These next two pictures show "trailing membranes." When the placenta is born, but some of the amniotic sac is left inside, this is called trailing membranes. The membranes can be very delicate (even though they are wicked tough when the baby is inside them!), so need to be "teased" out. Midwives have a variety of methods and each midwife finds her own style with making sure trailing membranes come out intact.
Some will use a forcep, clamp it to the membranes and then, gently, gently, slide the membranes back and forth (or up and down), inching them out slowly. Going fast can break them, so this is delicate work. Other midwives use gauze to hold the membranes as they tease them out, feeling they can "feel" them coming out more easily than with an instrument. It definitely helps to use something because they are so slippery, it would be easy to wrap them around your finger/s and not know the tension you're using to get them out.
I was reminded by doctorjen that a common (great) way to tease the membranes out is to twist them. Using a ring forceps, twirl it slowly to "pull" it out.
This is an example of how long the trailing membranes can be.
Why is it important to get the membranes out? Leaving even a small piece inside can keep the uterus from contracting fully, which can cause a postpartum hemorrhage... or infection. I doula'd for a mom who developed a fever of 104 within 24 hours of her homebirth. In the hospital, they started antibiotics as well as making sure her uterus was firm and contracted. The reason for her sepsis was still unknown, so, after another 24 hours on antibiotics still with a high fever, the doctor decided to do a D&C to make sure all the placenta was removed. When they returned from surgery, the doctor said he didn't find anything, but sent the what he removed to pathology. Within a few hours, the path lab said they found a piece of amniotic sac the size of a newborn's clipped fingernail. I remain amazed. Does a woman always need to have a D&C if a small piece of membranes remains inside? Certainly not. Most women are able to get the fragment out on their own.
If a woman has trailing membranes and, as you are pulling them out, they break, in order to help a woman pass the fragment, having her take an herb or medication that contracts her uterus can keep her safe. While I am not as well-versed in herbs or homeopathics, the medication of choice would be methargine, taken 3-4 times a day for 2-3 days (depending on the midwife's judgement of need). Having your client take her temperature every 4 hours would be important as well. Her bleeding is yet another aspect that needs to be monitored. If she's bleeding an unusual amount, if it begins to smell foul, if she feels poorly, if she develops a fever (usually high), getting her medical help is warranted.