Manual separation of the placenta and separation of the placenta algorithm. Manual separation of the placenta - process and consequences

METHODS FOR ISOLATION OF SEPARATED AFTERNATION

PURPOSE: To isolate the separated afterbirth

INDICATIONS: Positive signs of separation of the placenta and the ineffectiveness of attempts

ABULADZE'S METHOD:

Perform a gentle massage of the uterus, in order to reduce 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.

KREDE-LAZAREVICH METHOD: (used when the Abuladze method is ineffective).

Bring the bottom of the uterus to the middle position, with a light external massage, cause uterine contraction.

Stand to the left of the woman in labor (facing the legs), grasp the bottom of the uterus with your right hand, so that thumb was on the front wall of the uterus, the palm was on the bottom, and four fingers were on the back of the uterus.

Squeeze out the placenta: compress the uterus in the anteroposterior size and at the same time press on its bottom in the direction down and forward along the axis of the pelvis. The separated afterbirth with this method easily comes out. If the Krede-Lazarevich method is ineffective, the placenta is manually isolated according to the general rules.

Indications:

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

blood loss exceeding the allowable

third stage of labor

the need for rapid emptying of the uterus with previous difficult and operational delivery and histopathic state of the uterus.

2) start intravenous infusion of crystalloids,

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

4) tighten the umbilical cord on the clamp,

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

6) find the edge of the placenta,

7) with sawing movements, separate the placenta from the uterus (without applying excessive force),

8) without removing the hand from the uterus, remove the placenta from the uterus with the outer hand,

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 there are no elements of the fetal egg,

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

12) remove the hand from the uterus.

Assess the condition of the puerperal after surgery.

In case of pathological blood loss, it is necessary:

replenish blood loss.

Carry out measures to eliminate hemorrhagic shock and DIC syndrome. (Topic: Bleeding in the aftermath 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 the operation: treatment of the surgeon's hands, treatment of the external genitalia and inner thighs with an antiseptic solution. Put sterile liners on the anterior abdominal wall and under the pelvic end of the woman.

2. Narcosis (nitrous-oxygen mixture or intravenous injection of sombrevin or calypsol).

3. The genital slit is bred with the left hand, the right hand is inserted into the vagina, and then into the uterus, the walls of the uterus are inspected: if there are remnants 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 bottom of the uterus.

Instrumental revision of the cavity of the 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 (boumon) curette makes an audit of the walls of the uterus: from the bottom of the uterus towards the lower segment. The removed material is sent for histological examination (Fig. 1).

Rice. 1. Instrumental revision of the uterine cavity

TECHNIQUE OF MANUAL EXAMINATION OF THE UTERINE CAVITY

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

Indications:

1) defect of the placenta or membranes;

2) control of the integrity of the uterus after surgical interventions, prolonged childbirth;

3) hypotonic and atonic bleeding;

4) childbirth in women with a scar on the uterus.

Workplace equipment:

1) iodine (1% iodonate solution);

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 the manipulation.

Execution sequence:

Remove the foot end of Rakhmanov's bed.

Perform bladder catheterization.

Put 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).

Operations are performed under intravenous anesthesia against the background of inhalation of nitrous oxide with oxygen in a ratio of 1: 1.

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

The main stage of the manipulation.

Left hand 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 site, 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 a cerebrotomy is performed, the rupture is sutured or the uterus is removed (doctor).

The final stage of the manipulation.

11. Remove gloves, immerse in a container with a disinfectant

means.

12. Put an ice pack on the lower abdomen.

13. Conduct dynamic monitoring of the state of the puerperal

(control of blood pressure, pulse, color of skin

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

14. As prescribed by the doctor, start antibiotic therapy and administer

uterotonic agents.

Childbirth is divided into three periods: the opening of the cervix, straining, during which the fetus is expelled, and afterbirth. The separation and exit of the placenta is the third stage of labor, which is the least long, but no less responsible than the previous two. In our article, we will consider the features of the afterbirth period (how it is conducted), determining the signs of placental separation, the causes of incomplete separation of the placenta, and methods for separating the placenta and its parts.

