Paramedic and early postpartum hemorrhage. Bleeding in the afterbirth and early postpartum periods

Causes of bleeding developing in early postpartum period:

1. retention of parts of the placenta

2. soft injuries birth canal

3. violation of uterine contractility:

Hypotonic bleeding

Atonic bleeding

4. development of DIC syndrome.

Retention of parts of the placenta.

Occurs with unreasonably active management of the third stage of labor.

Pieces of placental tissue are foreign bodies, the contractility of the uterus is impaired, it does not contract, and the vessels of the placental area gape.

Diagnostics.

1) Inspection of the maternal part of the placenta:

Fabric defect

Absence of decidua (platinum)

2) Presence of bleeding

(blood enters from below - in the form of a spring)

Medical tactics:

Operation of manual examination of the uterine cavity

(parts of the placenta retained in the uterine cavity are removed).

Injuries of the soft birth canal.

A) Damage to the cervix, vagina and perineum:

1. Bleeding begins in the second stage of labor and continues in the third stage of labor and in the early postpartum period

2. The body of the uterus is dense

3. Massaging the uterus does not reduce the intensity of bleeding.

4. Blood is scarlet

5. Bleeding is continuous

6. The blood clotting process is not impaired

Diagnostics.

Inspection in mirrors.

Medical tactics:

Suturing the defect

B) Uterine rupture

Characteristic development of massive bleeding

Diagnostics.

The operation of manual examination of the walls of the uterine cavity.

Medical tactics:

Immediate laparotomy, excision of the edges of the rupture and suturing it.

If there is a significant defect,

Massive hemorrhagic impregnation of the uterine walls,

In case of damage to vascular bundles

Amputation or extirpation of the uterus is performed.

During amputation, the body of the uterus is cut off at the level of the internal os.

Extirpation of the uterus and tubes is performed if there are signs of infection.

Hypotonic bleeding.

This is the most common species obstetric hemorrhage in the postpartum period.

The incidence of hypotonic bleeding is 40-42% of all bleeding in the early postpartum period.

They develop in 2-2.5% of cases of all births.

There are two types of disorders of uterine contractility:

1) Atony

Complete loss of contractility and tone of the uterus

2) Hypotension

Partial impairment of basal tone and contractility varying degrees expressiveness.

Hypotension.

Characterized by an intermittent decrease and restoration of basal tone and contractility of the uterus.

Moreover, the phase of contractility reduction is insignificant.

Hypotonia is a response of the myometrium to the influence medicines and mental irritants.

This is a prolonged, severe insufficiency of uterine contractility in the early postpartum period.

Atony is the inability of the uterus to provide reliable and long-term hemostasis.

The development of hypotonic bleeding can be predicted.

It is related to:

1) violation of the neuro-endocrine regulation of the birth act

2) organic or functional inferiority of the uterine muscles.

Reasons for the development of hypotonic bleeding:

1. Dystrophic, cicatricial and inflammatory changes in the myometrium:

Acute and chronic inflammatory processes in the myometrium

2. Anomalies of the uterus

In which there is inferiority of the muscles of the uterus or its neuroreceptor apparatus

3. Genital infantilism

4. Tumors of the uterus

Part of the myometrium is replaced by tumor tissue

5. Scars on the uterus after surgery

6. Overstretching of the myometrium with:

Polyhydramnios

Multiple births

Large fruit

7. Rapid emptying of the uterus

(especially when surgical intervention- C-section)

8. Pathological localization of the placenta

Low-lying placenta

Placenta previa

Since they lead to hypotension of the lower segment

9. Anomalies labor activity:

Weakness of labor

Excessive labor

Discoordination of labor

With this pathology, energy reserves and the neuroreceptor apparatus are depleted, and tissue hypoxia develops.

10) Irrational use of antispasmodics, painkillers and even uterotonics (this is the so-called paradoxical reaction)

11) Endocrinopathies, late gestosis

They lead to the formation of placental insufficiency

Disruption of the endocrine balance and water-salt metabolism lead to a decrease in uterine contractility

12) Entry of thromboplastic substances into the general bloodstream,

Which happens when:

Uteroplacental apoplexy

Amniotic fluid embolism

Dead fetus

13) Traumatic and painful effects on the body with:

Uterine rupture

Cervical rupture

Vaginal rupture.

A particularly serious condition develops when several causes are combined.

There are two options for the development of hypotonic bleeding:

Option 1.

Bleeding is intense from the very beginning

Large volume of blood loss

The uterus is flabby and hypotonic

The uterus reacts sluggishly to massage, cold stimuli and the administration of uterotonic drugs

In this case:

Hypovolemia progresses rapidly

Hemorrhagic shock may develop

And then - DIC syndrome.

Diagnostics:

There is an obvious clinical picture: the appearance of bleeding after the appearance of the placenta.

Option 2.

Initial blood loss is negligible

Characteristic alternation of repeated blood loss with temporary restoration of hemostasis

Blood is released in small portions - 150-200 ml, bleeding is periodic

The size of the uterus is not constant

The uterus responds to massage, decreases in size, bleeding stops, but then the uterus enlarges and bleeding resumes.

The blood clotting process is not disrupted - clots form, and then liquid

Since bleeding is periodic, it is possible for a woman to develop temporary adaptation to blood loss

In this regard, the initial period of hypovolemia is missed, and the diagnosis of hypotonic bleeding is untimely.

