Manual Separation of the Placenta (or Removing of the Afterbirth)

The invasion of the uterus by the obstetrical hand for separation and removal of the placenta (or its separate parts that may be retained in the uterus) is always fraught with danger of infection. The microflora of the vulva and the vagina inevitably contaminates the obstetrical hand. The microbes carried into the uterus by the hand penetrate the disrupted blood and lymph vessels of the uterus.

Septic diseases often develop in puerperas after manual invasion of the uterus and this operation should therefore be done only for special indications and with strict observation of the asepsis rules.

Indications for manual separation and removal of the placenta are as follows:

· bleeding in the puerperium due to retention of separated placenta (or parts of placenta and amniotic membranes) in the uterine cavity;

· absence of spontaneous placental separation for more than 30 minutes. If the placenta is retained for more than half an hour, it should be removed manually even if the blood loss is inconsiderable;

· bleeding in the puerperium depending on the uterine hypotony or atony.

· Indications for manual intrauterine examination after the delivery of the placenta are:

· retention of parts of the placenta,

· if any suspicion arises concerning intactness of the delivered placenta.

Operative technique. The patient is placed on a transverse bed and her bladder is evacuated. The external genitalia are treated as for an obstetrical operation. The operator’s hands are washed thoroughly, disinfected, as for abdominal operation. The operation is performed on an anaesthetized patient, except as rare cases when the operation is performed by an unassisted obstetrician. (Fig.193).

The pudendal cleft is separated by the left hand and a conically shaped right “obstetrician hand” is introduced into the vagina and further into the uterus. The invading hand should be directed with its palm toward the symphysis. The left hand should then be placed on the bottom of the uterus.

Fig. 193. Manual removing of the afterbirth

In order not to mistake edematous margin of the os for the placental margin, the right hand should follow the umbilical cord as it is introduced into the uterus. As soon as the right hand, guided by the umbilical cord, reaches the placenta, its margin should be examined for the degree of separation. The hand should be inserted in space between the placenta and the uterine wall; while the right hand acts like a saw to separate the placenta, the left hand should press gently on the uterine bottom to aid the internal hand.

As soon as the entire placenta has thus been separated, it should be pulled by the umbilical cord toward the lower uterine segment and extracted from the uterus by the left hand. The internal (right) hand remains in the uterus to examine it for complete removal of the placenta. When the entire placenta has been removed, the uterine walls become smooth except the placental site, which is slightly rough. Remnants of the decidual membrane may remain on the placental site

After the uterine cavity has been examined thoroughly, the hand should be removed from the uterus, and 1 ml of methylergometrine should be given intravenously; an ice bag should be placed on the lower abdomen and blood (plasma, or blood substitute) transfused in case of anemia. If bleeding persists, extirpation of the uterus should be performed.

In the presence of complications (before the manual separation and removal of the placenta) predisposing to puerperal infection (prolonged labor, long “dry” period, signs of endometritis, etc.), antibiotics should be given during the course of two or three days: ceftriaxon 250 mg intramuscularly plus doxycycline 100 mg orally twice a day.

The separation of the placenta or its retained parts usually does not present any difficulty. In placenta accreta (fused placenta) the placenta fails to be separated, and attempts to separate it manually will cause uterine perforation and death of the patient. The uterus should therefore be extirpated.

Prophylaxis of blood loss in the placental stage consists in accurate adherence to the rules of conducting labor. The condition of the patient, the amount of the blood lost, and the urinary function should be carefully observed; stimulation of the uterus or traction by the umbilical cord is not recommended. Ergot and its preparations which cause spasm of the uterine muscles are prohibited. If profuse bleeding is anticipated (polyhydramnios, twin pregnancy, etc.), 1 ml of methylergometrine may be given during the delivery of the fetal head. Pituitrin and oxytocin are also recommended.

Bleedings During Postpartum Period. Early Postpartum Hemorrhages. Bleeding after the delivery of the placenta is a frequent obstetrical pathology. Bleeding in the early hours of the puerperium depends on the following:

· Retention of parts of the placenta in the uterus.

