the coming to the end placental detachment. On a tokogramma pains of low amplitude are fixed (if a placenta in a cavity of the uterus) or reductions of a uterus are not registered at all (an afterbirth in a vagina).
Tactics of maintaining the afterbirth period
Exists waiting, active and waiting and active tactics of maintaining physiological Pct.
Waiting tactics is the most approved and reliable method of maintaining Pct. It is that before emergence of signs of department of a placenta the obstetrician does not interfere during Pct if there are no complications. Expediency of such tactics is caused by the fact that in Pct the uterus is evenly and rhythmically reduced, the placenta exfoliates without disturbance of an integrity, napr, a separation of segments, i.e. strictly physiologically. Intervention in this period can break the normal course of process of placental detachment that» leads to serious complications (incomplete placental detachment, bleeding, etc.). Any massaging of a uterus or is even simple pressure upon it a hand, a pandiculation for an umbilical cord during placental detachment are considered as it is unconditional harmful.
During Pct watch the general condition of the woman in labor (pulse, the ABP, coloring of skin and visible mucous membranes, temperature), consult about its health (etc. h register dizziness - amount of the lost blood, watch signs of department of a placenta, do not allow overflow of a bladder since it interferes with amotio and allocation of a placenta. At fiziol, a current of Items pulse is not speeded up, rhythmical, good filling, temperature and the ABP within norm. The amount of the lost blood shall not exceed 0,5% of body weight (practically shall be within 250 — 300 ml). For the accounting of blood loss the woman in labor is stacked on the flat vessel, in a cut collect blood.
At good shape of the woman in labor and lack of indications to intervention it is possible to wait for placental detachment and allocation of an afterbirth till 1 — 1,5 o'clock. Waiting of placental detachment of St. 1,5 hours is inexpedient since if during this time placental detachment did not occur, then usually and further it independently will not come. Therefore it is very important to resolve an issue of the end of process of placental detachment because the last defines further tactics of the doctor.
After there is Schröder's sign, and the umbilical cord will fall by 10 — 15 cm (Alfeld's sign), it is possible to check carefully existence of a sign of Kyustner — Chukalova. If it is positive, then consider that the placenta separated. As soon as signs of department of a placenta are established, the doctor actively interferes with process of allocation of an afterbirth since long finding of the separated afterbirth in patrimonial ways leads to the ascending infection, interferes with reduction of a uterus and unfairly the termination of a childbed detains. Forcing of allocation of already separated afterbirth is technically simple and at the correct performance does not threaten with any dangerous effects (unlike forcing of process of department of a placenta). For acceleration of allocation of the separated afterbirth it is necessary to release urine a catheter; to suggest the woman in labor to be extinguished, having raised the head, an upper part of a trunk and having taken by hands by the edges beds, at the same time it is possible to press slightly palms on an uterine fundus (Chukalov's way) or to strengthen effect of a natuzhivaniya, having taken an abdominal wall both hands (fig. 2) in a longitudinal fold (rapprochement of direct muscles of a stomach and reduction of volume of an abdominal cavity) — Abuladze's reception. After bladder emptying, reductions of a uterus to the centerline and its light massage by fists (a dorsum of proximal phalanxes) of both hands press on side parts of an uterine fundus in the direction of a parturient canal (Genter's way); sometimes the natuzhivaniye at the legs raised and bent in knee and hip joints which the woman in labor fixes hands for a front surface of shins helps. If these receptions are ineffectual, resort to Krede's way — Lazarevich: after bladder emptying the uterine fundus is transferred to the centerline and slightly massed (the easy tickling movements of fingers), after reduction of a body of the womb (it becomes dense) through an abdominal wall bring 4 fingers for a uterus (the thumb is in front) and press on its bottom (without squeezing between fingers in order to avoid an injury of a wall of a uterus and crush of a placenta) in the direction from top to down (fig. 3). Non-compliance with all rules of use of a method of Krede — Lazarevich can lead to a serious complication — to an ectropion of a uterus (see). Rough performance of a method of Krede — Lazarevich can cause disturbances of coagulative properties of blood of mother. At spasms of an internal uterine pharynx or infringement (incarceration) of a placenta in a uterine corner squeezing of an afterbirth under anesthetic is admissible. Sometimes after the birth of an afterbirth in patrimonial ways are late fetal membranes (see). If they did not lose touch with a placenta, then they can be taken rotating it. At the same time the placenta pulls for itself covers which usually do not break.
