Manual separation of the placenta and release of the placenta. Operation of manual separation of placenta

Equipment:

Conditions:

· Intravenous anesthesia.

Preparation for surgery:

Technique:

The genital slit is opened with the left hand, and the right, cone-shaped hand of the obstetrician is inserted into the uterine cavity. After that left hand transferred to the fundus of the uterus. The umbilical cord serves as a guide to help find the placenta. Having reached the place of attachment of the umbilical cord, the edge of the placenta is determined and, using sawing movements, the placenta is separated from the wall of the uterus (without using excessive force). Then, by pulling the umbilical cord with the left hand, the placenta is released; the right hand remains in the uterine cavity to conduct a control examination of its walls. The delay of parts is determined by examining the released placenta and detecting a defect in the tissue, membranes, or the absence of an additional lobule. Defect placental tissue identified by examining the maternal surface of the placenta, spread out on a flat surface. Retention of the accessory lobe is indicated by the identification of a torn vessel along the edge of the placenta or between the membranes. The integrity of the membranes is determined after they have been straightened, for which the placenta should be raised.

With the right hand, under the control of the left, the entire inner surface of the uterus is examined in detail. At the same time, they make sure that there are no remains of the placenta or blood clots. The outer hand massages the uterus to contract it. After the operation is completed, the arm is removed from the uterine cavity. Assess the condition of the postpartum woman after surgery.

Manual examination of the uterine cavity

Equipment:

· sterile examination kit birth canal.

Conditions:

· Intravenous anesthesia.

Preparation for surgery:

The preparation of the surgeon's hands and the perineum of the woman in labor is carried out according to generally accepted standards.

Technique:

The genital slit is opened with the left hand, and the right, cone-shaped hand of the obstetrician is inserted into the uterine cavity. After this, the left hand is transferred to the fundus of the uterus. With the right hand, under the control of the left, the entire inner surface of the uterus is examined in detail. At the same time, the remains of the placenta and blood clots are removed. The outer hand massages the uterus to contract it. After the operation is completed, the arm is removed from the uterine cavity. Assess the condition of the postpartum woman after surgery.

To prevent postpartum infection in all cases surgical intervention antibiotics are prescribed.

In case of pathological blood loss, blood loss is compensated and symptomatic therapy is carried out.

Suturing ruptures in the birth canal

Equipment:

· sterile kit for examination of the birth canal

Conditions:

· Local infiltration anesthesia.

· Epidural anesthesia (if a catheter was installed during childbirth).

· Intravenous anesthesia as indicated (for example, for deep vaginal lacerations).

Preparation:

The preparation of the surgeon's hands and the perineum of the woman in labor is carried out according to generally accepted standards.

Technique:

Cervical rupture

Pain relief methods

Restoring the integrity of the cervix in cases of I and II degree rupture is usually performed without anesthesia. At III degree rupture, anesthesia is indicated.

Operation technique

Absorbable suture threads (catgut, vicryl) are used to close cervical tears. It is important to have good alignment of the wound edges to promote healing.

They expose the vaginal part of the cervix with wide, long speculums and carefully grasp the anterior and posterior uterine lips with bullet forceps, after which they begin to restore the cervix. Separate catgut sutures are applied from the upper edge of the rupture towards the outer pharynx, with the first ligature (provisional) slightly above the rupture site. This allows the doctor to easily, without injuring the already damaged cervix, lower it when necessary. In some cases, a provisional ligature allows one to avoid the application of bullet forceps. To ensure that the edges of the torn neck are correctly adjacent to each other when suturing, the needle is injected directly at the edge, and the puncture is made at a distance of 0.5 cm from it. Moving to the opposite edge of the tear, the needle is injected at a distance of 0.5 cm from it, and the puncture is made directly at the edge. With this application, the sutures do not cut through, since the cervix serves as a gasket. After fusion, the suture line is a thin, even, almost invisible scar.

In case of a third degree cervical rupture, a control manual examination of the lower uterine segment is additionally performed to clarify its integrity.

Method of suturing cervical ruptures with a double-row suture for cervical ruptures of II–III degree.

·The cervix is grasped with two fenestrated clamps at a distance of 1.5–2 cm from the edge of the rupture, the edges of the wound are spread in opposite directions. This provides good review wound surface. Considering that cut wounds heal better, crushed and necrotic tissues are excised with scissors. The wound is sutured from the upper edge towards the external os of the cervix.

The first row of sutures (muco-muscular) forms the anatomy cervical canal. In this case, the mucous membrane is pierced throughout its entire thickness, and muscle layer- only half the thickness. The injection and puncture of the needle are carried out at a distance of 0.3–0.5 cm from the edges of the wound. The first suture is placed at the corner of the apex of the tear. The distance between the sutures is 0.7–1 cm. The ligature is carried out from the side of the mucous membrane, by tightening the ligatures, correct and tight alignment of the edges of the wound is achieved, the nodes are turned into the cervical canal.