Over time, the disruption of uterine contractility worsens.

The response to mechanical and other stimuli progressively decreases, the volume of blood loss increases with each subsequent bleeding.

At a certain stage, when the next portion of blood is released, the woman’s condition sharply worsens, hemorrhagic shock develops and progresses.

Treatment of hypotonic bleeding.

It is necessary to restore normal contractility of the uterus.

Basic principles of stopping hypotonic bleeding:

1) The doses of uterotonics used should not exceed their average therapeutic doses

2) Not acceptable reuse therapeutic manipulations (especially manual examination of the uterine cavity)

3) The scope of interventions used should be small and should include only the most reliable and effective ways stop bleeding

In the case of persistent use of long-term conservative measures, the risk of hemorrhagic shock increases, the conditions of which are extremely unfavorable for performing surgical operations.

There are two stages in stopping hypotonic bleeding:

1) Conservative hemostasis

2) Surgical stop of bleeding

Conservative bleeding control.

By the end of this stage, the volume of maximum permissible blood loss should not exceed 700-750 ml.

If a woman has not undergone bleeding prevention, then in order to stop hypotonic bleeding, the following are used:

1. Emptying bladder

– his catheterization is carried out

2. External uterine massage

3. Local hypothermia

Ice pack on lower abdomen

4. Methylergometrine – 1 ml

Intravenous stream

Dilute in 20% glucose or saline. solution

5. Uterotonics:

Long-term infusion

Prostaglandins 1-2 ml

Oxytacin 5-10 units per 400 ml saline. solution

6. Prostaglandins

Use a long needle under the mucous membrane of the lower segment

7. Operation of manual examination of the walls of the uterine cavity and massage of the uterus on the fist

The sequence of examination of the walls of the uterine cavity:

Fundus of the uterus

Front wall

Right wall

Rear wall

Left wall of the uterus.

The first 4 points are also a way to prevent the development of bleeding in the postpartum period.

These measures should be applied to all women in labor who are at risk.

If ineffective conservative therapy, continued bleeding and a blood loss volume of more than 700-800 ml, surgical stop of bleeding is indicated.

Surgical stop of bleeding.

Supravaginal amputation of the uterus is performed.

When blood loss approaches 1.5 liters, hysterectomy without appendages is performed.

Vessel ligation:

It is used only in primiparous women with an unfavorable outcome of childbirth.

In this case, the following are ligated:

Uterine arteries in the area of ​​the internal os

Arteries of the round ligaments of the uterus

Ovarian arteries

Arteries of the uterosacral ligament.

This method of stopping bleeding is dangerous, as ischemia develops and uterine necrosis may occur.

In addition, changes occur in the endometrium, and loss of menstrual and reproductive function may occur.

Temporary ways to stop bleeding during the transition from the first stage to the second:

1) Pressure of the abdominal aorta

Blood loss is reduced

Hypoxia develops and uterine contractility is restored

If after this manipulation the bleeding has stopped, then such a woman in labor must be observed for 1 hour and in the presence of a deployed operating room.

If after an hour the bleeding has not resumed, then only replenishment of the volume of blood loss is performed.

2) Insertion of a tampon soaked in ether into the posterior fornix

Its action is based on the occurrence of the cervical-pituitary reflex when oxytacin is released.

Previously used for the purpose of hemostasis, but no longer used:

1. Clamping of parametriums of the lateral parts of the uterus

2. Uterine tamponade

This is due to the fact that they do not stop bleeding and take time.

In addition, when clamping, damage may occur from the clamps:

Venous plexuses

Ureter (there is a double crossing of the ureter with the uterine artery)

3. Seam according to Lositskaya

We look at the cervix in the mirrors and stitch the back lip with catgut

Only 14% of births occur without complications. One of the pathologies of the postpartum period is postpartum hemorrhage. Causes of occurrence this complication quite a lot. These can be either diseases of the mother or complications of pregnancy. Postpartum bleeding also occurs.

Early postpartum bleeding

Early postpartum bleeding is bleeding that occurs within the first 2 hours after the birth of the placenta. The rate of blood loss in the early postpartum period should not exceed 400 ml or 0.5% of a woman’s body weight. If blood loss exceeds the indicated figures, then they speak of abnormal bleeding, if it is 1 percent or more, then this indicates massive bleeding.

Causes of early postpartum bleeding

The causes of early postpartum hemorrhage may be related to maternal illness, complications of pregnancy and/or childbirth. These include:

• long and difficult labor;
• stimulation of contractions with oxytocin;
• overdistension of the uterus (large fetus, polyhydramnios, multiple births);
• age of the woman (over 30 years);
• blood diseases;
• rapid labor;
• use of painkillers during childbirth;
• (for example, fear of surgery);
• dense attachment or placenta accreta;
• retention of part of the placenta in the uterus;
• and/or rupture of the soft tissues of the birth canal;
• uterine malformations, uterine scar, myomatous nodes.

Early Postpartum Hemorrhage Clinic

As a rule, early postpartum hemorrhage occurs as hypotonic or atonic (with the exception of injuries to the birth canal).

Hypotonic bleeding

This bleeding is characterized by rapid and massive blood loss when a woman in labor loses 1 liter of blood or more in a few minutes. In some cases, blood loss occurs in waves, alternating between good contraction of the uterus and absence of bleeding with sudden relaxation and laxity of the uterus with increased bloody discharge.

