1. Birth of
    the baby

  2. Birth of
    the placenta

  3. Local anesthesia for vaginal/
    perineal repair

  4. Repair of the Perineum

Tutorial 2: Birth of the Placenta

Birth of the Problem Placenta During Childbirth

3. Events Immediately After the Birth of the Placenta

Third stage labor problems, associated with the placenta, which may be identified just after the actual birth of the placenta include the following:
  1. Delivery with Retained Fragments of the Placenta or Membranes
  2. The key to effective management is to ensure immediate recognition of retained fragments (cotyledons and/or membranes) in order to respond promptly before heavy blood loss ensues. Most often there will be continued bleeding after the placenta is out. However, it is not uncommon to have the heavy bleed occur some minutes or hours later, following a smaller but continuous flow. Therefore, immediate and careful inspection of the placenta and membranes should always be conducted as soon as the placenta is delivered. This inspection is detailed in the section Birth of the Normal Placenta: Procedures for Birth of the Normal Placenta, Section E.

    If there appears to be a placental or membranous fragment missing, inspect the vaginal canal and cervical os for evidence of trailing membranes, or other tissue. These may be teased out carefully with a ring forceps followed by gentle but firm massage of the uterus with the abdominal hand, to encourage contraction of the uterus.

    If there is any question about fragments of the placenta or membranes still remaining within the uterus, a manual sweep of the uterus is the next step. See Manual Removal of the Placenta and Membranes

    Once the uterus, cervical os, and vagina are cleared of placental and membranous fragments, an injection of 10 I.U. I.M. of Pitocin is appropriate to encourage further contraction of the uterus.

  3. Excessive Bleeding occurring During or Immediately After the Placenta is Delivered
  4. Bleeding after the placenta is delivered is usually due to one or more of the following three reasons:

    1. Retained fragments - discussion above

    2. Lacerations of the vagina, cervix, introitus or perineum - see repair of the perineum: Lacerations

    3. Atony of the uterine muscle due to poor uterine contractility

      Atony due to retained fragments will usually be effectively overcome by the procedures described above. However, it is quite possible to have complete delivery of the placenta and membranes followed by an immediate postpartum hemorrhage. This is due to failure of the myometrium to contract sufficiently to cause local vasoconstriction at the placental site.

      See Management of Third Stage Hemorrhage due to Uterine Atony

click on the links below to continue:
  1. Introduction
  2. Events prior to the birth of the placenta
  3. Events immediately after the birth of the placenta
  4. Procedures for management of third stage hemorrhage due to uterine atony
  5. Procedures for manual removal of the placenta and membranes
  6. Clinical Case
  7. End Note

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