·The second row of catgut sutures (separate or continuous) forms the vaginal portion of the cervix. The first ligature is applied 0.5 cm above the upper corner of the tear. Ligatures are carried out from the vaginal surface of the cervix, capturing the remaining part of the muscle layer and placed between the sutures of the first row. Special attention pay attention to comparison of tissues in the area of the external pharynx.

Vulvar rupture

For cracks and slight tears in the area of the vulva and vaginal vestibule, there are usually no symptoms and no medical intervention is required.

Operation technique

For ruptures in the clitoral area, a metal catheter is inserted into the urethra and left there for the entire duration of the operation.

Then a deep puncture of the tissues is performed with a solution of novocaine or lidocaine, after which the integrity of the tissues is restored using a separate and nodal or continuous superficial (without underlying tissues) catgut suture.

Rupture of the vaginal wall

The vagina can be damaged during childbirth in all parts (lower, middle and upper). Bottom part The vagina is torn simultaneously with the perineum. Ruptures of the middle part of the vagina, as less fixed and more extensible, are rarely noted. Vaginal ruptures usually go longitudinally, less often - in the transverse direction, sometimes penetrating quite deeply into the peri-vaginal tissue; V in rare cases they also invade the intestinal wall.

Operation technique

The operation consists of applying separate interrupted catgut sutures after exposing the wound using vaginal speculum. If there is no assistant for exposing and suturing vaginal tears, you can open it with two fingers (index and middle) of the left hand spread apart. As the wound in the depths of the vagina is sutured, the fingers that expand it are gradually pulled out.

Perineal rupture

A distinction is made between spontaneous and violent rupture of the perineum, and according to its severity, three degrees are distinguished:

· I degree - the integrity of the skin and subcutaneous fat layer is compromised posterior commissure vagina;

Second degree - in addition to the skin and subcutaneous fat layer, muscles are affected pelvic floor(bulbspongiosus muscle, superficial and deep transverse perineal muscles), as well as the posterior or lateral walls of the vagina;

III degree - in addition to the above formations, there is a rupture of the external sphincter anus, and sometimes the anterior wall of the rectum.

Pain relief methods

Pain relief depends on the degree of perineal rupture. For ruptures of the perineum of the 1st and 2nd degrees, local anesthesia is performed; for suturing the tissues for ruptures of the perineum of the 3rd degree, anesthesia is indicated.

Local infiltration anesthesia is carried out with a 0.5% solution of novocaine, which is injected into the tissues of the perineum and vagina outside birth trauma; the needle is inserted from the side of the wound surface in the direction of undamaged tissue. If regional anesthesia was used during childbirth, it is continued for the duration of suturing.

Operation technique

Restoration of perineal tissue is carried out in a certain sequence in accordance with anatomical features pelvic floor muscles and perineal tissues. Wound surface exposed with mirrors or fingers of the left hand. First, sutures are placed on the upper edge of the tear in the vaginal wall, then sequentially from top to bottom, knotted catgut sutures are placed on the vaginal wall, spaced 1–1.5 cm apart until a posterior adhesion is formed.

The application of knotted silk (lavsan, letilan) sutures to the skin of the perineum is carried out in the first degree of rupture.

For stage II rupture before (or as) suturing back wall The vaginas are sewn together with separate interrupted submersible sutures using catgut, the edges of the torn pelvic floor muscles, then silk sutures are placed on the skin of the perineum (separate interrupted ones according to Donati). When applying sutures, the underlying tissues are picked up so as not to leave pockets under the suture, in which subsequent accumulation of blood is possible. Individual heavily bleeding vessels are tied with catgut. Necrotic tissue is first cut off with scissors.

At the end of the operation, the suture line is dried gauze swab.

In case of a third-degree perineal rupture, the operation begins with disinfection of the exposed area of the intestinal mucosa (with ethanol or chlorhexidine solution) after removing feces with a gauze swab. Then sutures are placed on the intestinal wall. Thin silk ligatures are passed through the entire thickness of the intestinal wall (including through the mucosa) and tied from the intestinal side. The ligatures are not cut and their ends are brought out through the anus (in postoperative period they come off on their own or they are pulled up and cut off on the 9–10th day after surgery).

Gloves and instruments are changed, and then the separated ends of the external anal sphincter are connected using a knotted suture. Then the operation is performed as for a II degree rupture.

Amniotomy

Amniotomy - obstetric opening operation amniotic sac.

Equipment:

Bullet forceps (amniotome).

Conditions for the operation:

During pregnancy necessary condition for amniotomy - the presence of a mature cervix (on the Bishop scale, cervical maturity is 6 points). During childbirth, amniotomy is performed in the absence of contraindications.

Preparation for surgery:

It is advisable to administer antispasmodic drugs 30 minutes before amniotomy.

