With atonic bleeding in the early postpartum period. Postpartum hemorrhage: symptoms and treatment

6607 0

Bleeding in the early postpartum period is bleeding that occurs in the first 2 hours after delivery.

Hypotension of the uterus - weakness of the contractility of the uterus and its insufficient tone.

Atony of the uterus is a complete loss of tone and contractility of the uterus, which does not respond to medical and other stimulation.

Epidemiology

Classification

See the subchapter "Bleeding in the afterbirth period".

Etiology and pathogenesis

Bleeding in the early postpartum period may be due to retention of parts of the placenta in the uterine cavity, hypo- and atony of the uterus, a violation of the blood coagulation system, uterine rupture.

The causes of hypo- and atonic bleeding are violations of the contractility of the myometrium due to childbirth (preeclampsia, somatic diseases, endocrinopathies, cicatricial changes in the myometrium, etc.).

The causes of bleeding in violations of the hemostatic system can be both congenital and acquired defects of the hemostatic system (thrombocytopenic purpura, von Willebrand disease, angiohemophilia) that are present before pregnancy, as well as various types of obstetric pathology that contribute to the development of DIC and the occurrence of bleeding during childbirth and the early postpartum period. The development of thrombohemorrhagic blood coagulation disorders is based on the processes of pathological activation of intravascular blood coagulation.

Clinical signs and symptoms

Bleeding due to retention of parts of the placenta is characterized by profuse bleeding with clots, large postpartum uterus, its periodic relaxation and copious discharge of blood from the genital tract.

With hypotension of the uterus, bleeding is characterized by undulations. Blood is secreted in portions in the form of clots. The uterus is flabby, its contractions are rare, short. Blood clots accumulate in the cavity, as a result of which the uterus enlarges, loses its normal tone and contractility, but still responds to common stimuli with contractions.

The relatively small size of fractional blood loss (150-300 ml) provides temporary adaptation of the puerperal to developing hypovolemia. BP remains within normal limits. Pallor of the skin, increasing tachycardia is noted.

With insufficient treatment in the early initial period of uterine hypotension, the severity of violations of its contractile function progresses, therapeutic measures become less effective, the volume of blood loss increases, symptoms of shock increase, DIC develops.

Uterine atony is an extremely rare complication. With atony, the uterus completely loses its tone and contractility. Its neuromuscular apparatus does not respond to mechanical, thermal and pharmacological stimuli. The uterus is flabby, poorly contoured through the abdominal wall. Blood flows out in a wide stream or is released in large clots. The general condition of the puerperal progressively worsens. Hypovolemia rapidly progresses, hemorrhagic shock, DIC-syndrome develops. With continued bleeding, the death of the puerperal may occur.

In the practice of an obstetrician-gynecologist, the division of bleeding into hypotonic and atonic is conditional due to the complexity of differential diagnosis.

In violation of the hemostasis system, the clinical picture is characterized by the development of coagulopathy bleeding. In conditions of a deep deficiency of coagulation factors, the formation of hemostatic thrombi is difficult, blood clots are destroyed, the blood is liquid.

With bleeding due to retention of parts of the placenta, the diagnosis is based on a thorough examination of the placenta and membranes after the birth of the placenta. If there is a defect or doubts about the integrity of the placenta, manual examination of the postpartum uterus and removal of the retained parts of the placenta are indicated.

The diagnosis of hypotonic and atonic bleeding is made on the basis of the results of the physical examination and the clinical picture.

The diagnosis of coagulopathic bleeding is based on hemostasis parameters (absence of platelets, presence of high molecular weight fractions of fibrin/fibrinogen degradation products).

Differential Diagnosis

Bleeding resulting from the retention of parts of the placenta in the uterine cavity should be differentiated from bleeding associated with hypotension and atony of the uterus, a violation of the blood coagulation system, and uterine rupture.

Hypotonia and atony of the uterus are usually differentiated from traumatic injuries of the soft birth canal. Severe bleeding with a large, relaxed, poorly contoured uterus through the anterior abdominal wall indicates hypotonic bleeding; bleeding with a dense, well-contracted uterus indicates damage to the soft tissues of the birth canal.

Differential diagnosis in coagulopathy should be carried out with uterine bleeding of a different etiology.

Bleeding due to retention of parts of the placenta

With a delay in the uterus of parts of the placenta, their removal is indicated.

Hypotension and atony of the uterus

In case of violation of the contractility of the uterus in the early postpartum period with blood loss exceeding 0.5% of body weight (350-400 ml), all means of combating this pathology should be used:

■ emptying the bladder with a soft catheter;

■ external massage of the uterus;

■ applying cold to the lower abdomen;

■ the use of agents that enhance the contraction of the myometrium;

■ manual examination of the walls of the cavity of the postpartum uterus;

■ terminals for parameters according to Baksheev;

■ if the measures taken are ineffective, laparotomy and extirpation of the uterus are justified.

With continued bleeding, pelvic embolization or ligation of the internal iliac arteries is indicated.

Important in the treatment of hypotonic bleeding are timely infusion therapy and compensation for blood loss, the use of agents that improve the rheological properties of blood and microcirculation, preventing the development of hemorrhagic shock and coagulopathic disorders.

Therapy with uterotonic agents

Dinoprost IV drip 1 ml (5 mg) in 500 ml 5% dextrose solution or 500 ml 0.9% sodium chloride solution, once

Methylergometrine, 0.02% solution, i.v. 1 ml, once

Oxytocin IV drip 1 ml (5 U) in 500 ml of 5% dextrose solution or 500 ml of 0.9% sodium chloride solution, once.

Hemostatic

and blood replacement therapy

Albumin, 5% solution, intravenous drip 200-400 ml 1 r / day, the duration of therapy is determined individually

Aminomethylbenzoic acid IV 50-100 mg 1-2 r / day, the duration of therapy is determined individually

Aprotinin IV drip 50,000-100,000 IU up to 5 r / day or 25,000 IU 3 r / day (depending on the specific drug), the duration of therapy is determined individually

Hydroxyethyl starch, 6% or 10% solution, IV drip 500 ml 1-2 r / day, the duration of therapy is determined individually

It is due to the fact that this pathology acts as the main and immediate cause of death of 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 hemorrhages is occupied by hypotonic ones, which opened after childbirth in the first 4 hours.

