Thursday, March 9, 2023

Placenta manual removal

Looking for:

Manual removal of the placenta after vaginal delivery: an unsolved problem in obstetrics.Nurse-Midwifery at University of Utah - Module2 - Tutorial 2 - Birth of the Placenta 













































     


- Placenta manual removal



  5. Procedures for Manual Removal of the Placenta and Membranes · Quickly draw a sterile glove over your existing glove on your dominant hand. · Fold a sterile. Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the. Manual removal of the placenta is an option for the treatment of retained placenta, but it carries the risks for hemorrhage, infection, and genital tract trauma.    

 

Manual Removal of the Placenta after Vaginal Delivery: An Unsolved Problem in Obstetrics - Main navigation



   

One size larger than the gloves you are wearing may be put on more rapidly. 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.

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 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.

If the placenta remains inside the uterus after one hour, OR if the placenta has missing pieces OR the woman is bleeding heavily -- remove the placenta or pieces with your hand. Do not delay! Here the cord breaks. You wait one hour, since the woman is not bleeding, but the placenta fails to come. Tell the woman you will now need to remove her placenta with your hand and why.

Ask for her consent. Be sure she has an IV and her bladder is empty. Then give her diazepam 10 milligrams IV — if she is not in shock. Also give her a single dose of antibiotics to prevent infection, either 2 grams of ampicillin IV or 1 gram of cefazolin IV. Then, wash your hands, and put on long, sterile gloves up to your elbows. With your thumb in your palm and fingers together, carefully insert your flattened hand.

Move it gently into the vagina, forward through the cervix and into the uterus. If the cord is present, pull it gently until it is taut and then follow it into the uterus. The third stage of labor is associated with considerable maternal morbidity and mortality. The major complication is postpartum hemorrhage PPH , which is the leading cause of maternal morbidity and mortality worldwide.

Whereas in the event of PPH due to atony of the uterus there exist numerous treatment guidelines; for the management of retained placenta the general consensus is more difficult to establish.

Active management of the third stage of labour is generally accepted as standard of care as already its duration is contributing to the risk of PPH. Despite scant evidence it is commonly advised that if the placenta has not been expelled 30 minutes after delivery, manual removal of the placenta should be carried out under anaesthesia.

Pathologic adhesion of the placenta in the low risk situation usually is diagnosed at the time of delivery; therefore a pre- or intrapartum screening opportunity for placenta accreta would be desirable. But diagnosis of abnormalities of placentation other than placenta previa remains a challenge.

Nevertheless the use of ultrasound and doppler sonography might be helpful in the third stage of labor. An improvement might be the implementation of standardized operating procedures for retained placenta which could contribute to a reduction of maternal morbidity.

The third stage of labor is still associated with considerable maternal morbidity and mortality. Therefore it is the leading cause of maternal morbidity and mortality worldwide [ 3 ]. It has a mortality rate of 0. Unfortunately, it is still not. Whereas in the event of PPH due to atony of the uterus there exist numerous guidelines, recommendations, and flowcharts for its management; in the treatment of retained placenta the general consensus is more difficult to establish.

With this paper our aim was to attract the obstetricians' attention to the potential risk of retained placenta in the low risk setting where it occurs without prior warning and to present a possible flowchart for the timing of treatment to reduce blood loss and therefore maternal morbidity. In general it can be said that already the duration of the third stage of labour is contributing to the risk of PPH as the risk of major bleeding is believed to increase with time elapsed after birth.

Hence, active management of third stage of labour using prophylactic oxytocics is accepted as standard of care. Active management of the third stage of labour involves administration of intravenous oxytocin, early cord clamping, transabdominal manual massage of the uterus, and controlled traction of the umbilical cord.

Should this appear insufficient, the next step is usually manual removal of the placenta MROP. However, the timing of this manoeuver is difficult as the risk of PPH from leaving the placenta in situ has to be weighed against the knowledge that manual removal can itself cause hemorrhage. It should also be borne in mind that the placenta may be delivered spontaneously up to 30 minutes or more after delivery of the child, without major additional blood loss.