Operation technique:

During a vaginal examination, a jaw of bullet forceps is passed along the fingers of the examining hand and the membranes are punctured with the sharp end of the instrument. Fingers are inserted into the puncture site and the hole in the membranes is widened. The puncture is performed outside the contraction with minimal tension on the amniotic sac, eccentrically, which ensures ease of execution and safety. In case of polyhydramnios, the OB is released slowly under the control of the fingers to prevent the loss of small parts of the fetus and the umbilical cord.

METHODS FOR ISOLATING SEPARATED AFTERMISSION

PURPOSE: To isolate the separated placenta

INDICATIONS: Positive signs of placenta separation and ineffective pushing

ABULADZE METHOD:

Perform a gentle massage of the uterus in order to contract it.

Take with both hands abdominal wall into the longitudinal fold and invite the woman in labor to push. The separated placenta is usually born easily.

CREDET–LAZAREVICH METHOD: (used when Abuladze’s method is ineffective).

Bring the fundus of the uterus to the middle position, and with a light external massage cause the uterus to contract.

Stand to the left of the woman in labor (facing her feet), grasp the fundus of the uterus with your right hand, so that thumb was on the anterior wall of the uterus, the palm was on the fundus, and four fingers were on the posterior surface of the uterus.

Squeeze the placenta: squeeze the uterus anteroposteriorly and at the same time press on its bottom downward and forward along the pelvic axis. With this method, the separated afterbirth easily comes out. If the Credet-Lazarevich method is ineffective, manual separation of the placenta is carried out according to the general rules.

Indications:

no signs of placenta separation within 30 minutes after birth of the fetus,

blood loss exceeding the permissible level

third stage of labor,

· the need for rapid emptying of the uterus in case of previous difficult and operative childbirth and histopathic condition of the uterus.

2) start intravenous crystalloid infusion,

3) provide adequate pain relief (short-term intravenous anesthesia (anesthesiologist!

4) tighten the umbilical cord on the clamp,

5) insert a sterile gloved hand along the umbilical cord into the uterus to the placenta,

6) find the edge of the placenta,

7) using a sawing motion, separate the placenta from the uterus (without using excessive force),

8) without removing your hand from the uterus, use your outer hand to remove the placenta from the uterus,

9) after removing the placenta, check the integrity of the placenta,

10) control the walls of the uterus with the hand in the uterus, make sure that the walls of the uterus are intact and that there are no elements of the fertilized egg,

11) do light massage the uterus, if it is not dense enough,

12) remove the hand from the uterus.

Assess the condition of the postpartum woman after surgery.

In case of pathological blood loss it is necessary:

· replenish blood loss.

· Carry out corrective measures hemorrhagic shock and DIC syndrome (topic: Bleeding in the afterbirth and early postpartum period. Hemorrhagic shock and DIC syndrome).

18. Manual examination of the walls of the uterine cavity

Manual examination of the uterine cavity

1. Preparation for surgery: cleaning the surgeon’s hands, treating the external genitalia and inner thighs with an antiseptic solution. Place sterile pads on the anterior abdominal wall and under the pelvic end of the woman.

2. Anesthesia (nitrous-oxygen mixture or intravenous administration of sombrevin or calypsol).

3. With the left hand, the genital slit is spread, the right hand is inserted into the vagina, and then into the uterus, the walls of the uterus are inspected: if there are remains of the placenta, they are removed.

4. With a hand inserted into the uterine cavity, the remains of the placenta are found and removed. The left hand is located at the fundus of the uterus.

Instrumental cavity revision postpartum uterus

A Sims speculum and a lift are inserted into the vagina. The vagina and cervix are treated with an antiseptic solution, the cervix is fixed by the front lip with bullet forceps. A blunt large (Bumon) curette is used to inspect the walls of the uterus: from the fundus of the uterus towards the lower segment. The removed material is sent for histological examination (Fig. 1).

Rice. 1. Instrumental examination of the uterine cavity

TECHNIQUE FOR MANUAL EXAMINATION OF THE UTERINE CAVITY

General information: retention of parts of the placenta in the uterus is a serious complication of childbirth. Its consequence is bleeding, which occurs soon after the birth of the placenta or more late dates. Bleeding may be severe life-threatening postpartum women. Retained pieces of the placenta also contribute to the development of septic postpartum diseases. In case of hypotonic bleeding, this operation is aimed at stopping the bleeding. In a clinical setting, before surgery, inform the patient about the need and essence of the operation and obtain consent for surgery.

Indications:

1) defect of the placenta or fetal membranes;

2) monitoring the integrity of the uterus after surgical interventions, long labor;

3) hypotonic and atonic bleeding;

4) childbirth in women with a uterine scar.

Workplace equipment:

1) iodine (1% solution of iodonate);

2) cotton balls;

3) forceps;

4) 2 sterile diapers;

6) sterile gloves;

7) catheter;

9) consent form for medical intervention,

10) anesthesia machine,

11) propafol 20 mg,

12) sterile syringes.

Preparatory stage of performing the manipulation.

Execution sequence:

Remove the foot end of Rakhmanov's bed.

Perform bladder catheterization.

Place one sterile diaper under the woman in labor, the second on her stomach.