Possible reasons

The main causes of possible hypotonic bleeding can be: atony and hypotension of the uterus, poor blood clotting, part of the child's place that has not left the uterine cavity, trauma to the soft tissues in the birth canal.

What is uterine hypotension

Hypotension 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 excite the contractile function, the muscle begins to contract, although often the strength of the contractile reaction is not equal to the strength of the impact. For this reason, hypotonic bleeding develops.

Atony

Atony of the uterus is a condition in which funds aimed at excitation of the uterus are not able 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 happen often, but can cause severe bleeding.

Provoking factors of bleeding

The causes of bleeding hypotonic and atonic character may be different. One of the main reasons is the weakening of the body, i.e. the central nervous system weakens due to prolonged and painful childbirth, persistent labor activity weakens, in addition, rapid labor and the use of oxytocin can be the cause. Also, the causes include severe gestosis (nephropathy, eclampsia) and hypertension. Postpartum hypotonic bleeding is very dangerous.

The next reason may be the 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 abortion, replacing a significant part of the muscle with connective tissue.

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

Hypotension or atony

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

What is bleeding stop

The stoppage of bleeding, which was caused by the fact that placental abruption and the birth of the placenta occurred, as a rule, is explained by two main factors: myometrial retraction and thrombus formation in the vessels of the placenta site. The increased retraction of the myometrium leads to the fact that the venous vessels are compressed and twisted, and the spiral arteries are also drawn into the thickness of the uterine muscle. After this, thrombus formation begins, in which the blood coagulation process contributes. The process of formation of blood clots can last quite a long time, sometimes several hours.

Women in labor who are at high risk for early postpartum hypotonic bleeding must be carefully anesthetized, due to the fact that contractions, which are accompanied by 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 is manifested in the fact that it can often begin in the afterbirth period, and then go 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 huge. The uterus becomes flabby, atonic, shows a weak reaction to the introduction of drugs that contribute to its reduction. Hypovolemia rapidly develops, hemorrhagic shock sets in, and disseminated intravascular coagulation 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 stoppage of bleeding as a result of conservative treatment (such as the introduction of reducing agents, external uterine massage). As a result of relatively small repeated blood loss, a woman begins to temporarily get used to progressive hypovolemia: blood pressure decreases slightly, the appearance of pallor of the skin and visible mucous membranes is observed, and insignificant tachycardia occurs.

As a result of compensated fractional blood loss, the onset of hypovolemia often goes unnoticed by medical professionals. When treatment at the initial stage of uterine hypotension was ineffective, its impaired contractile function begins to progress, responses to therapeutic effects become short-lived, and the volume of blood loss increases. At some stage, bleeding begins to increase significantly, leading to a sharp deterioration in the patient's condition and all signs of hemorrhagic shock and DIC syndrome begin to develop.

Determination of the effectiveness of the measures of the first stage should be relatively fast. If for 10-15 minutes. If the uterus does not shrink well, and hypotonic bleeding in the postpartum period does not stop, then a manual examination of the uterus should be carried out immediately and a uterine massage on the fist should be applied. Based on practical obstetric experience, a timely manual examination of the uterus, cleaning it of accumulated blood clots, and then massaging it on the fist helps to ensure correct uterine hemostasis and prevent severe blood loss.

Significant information that necessitates an appropriate hand examination of the uterus in the event of hypotonic bleeding in the early postpartum period is given by M. A. Repina in her 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 is on average 50-70 minutes. In addition, the lack of effect of this operation and the invariance of the hypotonic state of the myometrium indicate not only that the operation was performed late, but also about the unlikely prognosis of stopping bleeding even with the use of other conservative methods of treatment.

Terminal method according to N. S. Baksheev

During the activities of the second stage, it is necessary to use techniques that contribute to at least the slightest decrease in blood flow to the uterus, which can be achieved using finger pressure on the aorta, clamping parametria, ligation of the main vessels, etc. To date, among the many of these methods, the clamping method is the most popular according to N. S. Baksheev, thanks to which in many cases it was possible to stop hypotonic uterine bleeding, which in turn helped to do without 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 terminals on the parameters should not be more than 6 hours. In cases where, in the presence of superimposed terminals, the bleeding does not stop, at least in small quantities, it is necessary to be puzzled in time by the question of removing the uterus. This operation is called supravaginal amputation or extirpation of the uterus. Surgery to remove the uterus, done on time, is the most reliable method to stop hypotonic bleeding after childbirth.

Timely and necessary measures

This is due to the risk of bleeding disorders. Thus, in the fight against uterine hypotension, as well as to restore hemodynamics, it is necessary to carefully monitor the nature of the blood clots formed in the patient, which follows 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, they begin the urgent administration of drugs that increase the coagulating properties of the blood. When in this case the question arises of the mandatory operation to remove the uterus, extirpation is required, and 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 there is a violation of blood clotting. And the stop of hypotonic bleeding should be timely.

Lecture 8

BLEEDING IN THE SUBSEQUENT AND EARLY

POSTPARTUM

1. Bleeding in the afterbirth period.

2. Bleeding in the early postpartum period.

3. Pathogenesis of bleeding.

4. Therapy.

5. Literature.

In modern obstetrics, bleeding remains one of the main causes of maternal death. They not only complicate the course of pregnancy, childbirth and the postpartum period, but also lead to the development of neuroendocrine pathology in the late period of a woman's life.

Every year, 127,000 women die from bleeding worldwide. This accounts for 25% of all maternal mortality. In Russia, bleeding is the leading cause of death in patients and accounts for 42% of deaths associated with pregnancy, childbirth and the postpartum period. At the same time, in 25% of cases, bleeding is the only cause of an unfavorable outcome of pregnancy.

Causes of mortality:

belated inadequate hemostasis;

Incorrect infusion-transfusion tactics;

Violation of the stages and sequence of obstetric care.

Physiologically occurring pregnancy is never accompanied by bleeding. At the same time, the hemochorial type of human placentation predetermines a certain amount of blood loss in the third stage of labor. Consider the mechanism of normal placentation.

