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it's funny I remember in the very first delivery I ever attended right after the baby was delivered and the umbilical cord was cut I started to unscrew and remove my gloves and then I heard someone yell out hey where you going we still have to deliver the placenta so they were right that delivery of the baby is followed by the delivery of the placenta which usually occurs within five to fifteen minutes but it shouldn't take longer than 30 minutes after 30 minutes you start to think that something might be wrong and as you're standing there with your hand gently very gently holding on to the umbilical cord there are four key signs that you look out for that signal that the placenta is separating from the wall of the uterus so let's talk about what those four signs are the first is that the umbilical cord lengthens and that makes sense the umbilical cord is attached to the placenta and if the placenta is detaching from the uterus more of the umbilical cord should appear in front of you so that's the first sign that the umbilical cord the umbilical cord umbilical cord lengthens vocal cord lengthens the second sign is a gush of blood the second sign that the placenta is separating from the wall of the uris is a gush of blood which if you can visualize the placenta is shearing away from the underlying endometrium and that she erupts apart blood vessels causing the bleeding to occur and all of this is happening spontaneously how well after the babies delivered the uterus shrinks in size because the uterus is muscle after all so it has the ability to stretch and shrink really rapidly but the placenta isn't a muscle it doesn't change shape as readily so as the uterus shrinks and kind of kind of retracts away the blood vessels in the placenta tear so that accounts for the bleeding now to understand the third and the fourth signs of placental separation you have to understand what I think is the absolute most amazing thing about the uterus and the placenta and that is the structure with which the muscle fibers of the uterus are arranged so the muscle fibers of the uterus arranged in a kind of and a kind of crisscross fashion around the blood vessels so so here you have the muscle fibers of the uterus and they're arranged kind of in a crisscross fashion kind of like kind of like a lattice around the blood vessels so when the uterus contracts it squeezes on these blood vessels which have now been sheared and ruptured to stop the bleeding without this feature the mom would probably die of a hemorrhage from the separation of the placenta but the uterus contracting down on these blood vessels stops the bleeding and the third and fourth signs are related to that contraction of the uterus so you feel the third sign is that you feel the uterus feels firm and globular so you can actually feel that it's firming up and it's more globular globular in shape right and you also the fourth sign is that you're able to feel the uterus rising up to the anterior abdominal wall so you actually feel the uterus contracting and sort of pushing up or rising up to the to the anterior abdominal wall so why am I going into so much detail about these signs well it's because we look for them we wait for them because when they all occur we know that the placenta is coming and we can sort of help the process out but sometimes a practitioner can can put too much pressure on the umbilical cord too early that is when the placenta is still firmly attached to the uterus and that can lead to inversion of the uterus or the uterus sort of turning inside out and coming out through the vagina and that kind of looks like this the uterus is kind of turned inside-out because you pulled on the umbilical cord to hardly and the best way to prevent this from happening is to wait till all four signs not two not three but all four signs of placental separation occur before you put any traction on the umbilical cord but if the uterine inversion does occur the very first step is to try to reposition the uterus back into its normal position and that can be pretty challenging because uterus is in a contracted position rights contracted and that makes it harder to manipulate so that's why we'll often start off by using uterine relaxing agents so uterine relaxation agents to first sort of relax the uterus make it softer more pliable and then after the uterus is relaxed the practitioner will then place the uterus back into its normal position and after the uterus is placed back into its normal position we'll usually follow this with a uterine contracting agent or or what's called a utero a utero tonic agent right so you Roman uterus tonic meaning tone contraction right so uterotonic agent and the uterotonic agent helps to limit the bleeding because again when the uterus contracts down it squeezes off those blood vessels that are running through it and it also helps the utero tonic agent also helps to prevent re inversion of the uterus so that's why we use it now another thing that's also very important to keep in mind is that uterine inversion can be accompanied by a lot of bleeding so volume replacement sort of blood volume replacement is a very essential part of treatment so before we finish off this topic I want to mention a couple of things that put a woman at risk for uterine inversion I already mentioned that putting too much traction on the umbilical cord is one huge major risk factor another thing that makes uterine inversion a lot more likely is having a placenta that's too firmly attached to the uterus you can imagine the the placenta is too firmly attached to the uterus and that makes you that would probably make a person pull on the umbilical cord to hardly write in that condition where the where the placenta is attached to firmly to the uterus is called placenta it's called placenta Santa accreta placenta accreta right or very firmly adherent to placenta and you can also probably imagine that having a floppy uterus makes it easier to invert so the use of uterine relaxing agents can also increase the risk of inversion okay so that's uterine inversion in a nutshell a condition that teaches us to be or reminds us to be patient and to remember that even though the umbilical cord may look like a rope we're not playing tug-of-war with the placenta