Treat the external genitalia, inner thighs, perineum and anal area with iodine (1% iodonate solution).

The operations are performed under intravenous anesthesia against the background of inhalation of nitrous oxide and oxygen in a 1:1 ratio.

Put on an apron, sanitize your hands, put on a sterile mask, gown, and gloves.

The main stage of the manipulation.

With the left hand they spread labia, and the right hand, folded in the form of a cone, is inserted into the vagina and then into the uterine cavity.

The left hand is placed on the anterior abdominal wall and the wall of the uterus from the outside.

The right hand, located in the uterus, controls the walls, placental area, and uterine angles. If lobules, fragments of the placenta, membranes are found, they are removed by hand

If defects in the walls of the uterus are detected, the hand is removed from the uterine cavity and transection, suturing of the rupture or removal of the uterus (doctor) is performed.

The final stage of the manipulation.

11.Remove gloves, immerse in a container with disinfectant

means.

12.Place an ice pack on your lower abdomen.

13. Conduct dynamic monitoring of the condition of the postpartum woman

(control of blood pressure, pulse, skin color

integument, condition of the uterus, discharge from the genital tract).

14.As prescribed by the doctor, begin antibacterial therapy and administer

uterotonic drugs.

Indications:

Bleeding in the 3rd stage of labor caused by abnormalities in the separation of the placenta.
No signs of placental separation or bleeding within 30 minutes after birth.
If external methods of releasing the placenta are not effective.
At premature detachment normally located placenta.

Equipment: clamp, 2 sterile diapers, forceps, sterile balls, skin antiseptic.

Preparation for manipulation:

Wash your hands surgically, wear sterile gloves.
Toilet the external genitalia.
Place sterile diapers under the woman's pelvis and on her stomach.
Treat the external genitalia with a skin antiseptic.
The operation is performed under IV anesthesia.

Performing the manipulation:

The labia are spread apart with the left hand, and the right hand is folded into a cone, back side facing the sacrum, inserted into the vagina, and then into the uterus, guided by the umbilical cord.
The edge of the placenta is found and, using “sawing” movements of the hand, the placenta is gradually separated from the wall of the uterus. At this time, the outer hand helps the inner hand, pressing on the fundus of the uterus.
After separation of the placenta, it is brought to the lower segment of the uterus and removed with the left hand by pulling the umbilical cord.
With the right hand, carefully examine the inner surface of the uterus again to exclude the possibility of retention of parts of the placenta.
Then the hand is removed from the uterine cavity.

Completing the manipulation:

Inform the patient that the procedure is complete.
Disinfection of reusable equipment: mirror, lifting forceps according to OST in 3 stages (disinfection, pre-sterialization cleaning, sterilization). Disinfection of used gloves: (O cycle - rinse, I cycle - immerse at 60 /) with subsequent disposal class “B” - yellow bags.
Disinfection of used dressing material with subsequent disposal in accordance with SanPiN 2.1.7. – 2790-10..
Handle gynecological chair with a rag soaked in disinfectant. solution twice with an interval of 15 minutes.
Wash the hands in the usual way and drain. Treat with moisturizer.
Help the patient rise from the chair.

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Surgical interventions in the afterbirth and early postpartum period include:
- manual separation of the placenta and release of the placenta;
- manual examination of the walls of the uterine cavity;
- suturing ruptures in the soft tissues of the birth canal (cervix, vagina, vulva), perineum (perineorrhaphy);
- curettage of the postpartum uterus.

OPERATIONS IN THE FOLLOW-UP PERIOD
Manual release placenta and placenta discharge
Manual separation of the placenta is an obstetric operation that involves separating the placenta from the walls of the uterus with a hand inserted into the uterine cavity, followed by removal of the placenta.

Indications:
Partial or complete tight attachment of the placenta. Normal succession period characterized by separation of the placenta from the walls of the uterus and expulsion of the placenta in the first 10-15 minutes after the birth of the child. If there are no signs of placenta separation within 30 minutes after the birth of the baby (with partial or complete tight attachment of the placenta), an operation to manually separate the placenta and release the placenta is indicated.

The picture of tight attachment of the placenta may occur with placenta accreta. However, in the absence of data for accreta at the antenatal stage, this diagnosis can only be established during the operation of manual separation of the placenta. In some observations, usually after the use of uterine contractions or during rough palpation of the uterus before the birth of the placenta, the separated placenta is strangulated in the cervix, which can simulate the picture of a placenta that has not separated.

Pain relief methods
Intravenous or inhalation general anesthesia, in the presence of a catheter installed in the epidural space for the purpose of pain relief during childbirth - extended regional.

Operation technique
The position of the woman on the operating table (birth bed) corresponds to that during vaginal operations - on her back, legs bent at the hips and knee joints and fixed in leg holders.