The fertilized egg enters the uterine cavity in the morula stage, surrounded on all sides by the trophoblast. Trophoblast cells have the ability to secrete a proteolytic enzyme, due to which the fetal egg, in contact with the uterine mucosa, attaches to it, dissolves the underlying areas of the decidual tissue, and nidation occurs within 2 days. With nidation, the proteolytic properties of the cytotrophoblast increase. Destruction of the decidua on the 9th day of ontogenesis leads to the formation of lacunae containing maternal blood poured out of the destroyed vessels. From the 12-13th day, the connective tissue begins to grow into the primary villi, and then the vessels. Secondary and then tertiary villi are formed. Gas exchange and the provision of nutrients to the fetus will depend on the correct formation of the villi. The main organ of pregnancy is formed - the placenta. Its main anatomical and physiological unit is placenton. Its constituent parts are cotylidon and curuncle. Cotylidone- this is the fruiting part of the placenton, it consists of a stem villus with numerous branches containing fruiting vessels. Their main mass is localized in the superficial - compact layer of the endometrium, where they swim freely in the intervillous spaces filled with maternal blood. To ensure the fixation of the placenta to the wall of the uterus, there are "anchor" villi that penetrate into the deeper - spongy layer of the endometrium. They are much smaller than the main villi and it is they that are torn in the process of separation of the placenta from the uterine wall in the afterbirth period. The loose spongy layer is easily displaced with a sharp decrease in the uterine cavity, while the number of opened anchor villi is not large, which reduces blood loss. In normal placentation, chorionic villi never penetrate the basal layer of the endometrium. From this layer, the endometrium will be reborn in the future.

Thus, normal placentation guarantees a woman in the future the normal functioning of the most important organ - the uterus.

From the maternal surface, each cotyledon corresponds to a certain section of the decidua - curuncle. At the bottom of it, a spiral artery opens, supplying the lacuna with blood. They are separated from each other by incomplete partitions - septa. Thus, the cavities of the intervillous spaces - curuncles, are communicated. The total number of spiral arteries reaches 150-200. Since the formation of the placenta, the spiral arteries approaching the intervillous space, under the influence of the trophoblast, lose their muscle elements and lose their ability to vasoconstriction, not responding to all vasopressors. Their lumen increases from 50 to 200 microns, and by the end of pregnancy up to 1000 microns. This phenomenon is called "physiological denervation of the uterus" This mechanism is necessary to maintain the blood supply to the placenta at a constant optimal level. With an increase in systemic pressure, the blood supply to the placenta does not decrease.

The process of trophoblast invasion is completed by the 20th week of pregnancy. By this time, the uteroplacental circuit contains 500-700 ml of blood, the fetal-placental circuit contains 200-250 ml.

During the physiological course of pregnancy, the uterus-placenta-fetus system is closed. Maternal and fetal blood does not mix and does not pour out. Bleeding occurs only in case of violation of the connection between the placenta and the uterine wall, normally occurs in the third stage of labor, when the volume of the uterus decreases sharply. The placental platform does not shrink throughout pregnancy and childbirth. After the expulsion of the fetus and the outpouring of the posterior waters, the intrauterine pressure sharply decreases. In a small area of ​​the placental site within the spongy layer, the anchor villi rupture, and bleeding begins from the exposed spiral arteries. The area of ​​the placental site is exposed, which is a vascularized wound surface. 150-200 spiral arteries open into this zone, the end sections of which do not have a muscular wall, and create the danger of a large loss of blood. At this point, the mechanism of myotamponade begins to operate. Powerful contractions of the muscular layers of the uterus lead to a mechanical overlap of the mouths of the bleeding vessels. In this case, the spiral arteries are twisted and drawn into the thickness of the muscles of the uterus.

At the second stage, the mechanism of thrombotamponade is realized. It consists in the intensive formation of clots in the clamped spiral arteries. The processes of blood coagulation in the area of ​​the placental site are provided by a large amount of tissue thromboplastin formed during placental abruption. The rate of formation of clots in this case exceeds the rate of thrombus formation in the systemic circulation by 10-12 times.

Thus, in the postpartum period, hemostasis is carried out at the first stage by effective myotamponade, which depends on the contraction and retraction of myometrial fibers, and full-fledged thrombotamponade, which is possible in the normal state of the hemostasis system of the puerperal.

It takes 2 hours for the final formation of a dense thrombus and its relatively reliable fixation on the vessel wall. In this regard, the duration of the early postpartum period, during which there is a risk of bleeding, is determined by this time period.

In the normal course of the succession period, the volume of blood lost is equal to the volume of the intervillous space and does not exceed 300-400 ml. Taking into account the thrombus formation of the placental bed, the volume of external blood loss is 250-300 ml and does not exceed 0.5% of the woman's body weight. This volume does not affect the condition of the puerperal, in connection with which there is the concept of "physiological blood loss" in obstetrics.

This is the normal mechanism of placentation and the course of the afterbirth and early postpartum period. With mechanisms of placentation - the leading symptom is bleeding.

Violations of the mechanism of placentation

The reasons for the violation of the mechanism of placentation are pathological changes in the endometrium that occurred before pregnancy:

1. Chronic inflammatory processes in the endometrium (acute or chronic endomyometritis).

2. Dystrophic changes in the myometrium resulting from frequent abortions, miscarriages with curettage of the walls of the uterine cavity, especially complicated by subsequent inflammatory complications.

3. Dystrophic changes in the myometrium in multiparous women.

4. Inferiority of the endometrium in infantilism.

5. Changes in the endometrium in pregnant women with uterine fibroids, especially with submucosal localization of nodes

6. Inferiority of the endometrium with anomalies in the development of the uterus.

Bleeding in the postpartum period

Violation of the processes of separation of the placenta

Tight attachment of the placenta

True placental accreta

Hypotonic condition of the uterus

The location of the placenta in one of the uterine angles

Rupture of the uterus, soft birth canal

Ø Infringement of the separated placenta

Ø DIC

Ø Irrational management of the afterbirth period (pulling the umbilical cord - eversion of the uterus, untimely use of uterotonics).

With changes in the endometrium, the essence of which is the thinning or complete absence of the spongy layer, four options for the pathological attachment of the placenta are possible.

1. Placentaadhaerens- False rotation of the placenta. Occurs in the case of a sharp thinning of the spongy layer of the endometrium. Separation of the placenta is possible only with mechanical destruction of the villi within the compact layer. Anchor villi penetrate into the basal layer, and are localized close to the muscular layer. The placenta, as it were, "sticks" to the wall of the uterus, and the absence of a spongy layer leads to the fact that after emptying the uterus, there is no violation of the connection between the placenta and the wall of the uterus.