Atonic bleeding

Bleeding that develops as a result of untreated hypotonic bleeding or inadequate therapy for the latter. The uterus completely loses contractility and does not respond to stimuli (pinching, external massage uterus) and therapeutic measures(Kuveler's uterus). Atonic bleeding is profuse and can lead to the death of the mother.

Treatment options for early postpartum hemorrhage

First of all, it is necessary to assess the woman’s condition and the amount of blood loss. You need to put ice on your stomach. Then inspect the cervix and vagina and, if there are ruptures, close them. If bleeding continues, you should begin a manual examination of the uterus (necessarily under anesthesia) and after emptying the bladder with a catheter. During manual inspection of the uterine cavity, the hand carefully examines all the walls of the uterus and identifies the presence of a rupture or fissure of the uterus or remnants of placenta/blood clots. Remains of the placenta and blood clots are carefully removed, then a manual massage of the uterus is performed. At the same time, 1 ml of a contracting agent (oxytocin, methylergometrine, ergotal and others) is injected intravenously. To consolidate the effect, you can inject 1 ml of uterotonic into the anterior lip of the cervix. If there is no effect from manual control of the uterus, it is possible to insert a tampon with ether into the posterior fornix of the vagina or apply a transverse catgut suture to the posterior lip of the cervix. After all procedures, the volume of blood loss is replaced infusion therapy and blood transfusion.

Atonic bleeding requires immediate surgery (hysterectomy or ligation of the internal iliac arteries).

Late postpartum bleeding

Late postpartum bleeding is bleeding that occurs 2 hours after birth or later (but not more than 6 weeks). The uterus after childbirth is an extensive wound surface that bleeds for the first 2 to 3 days, then the discharge becomes sanguineous and then serous (lochia). Lochia lasts 6 – 8 weeks. In the first 2 weeks of the postpartum period, the uterus actively contracts, so by 10–12 days it disappears behind the womb (that is, it cannot be palpated through the anterior abdominal wall) and during bimanual examination reaches a size that corresponds to 9–10 weeks of pregnancy. This process is called uterine involution. Simultaneously with the contraction of the uterus, the cervical canal is formed.

Causes of late postpartum bleeding

The main causes of late postpartum hemorrhage include:

• retention of parts of the placenta and/or fetal membranes;
• bleeding disorders;
• subinvolution of the uterus;
• blood clots in the uterine cavity when closed cervical canal(C-section);
• endometritis.

Late Postpartum Hemorrhage Clinic

Bleeding in the late postpartum period begins suddenly. It is often very massive and leads to severe anemia in the postpartum woman and even to hemorrhagic shock. Late postpartum bleeding should be distinguished from increased bleeding during breastfeeding (the uterus begins to contract due to increased production of oxytocin). A characteristic feature late bleeding is an increase in bright red bloody discharge or changing the pad more often than every 2 hours.

Treatment of late postpartum hemorrhage

If late postpartum hemorrhage occurs, an ultrasound of the pelvic organs should be performed, if possible. An ultrasound reveals a uterus that is larger than expected, the presence of blood clots and/or remnants of the membranes and placenta, and expansion of the cavity.

In case of late postpartum hemorrhage, it is necessary to perform curettage of the uterine cavity, although a number of authors do not adhere to this tactic (the leukocyte shaft in the uterine cavity is disrupted and its walls are damaged, which in the future can lead to the spread of infection outside the uterus or). After surgical stopping of bleeding, complex hemostatic therapy continues with the introduction of contractile and hemostatic agents, replenishment of circulating blood volume, blood and plasma transfusions, and the prescription of antibiotics.

BLEEDING DURING THE FOLLOW-UP PERIOD

The causes of bleeding in the third stage of labor are:

1) violation of the separation and discharge of the placenta from the uterus;

2) injuries to the soft tissues of the birth canal;

3) hereditary and acquired disorders of hemostasis.

A special role in the delayed separation of the placenta is played by various types of pathological attachment of the placenta to the wall of the uterus: tight attachment (placenta adhaerens), full or partial (Fig. 60), true increment (placenta accreta), full or partial. Complete placenta accreta is extremely rare.

The most common pathological attachment of the placenta, its tight attachment, when there is pathological change spongy layer of the decidua, in which, when physiological childbirth The placenta separates from the wall of the uterus. As a result of inflammatory or various

Rice. 60. Partial tight attachment of the placenta

Dystrophic changes cause the spongy layer to degenerate into scars, which is why tissue rupture in it in the third stage of labor is impossible, and the placenta is not separated.

In some cases, the change in the decidua is significant, the compact layer is undeveloped, the spongy and basal layers atrophy, and there is no zone of fibrinoid degeneration. In such conditions, the cathelidons (one or more) of the placenta are directly adjacent to the muscular layer of the uterus (placenta accreta) or sometimes penetrate into its thickness. At the same time we're talking about about true increment. Depending on the degree of ingrowth of villi into the muscular lining of the uterus, there are placenta increta, when it sprouts muscle layer, And placenta percreta- germination of villi throughout the thickness of the muscle and serous layer of the uterus. The likelihood of placenta accreta increases when it is located in the area postoperative scar or in the lower segment of the uterus, as well as with malformations of the uterus, neoplasms of the uterus.