The midwife produces antiseptic treatment external genitalia of a woman. The woman's bladder must be emptied using a catheter. The surgeon performs antiseptic treatment of hands according to the principle of preparation for abdominal surgery and wears sterile long surgical gloves. With his left hand he spreads the woman’s labia and inserts his cone-shaped (“obstetrician’s hand”) right hand into the uterine cavity. With his left hand he fixes its bottom from the outside through a sterile diaper. The umbilical cord serves as a guide to help find the placenta. Having reached the place of attachment of the umbilical cord, the doctor determines the edge of the placenta and uses a sawtooth motion to separate it from the wall of the uterus. Then, with the left hand, pulling the umbilical cord releases the placenta. The right hand remains in the uterine cavity to conduct a control examination of its walls. Particular attention is paid to the placental area, which has a rough surface due to the remaining fragments of the spongy layer of the decidua.

At control study it is necessary to establish the integrity of the walls and the absence of retained parts of the placenta and membranes that must be removed. The operation ends with a gentle external-internal massage of the uterus against the background reintroduction reducing drug.

In the situation of placenta accreta, attempting to remove it manually is ineffective. Placental tissue tears and does not separate from the uterine wall, causing profuse bleeding, which can quickly lead to the development of hemorrhagic shock. In this regard, if placenta accreta is suspected, laparotomy followed by hysterectomy is indicated.

In some cases, if appropriate capabilities are available (highly qualified experienced personnel, the possibility of blood reinfusion, emergency ligation or temporary internal iliac balloon tamponade or embolization uterine arteries) in the absence of massive bleeding and partial placenta accreta in a small area, it is possible to use organ-preserving treatment methods (excision of the affected area of the myometrium and plastic surgery of the uterine wall).

Manual examination of the walls of the uterine cavity
Manual examination of the uterus is an obstetric operation that involves examining the walls of the uterus with a hand inserted into its cavity.

Indications:
Defect of the placenta or membranes (retention of parts of the placenta in the uterus).
Uterine bleeding in the postpartum period (most often hypotonic bleeding, rarely - uterine rupture).
Monitoring the integrity of the uterus after surgical interventions, childbirth with a uterine scar, third degree cervical rupture, uterine malformations (bicornuate uterus, saddle uterus, septum in the uterus, etc.).

The delay of parts is determined by examining the released placenta and detecting a defect in the tissue, membranes, or the absence of an additional lobule. A placental tissue defect is identified by examining the maternal surface of the placenta, spread out on a flat surface. Retention of the accessory lobe is indicated by the identification of a torn vessel along the edge of the placenta or between the membranes. The integrity of the membranes is determined after they have been straightened, for which the placenta should be lifted. Bleeding from the uterus in the early postpartum period is most often caused by its hypotension, which is manifested by its large size, laxity and lack of adequate contraction to massage.

Pain relief methods
Intravenous, inhalational or prolonged regional anesthesia.

Operation technique
Technique of operation for manual examination of the walls of the uterine cavity on initial stages corresponds to that during separation of the placenta and discharge of the placenta. The localization of the placental site is determined by hand and if retained placental tissue, remnants of membranes and blood clots are detected, they are removed. The area of the uterine angles is carefully checked. The operation ends with a gentle external-internal massage of the uterus against the background of repeated administration of a contracting drug.

Manual examination of the walls of the postpartum uterus during postpartum hemorrhage has two objectives: diagnostic and therapeutic. The diagnostic task is to inspect the walls of the uterus to determine their integrity and identify the retained lobule of the placenta. The therapeutic goal is to stimulate the neuromuscular apparatus of the uterus through gentle external-internal massage of the uterus against the background of repeated administration of contractile drugs. If a rupture of the uterine wall is detected, they proceed to laparotomy with subsequent restoration of the integrity of the wall or hysterectomy (depending on the clinical situation). If remains of placental tissue are found, they are removed.

OPERATIVE INTERVENTIONS IN THE POSTPARTUM PERIOD
The postpartum period begins from the moment of birth of the placenta and lasts for 6-8 weeks. The postpartum period is divided into early (within 2 hours after birth) and late. In Western literature, early postpartum period includes the first 24 hours after birth.

Indications:
Indications for surgical intervention in the early postpartum period are:
- rupture or cut in the perineum;
- rupture of the vaginal walls;
- cervical rupture;
- vulvar rupture;
- formation of hematomas of the vulva and vagina;
- uterine inversion (discussed in the corresponding chapter).

Cervical rupture
Based on the depth of cervical ruptures, there are three degrees of severity of this complication:
- I degree - tears no more than 2 cm long;
- II degree - tears exceeding 2 cm in length, but not reaching the vaginal vault;
- III degree - deep ruptures of the cervix, reaching the vaginal vaults or extending to it.

Pain relief methods
Restoring the integrity of the cervix after a rupture of I and II degrees usually does not require anesthesia. For grade III rupture, pain relief is indicated (short-term intravenous anesthesia or epidural analgesia).