2. Placentaaccraeta - true rotation of the placenta. In the complete absence of the spongy layer of the endometrium, the chorionic villi, sprouting from the basal layer, penetrate into the muscle tissue. In this case, the destruction of the myometrium does not occur, but the separation of the placenta from the uterine wall by hand is impossible.

3. Placentaincraeta – deeper invasion of chorionic villi, accompanied by their penetration into the thickness of the myometrium with destruction of muscle fibers. Occurs with complete atrophy of the endometrium, as a result of severe septic postpartum, post-abortion complications, as well as endometrial defects that have arisen during surgical interventions on the uterus. At the same time, the basal layer of the endometrium loses its ability to produce antienzymes, which normally prevent the penetration of chorionic villi deeper than the spongy layer. An attempt to separate such a placenta leads to massive trauma to the endometrium and fatal bleeding. The only way to stop it is to remove the organ along with the ingrown placenta.

4. Placentapercraeta- rare, chorionic villi germinate the wall of the uterus to the serous cover and destroy it. The villi are exposed, and profuse intra-abdominal bleeding begins. Such a pathology is possible when the placenta is attached in the area of ​​the scar, where the endometrium is completely absent, and the myometrium is almost not expressed, or when the ovum is nidiated in the rudimentary horn of the uterus.

If a violation of the attachment of the placenta occurs in some area of ​​the placental site, this is a partial abnormal attachment of the placenta. After the birth of the fetus, normal processes of placental separation begin in unchanged areas, which is accompanied by blood loss. It is the greater, the larger the area of ​​the exposed placental area. The placenta sags on a non-separated, abnormally attached area, does not allow the uterus to contract, and there are no signs of placental separation. The absence of myotamponade leads to bleeding in the absence of signs of separation of the placenta. This is afterbirth bleeding, the method of stopping it is the operation of manual separation and removal of the placenta. The operation is performed under general anesthesia. The operation lasts no more than 1-2 minutes, but requires a quick introduction of the patient into a state of anesthesia, because. everything happens against the background of unstopped bleeding. During the operation, it is possible to determine the type of placentation pathology and the depth of villus invasion into the uterine wall. With Pl adharens, the placenta is easily separated from the uterine wall, because. you work within the functional layer of the endometrium. With Pl accraeta, it is not possible to separate the placenta in this area - sections of tissue hang from the uterine wall, and bleeding intensifies and begins to take on the character of profuse. With Pl incraeta, attempts to remove the placental tissue lead to the formation of defects, niches in the uterine muscle, bleeding becomes threatening. With partial dense attachment of the placenta, one should not persist in trying to separate the non-separating areas of the placenta and proceed to surgical methods of treatment. An attempt should never be made to isolate the placenta in the absence of signs of separation of the placenta in conditions of afterbirth bleeding.

The clinical picture in cases of total dense attachment of the placenta is extremely rare. In the succession period, there is no violation of the integrity of the intervillous spaces, there are no signs of separation of the placenta and bleeding. In this situation, the waiting time is 30 minutes. If during this time there are no signs of placental separation, there is no bleeding, the diagnosis of total dense attachment of the placenta becomes obvious. Tactics - active separation of the placenta and the allocation of the placenta. The type of anomaly of placentation is determined during the operation. In this case, blood loss exceeds physiological, because. separation occurs within the compact layer.

BLEEDING IN THE SUBSEQUENT PERIOD.

RETENTION OF THE CHILD'S PLACE AND ITS PARTS IN THE UTERINE CAVITY

Bleeding that occurs after the birth of the fetus is called bleeding in the afterbirth period. It occurs when a child's place or its parts are delayed. With the physiological course of the succession period, the uterus after the birth of the fetus decreases in volume and contracts sharply, the placental site decreases in size and becomes smaller than the size of the placenta. During subsequent contractions, retraction of the muscular layers of the uterus occurs in the area of ​​​​the placental site, due to this, a rupture of the spongy layer of the decidua occurs. The process of separation of the placenta is directly related to the strength and duration of the retraction process. The maximum duration of the follow-up period is normally no more than 30 minutes.

Postpartum bleeding.

According to the time of occurrence, they are divided into early - arising in the first 2 hours after childbirth and late - after this time and up to the 42nd day after childbirth.

Early postpartum hemorrhage.

The causes of early postpartum hemorrhage can be:

a. hypo- and atony of the uterus

b. birth canal injury

in. coagulopathy.

Hypotension of the uterus- this is a condition in which the tone and contractility of the uterus is sharply reduced. Under the influence of measures and means that stimulate the contractile activity of the uterus, the uterine muscle contracts, although often the strength of the contractile reaction does not correspond to the strength of the impact.

Uterine atony- this is a condition in which stimulants of the uterus do not have any effect on it. The neuromuscular apparatus of the uterus is in a state of paralysis. Atony of the uterus is rare, but causes massive bleeding.

Causes of uterine hypotension in the early postpartum period. A muscle fiber loses its ability to contract normally in three cases:

1. Excessive overstretching: this is facilitated by polyhydramnios, multiple pregnancies and the presence of a large fetus.

2. Excessive fatigue of the muscle fiber. This situation is observed during the long course of the birth act, with the irrational use of large doses of tonomotor drugs, with fast and rapid childbirth, as a result of which exhaustion occurs. I remind you that fast should be considered in primiparous labor lasting less than 6 hours, in multiparous - less than 4 hours. Childbirth is considered to be rapid if it lasts less than 4 hours for the first and less than 2 hours for the multiparous, respectively.

3. The muscle loses the ability to normal contraction in case of structural changes of a cicatricial, inflammatory or degenerative nature. Transferred acute and chronic inflammatory processes involving the myometrium, uterine scars of various origins, uterine fibroids, numerous and frequent curettage of the walls of the uterine cavity, in multiparous women and with short intervals between births, in parturient women with manifestations of infantilism, anomalies in the development of the genital organs.

The leading syndrome is bleeding, in the absence of any complaints. An objective examination reveals a decrease in the tone of the uterus, determined by palpation through the anterior abdominal wall, a slight increase in it due to the accumulation of clots and liquid blood in its cavity. External bleeding, as a rule, does not correspond to the volume of blood loss. When massaging the uterus through the anterior abdominal wall, liquid dark blood with clots is poured out. The general symptomatology depends on the BCC deficiency. With a decrease in it by more than 15%, manifestations of hemorrhagic shock begin.

