Treatment of third stage of labor

TREATMENT

OF THIRD STAGE OF LABOR

JOSEPH L. BAER, Senior

Attending

GynecoIogist

M.D.,

F.A.C.S.

and Attending Obstetrician, Michael Reese Hospital; and GynecoIogy, Rush MedicaI CoIIege

Clinical

Professor

of Obstetrics

CHICAGO

I

HAVE seen an attempt at manuaI remova1 of the pIacenta in which the physician’s hand went through a rupture in the uterus and brought forth severa co& of intestine avuIsed from their mesenteric attachment. The pIacenta, of course, had previousIy escaped into the abdomina1 cavity through the same rupture. I have seen inversion of the uterus which foIIowed vioIent attempts to express the pIacenta by pressure on the fundus. I have seen uteri quietIy distend with enough bIood to exsanguinate the patient and no one the wiser. I have seen futiIe attempts to express an adherent pIacenta which produced tremendous abdomina1 bruising and disabiIity. I have seen immediate postpartum hemorrhage so profuse that death ensued in ten minutes, and others that were controIIed and the patient saved onIy by a display of magnificient team work, The third stage of Iabor which normaIIy passes off so smoothIy can suddenIy or graduaIIy require the utmost in obstetric experience, ski11 and technica resources to terminate it successfuIIy and safeIy. Nature handIes this probIem in two totaIIy distinct and different acts; the first is separation of the pIacenta from the uterine pIacenta1 site and the second is the extrusion of the separated pIacenta from the birth cana1. InteIIigent treatment of the third stage of Iabor is primariIy dependent on the recognition of these steps. Under modern conditions of deIivery, the patient aIways recumbent, often under the inff uence of anesthetic, analgesic or amnesic drugs, the third stage terminates spontaneousIy in not more than IO per cent to 13 per cent of a11 deliveries. In the remainder some f&m of aid is required. This

interference to be heIpfu1 and not harmfu1 must be based on a recognition of the two distinct acts mentioned. Separation of the pIacenta occurs very rapidIy after the birth of the chiId, usuaIIy in three to five minutes. Retraction of the uterus rapidIy decreases the surface area of the corpus cavity. This normaIIy invoIves the pIacenta1 site which is near the fundus, the cotyIedons are squeezed off of the network of materna1 sinuses, the retropIacenta1 bIood gathers in the space between the two surfaces unti1 finaIIy the entire organ is Ioose and sIides into the Iower uterine segment. If the inferior margin of the pIacenta Ioosens first the retropIacenta1 bIood passes down the birth cana and out in a steady norma trickle. The pIacenta eventuaIIy foIIows, maternal surface first (Duncan). If the lower margin hoIds unti1 the pIacenta slides down, the membranes invert above it and the retropIacenta1 bIood is heId in this pouch of membrane unti1 pIacenta and bIood are extruded together. This pIacenta presents the feta1 surface first (SchuItz). These two types of delivery are determined in the Iower uterine segment and not in the corpus uteri. Their cIinica1 significance is mereIy an understanding of the steady trickIe as something physioIogica1 while that pIacenta is separating. SIGNS

OF

SEPARATION

OF

THE

PLACENTA

I. Change in the shape and IeveI of the fundus and corpus uteri. The broad thick corpus fiIIed with pIacenta becomes more conica1; hence the fundus IeveI rises sIightIy reaching even a IittIe above the umbiIicus. 2. The depression above the symphysis fiIIs out. The pIacenta has Ieft the corpus cavity and Iies in the Iower uterine seg-

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Recognition

No.

z

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of this sign requires

Stage an

empt>- bladder and an abdomen not too fat. 3. Advancement of the cord. If a tape

of Labor DELIVERY

An,tric.ln

OF

JC,~II n:ll cxf ~ll~~c<~r\

THE

24:

PI.ACENT.4

“ Indirect expulsion ” as described I~>-the author affords the closest approximation