Operation technique
The sewing technique does not present any great difficulties. They expose the vaginal part of the cervix with wide, long speculums and carefully grasp the anterior and posterior uterine lips with window clamps, determine the severity of the cervical rupture, and then begin to restore it. In case of a third degree cervical rupture, before suturing, a control manual examination of the lower uterine segment is performed to clarify its integrity.

From the angle of the rupture towards the external pharynx, separate sutures are placed with absorbable, preferably synthetic (Vicryl Rapid, Safil Rapid), material. The first ligature (provisional) is applied slightly above the rupture site. This allows the doctor to easily, without injuring the already damaged cervix, lower it when necessary and prevents the possibility of bleeding from a vessel not captured in the suture in the corner of the wound. To ensure that the edges of the torn neck are correctly adjacent to each other when suturing, the needle is injected directly at the edge, and the puncture is made at a distance of 0.5 cm from it. Moving to the opposite edge of the tear, the needle is injected at a distance of 0.5 cm from it, and the puncture is made directly at the edge. After the cervix has healed, the suture line appears as a thin, even, almost invisible scar.

Rupture of the vaginal wall
The vagina can be damaged in any of its sections (lower, middle, upper third) or along its entire length. The lower part of the vagina often ruptures at the same time as the perineum. Ruptures of the middle part of the vagina, as less fixed and more extensible, are rarely noted. Gap in upper third usually continues into the gap throughout. Vaginal ruptures usually run longitudinally, less often - in the transverse direction; they can also have a combination of a longitudinal beginning from the fornix, with an oblique transition to the side wall and then in the transverse direction to the womb in the lower third of the vagina. Sometimes the ruptures penetrate quite deeply into the peri-vaginal tissue; in rare cases they move to the wall of the rectum.

Pain relief methods
Restoring the integrity of the vagina with a small rupture sometimes does not require anesthesia or local anesthesia with a solution of novocaine 0.5% or lidocaine 1-2% is sufficient, you can also use lidocaine spray 10%. It is advisable to perform epidural anesthesia if the catheter inserted during childbirth is preserved. For grade III rupture, pain relief is required (short-term intravenous anesthesia or epidural anesthesia).

Operation technique
The operation consists of placing separate interrupted sutures with absorbable material after exposing the wound using vaginal speculum. If there is no assistant for exposing and suturing vaginal tears, you can open it with two fingers (index and middle) of your left hand spread apart. As the wound in the depths of the vagina is sutured, the fingers that expand it are gradually pulled out. Suturing can sometimes present significant difficulties; it is necessary to select the appropriate needle size and thread length to ensure safe closure of the vagina for deep, high-lying tears. When piercing the back wall of the vagina, piercing the rectum should be avoided. If there is a suspicion of suturing of the rectum, it is necessary to perform rectal examination. If a suture is detected on the intestinal wall, gloves are changed and this suture is removed from the vaginal side. Rupture of the vulva

Damage to the vulva and vaginal vestibule during childbirth, especially in primigravidas, is often noted. For cracks and minor tears in this area, there are usually no symptoms and no medical intervention is required. If suturing is required, then local anesthesia is used (Novocaine, lidocaine or epidural - if the epidural catheter inserted during childbirth is preserved).

Operation technique
For deep tears in the clitoral area, it is recommended to insert a metal catheter into the urethra and leave it in place for the entire duration of the operation to avoid stitching and subsequent occlusion or deformation of the urethra. Then local anesthesia is performed by injecting tissue with a solution of novocaine or lidocaine; you can use epidural anesthesia through a catheter inserted during childbirth. After anesthesia with separate interrupted or continuous superficial (possibly without involving the underlying tissues) suture, the integrity of the tissues is restored with absorbable suture material.

Hematomas of the vulva and vagina
Hematoma is a hemorrhage due to rupture of blood vessels in the tissue below and above the main pelvic floor muscle (levator ani muscle) and its fascia. More often, a hematoma occurs below the fascia and spreads to the vulva and buttocks, less often - above the fascia and spreads along the peri-vaginal tissue retroperitoneally (in severe cases, up to the perinephric region).

Symptoms of hematomas of significant size are pain and a feeling of pressure at the site of localization (tenesmus due to compression of the rectum), as well as general anemia (with a large hematoma). When examining postpartum women, a tumor-like formation of a blue-purple color is discovered, protruding outward towards the vulva or into the lumen of the vaginal opening. When palpating a hematoma, its fluctuation is noted. If the hematoma spreads to the parametric tissue, vaginal examination The uterus is pushed to the side and between it and the pelvic wall there is a stationary and painful tumor-like formation. In this situation, it is difficult to differentiate a hematoma from an incomplete uterine rupture in the lower segment. Urgent surgery necessary for a rapid increase in hematoma size with signs of anemia, as well as for a hematoma with heavy external bleeding.

Pain relief methods
The operation is performed under general anesthesia or epidural anesthesia. Operation technique

The operation consists of the following steps:
- tissue incision above the hematoma;
- removal of blood clots;
- ligation of bleeding vessels or stitching with 8-shaped sutures with absorbable suture material;
- closure sometimes with drainage of the hematoma cavity.

