– Place the fi rst and third fi ngers of this hand on the baby’s cheekbones to encourage fl exion of the head. Current advice is to avoid placing a fi nger in the baby’s mouth as this can damage the jaw. An assistant could be asked to push above the mother’s pubic bone as the head delivers, to keep the head fl exed
– Use the other hand to grasp the baby’s shoulders and fl ex the baby’s head towards its chest, while applying downward pressure to gently deliver the head (WHO 2003)
• Some breech babies will be slow to breathe spontaneously at birth, usually due to shock. It is important to have resuscitation equipment available and ready, and that the parents are aware that this may be required (Cronk 1998)
• As with any event, good communication with the parents is important as well as the maintenance of contemporaneous records
• Formation of a constriction ring or spasm between the upper and lower uterine segment
• Uterine abnormality, e.g. bicornuate uterus
If the placenta is morbidly adherent and there is no separation, bleeding may not occur. Risk factors for this include:
• Previous caesarean section
• Previous placenta praevia
• Previous retained placenta
• High parity
An adherent placenta occurs when there is a scanty or absent layer of decidua basalis (the maternal part of the placenta) at the site of implantation. Types of adherent placenta are:
• Placenta accreta. The chorionic villi have adhered to the myometrium
• Placenta increta. The chorionic villi invade the myometrium
• Placenta percreta. The chorionic villi have penetrated through the myometrium either to or beyond the serosa (outer layer of the uterine wall)
As with any emergency procedure, referral should be made to an appropriately qualifi ed professional, in this case an obstetrician, to undertake a manual removal of the placenta (NMC 2004a). However, it is a procedure all midwives should be familiar with in case of emer- gency and there is no appropriate assistance available. The following actions will help to promote a safe outcome:
• Call for help. If at home this will be a paramedic ambulance
• If the bladder is not empty, catheterisation will be required
• Oxytocin 10 iu can be given by intramuscular injection if it has not already done for active management of third stage. Do not give ergometrine as it can cause a tonic uterine contraction, which may delay expulsion
• An intravenous infusion should be commenced as soon as pos- sible to provide intravenous access and replace fl uid loss
• Analgesia must be given as available. Shock may occur due to pain from the procedure if analgesia is not adequate
• Full aseptic precautions must be taken to minimise risk of infection
• The umbilical cord should be made taut and the attendant’s leading hand inserted into the vagina and uterus following the direction of the cord. If the cord has separated, this will still need to be done
• Once the placenta is located, the cord should be released and the fundus supported. This will provide counter-traction to prevent inversion of the uterus
• A separated edge of the placenta should be felt for and the edge of the attendant’s hand should be eased between the placenta and the uterine wall (Figure 6.5). A careful slicing motion with the edge of the hand should be used to continue to separate the placenta until it is detached
• The fundus can then be massaged to assist the hand holding the placenta to be expelled from the uterus, still grasping the placenta
Following the procedure:
• The placenta must immediately be inspected for completeness.
If any placental lobe or tissue is missing, the uterine cavity must be explored to remove it (see next section)
• An assistant should then massage the fundus of the uterus to encourage a tonic uterine contraction
• An intravenous bolus of oxytocin (10 iu) should be given after successful removal of the placenta, followed by an intravenous infusion of oxytocin
• Observations should be made for:
– Vital signs (pulse, blood pressure, respirations) at least every 30 minutes for 6 hours or until the woman is stable
Figure 6.5 Removal of the placenta
– Uterine contraction. The uterine fundus should be palpated and lochia should be monitored to ensure it is not excessive
– Signs of coagulopathy (the ability of the blood to clot), par- ticularly if bleeding has been excessive
– Signs of infection, i.e. fever or foul-smelling vaginal dis- charge. Intravenous antibiotics should be given prophylacti- cally, according to local protocols
• Intravenous fl uid administration should be continued and a blood transfusion considered as necessary
(WHO 2003)
Problems
Tissue that is extremely adherent may be placenta accreta. If the placenta is unable to be separated easily, heavy bleeding or perfora- tion of the uterus may result. There are two choices:
1. A hysterectomy
2. The placenta can be left in situ to be reabsorbed
If the placenta is retained due to a constriction ring, or if hours or days have passed since delivery, it may not be possible to get the entire hand into the uterus. The placenta should be removed in frag- ments using two fi ngers, ovum forceps or a wide curette. As with any event, good communication with the parents is important, as well as the maintenance of contemporaneous records.
Manual examination of the uterus
A manual examination of the uterus will be necessary following a manual removal of the placenta. This is because the placenta is likely to be evacuated in pieces and it may be very diffi cult to ensure it is complete. A careful examination of the uterus will ensure there are no remaining fragments of placental tissue left in situ. If placental fragments are retained, there may initially be minimal blood loss from the vagina. However, there is a high risk that bleeding will eventually occur as retained tissue will prevent the uterus from contracting effectively, and also the risk of infection will be increased.
The procedure for manual examination of the uterus is similar to the technique described for manual removal of the placenta.
However, it is important to recognise that efforts to extract frag- ments of placental tissue that do not separate easily may result in heavy bleeding or uterine perforation, which usually requires
hysterectomy. This procedure is carried out by a midwife in an emergency only when no obstetric help is available (NMC 2004a).