FIN:. I. Indirect expulsion of the separated placenta. The abdominal rccti are grasped at the outer margins in the upper abdomen when the uterus is in firm contl-action. They are puIIed together toward the midline and held while the patient makes a single vigorous bearing-down effort. (Curtis, A. I-1. Obstetrics and Gvnecology, vol. 1. PhiIa., Saunders Co.)

or instrument marker is pIaced on the cord flush with the vuIva after taking out the sIack in the cord and this is done immediale&: after deIivery, the marker wiI1 advance IO cm. to 13 cm. ObviousIy the placenta has moved the same distance from its pIacenta1 site to its Iodgement in the Iower uterine segment and upper vagina. 4. Upward pressure on the corpus wiI1 drag the cord and marker into the vagina if separation has not occurred but wiI1 not do so if the pIacenta is out of the corpus This test is not cavity, i.e., is separated. desirabIe as it may contaminate the vagina. In the further course of an unaided normal third stage of Iabor the woman becomes aware of painful contractions ten to fifteen minutes after deIivery. She again bears down under this stimuIus and the stony hard corpus uteri drives the separated pIacenta out of the birth cana1. UnfortunateI?;, as has been pointed out, this occurs in onIy a smaI1 percentage of deIiveries.

to this spontaneous extrusion. It appIies onIy to the separated pIacenta and requires an alert cooperative patient; it is then 90.0 per cent successfu1. The bIadder shouId be empty. When the uterus is in stony hard contraction the recti muscIes are grasped as in Figures I and 2 and the patient is told to bear down vigorously. This temporary reconstruction of the abdominal waI1 directs her voluntary effort against the corpus and the placenta is expeIIed. Simple expression likewise appIies onIy to the separated pIacenta. The conditioris are identical with indirect expulsion but not the patient, suppIies the physician, the expeIIing force by grasping the fundus uteri with one or both hands, (Fig. sj, and pushing downward, without squeezing. If this fails make sure that separation of the pIacenta was correctIy diagnosed before trying again. Normal spontaneous separation of the pIacenta is usua1. Thereafter spontaneous extrusion, indirect expuIsion or simpIe ex-

248

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pression as outIined are the normal methods of deIivery of the placenta. The third stage of Iabor becomes ab-

Stage

of Labor

FEBRUARY, 193,

the corpus cavity with balIooning of the uterus foIIowed by a sudden Iarge gush of blood. Very infrequentIy (0.2 per cent) the

FIG. 2. Indirect expulsion of the separated placenta. The abdominal recti are grasped at the outer margins in the upper abdomen when the uterus is in firm contraction. They are pulled together toward the midIine and held whiIe the patient makes a single vigorous bearing-down effort. (Curtis, A. H. Obstetrics and GynecoIogy, vo1. I. Phila., Saunders Co.)

normaI if separation and advancement of the pIacenta does not occur. The pIacenta is usuaIIy adherent at the pIacenta1 site. OccasionaIIy it separates in part, uterine retraction and compression of the materna1 sinuses fai1 to take pIace at the separated area and postpartum hemorrhage ensues. Sometimes the pIacenta is compIeteIy separated but its Iower poIe is incarcerated in the cervix and bIeeding takes pIace into

attachment of the pIacenta is directIy into the uterine muscuIature (pIacenta accreta). When this involves the whoIe pIacenta1 site there is no bIeeding. The CredC method of termination is indicated if the pIacenta is adherent or mereIy retained (Fig. 4). This procedure was devised to extrude the pIacenta from the corpus cavity but thirty minutes shouId eIapse after deiivery before this is tried.

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The stony hard uterus is compressed to squeeze its contents out of the corpus If this is successful, the fina cavity.