There are two clinical variants of early postpartum hypotonic bleeding:

1. Bleeding from the very beginning is profuse, sometimes jet. The uterus is flabby, atonic, the effect of the ongoing therapeutic measures is short-lived.

2. The initial blood loss is small. The uterus periodically relaxes, blood loss increases gradually. Blood is lost in small portions - 150-200 ml each, in portions, which allows the body of the puerperal to adapt within a certain period of time. This option is dangerous because the relatively satisfactory state of health of the patient disorients the doctor, which can lead to inadequate therapy. At a certain stage, bleeding begins to increase rapidly, the condition deteriorates sharply and DIC begins to develop rapidly.

Differential Diagnosis hypotonic bleeding is carried out with traumatic injuries of the birth canal. In contrast to hypotonic bleeding in trauma of the birth canal, the uterus is dense, well reduced. Examination of the cervix and vagina with the help of mirrors, manual examination of the walls of the uterine cavity confirm the diagnosis of soft tissue ruptures of the birth canal and bleeding from them.

There are 4 main groups of methods to combat bleeding in the early postpartum period.

1. Methods aimed at restoring and maintaining the contractile activity of the uterus include:

The use of oxytotic drugs (oxytocin), ergot drugs (ergotal, ergotamine, methylergometrine, etc.). This group of drugs gives a quick, powerful, but rather short-term contraction of the uterine muscles.

Massage of the uterus through the anterior abdominal wall. This manipulation should be carried out dosed, carefully, without excessively rough and prolonged exposure, which can lead to the reflux of thromboplastic substances into the mother's bloodstream and lead to the development of DIC.

Cold in the lower abdomen. Prolonged cold irritation reflexively maintains the tone of the uterine muscles.

2. Mechanical irritation of the reflex zones of the vaginal vaults and cervix:

Tamponade of the posterior vaginal fornix with ether.

Electrotonization of the uterus, is performed in the presence of equipment.

The listed reflex effects on the uterus are performed as additional, auxiliary methods that complement the main ones, and are carried out only after a manual examination of the walls of the uterine cavity.

The operation of manual examination of the walls of the uterine cavity refers to the methods of reflex action on the uterine muscle. This is the main method that should be performed immediately after a set of conservative measures.

Tasks that are solved during the operation of manual examination of the uterine cavity:

n exclusion of uterine trauma (complete and incomplete rupture). In this case, they urgently switch to surgical methods to stop bleeding.

n removal of the remnants of the fetal egg, lingering in the uterine cavity (placental lobules, membranes).

n removal of blood clots that have accumulated in the uterine cavity.

n the final stage of the operation is the massage of the uterus on the fist, which combines mechanical and reflex methods of influencing the uterus.

3. Mechanical methods.

Refer to manual pressing of the aorta.

Clamping of parameters according to Baksheev.

It is currently used as a temporary measure to buy time in preparation for surgical methods to control bleeding.

4. Surgical operational methods. These include:

n clamping and ligation of the main vessels. They are resorted to in cases of technical difficulties when performing a caesarean section.

n hysterectomy - amputation and extirpation of the uterus. Serious, crippling operations, but, unfortunately, the only correct measures with massive bleeding, allowing for reliable hemostasis. In this case, the choice of the volume of the operation is individual and depends on the obstetric pathology that caused the bleeding, and the patient's condition.

Supravaginal amputation of the uterus is possible with hypotonic bleeding, as well as with true rotations of the placenta with a highly located placental site. In these cases, this volume allows you to remove the source of bleeding and provide reliable hemostasis. However, when a DIC syndrome developed as a result of massive blood loss, the scope of the operation should be expanded to a simple extirpation of the uterus without appendages with additional double drainage of the abdominal cavity.

Extirpation of the uterus without appendages is indicated in cases of cervical-isthmus location of the placenta with massive bleeding, with PONRP, Kuveler's uterus with signs of DIC, as well as with any massive blood loss accompanied by DIC.

Dressing Art Iliaca interna. This method is recommended as an independent, preceding or even replacing hysterectomy. This method is recommended as the final stage in the fight against bleeding in advanced DIC after hysterectomy and lack of sufficient hemostasis.

With any bleeding, the success of ongoing measures to stop bleeding depends on timely and rational infusion-transfusion therapy.

TREATMENT

Treatment for hypotonic bleeding is complex. It is started without delay, at the same time, measures are taken to stop bleeding and replenish blood loss. Therapeutic manipulations should begin with conservative ones, if they are ineffective, then immediately move on to surgical methods, up to ablation and removal of the uterus. All manipulations and measures to stop bleeding should be carried out in a strictly defined order without interruption and be aimed at increasing the tone and contractility of the uterus.

The system for combating hypotonic bleeding includes three stages.

First stage: Blood loss exceeds 0.5% of body weight, averaging 401-600 ml.

The main task of the first stage is to stop bleeding, prevent large blood loss, prevent a shortage of blood loss compensation, maintain the volume ratio of injected blood and blood substitutes, equal to 0.5-1.0, 100% compensation.

Activities of the first stage bleeding control are as follows:

1) emptying the bladder with a catheter, therapeutic dosed massage of the uterus through the abdominal wall for 20-30 seconds. after 1 min., local hypothermia (ice on the stomach), intravenous administration of crystalloids (saline solutions, concentrated glucose solutions);

2) simultaneous intravenous administration of methylergometrine and oxytocin, 0.5 ml each. in one syringe, followed by a drip of these drugs in the same dose at a rate of 35-40' cap. in min. within 30-40 minutes;

3) manual examination of the uterus to determine the integrity of its walls, remove parietal blood clots, conduct a two-handed massage of the uterus;

4) examination of the birth canal, stitching of gaps;

5) intravenous administration of a vitamin-energy complex to increase the contractile activity of the uterus: 100-150 ml. 40% glucose solution, 12-15 units of insulin (subcutaneously), 10 ml. 5% solution of ascorbic acid, 10 ml. calcium gluconate solution, 50-100 mg. cocarboxylase hydrochloride.

In the absence of effect, confidence in the cessation of bleeding, as well as in case of blood loss equal to 500 ml, one should proceed to blood transfusion.

