FUNDO PERINEAL EXPLORATION
Manual Exploration of the Uterus
In our opinion, the full potential of manual exploration of the uterus is underestimated in the existing PPH guidelines.
Thus, the new WHO recommendations on prevention and treatment of postpartum hemorrhage (2013) do not mention this technique at all; in it, administration of uterotonics and uterine massage are immediately followed by intrauterine balloon tamponade and uterine artery embolization .
However, we would like to draw attention to the following facts:
1.Inserting the balloon catheter in the uterine cavity not confirmed empty can adversely affect efficacy of the method.
2.Manual exploration of the uterus and removal of blood clots have its own intrinsic therapeutic potential often resulting in PPH cessation, thus obviating the need for balloon tamponade.
3.Balloon tamponade is contraindicated in case of certain pathologies detectable during manual exploration (uterine rupture, intrauterine structural abnormalities, etc.); for example, uterine rupture detected by manual exploration in the presence of PPH requires immediate laparotomy.
It is necessary to emphasize that even when completeness of placenta is not in doubt, blood clots adhering to the placental bed can cause ongoing PPH just as well as retained products of conception. They should always be removed before the tamponade procedure
. Thorough cleaning of uterine walls is best achieved when wrapping the examination hand with moist gauze facilitates removal of adhered blood clots or retained amniotic membranes, which prevent effective contraction.
In a correct checklist, PPH when not responsive to uterine massage and uterotonics administration should require immediate exploration of the uterus performed with gauze-covered hand .
This should be done even in the case of well-contracted uterus if bleeding persists .
Retained products of conception or accessory lobes are surprisingly common, even when the delivered placenta appears macroscopically intact
Moreover, manual exploration of the uterus with uterine wall cleaning sometimes ensures the arrest of bleeding even in the absence of retained placental tissue or noticeable amount of blood clots to be removed.
This manipulation is simultaneously therapeutic (emptying the uterus and aiding its contraction) and diagnostic (in cases of placenta accreta, uterine rupture, cervical and vaginal lacerations, etc.).
In the 1970s, the obstetricians considered the approach, later abandoned, of manual exploration of the uterus in all vaginal deliveries, yet it is interesting that in a study of 100 patients who had elective manual exploration of the uterus at the time of delivery compared with a control group of 100 patients
, this procedure was associated with decreases in febrile morbidity or blood loss; however, they did not reach statistical significance.
In our opinion, it is important to spotlight an article written more than 40 years ago that has retained its significance for obstetrics with its exemplary study of 1, 219 cases of maternal mortality during an 11-year period in the state of California
. On the subject of PPH, the author underscored two striking phenomena, a large number of placenta accreta cases in patients with previous CD and the lack of manual exploration of the uterus in many lethal cases of PPH in connection with uterine atony. Failure to explore the uterus after vaginal delivery was noted frequently in the series. We regard this study as very useful in elucidating certain classical obstetrical principles which still hold true nowadays.