The management questions that thus need answering are When and how to detect increased blood loss? When to call in support staff? When to contact the anesthesiologist? Observation of routine practice shows that MROP is regularly deferred beyond the limits recommended.

In the absence of immediate evidence of increased vaginal bleeding, management is often conservative and expectant, open to several different options, and paying little attention to the time elapsed since birth.

In a study of over 12, births, Combs and Laros found that the risk of hemorrhage increased after 30 minutes of placental retention [ 8 ]. Similarly, Magann et al. However, delaying the manual removal will lead to the spontaneous delivery of many placentas. Despite scant evidence it is commonly advised that if the placenta has not been expelled 30 minutes after delivery despite active management, MROP should be carried out under anaesthesia.

Clearly, in the published recommendations the choice of timing for manual removal depends on the facilities available and the local risks associated with both PPH and MROP. Accordingly, a survey in Europe showed that time until manual removal of placenta in the absence of bleeding varies widely between different countries, from under 30 minutes Spain and Hungary to 60 minutes and more The Netherlands [ 12 ]. There are different reasons for retained placenta and there is a wide variety in the nomenclature for disturbances in placental disruption.

We believe the following classification is sound: placenta adherens is caused by failed contraction of the retroplacental myometrium, incarcerated placenta is caused by a closed or closing cervix, and placenta accreta is caused by abnormal placental implantation [ 13 ].

A part of the placenta or the entire placenta is abnormally adherent to the uterine wall without underlying decidua basalis. In placenta increta the placental villi invade into the myometrium, while percreta placenta is classified as placental villi penetrating through the uterine serosa or the adjacent organs, usually the bladder [ 14 , 15 ]. Weeks observed a considerable variation in the retained placenta rate between countries [ 7 ]. In less developed countries it is less common about 0.

It is suggested that interventions common in the most developed countries such as abortions, uterine intervention, labour induction, and use of oxytocin could be contributing to the increase in retained placenta rate with increasing development. Commonly named risk factors for disturbances in placental disruption, such as placenta accreta, are history of retained placenta, previous caesarean section, maternal age over 35 years, preterm labour, induced labour, multiparity, previous uterine injury or surgery, uterine malformations, infection, and preeclampsia [ 1 , 3 , 6 — 8 , 14 — 18 ].

It is believed that placenta accreta is becoming more common due to the rising caesarean section rate and advancing maternal age, both independent risk factors for placenta accreta [ 2 , 17 ]. History of caesarean section and placenta previa are often of special interest as risk factors for placenta accreta. In a prospective observational cohort study of over 30, women who had caesarean delivery without labour, placenta accreta was present in 0.

With every additional caesarean delivery the risk for emergency hysterectomy was rising as well. Hysterectomy was required in 0. Some studies showed promising results by injecting oxytocin into the umbilical cord, as it increased the rate of spontaneous expulsions of the placenta and fewer manual removals of the placenta, but two Cochrane reviews, either investigating umbilical cord injection of saline or oxytocin in the routine management of the third stage of labour [ 20 ] or for the reduction of MROP [ 21 ], were not able to detect a significant reduction in the need for MROP.

Nevertheless, umbilical vein injection of oxytocin solution is an inexpensive and simple intervention that could be performed while placental delivery is awaited. However, high-quality randomized trials show that the use of oxytocin has little or no effect.

The same review showed a statistically lower incidence in manual removal of placenta if prostaglandin solution was used. Unfortunately, there were only two small trials contributing to this meta-analysis [ 21 ]. Eller et al. In 15 cases an attempt was made to remove the placenta manually, but these entire women required immediate hysterectomy for uncontrollable bleeding.



at

No comments:

Post a Comment

Subscribe to: Post Comments (Atom)

Scribblenauts Unlimited iOS Version Free Download

Looking for: Scribblenauts unlimited pc free download full version no survey  Click here to DOWNLOAD     ❿   Scribblenauts Unlimited Fe...