If the bleeding has not stopped or resumed in the ovary, they immediately proceed to the second stage of the fight against hypotonic bleeding.

With continued bleeding proceed to the third stage.

Third stage: blood loss exceeding masses body i.e. 1001-1500 ml.

The main tasks of the third stage of the fight against hypotonic bleeding: removal of the uterus before development hypocoagulation, compensation shortfall warning blood loss more than 500 ml., preservation of the volume ratio of injected blood and blood substitutes: 1, timely compensation of respiratory function (IVL) and kidneys, which allows stabilizing hemodynamics. Compensation for blood loss by 200 .

Activities of the third stage .

For uncontrolled bleeding, intubation anesthesia with mechanical ventilation, abdominal surgery, temporary stop of bleeding in order to normalize hemodynamic and coagulation indicators (the imposition of clamps on the corners of the uterus, the bases of the broad ligaments, isthmic part of the tubes, own ligaments of the ovaries and round ligaments of the uterus).

The choice of the volume of the operation (amputation or extirpation of the uterus) is determined by the pace, duration, volume blood loss the state of the systems hemostasis. With the development DIC only hysterectomy should be performed.

I do not recommend applying the position Trendelenburg, which drastically impairs lung ventilation and function cordially- vascular system, repeated manual examination and vyskab pouring uterine cavity, terminal repositioning, simultaneous administration of large amounts of drugs tonomotor actions.

Uterine tamponade and suture according to Lositskaya, as methods of combating postpartum hemorrhage, were withdrawn from the arena of funds as a dangerous and misleading doctor about the true value blood loss and uterine tone connections, with which operational intervention is belated.

The pathogenesis of hemorrhagic shock

The leading place in the development of severe shock belongs to the disproportion between the BCC and the capacity of the vascular bed.

BCC deficiency leads to a decrease in venous return and cardiac output. The signal from the valyumoreceptors of the right atrium enters the vasomotor center and leads to the release of catecholamines. Peripheral vasospasm occurs mainly in the venous part of the vessels, because. it is in this system that 60-70% of the blood is contained.

Redistribution of blood. In a puerperal, this is carried out due to the release of blood from the uterine circuit into the bloodstream, containing up to 500 ml of blood.

The redistribution of fluid and the transition of extravascular fluid into the bloodstream is autohemodilution. This mechanism compensates for blood loss up to 20% of the BCC.

In cases where blood loss exceeds 20% of the BCC, the body is not able to restore the compliance of the BCC and the vascular bed at the expense of its reserves. Blood loss passes into the decompensated phase and centralization of blood circulation occurs. To increase venous return, arteriovenous shunts are opened, and blood, bypassing the capillaries, enters the venous system. This type of blood supply is possible for organs and systems: skin, s / c fiber, muscles, intestines, and kidneys. This entails a decrease in capillary perfusion and hypoxia of the tissues of these organs. The volume of venous return slightly increases, but to ensure adequate cardiac output, the body is forced to increase the heart rate - in the clinic, along with a slight decrease in systolic blood pressure with increased diastolic tachycardia appears. The stroke volume increases, the residual blood in the ventricles of the heart decreases to a minimum.

The body cannot work in such a rhythm for a long time and tissue hypoxia occurs in organs and tissues. A network of additional capillaries is revealed. The volume of the vascular bed increases sharply with a deficiency of BCC. The resulting discrepancy leads to a drop in blood pressure to critical values, at which tissue perfusion in organs and systems practically stops. Under these conditions, perfusion is maintained in vital organs. With a decrease in blood pressure in large vessels to 0, blood flow in the brain and coronary arteries is maintained.

In conditions of a secondary decrease in BCC and low blood pressure due to a sharp decrease in stroke volume in the capillary network, a "sludge syndrome" ("scum") occurs. Bonding of formed elements occurs with the formation of microclots and thrombosis of the microvasculature. The appearance of fibrin in the bloodstream activates the fibrinolysis system - plasminogen turns into plasmin, which breaks the fibrin strands. The patency of the vessels is restored, but again and again formed clots, absorbing blood factors, lead the blood coagulation system to exhaustion. Aggressive plasmin, not finding a sufficient amount of fibrin, begins to break down fibrinogen - along with fibrin degradation products, fibrinogen degradation products appear in the peripheral blood. DIC enters the stage of hypocoagulation. Virtually devoid of clotting factors, the blood loses its ability to coagulate. In the clinic, bleeding with non-clotting blood occurs, which, against the background of multiple organ failure, leads the body to death.

Diagnosis of obstetric hemorrhagic shock should be based on clear and accessible criteria that would allow us to catch the moment when a relatively easily reversible situation decompensates and approaches irreversible. For this, two conditions must be met:

n blood loss should be determined as accurately and reliably as possible

n there must be an objective individual assessment of the response of a given patient to a given blood loss.

The combination of these two components will make it possible to choose the correct algorithm of actions to stop bleeding and draw up an optimal program of infusion-transfusion therapy.

In obstetric practice, accurate determination of blood loss is of great importance. This is due to the fact that any childbirth is accompanied by blood loss, and bleeding is sudden, profuse and requires quick and correct action.

As a result of numerous studies, average volumes of blood loss in various obstetric situations have been developed. (slide)

In case of delivery through the natural birth canal, a visual method for assessing blood loss using measuring containers. This method, even for experienced specialists, gives 30% errors.

Determination of blood loss by hematocrit represented by Moore formulas: In this formula, it is possible to use another indicator instead of hematocrit - hemoglobin content, the true values ​​of these parameters become real only 2-3 days after the blood is completely diluted.

The Nelson formula is based on the hematocrit. It is reliable in 96% of cases, but informative only after 24 hours. It is necessary to know the initial hematocrit.

There is an interdependence between blood density, hematocrit and blood loss (slide)

When determining intraoperative blood loss, a gravimetric method is used, which involves weighing the surgical material. Its accuracy depends on the intensity of soaking the operating linen with blood. The error is within 15%.

In obstetric practice, the most acceptable visual method and Libov's formula. There is a certain relationship between body weight and BCC. For women, BCC is 1/6 of body weight. Physiological blood loss is considered to be 0.5% of body weight. This formula is applicable to almost all pregnant women, except for patients who are obese and have severe forms of gestosis. Blood loss of 0.6-0.8 refers to pathological compensated, 0.9-1.0 - pathological decompensated and more than 1% - massive. However, such an assessment is applicable only in combination with clinical data, which are based on an assessment of the signs and symptoms of developing hemorrhagic shock using indicators of blood pressure, pulse rate, hematocrit, and Altgower index calculation.