For hematoma of the broad ligament of the uterus, laparotomy is performed; The peritoneum between the round ligament of the uterus and the infundibulopelvic ligament is opened, the hematoma is removed, and ligatures are applied to the damaged vessels. If there is no uterine rupture, the operation is completed. If the hematomas are small in size and localized in the wall of the vulva or vagina, their instrumental opening is indicated (under local anesthesia), emptying and suturing with X- or Z-shaped sutures.

Perineal rupture
Perineal rupture is more common in primigravidas. A distinction is made between spontaneous and violent rupture of the perineum, and according to its severity, three degrees are distinguished:
- I degree - the integrity of the skin and subcutaneous fat layer of the posterior vaginal commissure is damaged;
- II degree - in addition to the skin and subcutaneous fat layer, the pelvic floor muscles (bulbospongiosus muscle, superficial and deep transverse perineal muscles), as well as the posterior or lateral walls of the vagina, are affected;
- III degree - in addition to the above formations, there is a rupture of the external sphincter of the anus, and sometimes the anterior wall of the rectum. Some guidelines consider rectal wall involvement to be a grade IV tear.

Pain relief methods
Pain relief depends on the degree of perineal rupture. For ruptures of the perineum of the 1st and 2nd degrees, local anesthesia is performed; for suturing the tissues for ruptures of the perineum of the 3rd degree, anesthesia is indicated. Local infiltration anesthesia is carried out with a 0.25-0.5% solution of novocaine or 1-2% solution of lidocaine, which is injected into the tissues of the perineum and vagina outside the birth injury; the needle is injected from the side of the wound surface in the direction of undamaged tissue. If epidural anesthesia was used during childbirth, it is continued for the duration of suturing instead of local anesthesia or anesthesia.

Operation technique
Restoration of perineal tissue is carried out in a certain sequence in accordance with the anatomical characteristics of the pelvic floor muscles and perineal tissues.

The external genitalia and the hands of the obstetrician are treated. The wound surface is exposed with mirrors or fingers of the left hand. First, sutures are placed on the upper edge of the tear in the vaginal wall, then sequentially from top to bottom, interrupted sutures with absorbable suture material are placed on the vaginal wall, spaced 1-1.5 cm apart until a posterior adhesion is formed. The application of interrupted non-absorbable silk (lavsan, letilan) sutures to the skin of the perineum is carried out in the first degree of rupture. These stitches will be removed on day 5 postpartum period. Less commonly, a subcutaneous suture is used with absorbable suture material.

In case of II degree of rupture, after (or as) the posterior wall of the vagina is sutured, the edges of the torn pelvic floor muscles are sewn together with separate interrupted submersible sutures with absorbable material, then separate sutures are placed on the skin of the perineum (perhaps for a better comparison of the edges of the wound, separate interrupted ones according to Donati). When applying sutures, the underlying tissues are picked up so as not to leave pockets under the suture, in which subsequent accumulation of blood is possible. Individual heavily bleeding vessels are tied with suture material. Necrotic tissue is first cut off with scissors. Torn muscles and at the same time the skin of the perineum can be sutured using the Shute method. It is better to use absorbable suture material. The suture begins from the lower edge of the wound by puncturing the skin at a distance of 0.5-1 cm from its edge with a puncture into the subcutaneous layer. After this, the direction of the needle is changed and the muscle on the opposite side is captured in the suture, and then, passing under the bottom of the wound, the muscle on the original side is captured in the suture. Then the suture is directed again in the opposite direction into the subcutaneous layer and punctured into the skin. The seam is completed by returning to the original side, grabbing the upper edge of the skin according to Donati. The beginning and end of the thread are carefully pulled up and tied. Thus, when suturing according to Shuta, all layers of the perineum are captured, but there are no knots inside the tissues. Suturing the perineum when it is torn or cut usually requires 2 to 4 Shuta knots.

At the end of the operation, the suture line is dried with a gauze swab and treated antiseptic solution. In case of a third-degree perineal rupture, the operation begins with disinfection of the exposed area of the intestinal mucosa (with ethanol or chlorhexidine solution) after removing feces with a gauze swab. Then sutures are placed on the intestinal wall. Thin ligatures (Vicryl Rapid) are applied to the intestinal wall (including through the mucous membrane). If ligatures are supposed to be removed, they are carried out and tied from the side of the intestine. Then the ligatures are not cut off and their ends are removed through the anus (in the postoperative period they come off on their own or they are tightened and cut off on the 9-10th day after the operation).

Gloves and instruments are changed, and then the separated ends of the external anal sphincter are connected using interrupted sutures with absorbable material. In this case, it is necessary to find and output its reduced part to ensure a complete comparison of the edges. Then the operation is completed, as with a II degree rupture. Curettage of the postpartum uterus

Indications:
The main indication for curettage of the postpartum uterus is later postpartum hemorrhage, caused by retained placental tissue and subinvolution of the uterus.

