38. Manual separation and extraction of the placenta, manual and instrumental exploration of the uterine cavity, uterine packing - indications, technique

Introduction

These are the hand procedures of the third stage and the early puerperium, used when the placenta does not deliver or the uterus keeps bleeding.

Manual separation and extraction of the placenta

Indications

• Retained placenta: not delivered 30 minutes after birth despite active management.
• Heavy bleeding before the placenta is delivered (partial separation).

Technique

1. Anaesthesia (regional or general), aseptic conditions, IV line, blood crossmatched, empty bladder, antibiotic cover.
2. The outer hand steadies the fundus through the abdomen; the inner hand, shaped like a cone, follows the cord into the uterus.
3. Find the edge of the placenta and separate it with the side of the hand (ulnar edge), sweeping between the placenta and the uterine wall.
4. Remove it whole, check the cavity is empty, give oxytocin infusion, inspect the placenta.

If no plane can be found, suspect placenta accreta: stop, do not tear it out, and prepare for surgery (conservative management or hysterectomy).

Manual and instrumental exploration of the uterine cavity

Indications

• Incomplete placenta or membranes on inspection, or suspicion of retained tissue.
• Persistent bleeding after delivery; suspected uterine rupture (after a previous caesarean, difficult operative delivery, internal version).

Technique

• Manual exploration: under anaesthesia, the hand checks all the walls, cornua and the lower segment for retained tissue and tears.
• Instrumental (curettage): a large blunt curette (Bumm) or suction removes retained products; gentle technique, because the puerperal uterus is soft and perforates easily.