Active tactics maintaining physiological Pct it is applied usually at women in labor with threat of bleeding in Pct. Such women in labor consider those, at to-rykh the complicated current was observed pregnancies (see) or childbirth (see) — a multiple pregnancy, a hydramnion, a large fruit, weakness of patrimonial activity, long childbirth, etc. At the end of the II period of childbirth appoint drop intravenous administration methyl-ergometrine (0,2 mg to 400 ml of 5% of solution of glucose) or oxytocin (5 PIECES in 500 ml of 5% of solution of glucose, 6 — 8 drops a minute, quantity of drops gradually increase, but no more than 40 drops a minute). Some obstetricians apply one-time administration of methylergometrine (0,2 mg in 20 ml of 40% of solution of glucose). If intravenous administration of a metilergo-metrin or oxytocin does not lead to placental detachment, then it testifies to pathology of its attachment and is the indication to manual department of a placenta and allocation of an afterbirth.
Waiting and active tactics maintaining physiological Pct is that within 15 — 30 min. after the birth of a fruit wait for independent placental detachment. If signs of amotio during this time do not appear, then begin slow intravenous drop administration of oxytocin or methyl of ergometrine. In the absence of signs of department of a placenta in 15 — 30 min. after the beginning of intravenous use of the means reducing a uterus introduction them is stopped and wait for 10 — 15 min. since sometimes already separated afterbirth cannot be born because of the raised tone and frequent, but unproductive reductions of a uterus. If in 10 — 15 min. placental detachment does not occur, then it is regarded as the indication to manual department of a placenta and allocation of an afterbirth. At the same time assume either its dense attachment, or an increment (see. Increment of a placenta ).
After the birth of an afterbirth it is examined to be convinced of an integrity (tsvetn, the tab., St. From, fig. 4 and 5). For this purpose the afterbirth is displayed on any smooth (even better convex and shining) by surfaces and check an integrity of a maternal surface of a placenta and fetal membranes. The maternal surface of a placenta smooth is normal, segments are expressed clearly, covered with a thin coat decidua (see). Defect of placental fabric usually happens dark red color, differs from surrounding fabric. Edges of a placenta shall be smooth and not have the torn-off vessels. The vessels breaking in covers demonstrate existence of the additional segment which remained in a uterus. Sometimes at the same time in fetal membranes it is possible to see a light spot, vessels approach Krom. Numerous tests for check of an integrity of a placenta which were not repaid are offered. At milk test enter into vessels of a placenta the syringe milk (100 — 200 ml), a cut through defect of a placenta (if that is) follows outside. At air test of Franken the afterbirth is immersed in water, and in a vein of an umbilical cord force air. Emergence of air traps in water demonstrates disturbance of an integrity of a placenta.
At suspicion on disturbance of an integrity of a placenta (or on leaving in a uterus of an additional segment) it is necessary to make manual inspection of a cavity of the uterus and to allocate the late site. The partial delay of fetal membranes of manual intervention does not demand, the full delay of fetal membranes is the indication to their manual removal.
Complications of the afterbirth period
the Main complication of Pct is bleeding (see. Hypotonic bleedings ). Very seldom the full increment of a placenta meets.
According to A. P. Nikolaev, are the reasons of bleedings in Pct: disturbance of the mechanism of placental detachment from a wall of a uterus owing to patol, implantations of placenta or disturbances of sokratitelny function of a uterus, and also disturbance of exile of the separated placenta from a cavity of the uterus or from a vagina; infringement in a uterus of parts of a placenta; a delay in a uterus of covers; hypotonia and atony of a uterus; hypo - or an afibrinogene-miya; infection; damages of patrimonial ways (hysterorrheses, necks of uterus, vaginas).