The Altgower index is the ratio of heart rate to systolic blood pressure. Normally, it does not exceed 0.5.

The success of measures to combat bleeding is due to the timeliness and completeness of the measures to restore myotamponade and ensure hemostasis, but also the timeliness and well-designed program of infusion-transfusion therapy. Three main components:

1. infusion volume

2. composition of infusion media

3. rate of infusion.

The volume of infusion is determined by the volume of recorded blood loss. With blood loss of 0.6-0.8% of body weight (up to 20% of BCC), it should be 160% of the volume of blood loss. At 0.9-1.0% (24-40% BCC) - 180%. With massive blood loss - more than 1% of body weight (more than 40% of BCC) - 250-250%.

The composition of infusion media becomes more complex as blood loss increases. With a 20% deficiency of BCC, colloids and crystalloids in a ratio of 1: 1, blood is not transfused. At 25-40% of BCC - 30-50% of blood loss is blood and its preparations, the rest is colloids: crystalloids - 1:1. With blood loss of more than 40% of the BCC - 60% - blood, the ratio of blood: FFP - 1: 3, the rest - crystalloids.

The rate of infusion depends on the magnitude of systolic blood pressure. When blood pressure is less than 70 mm Hg. Art. - 300 ml / min, with indicators of 70-100 mm Hg - 150 ml / min, then - the usual infusion rate under the control of the CVP.

Prevention of bleeding in the postpartum period

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

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

3. Proper management of childbirth: competent assessment of the obstetric situation, optimal regulation of labor activity. Anesthesia of childbirth and timely resolution of the issue of operative delivery.

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

Mandatory emptying of the bladder after the birth of a child, ice on the lower abdomen after the birth of the placenta, periodic external massage of the uterus. Careful accounting of lost blood and assessment of the general condition of the puerperal.

1. Obstetrics / ed. G.M. Savelyeva. - M.: Medicine, 2000 (15), 2009 (50)

2. Gynecology / Ed. G.M. Savelieva, V.G. Breusenko.-M., 2004

3. Obstetrics. Ch. 1,2, 3 / Ed. V.E. Radzinsky.-M., 2005.

4. Obstetrics from ten teachers / Ed. S. Campbell.-M., 2004.

5. Practical skills in obstetrics and gynecology / L.A. Suprun.-Mn., 2002.

6. Smetnik V.P. Non-operative gynecology.-M., 2003

1. Bohman Ya.V. Guide to oncogynecology.-SPb., 2002
2. Practical guide for an obstetrician-gynecologist / Yu.V. Tsvelev et al. - St. Petersburg, 2001
3. Practical gynecology: (Clinical lectures) / Ed. IN AND. Kulakov and V.N. Prilepskaya.-M., 2002
4. Guide to practical exercises in gynecology / Ed. Yu.V. Tsvelev and E.F. Kira.-SPb., 2003
5. Khachkuruzov S.G. Ultrasound examination during early pregnancy.-M., 2002
6. Guide to endocrine gynecology / Ed. EAT. Vikhlyaeva.-M., 2002.

Only 14% of births proceed without complications. One of the pathologies of the postpartum period is postpartum hemorrhage. There are many reasons for this complication. It can be both diseases of the mother, and complications of pregnancy. There are also postpartum hemorrhages.

Early postpartum hemorrhage

Early postpartum hemorrhage 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 the woman's body weight. If the blood loss exceeds the indicated figures, then they speak of pathological bleeding, but if it is 1 percent or more, then this indicates massive bleeding.

Causes of early postpartum hemorrhage

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

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

Early postpartum hemorrhage clinic

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

Hypotonic bleeding

This bleeding is characterized by rapid and massive blood loss, when the puerperal loses 1 liter of blood or more in a few minutes. In some cases, blood loss occurs in waves, alternating between good uterine contraction and no bleeding, and sudden relaxation and flaccidity of the uterus with increased bleeding.

Atonic bleeding

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

Therapeutic measures for early postpartum hemorrhage

First of all, it is necessary to assess the condition of the woman and the amount of blood loss. Ice must be placed on the stomach. Then inspect the cervix and vagina and, if there are tears, suture them. If bleeding continues, a manual examination of the uterus (mandatory under anesthesia) should be started and after emptying the bladder with a catheter. During manual control of the uterine cavity, all the walls of the uterus are carefully examined by hand and the presence of a rupture or fissure of the uterus or residual placenta / blood clots is detected. The 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 enter 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 replenished with infusion therapy and blood transfusion.

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

Late postpartum hemorrhage

Late postpartum hemorrhage is bleeding that occurs 2 hours after delivery and 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 sanious, and then serous (lochia). Lochia lasts 6 to 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, with a bimanual examination, reaches sizes that correspond to 9-10 weeks of pregnancy. This process is called uterine involution. Simultaneously with the contraction of the uterus, the cervical canal is also formed.

Causes of late postpartum hemorrhage

The main causes of late postpartum hemorrhage include:

• retention of parts of the placenta and / or membranes of the fetus;
• blood clotting disorders;
• subinvolution of the uterus;
• blood clots in the uterine cavity with a closed cervical canal (caesarean section);
• endometritis.

Clinic of late postpartum hemorrhage

Bleeding in the late postpartum period begins suddenly. Often it is very massive and leads to a sharp anemia of the puerperal and even to hemorrhagic shock. Late postpartum hemorrhage should be distinguished from increased bleeding during breastfeeding (the uterus begins to contract due to increased production of oxytocin). A characteristic sign of late bleeding is increased spotting of a bright red color or changing the pad more often than every 2 hours.

Treatment of late postpartum hemorrhage

In the event of late postpartum hemorrhage, if possible, ultrasound of the pelvic organs should be performed. On ultrasound, the uterus is determined, it is larger than the prescribed size, the presence of blood clots and / or remnants of the membranes and placenta, the expansion of the cavity.