After the birth of the child must be born. It is important to note that in no case should you pull on the umbilical cord to speed up this process. A good prevention of retention of the placenta is the earlier application of the child to the breast. Breast sucking stimulates the production of oxytocin, which promotes uterine contraction and separation of the placenta. intravenous or intramuscular injection small doses of oxytocin, also accelerates the separation of the placenta. To understand whether the separation of the placenta has occurred or not, you can use the described signs of placental separation:

Schroeder's sign: after separation of the placenta, the uterus rises above the navel, becomes narrow and deviates to the right;
Alfeld's sign: the exfoliated placenta descends to the internal os of the cervix or into the vagina, while the outer part of the umbilical cord lengthens by 10-12 cm;
when the placenta separates, the uterus contracts and forms a protrusion over pubic bone;
sign of Mikulich: after the separation of the placenta and its lowering, the woman in labor has a need to push;
Klein's sign: when the woman in labor is strained, the umbilical cord lengthens. If the placenta has separated, then after an attempt the umbilical cord is not tightened;
sign of Kyustner-Chukalov: when the obstetrician presses over the pubic symphysis with the separated placenta, the umbilical cord will not be retracted.

If the birth proceeds normally, then no later than 30 minutes after the expulsion of the fetus.

Methods for isolating a separated placenta

If the separated placenta is not born, then special techniques are used to speed up its release. Firstly, they increase the rate of administration of oxytocin and organize the release of the placenta by external methods. After emptying the bladder, the woman in labor is offered to push, while in most cases the placenta comes out after childbirth. If this does not help, the Abuladze method is used, in which the uterus is gently massaged, stimulating its contractions. After that, the belly of the woman in labor is taken with both hands in a longitudinal fold and they are offered to push, after which the afterbirth should be born.

Manual separation of the placenta is carried out with the ineffectiveness of external methods or if there is a suspicion of placental remnants in the uterus after childbirth. The indication for manual separation of the placenta is bleeding in the third stage of labor in the absence of signs of separation of the placenta. The second indication is the absence of separation of the placenta for more than 30 minutes with the ineffectiveness of external methods of separation of the placenta.

Technique of manual separation of the placenta

Left hand spread birth canal, and the right one is inserted into the uterine cavity, and, starting from the left rib of the uterus, the placenta is separated by sawing movements. With the left hand, the obstetrician should hold the bottom of the uterus. Manual examination of the uterine cavity is also carried out with a separated placenta with identified defects, with bleeding in the third stage of labor.

After reading it, it is obvious that, despite the short duration of the third stage of labor, the doctor should not relax. It is very important to carefully examine the released placenta and make sure that it is intact. If parts of the placenta remain in the uterus after childbirth, this can lead to bleeding and inflammatory complications in the postpartum period.

All operations, accompanied by the introduction of a hand into the uterine cavity, are great danger for women's health. This danger is associated with the possibility of bringing pathogenic microbes into the uterine cavity by the operator's hand. The operation is especially dangerous in this regard. manual separation placenta, since during its implementation the operating hand comes into contact with the blood and lymphatic vessels placental site. Of all the women who die from postpartum septic diseases, 20% had manual removal of the placenta or manual examination of the uterine cavity. In this regard, all operations associated with the introduction of a hand into the uterine cavity require strict adherence to the indications for their use, the strictest asepsis during the operation, the mandatory and immediate replenishment of blood loss and the appointment of antibiotic therapy.

Indications for manual removal of the placenta are bleeding in consecutive period in the absence of signs of separation of the placenta and the absence of signs of separation of the placenta one hour after the birth of the fetus in the absence of bleeding.

The operation of manual removal of the placenta should be performed in a small operating room. maternity ward. In the absence of such a room or in case of intense bleeding, the operation is performed on the delivery bed. The woman in labor is placed with her sacrum on the edge of the operating table or a shifted Rakhmanov bed. Lower limbs bent at the knees and hip joints and widely spaced, held with an Ott leg holder (Fig. 36), sheets (Fig. 37), or operating table leg holders.