To patol, to an implantation of placenta carry its dense attachment to a wall of a uterus (usually the placenta rykhlo is connected to a wall of a uterus) because of patol, changes of a spongy layer of a decidual (deciduous) cover of a uterus (placenta adhaerens) and an increment of a placenta to a wall of a uterus, at Krom of a vorsina of chorion sprout a wall of a uterus. The increment of a placenta to a wall of a uterus can be full or incomplete (it is finally distinguished in attempt of manual department of a placenta). At patol, a dense implantation of placenta resort to operation of its manual department and allocation of an afterbirth. Operation is made under anesthetic. Enter a hand into a uterus and under control of touch consistently edge of a palm otslaivat a placenta from walls of a uterus. Then the afterbirth is deleted with a pandiculation for an umbilical cord other hand, and the hand which is in a uterus make audit of its walls — manual inspection of a cavity of the uterus, deleting if necessary the remained sites of placental fabric or fetal membranes. At a full or incomplete increment of a placenta on a considerable extent removal of a uterus is necessary (see. Hysterectomy ), since attempts to separate the grown placenta lead to profuse bleeding and can end with death of the patient.
Disturbances of sokratitelny function of a uterus lead to bleeding because of partial flaking of a placenta: uterine vessels in the place of amotio bleed, and the uterus cannot be reduced because in her cavity there is an afterbirth. Disturbances of exile of the separated placenta from a cavity of the uterus are connected or with insufficiency of sokratitelny activity of a uterus, or with infringement (incarceration) of an afterbirth. The last most often happens because of a spasm of muscles of a uterus in an internal uterine pharynx or (more rare) than a pipe corner of a uterus. At infringement of an afterbirth owing to a spasm of an internal uterine pharynx of outside bleeding from a genital tract can not be (the placenta interferes with the expiration of blood from a cavity of the uterus), but blood accumulates in a uterus and stretches it. The uterus becomes spherical (sometimes has the form of hourglasses); at the patient pulse becomes frequent, dizziness can develop. Urgent removal of an afterbirth by Krede's method — Lazarevich under anesthetic (or after introduction of spasmolysants) or manual department of an afterbirth is necessary. At a delay of an afterbirth in a vagina it is deleted by means of Abuladze's receptions, Genter, etc. (the pandiculation for an umbilical cord is not recommended since even in the presence of signs of department of a placenta some part of an afterbirth can be attached). The delay in a uterus of parts of a placenta demands their manual removal. At a delay of parts of fetal membranes manual removal is not applied, they are allocated independently.
At damage of patrimonial ways bleeding begins right after the birth of the child, the diagnosis is specified at manual inspection of a uterus and survey of patrimonial ways (a neck of uterus, a vagina) by means of mirrors. At a hysterorrhesis (see. The birth trauma) is necessary an urgent laparotomy with sewing up of a gap or removal of a uterus.