Recognition of forms of pathological attachment of the placenta is possible only with manual examination of the uterus in order to separate the placenta. If there is a tight attachment of the placenta, it is usually possible to remove all its parts by hand. With true placenta accreta, it is impossible to separate the placenta from the uterine wall without compromising the integrity of the uterus. Often, true placenta accreta is established during pathomorphological and histological examination of the uterus.

Violation of the separation and release of the placenta can be caused by the placenta attachment: in the lower uterine segment, in the corner or on the side walls of the uterus, on the septum, where the muscles are less complete and sufficient contractile activity necessary for separation of the placenta cannot develop.

The cause of bleeding can be not only a violation of the separation of the placenta, but also a violation of the discharge of the placenta, which is observed with discoordination of uterine contractions. In this case, it is possible that the already separated placenta may be retained in the uterus due to its pinching in one of the uterine angles or in the lower segment due to their contraction and spasm. The uterus often takes on an “hourglass” shape, which makes it difficult to release the placenta.

This pathology is observed with improper management of the postpartum period. Untimely, unnecessary manipulations, gru-

combative capture of the uterus or rough control over the separation of the placenta, massage of the uterus, attempts to squeeze out the placenta according to Crede-Lazarevich in the absence of signs of placental separation, attraction to the umbilical cord, administration of large doses of uterotonic drugs can disrupt the physiological course of the third stage of labor. With premature compression of the uterus, a retroplacental hematoma is squeezed out by hand, which normally contributes to the separation of the placenta.

Clinical picture. If the separation of the placenta and the discharge of the placenta are impaired, bleeding from the genital tract occurs. The blood flows out as if in spurts, temporarily stopping, sometimes the blood accumulates in the vagina, and then is released in clots; bleeding increases when external methods of separation of the placenta are used. Retention of blood in the uterus and vagina creates a false impression of the absence of bleeding, as a result of which measures aimed at identifying and stopping it are delayed. An external examination of the uterus shows no signs of separation of the placenta. The general condition of the woman in labor is determined by the degree of blood loss and can change quickly. In the absence of timely assistance, hemorrhagic shock develops.

Bleeding is sometimes caused by trauma to the soft tissues of the birth canal. These are more often observed with ruptures or separation of cervical tissues, when branches of the cervical vessels get into them. In this case, bleeding begins immediately after the birth of the child, can be massive and contribute to the development of hemorrhagic shock and death of the mother in labor if it is not recognized in a timely manner. Ruptures in the clitoral area, where there is a large network of venous vessels, are also often accompanied by severe bleeding. Bleeding from the walls of the vagina or from damaged veins is also possible. Ruptures of the perineum or vaginal walls rarely cause massive bleeding if large branch vessels are not damaged a. vaginalis or a. Pudenda. The exception is high vaginal tears that penetrate into the fornix.

If there are no signs of placenta separation within 30 minutes against the background of the introduction of reducing agents, manual release placenta and placenta discharge under anesthesia (Fig. 61).

If true placenta accreta is suspected, it is necessary to stop attempting to separate it and perform amputation, extirpation or resection of the area of ​​accreta.

Rice. 61. Manual separation of the placenta and placenta release

The walls of the uterus are carefully examined to identify additional lobules, remnants of placental tissue and membranes. At the same time, blood clots are removed. After removal of the placenta, the uterus usually contracts, tightly clasping the arm. If the tone of the uterus is not restored, then additional uterotonic drugs are administered, and an externally-internal dosed massage of the uterus is performed on the fist.

If true placenta accreta is suspected, it is necessary to stop separating it and perform amputation or extirpation of the uterus. The consequences of excessive zeal when trying to remove the placenta manually can be massive bleeding and uterine rupture.

Diagnostics. Basic clinical manifestations: bleeding occurs immediately after the birth of the child; despite the bleeding, the uterus is dense, well contracted, blood flows from the genital tract in a liquid stream of bright color.

Treatment. Therapeutic measures should be clearly aimed at separating the placenta and releasing the placenta.

Sequence of measures for bleeding in the third stage of labor

1. Bladder catheterization.

2. Puncture or catheterization of the ulnar vein.

3. Determination of signs of placental separation:

1) if the signs are positive, the placenta is isolated according to Crede-Lazarevich or Abuladze;

2) if there is no effect from the use of external methods for releasing the placenta, it is necessary to manually separate the placenta and release the placenta.

3) if there is no effect, lower median laparotomy, introduction of uterine contracting agents into the myometrium, and ligation of the uterine vessels are indicated. If bleeding continues during the administration of uterine contracting agents and plasma to correct hemostasis, hysterectomy after ligation of the internal iliac arteries is indicated.

4. Bleeding from ruptures of the cervix, clitoris, perineum and vagina is stopped by restoring tissue integrity.

bleeding in the early postpartum period

The causes of bleeding that begins after the birth of the placenta are ruptures of the uterus or soft tissues of the birth canal, hemostasis defects, as well as retention of parts of the placenta in the uterine cavity (lobules of the placenta, membranes), which prevents normal contraction of the uterus and promotes bleeding. Diagnosis is based on a thorough examination of the placenta immediately after birth to determine the tissue defect. If a defect is detected in the tissues of the placenta, membranes, as well as vessels located along the edge of the placenta and torn off at the point of their transition to the membranes (there may be a detached additional lobule retained in the uterine cavity), or if doubt arises about the integrity of the placenta, it is necessary to urgently perform a manual examination of the uterus and delete its contents.