36. Ott's leg holder.
a - in a disassembled state; b - in working position.

37. Leg holder made of sheets.
a - folding the sheet diagonally; b - twisting the sheet; c - use as a foot holder.

The operation of manual separation of the placenta should be performed under anesthesia, but in conditions where one midwife works independently, it is necessary to perform the operation without anesthesia, using 2 ml of a 1% solution of pantopon or morphine for anesthesia.

The external genital organs and the inner surface of the thighs of the woman in labor are processed antiseptic solution, dried and lubricated with a 5% solution of tincture of iodine. A sterile diaper is placed under the mother lower limbs and the abdomen are also covered with sterile linen. The operator thoroughly washes his hands up to the elbow using any of the available methods (Spasokukotsky, Furbringer, Alfeld, diacid solution, Pervomura, etc.), puts on a sterile gown and, before inserting the arm into the uterus, treats the hand and the entire forearm with 5% iodine solution.

With the left hand, the operator slightly presses through the abdominal wall on the bottom of the uterus to bring the cervix down to the entrance to the vagina and fixes the uterus in this position. This technique, which is easy to implement after the birth of the baby, allows the right hand to be inserted directly into the uterine cavity, bypassing the vagina, and thereby reduces the possibility of contamination of the hand by the vaginal flora. The hand is introduced folded in the form of a cone ("obstetrician's hand"). The umbilical cord is a landmark that helps to find the placenta in the uterine cavity. Therefore, when introducing a hand into the uterine cavity, it is necessary to hold the umbilical cord. Having reached the place of attachment of the umbilical cord to the placenta, you need to find the edge of the placenta and enter with your hand between the placenta and the wall of the uterus. The placenta is separated by sawtooth movements. At the same time, the outer hand helps the inner hand all the time, fixing the uterus. After separation of the placenta, it is removed with the left hand by pulling on the umbilical cord. The right hand must remain in the uterus at the same time, so that after the removal of the placenta, once again carefully check and examine the entire uterus and make sure that the entire placenta has been removed. A well-contracted uterus clasps the hand located in its cavity. The walls of the uterus are even, with the exception of the placental area, the surface of which is rough. After the end of the operation, means that reduce the uterus are applied, an ice pack is placed on the lower abdomen.

The process of separation of the placenta usually occurs without much difficulty. With a true increment of the placenta, it is not possible to separate it from the uterine wall. The slightest attempt at secession is accompanied heavy bleeding. Therefore, as already mentioned, when a true placental accreta is detected, an attempt to separate the placenta must be immediately stopped and doctors should be called in to perform a celiac surgery. If the bleeding is severe, then a self-employed midwife should apply uterine tamponade before the arrival of the medical team. This temporary event reduces blood loss only if a tight tamponade of the uterus is performed, in which the vessels of the placental site are compressed. Tamponade can be done by hand, or you can use forceps or tweezers. For tight filling of the uterus, at least 20 m of a wide sterile bandage is required.

The placenta is the organ that allows you to bear a child in the womb. It supplies the fetus useful material, protects it from the mother, produces hormones necessary to maintain pregnancy and much more different functions about which we can only guess.

Formation of the placenta

The formation of the placenta begins when fertilized egg attached to the wall of the uterus. The endometrium grows together with the fertilized egg, tightly fixing it to the wall of the uterus. In the place of contact between the zygote and the mucosa, the placenta grows over time. The so-called placentation begins from the third week of pregnancy. Until the sixth week, the embryonic membrane is called the chorion.

Until the twelfth week, the placenta does not have a clear histological and anatomical structure, but after, until the middle of the third trimester, it looks like a disk attached to the wall of the uterus. FROM outside the umbilical cord departs from it to the child, and inner side is a surface with villi that float in maternal blood.

