Consequences of bleeding during childbirth. Symptoms of postpartum hemorrhage

Prevention of obstetric hemorrhage

Prevention of obstetric hemorrhage includes several principles.

Pregnancy planning, timely preparation for it (identification and treatment chronic diseases before pregnancy, prevention of unwanted pregnancy).

Timely registration of a pregnant woman in a antenatal clinic (up to 12 weeks of pregnancy).

Regular visit obstetrician-gynecologist(1 time per month in the 1st trimester, 1 time in 2-3 weeks in the 2nd trimester, 1 time in 7-10 days in the 3rd trimester).

Removal of increased muscle tension of the uterus during pregnancy with the help of tocolytics (drugs that reduce muscle tension uterus).

Timely detection and treatment of pregnancy complications:

preeclampsia(a complication of the course of pregnancy, accompanied by edema, increased blood pressure and impaired renal function);
placental insufficiency(violation of the functioning of the placenta due to insufficient blood supply to the "womb-placenta" system);
arterial hypertension(persistent increase blood pressure).

Control of blood sugar levels with a glucose tolerance test (the pregnant woman is given 75 g of glucose and an hour later her blood sugar level is measured).

Compliance with a pregnant diet (with a moderate content of carbohydrates and fats (excluding fatty and fried foods, starchy foods, sweets) and sufficient protein content (meat and dairy products, legumes)).

Therapeutic exercise for pregnant women (minor physical exercise 30 minutes a day – breathing exercises, walking, stretching).

Rational management of childbirth:

assessment of indications and contraindications for childbirth through the natural birth canal or with the help of a caesarean section;
adequate use of uterotonics (drugs that stimulate uterine contractions);
exclusion of unreasonable palpations of the uterus and pulling on the umbilical cord in the afterbirth period of childbirth;
carrying out an episio- or perineotomy (dissection by a doctor of a woman's perineum (tissues between the entrance to the vagina and anus) as a prevention of perineal rupture);
examination of the discharged placenta (placenta) for integrity and the presence of tissue defects;
the introduction of uterotonics (drugs that stimulate muscle contractions of the uterus) in the early postpartum period.

For successful prevention and bleeding therapy is necessary:

Identify risk groups for the development of bleeding, which will allow a number of preventive measures to be taken to reduce the incidence of obstetric bleeding and reduce the severity of post-hemorrhagic disorders.

Currently, the main risk groups for the occurrence of massive coagulopathic bleeding in obstetrics are presented (A. D. Makatsaria et al., 1990).

I. Pregnant women and women in labor with preeclampsia and extragenital diseases (diseases of the cardiovascular system, kidneys, diathesis, venous insufficiency, etc.) In this group, 4 types of hemostasis disorders were found in DIC:

1) hypercoagulation and hyperaggregation of platelets with symptoms of thrombinemia;

2) hypercoagulability and consumption thrombocytopathy;

3) isocoagulation or hypocoagulation and platelet hyperaggregation;

4) isocoagulation or hypocoagulation and consumption thrombocytopathy.

The likelihood of bleeding during childbirth and postpartum period especially high in types 2, 3 and 4 of hemostasis disorders, in type 4 there is a 100% chance of coagulopathy bleeding.

II. Pregnant women with hereditary and congenital defects in coagulation and platelet hemostasis.

III. Pregnant women and women in labor with disadaptation of hemostasis - hypo- or isocoagulation in the third trimester of pregnancy, uncharacteristic for this period of pregnancy. Disadaptation of hemostasis is often observed in patients with recurrent miscarriage, endocrine disorders, and infectious diseases. In the absence of preventive measures in this group (administration of FFP), bleeding occurs in every third woman.

IV. Iatrogenic disorders (untimely start of infusion-transfusion therapy, insufficient pace and volume of administered solutions, incorrect choice of the qualitative and quantitative composition of solutions, homeostasis correction errors, incorrect choice of means and methods for stopping bleeding).

V. Parturients and puerperas with the circulation of specific and non-specific inhibitors of blood coagulation.

A specific and effective algorithm for predicting, monitoring and intensive care in the prevention of obstetric bleeding was proposed by O. I. Yakubovich et al. (2000): according to the authors, the application of the developed program made it possible to increase by 13.4% the number of women whose childbirth ended without pathological blood loss.

Hemostasiological indicators were determined that have the greatest information content in terms of predicting pathological blood loss in childbirth and its estimated volume - the number of platelets, fibrinogen, fibrinogen B, thrombin time, the K parameter of thromboelastogram under conditions of high-contact activation of hemocoagulation and the level of D-dimers, a number of regression equations and a scheme for the management of pregnant women has been developed, starting from the first visit of a woman to a antenatal clinic.

