Assessment of the newborn's condition
Immediately after birth, the baby's condition is assessed using the Apgar score. Each of the five clinical signs is assigned 0 to 2 points.
| Criterion | 0 points | 1 point | 2 points |
|---|---|---|---|
| Heart rate | Absent | Less than 100 bpm | 100–140 bpm |
| Respiration | Absent | Single movements | Good, loud cry |
| Reflexes (to plantar stimulation) | No response | Slight grimace, movements | Active movements, cry |
| Muscle tone | Absent | Decreased | Active motion |
| Skin color | White or severely cyanotic | Pink body, blue extremities | Completely pink |
Management tactics of the third stage of labor
The priority tactic is expectant. The doctor must not force events: premature interventions and uterine palpation severely disrupt the physiological process of placental separation and retroplacental hematoma formation. Active management is permitted exclusively with the patient's informed consent.
During the waiting period, continuous monitoring is carried out:
- General condition: skin color is assessed, as well as the woman's orientation in space and time, and her reaction to the surrounding environment.
- Hemodynamics: pulse and blood pressure are monitored (they should remain within physiological limits).
Signs of placental separation
If there is no bleeding, checking for signs of placental separation begins 15–20 minutes after the birth of the baby.
- Schroeder's sign: after separation, the placenta descends into the lower uterine segment or vagina. Because of this, the uterine fundus rises above the navel and deviates to the right, and the uterus itself takes on a characteristic "hourglass" shape.
- Kustner's sign (Chukalov-Kustner sign): the obstetrician presses the edge of the palm on the suprapubic area. If the placenta has not separated, the umbilical cord is drawn into the vagina. If the placenta has separated, the uterus rises, and the umbilical cord remains in place or extends even further outward.
- Alfeld's sign: a ligature is applied to the umbilical cord at the vaginal introitus. When the placenta is completely separated, this mark drops 8–10 cm below the vulvar ring.
Methods for external delivery of the placenta
These techniques are used to assist in the birth of the placenta only in the presence of positive signs of its separation.
- Abuladze method: after emptying the bladder, the physician grasps the anterior abdominal wall with both hands into a longitudinal fold, eliminating diastasis of the rectus abdominis muscles. The woman is asked to bear down. The placenta is delivered exclusively through an artificial increase in intra-abdominal pressure.
- Crede-Lazarevich method: the bladder is emptied with a catheter, and the uterine fundus is brought strictly to the midline position. Light stroking of the uterus is performed to stimulate contractions (strictly not massage!). Then the obstetrician grasps the fundus of the uterus with the hand: four fingers lie on the posterior wall, the thumb on the anterior wall, and the palm on the fundus. Expression is carried out by simultaneously pressing with the fingers from front to back, and with the palm from top to bottom (toward the pubic bone) until the placenta is completely delivered.
Retention of membranes and indications for manual removal
If the placenta has been delivered, but the fetal membranes are retained in the uterine cavity, special techniques are used:
- Twisting into a cord: the delivered placenta is taken in the hands and slowly rotated. The membranes are twisted, gradually peeling off from the uterine walls and coming out.
- Genter's method: after the birth of the placenta, the woman is invited to bear down while resting on a bedpan or tray, which helps the independent delivery of the membranes.
Indications for manual removal of the placenta:
- Complete absence of signs of placental separation.
- The duration of the third stage exceeds 30 minutes, even if bleeding is completely absent.
To remember the Chukalov-Kustner sign: if the placenta has separated, it is no longer connected to the uterine fundus. Therefore, when pressing above the pubic bone, the uterus moves upward, and the umbilical cord "stands still" (is not drawn inward).
Class and exam questions
Why is it strictly forbidden to massage the uterus in the third stage of labor?
Untimely palpation and massage disrupt the natural process of retroplacental hematoma formation, which prevents the normal separation of the placenta from the uterine wall.
How to determine that blood loss in the third stage remains physiological?
Normally, the volume of blood lost is 300–500 ml (about 0.5% of the woman's body weight), while hemodynamic parameters (pulse, BP) and the general condition of the mother remain stable.
What to do if 35 minutes have passed since the birth of the child, there is no bleeding, but the placenta has not been delivered?
It is necessary to proceed to the operation of manual removal of the placenta and delivery of the conceptus. Retention of the placenta for more than 30 minutes is a direct indication for intervention regardless of the presence of bleeding.
What else to study on this topic
- Technique of manual removal of the placenta and delivery of the conceptus
- Pathological blood loss in labor: causes and action algorithm
- Detailed analysis of the Apgar score and primary resuscitation of the newborn
- Anatomy and functions of the placenta and fetal membranes
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