· Uterine hypotony or atony.

· Rupture of the uterus (incomplete form).

· Coagulation defects.

· Water embolism.

Hypotony and atony of the uterus. Uterine hypotony is insufficiency of retractive capability of myometrium, alternated decline and renewal of its tone. By atony it is accepted to consider a complete absence of contractions of uterus, which is more often a prolonged severe form of uterine hypotony. In most cases bleeding starts as hypotonic and then atony of uterus develops. A complete atony of the uterus occurs on relatively rare occasions. Hypotony is more frequent in the early hours of the puerperium.

The causes of hypotonic bleeding after the delivery of the placenta are the same as of hemorrhage in the placental stage of labor, i.e., infantilism, multiple pregnancy, fatigue after tumultuous labor, changes in the uterine wall after previous inflammatory diseases, etc.

Apart from these reasons hypotonic bleeding may occur due to failure of processes of separation and expulsion of the afterbirth, placenta praevia, premature separation of normally located placenta, water embolism.

Clinical features. Usually bleeding begins in a placental stage of labor or in early postpartum period. Two clinical variants of hypotonic (or atonic) bleeding are known.

The first variant: bleeding from the very onset assumes a profuse character, the uterus remains flabby, not responding adequately to administration of uterotonic drugs, external massage. Hypovolemia developes quickly, hemorrhagic shock and disseminated intravascular coagulation syndrome (DIC) also develop. The condition of the patient can quickly pass into an irreversible phase. The second variant: bleeding has an undulating character. The initial hemorrhage is slight, the uterus is periodically weakened, the blood loss increases gradually.

Alternation of repeated hemorrhage with temporal renewal of uterus tone in reply to conservative medical treatment takes place (external massage of uterus, administration of uterotonic agents). Blood is lost by small portions of 150-300 ml. A comparatively small volume of repeated bleeding provides temporal adaptation of the patient to developing hypovolemia. Blood pressure can remain within the limits of norm; pulse rate reveals insignificant tachycardia; severe paleness of skin occurs.

Treatment. The basic tasks facing the obstetrician in case of hypotonic bleeding are a maximally rapid arrest of bleeding, prevention of development of massive blood loss, renewal of the circulating blood volume deficiency, stabilization of hemodynamics. Measures should be executed quickly, simultaneously, that determines their efficacy.

Hypotonic and atonic hemorrhage is controlled in the following way:

The first step:

· The bladder is evacuated. The uterus is massaged through the abdominal wall: the hand is placed on the uterine bottom and rubs it by slight circular movements (energetic movements fail to give the desired effect). The massage stimulates contraction of the uterus and it becomes firm. An ice bag should be placed on the lower abdomen.

· Manual removing of blood clots from the uterus and manual revision of the uterine cavity. Simultaneously, 0.5-1 ml of a 0.02 % methylergometrine solution is given intravenously. Oxytocin (5 units with 500 ml of a 5 % glucose solution) should be injected intravenously.

· Revision of soft tissue of the labor canal must be done to repair lacerations, if any, and to arrest bleeding.

· Infusion of frozen plasma, albumin, protein, transfusion of blood, infusion of saline solutions should be done to compensate the blood loss and to treat hypovolemia.

If the uterine hypotony is not marked, these measures will be enough.

The second step. If the bleeding persists and the volume of hemorrhage is 0.8-1.0% of body weight, a conservative treatment may be used to arrest bleeding.

Compression of the abdominal aorta. If hypotony (atony) is marked, the aorta should be compressed to decrease blood supply of the uterus. The obstetrician should assume her position by the patient’s side and, using the back surface of the main phalanges, press the abdominal aorta to the spinal column through the abdominal wall. If the hand becomes tired, it should be assisted by the other hand which should grasp the wrist of the pressing hand. The aorta can also be pressed against the spinal column by the fingers of both hands (Biryukov’s method), or by a soft roll which should be pulled tightly to the abdomen by bandaging.