In the first and second trimesters, 2 indicators are determined - fibrinogen level and thrombin time, and function F is determined:

F = 0.96a - 0.042b - 2.51,

where a is the concentration of fibrinogen in plasma, g/l;

b - thrombin time, s.

If the function value F>0.31, physiological blood loss is predicted, the woman continues to be observed in the antenatal clinic and hemostasis indicators are re-monitored in the third trimester.

At F value<-0,27, когда прогнозируется патологическая кровопотеря или при значении функции F в диапазоне от -0,27... до 0,31, что составляет зону неопределенного прогноза, пациентку направляют в стационар одного дня, где проводят углубленное комплексное исследование системы гемостаза и в зависимости от результата рекомендуют лечение в амбулаторных или стационарных условиях.

As a rule, in the first trimester of pregnancy, pathology of the vascular-platelet hemostasis is detected and therapy is aimed at stabilizing endothelial function and reducing platelet aggregation ability: metabolic therapy (riboxin, magnesium, vitamin B6), herbal medicine, disaggregants (aspirin) for 10- 14 days.

In the second trimester, given the more pronounced dysfunction of vascular-platelet hemostasis and the tendency to intravascular coagulation, this therapy is supplemented with prophylactic doses of low molecular weight heparins - fraxiparin at a dose of 7500 IU. When isolated activation of fibrinolysis is detected, Essentiale, lipoic acid, Vicasol are additionally prescribed, and the dosage of Riboxin is increased. In the absence of positive dynamics in the hemostasiogram, fibrinolysis inhibitors are used in prophylactic doses. The effectiveness of treatment is assessed 10 days after the start of therapy by re-determining the prognosis - the F function.

In the third trimester, prediction of pathological blood loss is carried out using the following parameters:

F = -0.89a - 0.59b + 0.014c + 0.012d - 1.14,

where a is the concentration of fibrinogen B in plasma, g/l;

b - D-dimers, ng/ml;

c - platelet count, 109/l;

d - parameter K of thromboelastogram (TEG) under conditions of high-contact activation of hemocoagulation, mm.

If the function value F>0.2, physiological blood loss is predicted, and the woman continues to be observed in consultation.

At F value<-0,2 прогнозируется патологическая кровопотеря, значения F от -0,2... до 0,2 составляют зону неопределенного прогноза и в этих случаях беременной проводится комплексное исследование системы гемостаза и в зависимости от выраженности гемостазиологических нарушений назначается терапия.

To decide the volume of intensive care, you can use an algorithm for predicting the estimated volume of blood loss. To do this, two discriminant functions are calculated:

F1 = -1.012a - 0.003b - 0.038c + 4.16

F2 = -0.36a + 0.02b + 0.03c - 4.96,

where a is the level of fibrinogen B, g/l;

b - platelet count, 10 to 9 degrees/l;

c - parameter K of TEG under conditions of high-contact hemocoagulation, mm.

With function values F, >0.2 and F2 >0.5, the volume of blood loss can be expected to be less than 500 ml; if F1 > 0.2 and F2< -0,2, ожидается объем кровопотери от 500 до 1000 мл и женщина может проходить лечение в акушерском стационаре. Если F1 < -0,5, a F2 >0.2, then the volume of blood loss is expected to be more than 1000 ml, and the woman should receive treatment in the intensive care unit.

In the third trimester, patients with a prognosis of pathological blood loss during childbirth, as a rule, already have profound disturbances in all parts of hemostasis, up to the development of a typical picture of disseminated intravascular coagulation. In this contingent of pregnant women, therapy includes low molecular weight heparin, fresh frozen plasma (antithrombin-III concentrate), if disseminated intravascular coagulation occurs, the deficiency of anticoagulants (antithrombin-III, protein C and S) is compensated, vascular-platelet hemostasis is corrected with the help of dicinone and ATP, coagulation the potential is replenished with supernatant donor plasma, cryoprecipitate in combination with fibrinolysis inhibitors.

The next step in solving the problem of combating bleeding is the use of modern methods of replenishing blood loss and preventing bleeding in women at “high risk” for bleeding. It's about about the types of autohemo- and plasma donation, which include: preoperative procurement of blood components, controlled hemodilution and intraoperative blood reinfusion (V.N. Serov, 1997, V.I. Kulakov et al., 2000).