Hypotonic and atonic bleeding. Common causes of bleeding in the early postpartum period are hypotension and uterine atony. Hypotonia of the uterus is understood as a condition in which there is a significant decrease in its tone and a decrease in contractility; the muscles of the uterus react to various irritants, but the degree of reactions is inadequate to the strength of irritation. Uterine hypotension is a reversible condition. With uterine atony, the myometrium completely loses its tone and contractility. Uterine atony is extremely rare, but it can be a source of massive bleeding. Causes of hypotension and atony of the uterus: uterine malformations, fibroids, dystrophic changes muscles, overstretching of the uterus during pregnancy and childbirth (multiple pregnancy, polyhydramnios, large fetus), rapid or prolonged labor with weak labor, the presence of an extensive placental area, especially in

lower segment, elderly or young age, neuroendocrine insufficiency. Severe forms Hypotension and massive bleeding, as a rule, are combined with impaired hemostasis, which occurs as a type of disseminated intravascular coagulation syndrome. Massive bleeding may be a manifestation of multiple organ failure. At the same time, against the background of microcirculatory insufficiency, ischemic and dystrophic changes and hemorrhages develop in the muscles of the uterus, characterizing the development of shock uterine syndrome.

Clinical picture. The main symptom of uterine hypotension is bleeding. On examination, the uterus is flabby and large in size. When performing an external massage of the uterus, blood clots are released from it, after which the tone of the uterus is restored, but then hypotension is possible again. With atony, the uterus is soft, doughy, its contours are not defined. The fundus of the uterus reaches xiphoid process. There is a continuous and profuse bleeding. The clinical picture of hemorrhagic shock develops rapidly.

Diagnostics presents no difficulties. Initially, the blood is released with clots, subsequently it loses its ability to clot. With atony, the uterus does not respond to mechanical stimuli, while with hypotension, weak contractions are observed in response to mechanical stimuli.

Measures to stop bleeding are carried out against the background of infusion-transfusion therapy (Table 16) and include the following.

1. Emptying the bladder.

2. If blood loss exceeds 350 ml, an external massage of the uterus is performed through the anterior abdominal wall. At the same time, uterotonic drugs are administered. On bottom part An ice pack is placed on the abdomen.

3. If bleeding continues and blood loss exceeds 400 ml, a manual examination of the uterus is performed under anesthesia, as well as dosed external-internal massage of the uterus on the fist, while uterotonic drugs with prostaglandins are administered intravenously. After the uterus contracts, the hand is removed from the uterus.

4. If bleeding continues, the volume of which is 1000-1200 ml, the issue of surgical treatment and removal of the uterus. You can't count on reintroduction uterotonic drugs, manual examination and massage of the uterus if they were ineffective the first time. Lost time when repeating these methods

Dodov leads to an increase in blood loss and a deterioration in the condition of the postpartum mother, the bleeding becomes massive, hemostasis is disrupted, hemorrhagic shock develops, and the prognosis for the patient becomes unfavorable.

Table 16

Protocol for infusion-transfusion therapy of obstetric hemorrhage

In the process of preparing for surgery, a number of measures are used: pressing the abdominal aorta to the spine through the anterior abdominal wall, applying Baksheev clamps to the cervix; 3-4 abortion tools are placed on the side walls, the uterus is shifted down.

If the operation is performed quickly with blood loss not exceeding 1300-1500 ml, and complex therapy has stabilized the functions of vital systems, you can limit yourself to supravaginal amputation of the uterus. With continued bleeding and the development of disseminated intravascular coagulation and hemorrhagic shock, hysterectomy and drainage are indicated abdominal cavity, ligation of the internal iliac arteries. A promising method is to stop bleeding by embolization of the uterine vessels.

Prevention of bleeding in the postpartum period

1. Timely treatment inflammatory diseases, the fight against abortion and recurrent miscarriage.

2. Proper management of pregnancy, prevention of gestosis and complications of pregnancy.

3. Correct management of childbirth: competent assessment of the obstetric situation, optimal regulation of labor. Pain relief during labor and timely resolution of the issue of surgical delivery.

4. Prophylactic administration of uterotonic drugs starting from the moment of cutting in the head, careful monitoring in the postpartum period. Especially in the first 2 hours after birth.

5. Mandatory emptying of the bladder after the birth of the child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus. Careful accounting of blood loss and assessment general condition postpartum women.

Is due to the fact that this pathology acts as the main and direct cause of death in 60-70% of women. It follows that postpartum hemorrhage is one of the most important places in the system of maternal mortality. By the way, it is noted that the leading role among obstetric bleedings is occupied by hypotonic ones, which open after childbirth in the first 4 hours.

Possible reasons

The main reasons for possible hypotonic bleeding may be: atony and hypotension of the uterus, poor clotting blood, part of the baby's place that has not left the uterine cavity, injury to soft tissues in the birth canal.

What is uterine hypotension

Hypotony of the uterus is a condition in which the tone and its ability to contract sharply decrease. Thanks to the measures taken and under the influence of agents that stimulate the contractile function, the muscle begins to contract, although often the force of the contractile reaction is not equal to the force of the impact. For this reason, hypotonic bleeding develops.

Atony

Uterine atony is a condition in which drugs aimed at stimulating the uterus are unable to have any effect on it. The apparatus of the neuromuscular system of the uterus is in a state of paralysis. This condition does not occur often, but can cause severe bleeding.

