Maintenance of succession of the period

Currently, the most accepted is active-waiting maintain succession period. After the baby is born the mother continues to lie on his back. Under it enclose sterile tray for collecting released blood, which is poured into a graduated container constant consideration of blood loss. You must use a catheter to empty your bladder as it prevents overflow correct uterine contractions; irritation of mucous membrane in the urethra and bladder reflex causes uterine contractions. During the following period (visually and by means of palpation of the lungs movements) have observed changes size and shape of the uterus, which is especially important for Central detachment of the placenta, when no external bleeding does not allow to judge 6 the amount of blood loss. In succession of the period necessary to avoid rough palpation of the uterus, as it may interfere with the process of separation of the placenta and cause bleeding. Constant attention should be paid to the General condition of the pregnant woman (subjective complaints, color of skin, heart rate, blood pressure).
Blood loss, not to exceed physiological border, waiting for a spontaneous birth of the placenta. In 10-15 minutes from the moment of birth the child will have light, contractions, indicating the beginning of the separation of placenta, and then with a little potage is born, the placenta. The birth of the placenta does not always occur immediately after the separation of the placenta. Long periods separated in the placenta in the uterus increases blood loss; therefore, in the course of succession period should watch for signs of separation of the placenta.
The most important of them are as follows. 1. Changing the shape of the uterus (the sign Schroeder) (Fig. 1). After the separation of the placenta last drops into the lower parts of the uterus, partly in the vagina, pushing the body of the uterus up. The bottom of the uterus is located slightly above the level of the navel and moves to the right. The uterus has elongated, 2. The lengthening of the external cut the umbilical cord (characteristic of Alfeld). Put a clamp or a ligature on the outer cut the umbilical cord immediately after birth, it is easy to observe "lengthening" of the umbilical cord. "Lengthening" of its 8-10 cm from the vagina indicates the separation of the placenta. 3. Changing the position of the outer cut the umbilical cord at pressing the edge of his palm on the anterior abdominal wall woman above the fold (characteristic Kustner - Kukalova). In the case of separated placenta squeezing the edge of his palm over the pubic joint does not cause pull the cord. 4. The lengthening of the external cut the cord at natureway (sign Klein) shows that the placenta had separated. Otherwise, the umbilical cord at natureway drawn. 5. The emergence urge "on the bottom" (the sign of Mikulich) - lowdown in the vagina recent pressure on the rectum.
If there are signs of separation of the placenta is a need to promote, separation of the placenta. Usually it is enough to ask a woman to potorytsia.
In the case of ineffectiveness of this action resorted to admission Abuladze. For this two hands grab the anterior abdominal wall in the longitudinal crease and asked the woman again potorytsia (figure 2). The most effective method of selection of the placenta is receiving the Cred - Lazarevic. The reception is held with bladder emptied. After an outdoor massage of the uterus and its launch to the middle line the bottom of the uterus seize hand so that your thumb is on the front surface of the uterus, and four other on the back. Clutching fingers and pressing down on the bottom towards the sacrum, allocate the latter (Fig. 3). With the failure of this method should be thought of having a spasm of the cervix and repeat administration under General anesthesia. Method the Cred - Lazarevic is quite rough, dangerous as it can cause increased bleeding. Therefore, before applying it is necessary to prepare for the possibility to perform manual separation of the placenta and the postpartum examination of the uterus.


Fig. 1. Changing the shape and position of the uterus: 1 - after the birth of a fetus; 2 - after the separation of the placenta; 3 - after the birth of the placenta.
Fig. 2. The selection of the placenta in Abuladze.

Fig. 3. The selection of the placenta in the Cred-Lazarevic. Fig. 4. Manual separation of the placenta.

The important point in doing a series of the period is a thorough inspection of maternal surface born placenta and membranes to identify them safe. It is necessary to examine the progress of the vessels to the edge of the placenta, which will detect the absence of the extension of the segments. An obvious defect of the placenta or even the doubts in its entirety require manual postpartum examination of the uterus and remove the rear parts of the placenta.
If the placenta is not separated in two hours, you must go to manual separation of the placenta and the separation of the placenta. The transition to more action is also shown in the blood loss in excess of the physiological norm. In such cases, injections are applied reduce the uterus funds, the method Cred - Lazarevic, manual separation of the placenta. Hydraulic method of placental abruption (method Gabalu), which consists in the introduction to the umbilical vein sterile physiological solution of sodium chloride, currently not used.
Pathological course of succession period may be due to unusually strong connection of the placenta from the uterine wall. The development of this complication is most often contribute to a Change in the spongy layer of the endometrium inflammatory and degenerative that develop due to previously deferred inflammatory diseases of female genital sphere, frequent abortions, and so on, With partial dense placentation the main symptom is bleeding. In such cases it is shown manual separation of the placenta and the selection of the placenta. After the introduction of arms into the uterus placenta separates from the uterus wall sawing motions of four fingers and ribs hands (Fig. 4). Thinning the lining of the uterus (submucosal fibroids, scars after surgery on the uterus) the chorionic villi (see the Last) can grow through the mucous membrane in the muscle layer develops real increment of the placenta. At partial true increment placenta main symptom is profuse bleeding. Manual separation truly incremental placenta is impossible without the threat of infringement of an integrity of the uterus, so in such cases shown operation supracervical amputation of uterus by brunetoochka laparotomy (see Panhysterectomy).
A careful analysis of historical data, pregnancy and childbirth allows in most cases, to foresee possible difficulties in succession period. Prevention of complications shows the use of funds, reduce the uterus. So, in the moment of the eruption of the head with the weakness of the labour forces is recommended intravenous (slowly!) enter 5 IU of oxytocin or of pituitrin with 20 ml of 40% glucose solution. At the same time it is necessary to introduce intramuscularly drug alkaloids LPV (erhotel 0,05% 1 ml), since oxytocin is quickly destroyed in the blood. More appropriate long drip solution of oxytocin (5 ED by 500 ml 5%glucose solution), since the end of the 2nd year of birth, and continuing in the early postpartum period. In addition, the lying-in the moment of the eruption of the head of the fruit can be introduced intravenously purified preparations of ergot alkaloids (metilargometrina, methergine). These medications in the amount of 0.5-1.0 ml dissolved in 20 ml of 40% glucose solution and introduce slowly simultaneously. If there is bleeding is of great importance to the timely and full compensation of blood loss.