The Brandt-Andrews maneuver is an obstetric technique used to remove the placenta and umbilical cord in the last stage of labor, after the mother expels the child.
The procedure is based on the doctor cutting the umbilical cord that connects the child with the placenta. Later, the stage of placental abruption and expulsion begins, known as delivery.
Placenta. By BruceBlaus - Own work, CC BY-SA 4.0, commons.wikimedia.org
The placenta is an organ that originates from gestation cells and is responsible for maintaining fetal vitality through the exchange of nutrients, oxygen and hormones that it receives from the maternal circulation.
Once the expulsion of the child occurs, the placenta begins a natural detachment process that can last up to 30 minutes.
The technique proposed by the North American obstetricians Murray Brandt and Charles Andrews consists of facilitating the placental exit by applying firm but subtle pressure from the umbilical cord, with one hand, while holding the uterine fundus fixed with the other. In this way the doctor can evaluate the bleeding, the consistency of the uterus and the integrity of the placenta, to avoid later complications.
History
Dr. Murray Brandt was a New York obstetrician who dedicated his professional life to studying the mechanism of labor. He was one of the first professionals to clarify that the separation and expulsion of the placenta were two different processes.
In 1933 he published his work Mechanism and Management of the Third Stage of Labor, in which he described a maneuver to facilitate placental outflow and avoid eversion of the uterus, a complication that was frequently observed with the technique used previously.
Later, in 1940, Norfolk, Virginia obstetrician Charles Andrews introduced a modification to the Brandt maneuver.
Around 1963 it was decided that both techniques were equally important and complementary, so the eponymous Brandt-Andrews began to be used to refer to the union of both descriptions of the procedure.
Technique
Murray Brandt described in 1933 his technique to facilitate placental expulsion, which he developed through a study that involved 30 patients in the period of labor that comes after the expulsion of the fetus, called delivery.
In each case, they waited between 5 and 10 minutes for the baby to come out and proceeded to place a surgical clamp on the umbilical cord that protruded through the vulva.
With one hand, the fundus of the uterus should be located, which is contracted with a hard consistency. Meanwhile, the clamp and umbilical cord are held with the other hand until it is felt to be easy to pull it out. This means that the placenta has detached and can now be manually helped to deliver it safely.
While the umbilical cord is found, the uterus is held firmly in place with the other hand, seeking to elevate it.
In 1940 Charles Andrews added a modification to the original procedure described by Murray Brandt. First, descent of the umbilical cord is expected, which indicates placental abruption.
Subsequently, a firm and slow traction is made with the hand that manipulates the cord while, with the other hand, the uterus is gently massaged to stimulate contraction and facilitate placental abruption.
Both techniques emphasize firmly holding the uterus in position and, if possible, pushing it vertically upward.
Clinical considerations
The placenta is a specialized and complex organ that forms around the 4 - ta week of gestation and fetal ensuring vitality within the uterus.
It is attached to the uterus and has a rich network of blood vessels which connects with the maternal circulation. Through this vascular matrix it performs functions of exchange of gases, nutrients, hormones and also acts as a barrier against some harmful particles.
Uterus and other elements of gestation. By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, commons.wikimedia.org
After birth and the interruption of circulation with the separation of the umbilical cord, the placenta begins a process of detachment and expulsion through the vaginal canal. This moment represents the third stage of labor and is known as delivery.
Delivery lasts about 30 minutes, however, some specialists agree that maneuvers should be started to facilitate the process in case there is no natural expulsion 10 minutes after birth.
When a natural delivery does not occur, the pertinent maneuvers are carried out to facilitate placental detachment and expulsion. This is known as active management of the third stage of labor, with the Brandt-Andrews technique being the most widely used maneuver.
The Credé maneuver was the one that had been performed since 1853. It consisted of making abdominal pressure near the symphysis pubis while pulling the umbilical cord with force, but it brought serious complications in many cases.
The Brandt-Andrews maneuver avoids postpartum complications, when done correctly. By stimulating the uterus so that it continues to contract, it is achieved that it does not enter a passive state, in which detachment is not possible. Uterine contractions at this stage also prevent massive bleeding that can be fatal.
Complications
The cord traction described according to the Brandt-Andrews maneuver, securing the uterus, prevents uterine inversion. That is, the inner part of the uterus protrudes through the vagina. This complication was frequent with the technique described by Credé.
When the placenta remains within the uterus for more than 30 minutes, it is considered a complication of childbirth known as placental retention. This can lead to infection of the uterine cavity.
Another complication that can occur due to poor technique on the part of the doctor is the detachment of the umbilical cord, which causes bleeding and placental retention.
This phenomenon is due to exaggerated traction on the umbilical cord in a placenta that has not completely detached from the uterine fundus.
Management in these cases is surgical and emergency, since it represents a danger to the life of the patient.
References
- Anderson, J. M; Etches D. (2007). Prevention and management of postpartum hemorrhage. Am Fam Physician. Taken from: aafp.org
- Baskett, T. (2019). Eponyms and names in obstetrics and gynaecology (3rd ed). Cambridge, United Kingdom: Cambridge University Press
- Brandt, M. (1933). The Mechanism and Management of the Third Stage of Labor. American journal of obstetrics & gynecology. Taken from: ajog.org
- Kimbell, N. (1958). Brandt-Andrews technique of delivery of the placenta. British medical journal. Taken from: ncbi.nlm.nih.gov
- Gülmezoglu, A. M; Widmer, M; Merialdi, M; Qureshi, Z; Piaggio, G; Elbourne, D; Armbruster, D. (2009). Active management of the third stage of labor without controlled cord traction: a randomized non-inferiority controlled trial. Reproductive health. Taken from: ncbi.nlm.nih.gov
- Barbieri, R. (2019). Retained placenta after vaginal birth: How long should you wait to manually remove the placenta? Taken from: mdedge.com