Provoking factors for bleeding

The causes of hypotonic and atonic bleeding may be different. One of the main reasons is exhaustion of the body, i.e. the central one weakens nervous system due to long and painful labor, persistent labor activity weakens, in addition, the cause may be quick birth and the use of oxytocin. Other causes include severe gestosis (nephropathy, eclampsia) and hypertension. Postpartum hypotensive bleeding is very dangerous.

The next reason may be inferiority of the uterus at the anatomical level: poor development and malformations of the uterus; various fibroids; the presence of scars on the uterus after previous operations; diseases caused by inflammation or abortions replacing connective tissue a significant part of the muscle.

In addition, the consequences of early hypotonic bleeding are: uterine dysfunction, i.e. its severe stretching as a result of polyhydramnios, the presence of more than one fetus, if the fetus large sizes; previa and low placenta attachment.

Hypotension or atony

Bleeding of a hypotonic and atonic nature can occur as a result of a combination of several of the above reasons. In this case, the bleeding becomes more dangerous. Based on the fact that at the first symptoms it can be difficult to find the difference between hypotonic and atonic bleeding, it would be correct to use the first definition, and diagnose uterine atony if the measures taken were ineffective.

What is the reason for stopping bleeding?

Stopping the bleeding, which was caused by placental abruption and the birth of the placenta, is usually explained by two main factors: myometrial retraction and thrombus formation in the vessels of the placenta. Increased retraction of the myometrium leads to the compression and twisting of the venous vessels, and the retraction of the spiral arteries into the thickness of the uterine muscle. After this, thrombus formation begins, which is facilitated by the process of blood clotting. The process of blood clot formation can last quite a long time, sometimes several hours.

Women giving birth in a group high risk in relation to early postpartum hypotonic bleeding, it is necessary to carefully anesthetize, due to the fact that the contractions that are accompanied severe pain, lead to disruption of the central nervous system and the necessary relationships between subcortical formations and, accordingly, the cerebral cortex. As a result, a violation of the generic dominant is possible, which is accompanied by equivalent changes in the uterus.

Clinically, such bleeding manifests itself in the fact that it can often begin in the afterbirth period, and then turn into bleeding in the early postpartum period.

Clinical variants of hypotension

M.A. Repina (1986) identified two clinical variants of uterine hypotension. According to this theory, in the first option from the very beginning, the blood loss is enormous. The uterus becomes flabby, atonic, and exhibits a weak response to the administration of drugs that promote its contraction. Hypovolemia rapidly develops, hemorrhagic shock begins, and disseminated intravascular coagulation syndrome often occurs.

In the second version of the theory, blood loss is insignificant, the clinical picture is characteristic of a hypotonic state of the uterus: repeated blood loss alternates with short-term regeneration of myometrial tone and temporary cessation of bleeding as a result conservative treatment(such as the introduction of contractile agents, external massage of the uterus). As a result of relatively small repeated blood losses, the woman begins to temporarily become accustomed to progressive hypovolemia: blood pressure decreases slightly, the appearance of pallor of the skin and visible mucous membranes is observed, and an insignificant tachycardia occurs.

As a result of compensated fractional blood losses, the onset of hypovolemia often goes unnoticed medical workers. When treatment is on initial stage hypotension of the uterus was ineffective, its impaired contractile function begins to progress, reactions to therapeutic effect, the volume of blood loss increases. At some stage, bleeding begins to increase significantly, leading to sharp deterioration the patient’s condition and all signs of hemorrhagic shock and DIC syndrome begin to develop.

Determining the effectiveness of the first stage measures should be relatively quick. If for 10-15 minutes. If the uterus contracts poorly, and hypotonic bleeding in the postpartum period does not stop, then a manual examination of the uterus should immediately be carried out and a massage of the uterus on the fist should be performed. Based on practical obstetric experience, a timely manual examination of the uterus, cleaning it of accumulated blood clots, and then massaging it with a fist helps ensure correct uterine hemostasis and prevents severe blood loss.

Significant information that determines the need for an appropriate manual examination of the uterus in the event of hypotonic bleeding in the early postpartum period is provided by M. A. Repin in his own monograph “Bleeding in Obstetric Practice” (1986). According to her observations, in those who died from it, the approximate time from the onset of bleeding to manual examination of the uterine cavity averages 50-70 minutes. In addition, the fact that there was no effect from this operation and the persistence of the hypotonic state of the myometrium indicate not only that the operation was performed late, but also an unlikely prognosis for stopping bleeding even with the use of other conservative methods treatment.

Clamping method according to N. S. Baksheev

During the second stage, it is necessary to use techniques that contribute to at least the slightest reduction in blood flow to the uterus, which can be achieved by digitally pressing the aorta, clamping the parametria, ligating the great vessels, etc. Today, among the many methods, the most popular is the clamping method according to N. S. Baksheev, thanks to whom in many cases it was possible to stop hypotonic uterine bleeding, which in turn helped to avoid surgery to remove the uterus.

N. S. Baksheev’s method is used when the volume of blood loss is not too large (no more than 700-800 ml). The duration of the presence of the clamps on the parameters should not be more than 6 hours. In cases where, in the presence of applied clamps, the bleeding does not stop, at least in small quantities, it is necessary to consider the question of removing the uterus in time. This operation is called supravaginal amputation or hysterectomy. Hysterectomy, done on time, is the most reliable method to stop hypotensive bleeding after childbirth.

