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

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Birth of the Problem Placenta During Childbirth

5. Procedures for Manual Removal of the Placenta and Membranes

Indications for use of Manual Removal Procedures

The decision to attempt manual removal of the placenta and membranes in an otherwise normal labor and birth should be based on one of two indications:

1. The sudden occurrence of hemorrhage but the placenta gives no indication of delivering. This may mean that at least partial separation has occurred. A portion of the placenta may have remained adhered to the wall of the uterus.



2. Hemorrhage after the birth of the placenta AND examination of the placenta also shows evidence of missing placental fragments, membranes or a cotyledon. This indicates the probability of retained tissue within the uterus.


Both of these events result in interference with the normal contraction of the uterus which usually enables the myofibrils of the uterine muscles to close off the small blood vessels and control bleeding. Removing the placenta and/or retained placental tissue and membranes is the critical first step to enable the uterus to contract effectively and stop the hemorrhage.

Preparation


1. Quickly draw a sterile glove over your existing glove on your dominant hand. One size larger than the gloves you are wearing may be put on more rapidly.



2. Fold a sterile towel on the mother's abdomen with the opening facing you. Place your non-dominant hand between the folds of the towel and grasp the uterus through the abdominal wall. The side of your hand should be around the fundus and your thumb just above the symphysis pubis.



3. Draw the uterus downward and continue to hold it stable with your hand.


Extraction of the placental tissue and membranes within the uterus

Make a cone with your dominant hand by holding the tips of your fingers and thumb together. Enter the vagina and gently push against the cervix to open it further, as you go into the lower portion of the uterus.

If the placenta is not yet delivered



1. Trace the umbilical cord with your hand as you enter the uterus and move laterally to identify the edge of the placenta. The membranes at the margin of the placenta are perforated by a stripping motion downward with the edge of your fingers directed toward the placenta. Be careful not to push the tips of your fingers against the wall of the uterus, as it is very thin and easily ruptured.



2. Insert the side of your hand between the placenta and the uterine wall. Gently use an up and down motion to establish a cleavage plane and then sweep behind the placenta and separate it from the wall of the uterus. Move carefully and sequentially from one side to the other around the back of the placenta, until it falls into your hand.


An analagous model for doing this may be practiced using a very large tangerine. This fruit separates very easily from its peel. Cut a 1/2 inch strip of the peel off of the fruit from top to bottom, then cut off the bottom section of the tangerine. Insert the side of your hand with your baby fingers between the peel and the fruit. Gently use an up and down sawing motion to separate the fruit from the peel. Proceed around the inside of the peel until the fruit falls into your hand.



See video of model for manual removal using a large tangerine



Another useful way to learn this technique, is to scrub in on a Caesarean birth with an experienced obstetric surgeon. He or she can guide you in the process of the removal of the placenta after the birth of the baby.


3. When the placenta is completely separated, draw it gently through the cervix, giving a slight forward twist of your hand as you enter the vagina, to help peel the membranes off the wall of the uterus, and also make a smaller bundle of the placenta as it is drawn out of the uterus and vagina. Use care in making a thicker cord of trailing membranes, then grasp them with your hand or a ring forceps to draw them out of the vagina without tearing a segment off and leaving it behind.



4. Rapidly examine the placenta and membranes to assure yourself that nothing had been left behind. It may be appropriate to make a second sweep of the uterus to identify, collect and remove any clots, membranes or small pieces of tissue left behind. Some practitioners will use a sterile gauze square in their hand to aid in this procedure. If you use a gauze sponge be sure to keep it firmly in your grasp and remove it from the uterus and vagina.



If the placenta has already delivered



1. Start on the lateral side of the uterus and conduct the same careful sweep of the inside wall of the uterus from side to side and top to bottom. Draw any clots or tissue into your hand in the lower uterine segment, and out through the cervix and vagina.



2. In the course of your sweep you may find a cotyledon still attached to the inside wall of the uterus. Use the same careful up and down sawing motion to establish a cleavage plane between the tissue and the wall, and separate the cotyledon from its attachment. Do not persist if it does not come away readily. It may be attached to the uterine muscle. Seek consultation immediately.



3. You occasionally might also come across tissue which is attached to the inner wall of the uterus with one or more "strings." Do not attempt to pull these strings out of the uterine wall. They may be deeply attached into the myometrium. Instead, attempt to pinch them to separate the cotyledon and remove it, leaving the string(s) behind. While not an easy maneuver to accomplish, one can also try using two fingers to tear the string, while buffering the string coming out of the wall with another finger so it does not put stress on the attachment. This is done by wrapping the string around the two fingers and then tearing it apart using two fingers. The strings left behind, or adherent tissue not able to be removed, will later slough off as long as bleeding is minimal.



After removal of the placenta and membranes



1. Assist the uterus to contract by firm, not vigorous, massage of the uterus through the abdominal wall. If bleeding is still brisk, immediately begin bimanual compression of the uterus. (see 4. procedures for management of third stage hemorrhage)



2. Once you are assured you do not need to enter the uterus again, an oxytocic agent should be given. (see 4. procedures for management of third stage hemorrhage) This is effectively accomplished by an intravenous infusion of Pitocin, followed by a course of oral Methergine, e.g. 0.2 mg Methergine tablets by mouth every 4 hours for 6 doses.



3. Depending upon the degree of invasion of the uterus, it may be appropriate to give the mother a course of antibiotic therapy.



Important Note:

If the problem of retained membranes or fragments is not solved immediately and effectively, assistance by a qualified and experienced obstetrician is an important next step. This may involve phone consultation, transfer of the mother to a facility where the problem can be best managed, and/or timely request for the assistance of the obstetrician within the facility in which the birth has occurred.

Timely assistance is always a key to an effective outcome.

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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