With late postpartum hemorrhage, it is necessary to curettage the uterine cavity, although a number of authors do not adhere to this tactic (the leukocyte shaft in the uterine cavity is disturbed and its walls are damaged, which can later lead to the spread of infection outside the uterus or). After surgical arrest of bleeding, complex hemostatic therapy continues with the introduction of reducing and hemostatic agents, replenishment of circulating blood volume, blood and plasma transfusion, and antibiotics.

Lecture #4

Pathological course of childbirth and the postpartum period

PM.02 Participation in medical diagnostic and rehabilitation processes

MDC 02.01 SP in obstetrics and pathology of the reproductive system in men and women

By specialty

nursing

Bleeding in the postpartum period

Causes of bleeding in the postpartum period:

- Decreased tone of the uterus.

- Violation of the contractile activity of the uterus.

- Anomalies of placenta attachment: incomplete placenta previa.

- Anomalies in the location of the placenta: low attachment or location in one of the tubal corners of the uterus.

- Irrational management of the afterbirth period: massaging the uterus, pressing on its bottom, pulling on the umbilical cord is unacceptable.

Clinical symptoms of bleeding in the postpartum period:

1) If the bleeding has reached 350 ml (or 0.5% of the mother's body weight) and it continues, this is pathological bleeding. The strength of bleeding depends on the size of the exfoliated part of the placenta and on the site of attachment of the placenta.

2) Pale skin, tachycardia, tachypnea, hypotension.

3) The uterus is enlarged, spherical, sharply tense, if the blood does not come out, but accumulates in the uterine cavity.

Diagnosis of afterbirth delay:

1) To understand whether the separation of the placenta has occurred or not, you can use the described signs of separation of the placenta:

- Schroeder sign: after separation of the placenta, the uterus rises above the navel, becomes narrow and deviates to the right;

- sign of Alfeld: the exfoliated placenta descends to the internal pharynx of the cervix or into the vagina, while the outer part of the umbilical cord lengthens by 10-12 cm;

- sign of Mikulich: after separation of the placenta and its lowering, the woman in labor has a need to push;

- Klein sign: when straining a woman in labor, the umbilical cord lengthens. If the placenta has separated, then after an attempt the umbilical cord is not tightened;

- sign of Kyustner-Chukalov: when the obstetrician presses over the pubic symphysis with the separated placenta, the umbilical cord will not be retracted.

If the birth proceeds normally, then the placenta will separate no later than 30 minutes after the expulsion of the fetus.

Diagnosis of delayed parts of the placenta:

1) Examination of the placenta and membranes after birth: if there are irregularities, roughness and depressions, then this is a defect in the placenta.

Treatment for retention of the placenta and its parts in the uterine cavity:

1) Conservative method:

Injection of 1 ml (5 units) of oxytocin to increase the aftereffects

In cases of separation of the placenta from the uterus, but its retention in the cavity, external methods are used to isolate the placenta from the uterus: Bayer-Abuladze, Krede-Lazarevich methods, etc.

2) Operative method: if conservative measures do not give an effect, and the blood loss has exceeded the physiological limits, then immediately proceed to the operation of manual separation and removal of the placenta (performed by a doctor)

After emptying the uterus, contracting agents are introduced, cold on them in the abdomen.

Antibiotics.

With blood loss of more than 0.7% of body weight - infusion therapy.

Prevention of the delay of parts of the placenta:

1) Rational management of childbirth and the postpartum period.

2) Prevention of abortion and inflammatory gynecological diseases.

Bleeding in the early postpartum period

Bleeding in the early postpartum period - bleeding from the genital tract that occurred in the first 4 hours after the birth of the placenta.

Causes of bleeding in the early postpartum period:

1) Delay in the uterine cavity of parts of the child's place.

2) Atony or hypotension of the uterus.

3) Injury to the soft tissues of the birth canal.

Hypotonic bleeding (Greek hypo- + tonos tension) - uterine bleeding, the cause of which is a decrease in the tone of the myometrium.

Causes of hypotonic bleeding:

1) Depletion of the forces of the body, the central nervous system as a result of prolonged painful childbirth.

2) Severe preeclampsia, GB.

3) Anatomical inferiority of the uterus.

4) Functional inferiority of the uterus: overstretching of the uterus due to multiple pregnancy, multiple pregnancy.

5) Presentation and low attachment of a child's seat.

Clinic of hypotonic bleeding:

1) Massive bleeding from the uterus: blood flows out in a jet or large clots.

2) Hemodynamic disorders, signs of anemia.

3) The picture of hemorrhagic shock gradually develops.

Diagnosis of hypotonic bleeding:

1) The presence of bleeding.

2) Objective data on the state of the uterus: on palpation, the uterus is large, relaxed.

Treatment of hypotonic bleeding:

1) Measures to stop bleeding: carried out simultaneously by all personnel without interruption

Emptying the bladder with a catheter.

Oxytocin or Ergometrine 1ml IV.

External massage of the uterus. If during the massage the uterus does not contract or contracts poorly, then proceed to:

Manual examination of the walls of the uterine cavity. If this is ineffective - laparotomy. If the bleeding has stopped, the increase in the tone of the uterus is conservative.

2) The fight against hemodynamic disorders.

3) Chestectomy and removal of the uterus.

4) Surgical methods:

Ligation of the vessels of the uterus. If that doesn't help, then

Amputation (removal of the body of the uterus) or extirpation (removal of both the body and the cervix) of the uterus.

Prevention of bleeding in the early postpartum period:

1) Identification and hospitalization in an obstetric hospital before delivery of pregnant women with pathology.

Anomalies of tribal forces

Anomalies of the birth forces are a fairly common complication of the birth act. The consequences of anomalies in the contractile activity of the uterus during childbirth can be very dangerous for both the mother and the fetus.

Causes of labor anomalies:

Maternal pathology: somatic and neuroendocrine diseases; complicated course of pregnancy; pathological change in the myometrium; overdistension of the uterus; genetic or congenital pathology of myocytes, in which the excitability of the myometrium is sharply reduced.

Pathology of the fetus and placenta: malformations of the nervous system of the fetus; fetal adrenal aplasia; placenta previa and its low location; accelerated, delayed maturation.

Mechanical obstacles to the advancement of the fetus: narrow pelvis; pelvic tumors; malposition; incorrect insertion of the head; anatomical rigidity of the cervix;

Non-simultaneous (non-synchronous) readiness of the body of the mother and fetus;

iatrogenic factor.