Timely and necessary measures

This is due to the risk of bleeding disorders. Thus, when combating uterine hypotension, as well as to restore hemodynamics, it is necessary to carefully monitor the nature of the blood clots that form in the patient, which flows from the genital tract, as well as the occurrence of petechial skin hemorrhages, especially at the injection site.

If the slightest symptoms of hypofibrinogenemia appear, immediate administration of drugs that increase the coagulating properties of blood begins. When in this case the question arises about the obligatory operation to remove the uterus, extirpation is required, not amputation of the uterus. This is explained by the fact that probably the remaining stump of the cervix can serve as a continuation of the frolicking pathological process if you have a bleeding disorder. And stopping hypotonic bleeding must be timely.

Bleeding from the genital tract in the early postpartum period (in the first 2 hours after birth of the placenta) can be caused by:

Retention of part of the placenta in the uterine cavity;

Hypotony and atony of the uterus;

Hereditary or acquired defects of hemostasis (see Disturbances of the hemostatic system in pregnant women);

Rupture of the uterus and soft tissues of the birth canal (see Maternal birth trauma).

Postpartum hemorrhage occurs in 2.5% of cases total number childbirth

Retention of parts of the placenta in the uterine cavity. Bleeding that begins after the birth of the placenta often depends on the fact that part of it (lobules of the placenta, membrane) is retained in the uterus, thereby preventing its normal contraction. The reason for the retention of parts of the placenta in the uterus is most often partial placenta accreta, as well as inept management of the placenta (excessive activity). Diagnosis of retention of parts of the placenta in the uterus is not difficult. This pathology is detected immediately after the birth of the placenta, during its careful examination, when a tissue defect is determined.

If there is a defect in the tissues of the placenta, membranes, torn placenta, as well as vessels located along the edge of the placenta and torn off at the place of their transition to the membranes (the possibility of having a detached additional lobule lingering in the uterine cavity), or even if there is doubt about the integrity of the placenta, it is necessary to urgently perform manually examine the uterus and remove its contents. This operation for defects in the placenta is also performed in the absence of bleeding, since the presence of parts of the placenta in the uterus eventually leads to bleeding, as well as infection, sooner or later.

Hypotony and atony of the uterus. Most common reasons bleeding in the early postpartum period are hypotension and atony of the uterus, in which postpartum hemostasis is disrupted and constriction of ruptured vessels in the placental area does not occur. Hypotonia of the uterus is understood as a condition in which there is a significant decrease in its tone and a decrease in contractility; the muscles of the uterus react to various stimuli, but the degree of these reactions is inadequate to the strength of the irritation. Hypotension is a reversible condition (Fig. 22.7).

Rice. 22.7.

The uterine cavity is filled with blood.

With atony, the myometrium completely loses its tone and contractility. The muscles of the uterus do not respond to stimuli. A kind of “paralysis” of the uterus occurs. Uterine atony is extremely rare, but it can be a source of massive bleeding.

Hypotonia and atony of the uterus are predisposed by excessively young or old age women in labor, neuroendocrine insufficiency, uterine malformations, fibroids, dystrophic changes in muscles (previous inflammatory processes, the presence of scar tissue, a large number of previous births and abortions); hyperextension of the uterus during pregnancy and childbirth (multiple pregnancy, polyhydramnios, large fetus); rapid or prolonged labor with weak labor and prolonged activation by oxytocin; the presence of an extensive placental area, especially in the lower segment. When several of the above reasons are combined, severe uterine hypotension and bleeding are observed.

Severe forms of uterine hypotension and massive bleeding are usually combined with hemostasis disorders occurring as disseminated intravascular coagulation (DIC syndrome). In this regard, a special place is occupied by bleeding that appears after shock of various etiologies (toxic, painful, anaphylactic), collapse associated with compression syndrome of the inferior pudendal vein, or against the background of acid aspiration syndrome (Mendelssohn syndrome), with amniotic fluid embolism. The cause of uterine hypotension with the indicated pathological conditions is a blockade of contractile proteins of the uterus by fibrin (fibrinogen) degradation products or amniotic fluid (more often embolism is associated with the penetration of a small amount amniotic fluid, thromboplastin of which triggers the mechanism of DIC syndrome).

Massive bleeding after childbirth can be a manifestation of multiple organ failure syndrome, observed with gestosis and extragenital pathology. At the same time, against the background of microcirculatory insufficiency, ischemic and dystrophic changes and hemorrhages develop in the muscles of the uterus, characterizing the development of shock uterine syndrome. There is a relationship between the severity of a woman’s general condition and the depth of damage to the uterus.

Measures to stop bleeding in case of impaired contractility of the uterus

All measures to stop bleeding are carried out against the background of infusion-transfusion therapy in the following sequence.

1. Emptying the bladder with a catheter.

2. If blood loss exceeds 350 ml, an external massage of the uterus is performed through the anterior abdominal wall. Place your hand on the bottom of the uterus and begin to make light massaging movements. As soon as the uterus becomes dense, using the Crede-Lazarevich technique, the accumulated clots are squeezed out of it. At the same time, uterotonic drugs (oxytocin, methylergometrine) are administered. Well established domestic drug Oraxoprostol. An ice pack is placed on the lower abdomen.

