Causes of hemorrhage
Hemorrhage develops when the placenta separates from the uterine wall only partially. In this situation, the myometrium cannot contract properly to compress the gaping vessels of the placental bed.
Main risk factors:
- Incarceration of the placenta: retention of the already separated placenta in the uterine horns or lower segment due to uncoordinated contractions.
- Iatrogenic errors: premature cord traction, aggressive uterine massage, or unjustified administration of high doses of uterotonics that disrupt the physiological contraction rhythm.
Clinical signs
The clinical presentation depends on whether the placenta is fully or partially attached:
- Complete attachment: no signs of separation, no hemorrhage either.
- Partial separation: accompanied by external bleeding. Blood is released in portions, often with clots.
It is important to remember concealed blood loss: blood may be retained in the uterine cavity, so the absence of visible discharge does not always mean the absence of a problem. Upon examination, the uterine fundus is usually high (at the navel level) and deviated to the right.
Algorithm of therapeutic measures
In the absence of signs of placental separation, the physician's actions are strictly regulated:
- Preparation: bladder catheterization (reflexively stimulates uterine contractions) and establishment of venous access for crystalloid infusion.
- Uterotonics: administration of oxytocin or carbetocin to enhance myometrial contractility.
- Expulsion: external methods (Abuladze or Credé-Lazarevich) are used only when signs of separation appear.
- Surgery: if there is no effect after 20–30 minutes, manual removal of the placenta is performed under anesthesia.
Briefly: answers to topical questions
What are the clinical signs of placental separation?
Signs of placental separation from the uterine wall include several classic manifestations. Schroeder's sign consists of the uterine fundus rising upward and deviating to the right of the navel, while the uterus takes on an hourglass shape. Chukalov-Kustner's sign is determined by pressing the edge of the hand onto the suprapubic area: if the placenta has separated, the uterus rises upward, and the umbilical cord does not retract into the vagina. According to Alfeld's sign, the ligature applied at the vaginal introitus descends 8–10 cm below the vulvar ring.
What external methods for expelling the separated placenta are used in obstetrics?
Special external methods are used to expel the separated placenta, employed exclusively in the presence of positive signs of placental separation. Abuladze's method involves emptying the bladder, grasping the anterior abdominal wall into a longitudinal fold with both hands to eliminate diastasis of the rectus muscles, and maternal bearing down. Credé-Lazarevich's method involves expressing the placenta by first bringing the uterus into the midline, gently stroking and grasping its fundus with the hand, followed by pressure.
Which uterotonic drugs are administered to stop bleeding in the third stage of labor?
Uterotonic drugs are administered to stimulate uterine contractility and stop bleeding. Oxytocin is prescribed as an intravenous infusion at a dose of 5 IU in 500 ml of isotonic sodium chloride solution. Carbetocin is used at a dose of 1 ml IV slowly. Misoprostol is also used at a dose of 800–1000 mcg rectally as a single dose.
What are the degrees of pathological attachment and invasion of the placenta?
The depth of pathological placental invasion is subdivided into three degrees depending on the penetration of chorionic villus. The first degree reaches the muscle layer without penetrating it. The second degree is characterized by invasion of the villi directly into the myometrium. In the third degree, the villi grow entirely through the muscle layer, reaching the serosa of the uterus.
What is the technique for performing the Credé-Lazarevich maneuver?
The technique for performing the Credé-Lazarevich maneuver includes emptying the bladder with a catheter, bringing the uterine fundus strictly to the midline, and gently stroking it to stimulate contractions. The uterine fundus is grasped with the working hand so that four fingers are on the posterior wall, the palm is on the fundus, and the thumb is on the anterior wall. Simultaneous pressure is applied with the entire hand in two intersecting directions: fingers from front to back and palm from top to bottom toward the pubis until the secundines are completely delivered.
What types of anesthesia are used for manual removal of the placenta?
Epidural anesthesia (if used during labor), intravenous anesthesia, or spinal anesthesia are used for pain relief during manual removal of the placenta and expulsion of the secundines.
"Bladder — Vein — Uterotonic — Hand": first empty the bladder, establish venous access, administer uterotonic agents, and only in case of failure — manual removal.
Class and exam questions
Is it possible to immediately pull on the umbilical cord during bleeding?
No, this is dangerous. Umbilical cord traction before the appearance of signs of placental separation can lead to its incarceration and increased bleeding.
Why is it important to empty the bladder during manual removal of the placenta?
A full bladder prevents normal uterine contraction and can reflexively inhibit the process of placental separation.
What to do if bleeding has started, but there are no signs of placental separation?
It is necessary to immediately initiate infusion therapy, administer uterotonics, and prepare for manual removal of the placenta, as delay leads to hemorrhagic shock.
What else to study on this topic
- Anatomical anomalies of the placenta (placenta bilobata, succenturiata).
- Differential diagnosis between placental incarceration and morbid adherence.
- Safety precautions when performing the Credé-Lazarevich maneuver.
- Features of anesthetic management during manual removal.
- Correction of hemostasis in massive blood loss.
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