Features of management of childbirth with premature detachment of a normally located placenta

Premature detachment of the normally located placenta occurs more often in pregnant women with late toxicosis with prolonged and severe course of it. This is facilitated by increased blood pressure, as well as pathological fragility and excessive permeability of blood vessels in these diseases. This complication develops in severe kidney diseases - glomerulonephritis and hypertensive form of pyelonephritis.

Premature detachment of the normally located placenta can occur as a result of mechanical action:

• late autopsy of the fetal bladder when the fetus is born in the "shirt"( in the shells);

• rough exposure to the abdominal wall and to the uterus of a pregnant woman or woman in childbirth that entails a trauma in the abdominal area, or hand pressure on the uterine fundus area to accelerate fetal birth;

• Absolute or relative shortness of the umbilical cord, which leads to a strong tension of the cord as the fetus moves along the birth canal and placental abruption.

With premature placental abruption, as with the presentation of the placenta, one of the leading signs is uterine bleeding. Later, a woman can complain of worsening of health - increasing weakness, cold sweat, violent pain in the abdomen, lack of fetal movement, etc. On examination, paleness of the skin, frequent pulse, lowering of blood pressure is noted. In obstetric examination, a change in the shape of the uterus is observed with the appearance of protrusion on one of its sections, the stress of the uterus wall at the site of this protrusion, the painfulness of palpation in the same place, a significant deterioration in the cardiac activity of the fetus( rapidity or deceleration, deafness of the heart tones and their arrhythmia ordisappearance).

If the placenta is located on the posterior surface of the uterus, the local tension and tenderness of its wall with premature placental abruption are either completely absent or slightly expressed.

If the detachment has occurred along the edge of the placenta, the blood that has accumulated between the placenta and the wall of the uterus goes out. If the detachment occurs in the center of the placenta, even with large retroplacental hematomas, the blood does not pour out for a long time, and signs of internal bleeding appear( pallor of the skin, rapidity of the pulse and a decrease in its filling, lowering of blood pressure).With the central detachment of the placenta on the mother's surface, a cup-shaped depression is often formed, to which dark clots of blood are tightly attached. These changes on the placenta are detected when she is examined after separation and separation of the placenta.

The task of a midwife in a maternity ward is to monitor a woman who is suspected or has already established a beginning premature detachment of a normally located placenta, in identifying new signs and alerting the doctor. If a woman's condition is severe, and all symptoms of detachment are clearly expressed, then the pregnant woman should be immediately delivered through a caesarean section. With a prolonged and extensive hemorrhage behind the child's place during the operation, signs of a so-called uteroplacental apoplexy, or Nuveller's uterus, may be found. Such an outcome of placental abruption occurs when blood is poured between the uterine wall and a child's place under high pressure, and then the liquid component of blood and its uniform elements penetrate deeply into the thickness of the uterine wall, up to the external peritoneum cover. As a result, the uterus loses its ability to contract, and at the same time there are signs of a clotting disorder in the form of hypo- or afibrinogenemia, a pathological condition caused by a sharp decrease or complete disappearance of fibrinogen in the blood, a biologically active substance necessary for blood clotting. The combination of these two complications leads to massive uterine bleeding and the death of a woman. In such cases, urgent surgery is necessary to remove the uterus with simultaneous transfusion of large amounts of blood, the introduction of blood substitute solutions, cardiac agents with parallel correction of the blood coagulation system by prescribing appropriate medications( fibrinogen, aminocaproic acid, countercrack, etc.).

If the clinical signs of premature detachment of the normally located placenta are poorly expressed, and the condition of the woman remains relatively satisfactory, this indicates that the child's place has peeled off in a small area. In such a situation conservative-expectant management of a woman is permissible.

If a premature detachment of a normally located placenta occurs in childbirth and its clinical manifestations are moderately expressed, then, in the presence of regular contractions and the opening of the uterine pharynx not less than 2-3 cm, an early opening of the fetal bladder should be performed, which usually prevents further growth of this pathology. In the conservative-expectant management of women with premature detachment of the normally located placenta, it is necessary to widely prescribe antispasmodics, as well as means for the prevention and treatment of fetal hypoxia.