At bleeding in Pct it is necessary to remove an afterbirth from a uterus first of all. In the presence of signs of department of an afterbirth most quicker to make it Krede's method — Lazarevich. If there are no signs of department of an afterbirth, also apply the specified method, at failure — the same method under anesthetic, in the absence of effect resort to manual department of a placenta and allocation of an afterbirth. Are not justified at bleeding of attempt of allocation of an afterbirth, e.g., by Moyon's method — to Gabast (filling of a placenta through an umbilical vein isotonic r-rokhm for the purpose of strengthening of turgor of a placenta and simplification of its department). At the same time mistakenly believed that department of a placenta can be accelerated a violent rupture of fibers of a placenta and creation of an artificial retroplacental hematoma. After manual allocation of an afterbirth the obstetrician leaves a hand in a uterus, the palm squeezes in a fist, and the second hand carefully runs massage of a uterus (the easy, stroking or tickling movements) on a fist of an internal hand — so-called outside and internal massage on Hrobaka. However many obstetricians refuse this method because of danger of strengthening of bleeding. If after removal of an afterbirth by means of Krede's method — Lazarevich and massage of a uterus the last is badly reduced and bleeding proceeds, then even in the absence of suspicion on disturbance of an integrity of a placenta (i.e. on stay in a uterus of the site of a placenta) manual inspection of a cavity of the uterus is necessary for an exception of existence of the rest of a placenta, a hysterorrhesis and performing massage on Hrobaka. At the same time begin intravenous drop administration of oxytocin (5 PIECES in 500 ml of 5% of solution of glucose, since 8 — 10 drops a minute to 30 — 40 drops a minute) and start completion of blood loss (jet hemotransfusion or Polyglucinum, solution of dry plasma, etc.), put a bubble with ice on suprapubic area, carefully continue outside massage of a uterus. At this time it is necessary to examine by means of mirrors a neck of uterus and a vagina for an exception of gaps. Existence of ruptures of soft patrimonial ways at well reduced uterus and the proceeding bleeding is especially suspicious scarlet blood (usually dark blood follows from a uterus). If as a result of manual inspection of a cavity of the uterus patol, changes in it are not found, and the uterus continues to relax, then it demonstrates existence of hypotonia (or atonies) a uterus.
Before manual inspection of a cavity of the uterus and during it (some obstetricians do it after manual examinations of a uterus) reasonablly to conduct pressing of an aorta for the purpose of reduction of blood loss, especially at severe bleeding. At the same time the hypoxia of a myometrium and its reflex reduction develops. Long pressing of an aorta (St. 5 min.) it is inexpedient since initial reflex reduction of a myometrium is followed by its relaxation — the second phase of reaction to a hypoxia. Besides, long pressing of an aorta can cause damage of its intima.
There are several methods of pressing of an aorta. Schmitt's way — pressing of an aorta a fist (the back of proximal phalanxes) to a backbone over an uterine fundus is up to disappearance pulsations lower than the place of pressing. It is possible to help the pressing hand other hand, having captured it a brush of the first. Biryukov's way — pressing of an aorta fingers: fingers of one hand have between fingers another and press a ventral aorta over a navel on an extent apprx. 10 cm.
For a stop of bleeding it is possible to try to bend a uterus of a kpereda, as if too much a pubic joint, in deepening over it put the curtailed towel or napkins, and then fix them to a stomach bandage. The uterus compressed between a pubic joint and a towel is reduced (Rachin-sky's method). Sometimes reception of Gen-tera helps: after bladder emptying to the woman in labor who is in the provision of Trendelenburga cover big and index fingers of the right hand (through skin of a stomach) the lower segment of a uterus, squeeze it from sides (in uterine arteries) and as much as possible displace a uterus up (kranialno), at the same time pressing for 5 — 15 min. its lower segment to a backbone. Reception is counted on reduction of a uterus owing to a hypoxia of a myometrium. Arendt and Lositskaya's ways are based on irritation of neuroplex in okolosheech-ache to cellulose, causing reduction of a body of the womb. Arendt's way consists in numerous bringing down of a uterus the bullet nippers imposed on front and back lips of a neck of uterus. After each pandiculation give the chance to a uterus freely to depart on the place. Lositskaya's way — imposing of a cross catgut seam on a back wall of a neck of uterus. For this purpose the neck of uterus needs to be bared by means of mirrors, to fix its back wall clips and to tighten on itself and kpered. The stitch is put on a back wall of a neck of uterus, is closer to the back arch. The wall of a neck of uterus is punctured with a needle, get into her cavity, and then remove a needle on the opposite side and tie the ends of a catgut.