Pain relief methods
Intravenous, less often inhalation anesthesia or prolonged epidural anesthesia.

Operation technique
Under aseptic conditions after emptying Bladder The cervix of the uterus is exposed with a catheter using spoon-shaped mirrors, fixed with bullet forceps and brought downwards. If necessary, the cervix is dilated with Hegar dilators. Determine the length of the uterine cavity using a probe. A blunt curette is inserted into the uterine cavity and its walls are scraped using movements from the fundus to the cervix. It is advisable to carry out ultrasound monitoring of the effectiveness of curettage of the walls of the cavity of the postpartum uterus. If placenta accreta is suspected, hysteroscopy and, according to indications and if conditions exist, hysteroresectoscopy are recommended.

It is necessary to distinguish: a) manual separation of the placentae (separatio placentae manualis); b) manual extraction of the placenta (extractio placentae manualis); c) manual examination of the uterus (revisio uteri manualis). In the first case we're talking about about the separation of the placenta, which has not yet separated (partially or completely) from the walls of the uterus; in the second case - about the removal of the placenta that has already separated, but has not been released due to hypotension of the uterus, abdominal covers or spastic contraction of the uterine walls. The first operation is more difficult and is accompanied by a known danger of infection of the woman in labor compared to manual examination of the uterus. The operation of manual examination of the uterus is understood as an intervention undertaken to detect, separate and remove a retained part of the placenta or to control the uterine cavity, which is usually necessary after difficult rotation, application obstetric forceps or embryotomy.

Indications for manual separation of placenta

1) bleeding in the third stage of labor, affecting the general condition of the mother in labor, blood pressure and pulse; 2) delay in the release of the placenta for more than 2 hours and the failure of using pituitrin, taking Crede without anesthesia and under anesthesia. For manual separation of the placenta, inhalation anesthesia or intravenous administration of epontol is used. The woman in labor is placed on operating table or on a transverse bed and carefully prepare. The obstetrician washes his hands up to the elbows with diocide or according to Kochergin - Spasokukotsky. Technique of the operation. The obstetrician lubricates one hand with sterile Vaseline oil, folds the hand of one hand into a cone and, spreading the labia with fingers I and II of the other hand, inserts the hand into the vagina and uterus. For orientation, the obstetrician leads his hand along the umbilical cord, and then, approaching the placenta, goes to its edge (usually already partially separated).

Having determined the edge of the placenta and starting to separate it, the obstetrician massages the uterus with his outer hand in order to contract it, and inner hand, coming from the edge of the placenta, separates the placenta with sawtooth movements (Fig. 289). Having separated the placenta, the obstetrician, without removing his hand, with the other hand, carefully pulling the umbilical cord, removes the placenta. Secondary insertion of the hand into the uterus is extremely undesirable, as it increases the risk of infection. The hand should be removed from the uterus only when the obstetrician is convinced that the removed placenta is intact. Manual removal of the already separated placenta (if external methods are unsuccessful) is also performed under deep anesthesia; this operation is much simpler and gives better results.

Rice. 289. Manual separation of the placenta.

Manual examination of the uterine cavity

Indications for surgery: I) retention of lobules or parts of lobules of the placenta, doubt about its integrity, regardless of the presence or absence of bleeding; 2) bleeding in the presence of retention of all membranes; 3) after such obstetric operations, such as embryotomy, external-internal rotation, application of abdominal forceps, if the last two operations were technically difficult. Manual examination of the uterine cavity when retained placental lobes or doubts about their integrity is certainly indicated, since retained placental lobules threaten bleeding and infection. The prognosis is worse the later after birth the intervention is performed. Manual examination of the uterus (as well as examination of the cervix using mirrors) is indicated after all difficult vaginal operations in order to timely identify (or exclude) rupture of the uterus, vaginal vaults, and cervix. When manually examining the uterus, it is necessary to remember the possibility of error due to the fact that the obstetrician poorly examines the side of the uterus that is adjacent to the dorsum of his hand (the left one when inserting right hand, right - when inserting the left hand). To prevent such a very dangerous error and conduct a detailed examination of the entire inner surface uterus, it is necessary to make an appropriate circular rotation of the hand during the operation. Manual separation of the placenta (to a lesser extent, manual examination of the uterus) is still a serious intervention, although the frequency of complications after this operation has decreased significantly. However, the enormous danger that threatens the mother not only if she refuses this operation, but also if she delays the manual separation of the placenta, requires every doctor and midwife to master it. Obstetric hemorrhage is a pathology in which emergency care is not only the responsibility of every doctor regardless of his experience and specialty, but also midwives.

Instrumental examination of the uterine cavity

Indications for uterine curettage are delayed lobules or doubts about the integrity of the placenta. This operation has individual supporters. However, our data on its immediate and long-term results indicate the need for a more careful manual examination of the uterine cavity. If there is a suspicion of retention of a lobule in the uterus in those days of the postpartum period, when the uterus has already sharply decreased in size, curettage is indicated.