3. If bleeding continues and blood loss exceeds 400 ml or high speed bleeding, it is necessary to perform a manual examination of the uterus under anesthesia, during which its contents (membranes, blood clots) are removed, after which an external-internal massage of the uterus is performed on the fist (Fig. 22.8). The hand located in the uterus is clenched into a fist; on a fist, as on a stand, with the outer hand through the anterior abdominal wall, successively massage different parts of the uterine wall, while at the same time pressing the uterus to the pubic symphysis. Simultaneously with manual examination of the uterus, oxytocin (5 units in 250 ml of 5% glucose solution) with prostaglandins is administered intravenously. After the uterus contracts, the hand is removed from the uterus. Subsequently, the tone of the uterus is checked and drugs that contract the uterus are administered intravenously.

4. If bleeding continues, the volume of which is 1000-1200 ml, the issue of surgical treatment and removal of the uterus should be decided. You cannot rely on repeated administration of oxytocin, manual examination and uterine massage if they were not effective the first time. Losing time when repeating these methods leads to increased blood loss and deterioration of the mother's condition: the bleeding becomes massive, hemostasis is disrupted, hemorrhagic shock develops and the prognosis for the patient becomes unfavorable.

In the process of preparing for surgery, a number of measures are used to prevent blood flow to the uterus and cause ischemia, thereby increasing uterine contractions. This is achieved by pressing the abdominal aorta to the spine through the anterior abdominal wall (Fig. 22.9). To enhance uterine contractions, you can apply clamps to the cervix according to Baksheev. For this purpose, the cervix is ​​exposed with mirrors. 3-4 abortionists are placed on its sides. In this case, one branch of the clamp is placed on the inner surface of the neck, the second - on the outer surface. By pulling the handles of the clamps, the uterus is moved down. A reflex effect on the cervix and possible compression of the descending branches of the uterine arteries help reduce blood loss. If the bleeding stops, the abortion collets are gradually removed. Surgical treatment in case of uterine hypotension, it should be carried out against the background of intensive complex therapy, infusion-transfusion therapy using modern anesthesia, and artificial ventilation. If the operation is performed quickly with blood loss not exceeding 1300-1500 ml, and complex therapy made it possible to stabilize the functions of vital systems, we can limit ourselves to supravaginal amputation of the uterus. If bleeding continues with a clear violation of hemostasis, development of disseminated intravascular coagulation syndrome and hemorrhagic shock, hysterectomy is indicated. During surgery (extirpation or amputation), the abdominal cavity should be drained; after extirpation, the vagina is additionally left unsutured. Ligation of uterine vessels as an independent surgical method stopping the bleeding did not spread. After extirpation of the uterus against the background of a developed picture of disseminated intravascular coagulation syndrome, bleeding from the vaginal stump is possible. In this situation, it is necessary to ligate the internal iliac arteries. The method of stopping bleeding by embolization of the uterine vessels seems promising.

Clinical picture. The main symptom of uterine hypotension is bleeding. Blood is released in clots of various sizes or flows out in a stream. Bleeding may have a wave-like character: it stops, then resumes again. Subsequent contractions are rare and short. Upon examination, the uterus is flabby, large in size, its upper border reaches the navel and above. When performing an external massage of the uterus, blood clots are released from it, after which the tone of the uterus can be restored, but then hypotension is possible again.

With atony, the uterus is soft, doughy, its contours are not defined. The uterus seems to spread across the abdominal cavity. Its bottom reaches the xiphoid process. Continuous and heavy bleeding occurs. If timely assistance is not provided, the clinical picture of hemorrhagic shock quickly develops. Appearing pale skin, tachycardia, hypotension, cold extremities. The amount of blood lost by a postpartum woman does not always correspond to the severity of the disease. The clinical picture largely depends on the initial condition of the postpartum woman and the rate of bleeding. With rapid blood loss, hemorrhagic shock can develop in a matter of minutes.

Diagnostics. Taking into account the nature of the bleeding and the condition of the uterus, diagnosing uterine hypotension is not difficult. At first, the blood is released with clots, but subsequently it loses its ability to clot. The degree of impairment of uterine contractility can be clarified by inserting a hand into its cavity during a manual examination. With normal motor function of the uterus, the force of uterine contractions is clearly felt by a hand inserted into its cavity. With atony there are no contractions, the uterus does not respond to mechanical stimulation, while with hypotension there are weak contractions in response to mechanical stimulation.

Differential diagnosis is usually made between uterine hypotension and traumatic injuries of the birth canal. Heavy bleeding when the uterus is large and poorly contoured through the anterior abdominal wall, it indicates hypotonic bleeding; bleeding with a dense, well-contracted uterus indicates damage to the soft tissues, cervix or vagina, which are definitively diagnosed by examination using vaginal speculum. Measures to stop bleeding.

Prevention. In the postpartum period, prevention of bleeding includes the following.

1. Timely treatment of inflammatory diseases, the fight against induced abortions and miscarriages.

2. Rational management of pregnancy, prevention of gestosis and pregnancy complications, complete psychophysiological and preventive preparation for childbirth.

3. Rational management of labor: correct assessment of the obstetric situation, optimal regulation of labor, pain relief during labor and timely resolution of the issue of surgical delivery.

4. Rational management of the afterbirth period, prophylactic administration medications, causing contraction of the uterus, starting from the end of the expulsion period, including succession period and the first 2 hours of the early postpartum period.

5. Increased contractility of the postpartum uterus.

Emptying the bladder after the birth of the child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus, careful recording of the amount of blood lost and an assessment of the general condition of the postpartum woman are mandatory.