Functions of the placenta

The child's place forms a bond between the fetus and the mother's body through the exchange of blood. This is called the hematoplacental barrier. Morphologically, it represents young vessels with thin wall, which form small villi over the entire surface of the placenta. They come into contact with the gaps located in the wall of the uterus, and blood circulates between them. This mechanism provides all the functions of the body:

Gas exchange. Oxygen from the mother's blood flows to the fetus, and carbon dioxide is transported back.
Nutrition and excretion. It is through the placenta that the child receives all the substances necessary for growth and development: water, vitamins, minerals, electrolytes. And after the body of the fetus metabolizes them into urea, creatinine and other compounds, the placenta utilizes everything.
hormonal function. The placenta secretes hormones that help maintain pregnancy: progesterone, chorionic gonadotropin, prolactin. In the early stages, this role is taken over by corpus luteum located in the ovary.
Protection. The hematoplacental barrier does not allow antigens from the mother's blood to enter the child's blood, in addition, the placenta does not allow many medications, own immune cells and circulating immune complexes. However, it is permeable to narcotic substances, alcohol, nicotine and viruses.

Degrees of maturity of the placenta

The degree of maturation of the placenta depends on the duration of the woman's pregnancy. This organ grows with the fetus and dies after birth. There are four degrees of placental maturity:

Zero - at normal flow pregnancy lasts up to seven lunar months. It is relatively thin, constantly increasing and forming new gaps.
The first - corresponds to the eighth gestational month. The growth of the placenta stops, it becomes thicker. This is one of critical periods in the life of the placenta, and even a minor intervention can provoke detachment.
The second - continues until the end of pregnancy. The placenta is already beginning to age, after nine months of hard work, it is ready to leave the uterine cavity after the baby.
The third - can be observed from the thirty-seventh week of gestation inclusive. This is the natural aging of an organ that has fulfilled its function.

Attachment of the placenta

Most often located or goes to the side wall. But it is finally possible to find out only when two-thirds of the pregnancy is already over. This is due to the fact that the uterus increases in size and changes its shape, and the placenta moves along with it.

Usually, during the current ultrasound examination, the doctor notes the location of the placenta and the height of its attachment relative to the uterine os. The placenta is normal back wall is high. At least seven centimeters must be between internal os and the edge of the placenta by the third trimester. Sometimes she even crawls to the bottom of the uterus. Although experts believe that such an arrangement is also not a guarantee of successful delivery. If this figure is lower, then obstetrician-gynecologists talk about. If there are placental tissues in the throat area, then this indicates its presentation.

There are three types of presentation:

Complete when so in case of her premature detachment there will be massive bleeding, which will lead to the death of the fetus.
Partial presentation means that the pharynx is blocked by no more than a third.
Regional presentation is established when the edge of the placenta reaches the pharynx, but does not go beyond it. This is the most favorable outcome events.

Periods of childbirth

Normal physiological childbirth begin at the time of the appearance of regular contractions with equal intervals between them. In obstetrics, three stages of childbirth are distinguished.

The first period is the birth canal must prepare for the fact that the fetus will move along them. They should expand, become more elastic and softer. At the beginning of the first period, the opening of the cervix is only two centimeters, or one obstetrician's finger, and by the end it should reach ten or even twelve centimeters and skip a whole fist. Only in this case the baby's head can be born. Most often, at the end of the disclosure period, an outpouring occurs amniotic fluid. In total, the first stage lasts from nine to twelve hours.

The second period is called the expulsion of the fetus. The contractions are replaced by attempts, the bottom of the uterus contracts intensely and pushes the baby out. The fetus moves through the birth canal, turning according to anatomical features pelvis. Depending on the presentation, the child may be born with a head or booty, but the obstetrician must be able to help him be born in any position.

The third period is called the afterbirth and begins from the moment the child is born, and ends with the appearance of the placenta. Normally, it lasts half an hour, and after fifteen minutes the placenta separates from the wall of the uterus and is pushed out of the womb with the last attempt.