Stage

of Labor

Amer~c;rn

Jwrm~l

OF Surwy

-39

AbfunuaZ removal of the pIacenta is the last resort and least desirable method. The primary indication is postpartum

FIG. 3. Simple expression of the separated placenta. The placenta Lies in the lowm uterine segment and upper vagina. The firmly contracted uterus, acting as :I pIunger, is pushed downward in the axis of the inlet without squeezing. Kurtis. A. Fl. Obstetrics and Gynecology, vol. I. PhiIa., Saunders Co.)

delivery is accomplished by simpIe expression. If the CredC: method fails it may be repeated every fifteen minutes, avoiding bruising of the uterus and abdominal wall. Gentle massage of the posterior surface of the uterus is justifiabIe to bring on the stony contraction necessary to carry out the technique.

hemorrhage. It must be remembered that postpartum hemorrhage may be concealed as we11 as external. The systemic evidences of such bleeding must be recognized before the bIood loss is great. Retention of the placenta without hemorrhage may occasionally be accompanied of shock. This Iikewise by symptoms

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American

Journal

of Surgery

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justifies manuaI remova1. FinaIIy, an arbitrary time Iimit of two hours of third stage

Stage

of Labor

1937

actuaIIy within the amniotic sac and not in the naked corpus cavity. Separation

FIG. 4. Cred6 method. The pIacenta is not yet separated. compressed, not pushed downward, in order to squeeze corpus cavity. When this is accomplished the pIacenta push as described for “simple expression.” (Curtis, A. voI. I. Phila., Saunders Co.)

and faiIure of the Credi: method is sufficient warrant for manua1 remova1. This procedure shouId be regarded as a major obstetrica operation. Fresh asepsis must be assured and anesthesia is required. The hand foIIows the cord to its point of insertion into the pIacenta whiIe the fundus uteri is fixed abdominaIIy by the other hand. The hand within the uterus is

FEBRUARY,

The firmly contracted uterus is the retained pIacenta out of the is then deLvered by a downward H. Obstetrics and GynecoIogy,

shouId begin at the most superior poIe of pIacenta1 attachment. The side of the hand is insinuated between pIacenta and uterus carrying the intact membranes ahead of it. As the pIacenta is Ioosened the hand is cupped above it and is withdrawn bringing the hand has the pIacenta out. Thus remained within the amniotic sac and the uterine cavity has not been soiIed.

to find a cleavage plane raises suspicion of placenta accreta. If this

I-‘ailure the

low grade

fe\-er is not unusual

I_inder such

circumstances.

Frc. ~.‘Inspection of the placenta. The placenta should be spread out on a flat surface, maternal side up. All blood clots must be gently wiped away. To expose the fetal surface the placenta should be lifted by the cord. This permits of careful and complete inspection of the pIacenta and mcmbrnnrs without the risk of producing artifacts or of overIooking any defects. (Curtis, A. kl. Obstetrics and Gynecology-, vol. 1. Phila., Saunders Co.)

is definitely diagnosed permission for a hysterectomy must be obtained. Inspection of the placenta is an indispensable part of the treatment of the third To avoid artifacts the placenta stage. shouId be received in a towel, the membranes teased out gently and then the organ should be spread out on a flat platter (Fig. 3). Clots must be wiped off and the placenta should be handled by the cord rather than grasped directIy and mutilated. Diagnosis of missing placental tissue whether part of the main structure or an aberrant cotyledon (placenta succenturiata) requires manual search of the corpus cavity and removal of such placental may be Missing membranes tissue. ignored as they usualIy come away in the early puerperium. A foul odor and

Postpartum hemorrhage and birth injuries do not come within the scope of this article. SUMMARY

The safe delivery of the placenta is more important to the maternal health than the safe delivery of the fetus. Recognition of separation of the placenta is an outstanding item in the conduct of the third stage of Iabor. Mechanism of placental separation and signs of separation are described. Spontaneous delivery of the placenta, “inand simple expression direct expulsion,” are essentially physiological. Crede method and manua1 removal of the placenta represent pathology in the third stage of labor. The importance and technique of placental inspection are also gi\,en.