Name: Gita Pramodha W.R.S (0056) Source: William Obs. Ed.

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Review Of Placenta Delivery

Signs of Placental Separation: 1. The uterus becomes globular and as a rule, firmer 2. There is often a sudden gush of blood 3. The uterus rises in the abdomen because the placenta, having separated, passes down into the lower uterine segment and vagina. Here, its bulk pushes the uterus upward 4. The umbilical cord protrudes farther out of the vagina, indicating that the placenta has descended. These signs sometimes appear within 1 minute after delivery of the newborn and usually within 5 minutes.

Delivery of the Placenta Expression of the placenta should never be forced before placental separation lest the uterus becomes inverted. Traction on the umbilical cord must not be used to pull the placenta outof the uterus. As downward pressure toward the vagina is applied to the body of the uterus, the umbilical cord is kept slightly taut. The uterus is then lifted cephalad with the abdominal hand. This maneuver is repeated until the placenta reaches the introitus. As the placenta passes through the introitus, pressure on the uterus is stopped. The placenta is then gently lifted away from the introitus Care is taken to prevent the membranes from being torn off and left behind. If the membranes start to tear, they are grasped with a clamp and removed by gentle teasing. The maternal surface of the placenta should be examined carefully to ensure that no placental fragments are left in the uterus.

Complication of Placenta Delivery

1. Inversio Uteri Complete uterine inversion after delivery of the infant is almost always the consequence of strong traction on an umbilical cord attached to a placenta implanted in the fundus. Contributing to uterine inversion is a sturdy cord that does not readily break away from the placenta, combined with fundal pressure and a relaxed uterus, including the lower segment andcervix. Placenta accreta may be implicated as in the case.

2. Retentio Placenta a. Placenta Accreta is used to describe any implantation in which there is abnormally firm adherence to the uterine wall. As the consequence of partial or total absence of the decidua basalis and imperfect development of the fibrinoid or Nitabuch layer, placental villi are attached to the myometrium in placenta accreta. Placenta accreta can cause trouble in stage III because it is difficult to escape from uterine wall. It may involve only a few to several lobulespartial placenta accreta All or part of a single lobule may be attachedfocal placenta accreta. b. Placenta Increta Villi actually invade into the myometrium c. Placenta Percreta villi penetrate through the myometrium

3. Abnormal Shape or Implantation a. Multiple Placentas with a Single Fetus Uncommonly, the placenta forms as separate, near equally sized disks. The cord inserts between the two placental lobeseither into a connecting chorionic bridge or into intervening membranes. This condition is termed bilobate placenta, but is also known as bipartite placenta or placenta duplex A placenta containing three or more lobes is rare and termed multilobate b. Succenturiate Lobe These placentas are a smaller version of the bilobate placenta. One or more small accessory lobes develop in the membranes at a distance from the main placenta, to which they usually have vascular connections of fetal origin. The accessory lobe may sometimes be retained in the uterus after delivery and may cause serious hemorrhage. c. Placenta Membranacea Rarely, all or a large part of the fetal membranes are covered by functioning villi. Placenta membranacea may occasionally give rise to serious hemorrhage because of associated placenta previa or accreta. d. Ring-Shaped Placenta the placenta is annular in shape, and sometimes a complete ring of placental tissue is present. This development may be a variant of placenta membranacea. Because of tissue atrophy in a portion of the ring, a horseshoe shape is more common. These abnormalities appear to be associated with a greater likelihood of antepartum and postpartum bleeding and fetal-growth restriction.
e. Placenta Fenestrata

There is an actual hole in the placenta, but more often, the defect involves only villous tissue, and the chorionic plate remains intact.

f. Extrachorial Placenta

When the chorionic plate, which is on the fetal side of the placenta, is smaller than the placental basal plate, which is located on the maternal side, the periphery is uncovered, and the term extrachorial placenta is used.