Delayed placenta separation

The reasons for the retention of the placenta in the uterine cavity may be its hypotension, placenta accreta, anomalies in the structure or location of the placenta, fusion of the placenta with the wall of the uterus. The risk factors in this case are inflammatory diseases uterine mucosa, the presence of scars from caesarean section, fibroids, as well as a history of miscarriages.

A symptom of retained placenta is bleeding in the third stage of labor and after it. Sometimes the blood does not immediately flow out, but accumulates in the uterine cavity. Such occult bleeding can lead to hemorrhagic shock.

placenta accreta

It is called tight attachment to the wall of the uterus. The placenta can lie on the mucous membrane, be immersed in the wall of the uterus to the muscle layer and grow through all layers, even affecting the peritoneum.

Manual separation of the placenta is possible only in the case of the first degree of increment, that is, when it is tightly adherent to the mucosa. But if the increment has reached the second or third degree, then it requires surgical intervention. As a rule, on an ultrasound scan, you can distinguish how the baby's place is attached to the wall of the uterus, and discuss this point with the expectant mother in advance. If the doctor finds out about such an anomaly in the location of the placenta during childbirth, then he must decide to remove the uterus.

Methods for manual separation of the placenta

There are several ways to perform manual separation of the placenta. These can be manipulations on the surface of the abdomen of the woman in labor, when the afterbirth is, as it were, squeezed out of the uterine cavity, and in some cases, doctors are forced to literally take out the placenta with membranes with their hands.

The most common is Abuladze's technique, when the woman's obstetrician gently massages the anterior abdominal wall with his fingers, and then invites her to push. At this moment, he himself holds his stomach in the form of a longitudinal fold. So the pressure inside the uterine cavity increases, and there is a chance that the placenta will be born by itself. In addition, the puerperium is catheterized bladder, it stimulates the contraction of the muscles of the uterus. Oxytocin is administered intravenously to stimulate labor.

If manual separation of the placenta through the anterior abdominal wall is ineffective, then the obstetrician resorts to internal separation.

Placenta separation technique

The technique of manual separation of the placenta is removing it from the uterine cavity in pieces. An obstetrician in a sterile glove inserts his hand into the uterus. At the same time, the fingers are maximally brought to each other and extended. To the touch, she reaches the placenta and carefully, with light chopping movements, separates it from the wall of the womb. Manual removal of the afterbirth must be very careful not to cut through the wall of the uterus and cause massive bleeding. The doctor gives a sign to the assistant to pull the umbilical cord and pull out the child's place and check it for integrity. The midwife, meanwhile, continues to feel the walls of the uterus to remove any excess tissue and make sure that there are no pieces of the placenta left inside, as this can provoke a postpartum infection.

Manual separation of the placenta also involves uterine massage, when one hand of the doctor is inside, and the other gently presses on the outside. This stimulates the receptors of the uterus, and it contracts. The procedure is carried out under the general or local anesthesia under aseptic conditions.

Complication and consequences

Complications include bleeding in the postpartum period and hemorrhagic shock associated with massive blood loss from the vessels of the placenta. In addition, manual separation of the placenta can be dangerous and the development postpartum endometritis or sepsis. Under the most unfavorable circumstances, a woman risks not only her health and the possibility of having children in the future, but also her life.

Prevention

In order to avoid problems in childbirth, it is necessary to properly prepare your body for pregnancy. First of all, the appearance of a child should be planned, because abortions disrupt the structure of the endometrium to some extent, which leads to dense attachment children's place in subsequent pregnancies. It is necessary to diagnose and treat diseases in a timely manner genitourinary system, as they may affect reproductive function.

Timely registration of pregnancy plays an important role. The sooner the better for the child. Obstetrician-gynecologists insist on regular visits antenatal clinic during the period of gestation. Be sure to follow the recommendations, walks, proper nutrition, healthy sleep and physical exercises, as well as the rejection of bad habits.

