OBGYNE LECTURES

abnormalities of the reproductive tract ...
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PCOS, Endometriosis and Pelvic Pain
Outlines PCOS, Endometriosis and Pelvic Pain. This took forever - hope you enjoy it and find it useful
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Dr. Khalid Abdel-Malik 2012
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Gynecology & obstetrics revision
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محاضرات د. محمود سالم 2011-2012
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DIGITAL OBGYNE
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Retained Placenta

After delivery of the baby, the placenta normally detaches from the inside of the uterus and is expelled, often with additional pushing efforts by the mother. Normally this occurs within a few minutes of delivery of the baby, but may take as long as an hour.
The four signs of placental separation are:
1. Apparent lengthening of the visible portion of the umbilical cord.
2. Increased bleeding from the vagina.
3. Change in shape of the uterus from flat (discoid) to round (globular).
4. The placenta being expelled from the vagina.
Commonly, after about 30 minutes of waiting or if there is increased bleeding without evidence of placental separation, a manual removal of the placenta is undertaken. Anesthesia (regional or general) is typically used for this as manual removal can cause considerable abdominal cramping. Sometimes, analgesia will prove helpful in relieving this discomfort
Manual Removal of the Placenta
One hand is inserted through the vagina and into the uterine cavity.
1. Insert the side of your hand in between the placenta and the uterus. You may need to push through the placental membranes to accomplish this
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[/center]Separate the placenta from the uterus with a sweeping motion

2. Using the side of your hand, sweep the placenta off the uterus.

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After the placenta is mostly separated, curl your palm around the bulk of it.

3. After most of the placenta has been swept off the uterus, curl your fingers around the bulk of the placenta and exert gentle downward and outward traction. You may need to release the placenta and then re-grab it.

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Continue to grasp the placenta as you remove it from the uterine cavity.
4. Then pull the placenta through the cervix. Most placentas can be easily and uneventfully removed in this way. A few prove to be problems.
[center]Placenta Accreta and Percreta

When you manually remove the placenta, be prepared to deal with an abnormally adherent placenta (placenta accreta or placenta percreta). These abnormal attachments may be partial or complete.
• If partial and focal, the attachments can be manually broken and the placenta removed. It may be necessary to curette the placental bed to reduce bleeding. Recovery is usually satisfactory, although more than the usual amount of post partum bleeding will be noted.
If extensive or complete, you probably won't be able to remove the placenta in other than handfuls of fragments. Bleeding from this problem will be considerable, and the patient will likely end up with multiple blood transfusions while you prepare her for a life-saving, post partum uterine artery ligation or hysterectomy. If surgery is not immediately available, consider tight uterine and/or vaginal packing to slow the bleeding until surgery is available.

Edited by dr.edrees telfah, 16 March 2010 - 04:49 PM.
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