Ten units of oxytocin with 400 ml of isotonic solution of sodium chloride should be injected intravenously droppingly. 1 ml of prostaglandin should be injected into the cervical muscles. 10-20 ml of essenciale forte intravenously, prednizolone 30 mg, dicinon (etamzilat natrium) 2-4 ml of 2.5% solution should be introduced intravenously. Transfusion of blood is recommended.

The main rule is not to lose time for any ineffective conservative methods of arresting bleeding if it continues. Urgent operation is the best.

The third step is laparotomy and extirpation of the uterus.

Features of this operation are the following: after the opening of the abdominal cavity a temporary hemostasis should be done by clamping of the uterine and ovarian arteries. During the next 10-15 minutes (an operating pause) the resuscitation of the patient should be done (infusions of blood, plasma, saline solutions for stabilizing blood pressure, etc.). Extirpation of the uterus may be perfomed after an operating pause.

However, arrest of bleeding is not the only component of successful medical treatment, because more often the direct reason of death of patients is multiple organ insufficiency developing in the postreanimation period, i.e. after the stop of bleeding. Death is caused by disturbances of micro- and macrocirculations. Prophylaxis and medical treatment of these complications should start during the 1st step, i.e. the step of diagnostics and arresting of bleeding.

The basic principles of infusion-and-transfusion therapy of hemorrhagic complications in modern obstetrics are the following:

· Renewal of hemodynamic system by introduction of solutions of a high molecular mass — Refortan (6% solution), pentastarch (infucol) — a 6–10% solution in doses of 10-20 ml/kg/body weight, voluven (6% solution), volekam — from 500 to 1000 ml;

· For suppression of excessive fibrinolysis and prevention of DIC it is recommended to use protease inhibitors (gordocs, trasilol) in doses not less than 10 ml/kg /hour;

· An early and rapid administration of fresh frozen plasma (FFP). If blood loss is less than 1,000 ml it is recommended to inject 2 doses (1 dose is 300 ml), if blood loss is more than 1,000 ml — 4-5 doses of FFP should be administered (1,200-1,500 ml). On occurrence of tissue diathesis a rapid, almost stream introduction of 7 doses of FFP is needed. The primary purpose of FFP application is not compensation of circulated blood volume, but renewal of hemostatic potential of blood, as it is the substance, saving in an active balanced state all factors participating in bleeding arrest;

· Stimulation of thrombocyte link of hemostasis (ditsinon 2-4 ml of a 2.5% solution intravenously, adenosine triphosphate (ATP) 1.0 ml intramuscularly);

· Transfusion of blood or red cell mass (better washed red cells);

· At unstable hemodynamics glucocorticoids should be administered (prednisolone in a dose of 10 mg/kg/hour or hydrocortisone — not less 100 mg/kg/hour).

Coagulation defects are rare causes of intrapartum and postpartum hemorrhage. In cases of hypofibrinogenemia, afibrinogenemia the ability of blood to clot sharply decreases or is lost completely, which becomes the cause of persistent bleeding regardless of massage of the uterus or drugs stimulating its contractions, etc. Coagulation defects may develop in cases of longstanding fetal death in the uterus, amniotic fluid embolism, and in profuse (hypotonic or atonic) bleeding.

The prophylaxis of coagulation defects consists in a correct management of the placental stage of labor, careful inspection of the delivered placenta, and prevention of lacerations of the soft tissues of the reproductive tract. The obstetrician must be ready for possible hypotonic hemorrhage (infantilism, hydramnion, multiple pregnancy, fibromyoma, etc.). She must prepare beforehand all articles that might be necessary to stop bleeding and control anemia.

Late Postpartum Hemorrhages. Bleeding is considered late if it develops 24 hours (and later) after the delivery. Sometimes hemorrhage develops in 10-15 days postpartum.

The most common cause of late postpartum hemorrhage is retention of placental remnants in the uterus. The remnant gradually assumes the form of a polyp and becomes the cause of inevitable bleeding. Less frequently late hemorrhage is caused by retention of fetal membranes or due to infection.

If postpartum hemorrhage is due to retention of the placenta or fetal membranes, the treatment consists in their instrumental removal (curettage).

Cure of infection will stop bleeding.