At last, as the last and more often a temporary measure before a laparotomy it is possible to use methods Buck-sheeva, Tikanadze, Chiladze. By Baksheev's method by means of fenestrated nippers (3 — 4 from each party) make a klemmirovaniye of side departments of a uterus. One branch of a clip is entered into a cavity of the uterus, and another — into a side vault of the vagina (in the field of a vascular bundle). If clips are imposed correctly, then as a result of a prelum of vessels bleeding stops. I. E. Ti-kanadze offered with the same purpose to impose intestinal clips on side vaults of the vagina. Electrostimulation of a body of the womb a defibrillator across Chiladze can be the last method before a chrevosecheniye. Electrodes of a defibrillator impose on a front surface of an abdominal wall (on area of a uterus) and a waist; voltage of a direct current is 4000 century. The special electrode can be entered into a uterus, then tension is reduced up to 2000 century. In case of inefficiency of this method the laparotomy is necessary. A number of authors offer bandaging of vessels of a uterus across Tsitsishvili (both uterine and both ovarian arteries). If the last operation gives only short-term effect (to wait for 15 — 20 min.), then it is necessary to remove a uterus.
The method of bandaging and crossclamping of vessels of a uterus by most of authors is rejected as not effective, and sometimes and unsafe. The tamponade of a uterus can be used only as the temporary action necessary for preparation for a laparotomy. The tamponade of a uterus is reasonable if there are no conditions for carrying out a laparotomy, napr, for the period of evacuation of the patient in a hospital.
Excessive hobby for various not radical methods of controlling with hypotonia can lead to loss of a vrekh\shna and to death of the woman in childbirth from the irreversible changes connected with blood loss.
It is very important to notice disturbances in time in system of a hemostasis (the disseminated intravascular blood coagulation) which can be primary or join hypotonic (atonic) bleeding. Their first sign is continuous bleeding at well reduced uterus, decrease in the coagulability of the blood following from a uterus and taken from a vein of the woman in childbirth. This diagnosis needs to be confirmed by determination of content of fibrinogen, a blood clotting time and its fibrinolitic activity, etc. Sometimes hypotonia (atony) of a uterus is combined with disturbance of system of a hemostasis. Therefore the diagnosis of disturbance of system of a hemostasis in the presence of symptoms of hypotonia (atony) of a uterus not dolzhets to be the cause for the termination of fight against hypotonia. In the presence of disturbance of system of a hemostasis apply fibrinogen, the lyophilized plasma, warm donor blood, inhibitors of a fibrinolysis and fibrinoge-noliz.
Prevention of bleedings in Pct comes down to prevention of disturbances of physical development of girls, increase in physical fitness of the women especially pregnant (special classes in physiopsychoprophylactic preparation for childbirth, etc.), to identification of somatopathies and their timely treatment, early identification and treatment of toxicoses of pregnant women, creation of the guarding mode in labor and to their rational maintaining.
Bibliography: Baksheev N. S. Uterine bleedings in obstetrics, Kiev, 1975; Gulkevich Yu. V., M and to-to and in e e in and M. Yu. and Nikiforov of B. I. Patologiya of an afterbirth of the person and its influence on a fruit, Minsk, 1968; The Zhukovsky Ya. G. and Kiryushchen-k about in A. P. O the factors defining pathological blood loss in the third period of childbirth, Akush, and ginek., No. 7, page 55, 1978; Persianinov L. S. Obstetric seminar, t. 1 — 2, Tashkent * 1973; Susloparov L. A. The mechanism of a hemostasis in a uterus in the third period of childbirth, Akush, and ginek., No. 3, page 6, 1979; E. A. Seamy side, Novikova 3. Century and Tikhonova I. S. Prevention of uterine bleedings in labor and an early puerperal period, in the same place, page 9; P about p-t u with h A., Philadelphy I. i. L u p t a k I. Aktualne poznamky k she-dikamentoznemu vedeniu 3 porodnej doby, Cs. Gynek., sv. 35, s. 121, 1970; Schmidt-Matthiesen H. Gyna-kologie und Geburtshilfe, Stuttgart — N. Y., 1975.
Yu. I, Novikov.