It is necessary to distinguish between: a) manual separation of the placenta (separatio placentae manualis); b) manual selection afterbirth (extractio placentae manualis); c) manual examination of the uterus (revisio uteri manualis). In the first case we are talking about the separation of the placenta, which has not yet separated (partially or all) from the walls of the uterus; in the second case, the removal of an already separated, but not released, placenta due to hypotension of the uterus, abdominal integuments or spastic contraction of the walls of the uterus. The first operation is more difficult and is accompanied by a known risk of infection of the woman in labor compared to manual examination of the uterus. Under the operation of manual examination of the uterus is understood an intervention undertaken to locate, separate and remove the retained part of the placenta or to control the uterine cavity, which is usually necessary after a difficult rotation, imposition obstetric forceps or embryotomy.

Indications for manual removal of the placenta

1) bleeding in the third stage of labor, which affects the general condition of the woman in labor, blood pressure and pulse; 2) a delay in the release of the placenta for more than 2 hours and the failure of the use of pituitrin, taking Crede without anesthesia and under anesthesia. With manual separation of the placenta, they use inhalation anesthesia or intravenous administration of Epontol. The mother is placed on operating table or on a transverse bed and prepare carefully. The obstetrician washes his hands up to the elbow with diocide or according to Kochergin - Spasokukotsky. Operation technique. The obstetrician lubricates one hand with sterile vaseline oil, folds the brush of one hand cone-shaped and, spreading the labia with fingers I and II of the other hand, inserts the hand into the vagina and into the 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 proceeding to its separation, the obstetrician with the outer hand massages the uterus in order to reduce it, and inner hand, going from the edge of the placenta, with sawtooth movements separates the placenta (Fig. 289). Having separated the placenta, the obstetrician, without removing his hand, with the other hand, gently pulling on the umbilical cord, removes the placenta. The second introduction of the hand into the uterus is highly undesirable, as it increases the risk of infection. The hand should be removed from the uterus only when the obstetrician is convinced of the integrity of the extracted placenta. Manual selection of the already separated placenta (with the failure of external methods) is also performed under deep anesthesia; this operation is much easier and gives better results.

Rice. 289. Manual separation of placenta.

Manual examination of the uterine cavity

Indications for surgery: I) retention of lobules or parts of the lobules of the placenta, doubts about its integrity, regardless of the presence or absence of bleeding; 2) bleeding in the presence of delay of all membranes; 3) after such obstetric operations, as an embryotomy, external-internal rotation, application of cavity forceps, if the last two operations were technically difficult. Manual examination of the uterine cavity with retention of placental lobules or doubts about their integrity is certainly indicated, since retained placental lobules threaten with bleeding and infection. The prognosis is the worse the later after childbirth the intervention is performed. Manual examination of the uterus (as well as examination of the cervix with the help of mirrors) is indicated after all difficult vaginal operations in order to timely establish (or exclude) rupture of the uterus, vaginal vaults, cervix. When manually examining the uterus, it is necessary to remember the possibility of error due to the fact that the obstetrician poorly examines that side of the uterus, which is adjacent to the back surface of his hand (left - with the introduction right hand, right - with the introduction of the left hand). To prevent such a very dangerous mistake and a detailed examination of the entire inner surface the uterus, it is necessary to make an appropriate circular rotation of the hand during the operation. Manual removal 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 huge danger that threatens the puerperal not only when refusing this operation, but also when delaying the manual separation of the afterbirth, requires the mastery of it by every doctor and midwife. Obstetric bleeding refers to the pathology in which emergency care is the responsibility of not only every doctor regardless of his length of service and specialty, but also midwives.

Instrumental examination of the uterine cavity

An indication for curettage of the uterus is a delay in the lobule or doubts about the integrity of the placenta. This operation has some supporters. However, our data on its nearest and long-term results indicate the need for a more careful manual examination of the uterine cavity. If you suspect a delay in the lobule in the uterus in those days of the postpartum period, when the uterus has already sharply decreased in size, curettage is indicated.