Preoperative collection of blood components

Procurement of red blood cells is not used in obstetrics. The collection of red blood cells from gynecological patients in the amount of 200-300 ml is carried out 2-7 days before surgery for 1 and 2 exfusions with replacement with colloid and crystalloid solutions in a ratio of 2:1. Erythromass is stored at a temperature of +4°C. Procurement of autoerythrocytes is indicated for an estimated blood loss of 1000-1200 ml (20-25% of the blood volume), difficulties in selecting donor erythrocytes, transfusion reactions, and a high risk of thromboembolic complications in the postoperative period.

The following contraindications to the procurement of autoerythrocytes have been identified: anemia (Hb less than 110 g/l and Ht less than 30%), various forms of hemoglobinopathies, hypotension (BP less than 100/60 mm Hg), cardiovascular decompensation, sepsis, septic conditions, Acute respiratory infections, exhaustion, hemolysis of any origin, chronic renal failure with azotemia, liver failure, severe atherosclerosis, cancer cachexia, severe hemorrhagic syndrome and thrombocytopenia (platelet content less than 50 10 in 9 degrees / l).

When harvesting autoerythrocytes, venipuncture, infusion of 200-300 ml of 0.9% NaCl, exfusion of the calculated volume of blood taking into account body weight, initial Hb and Ht (usually 15% of the bcc) and blood centrifugation (speed 2400 rpm for 10 min) are performed ). Additionally, 0.9% NaCl is administered and autoplasma is retransfused. In one procedure, when performing two exfusions, 200-450 ml of erythroconcentrate are obtained. The optimal period for harvesting autoerythrocytes before surgery is usually 5-8 days, provided that the main hemodynamic parameters are stable; after harvesting autoerythrocytes, a decrease in Ht is not allowed less than 30%, respectively, the level of Hb is not less than 100 g/l.

If the need for red blood cells exceeds 15% of the bcc, which cannot be prepared in one procedure, the “jumping frog” method is used: Stage I - exfusion of 400-450 ml of blood, Stage II - after 5-7 days, infusion of blood collected at stage I, exfusion 800-900 ml of blood, stage III - 5-7 days after stage II, exfusion of blood in a volume of 1200-1400 ml with infusion of 800-900 ml of blood collected at stage II. The method allows you to prepare 1200-1400 ml of autologous blood with a short shelf life and high oxygen transport function.

At obstetric operations A woman’s body needs to replenish blood clotting factors, fibrinogen, antithrombin-III, the deficiency of which is caused by the subclinical course of DIC during pregnancy. The main source of coagulation factors is FFP. Autoplasma is harvested using discrete plasmapheresis in an amount of 600 ml in 2 exfusions at a weekly interval 1-2 months before the expected date of delivery.

Indications for autoplasma donation in pregnant women are abdominal delivery according to absolute indications (uterine scar, high degree of myopia, placenta previa, anatomically narrow pelvis), or according to the sum of relative indications with a volume of predicted blood loss of no more than 1000 ml (no more than 20% of the blood volume), estimated during surgery by hypocoagulation, with an initial Hb content of 100-120 g/l, total protein not less than 65 g/l.

Harvesting of autoplasma is contraindicated in case of low content of total protein - less than 65 g/l, albumin content less than 30 g/l, in case of pulmonary, renal, hepatic or cardiovascular insufficiency, septic conditions, hemolysis of any genesis, severe disorders of coagulation and thrombocytopenia (less than 50 10 to the 9th degree/l).

2 stages of plasmapheresis are performed to obtain 800-1200 ml of plasma. 400-500 ml of blood is exfuse simultaneously, centrifugation is carried out at a speed of 2800 rpm for 10 minutes or 2200 rpm for 15 minutes. After compensation (1:1) with isotonic solutions and reinfusion of erythrocytes, the next 400-500 ml of blood is taken. The total volume of plasma obtained is determined by the patient’s condition, the initial content of total protein and albumin, and the calculated value of the total blood volume. The total protein content after plasmapheresis should be at least 60 g/l; more often, 0.25 TCP is exfused. Plasma replacement is carried out with colloidal or crystalloid solutions in a 2:1 ratio. Plasma is stored at a temperature of -18°C and transfused during cesarean section in order to stabilize coagulological and hemodynamic parameters and protein parameters (M. M. Petrov, 1999).

One more modern method controlled hemodilution is used to replace surgical blood loss. There are normovolemic and hypervolemic hemodilution.

Normovolemic hemodilution is indicated during operations in gynecological patients. After the patient is put under anesthesia, 500-800 ml of blood is exfused with simultaneous replacement with colloids in an equal volume. The blood collected in this way is reinfused after surgical hemostasis is achieved. Contraindications to the method are initial anemia, severe coronary pathology, obstructive pulmonary diseases, severe hypertension, liver cirrhosis, defects in the hemostasis system (hypocoagulation), endogenous intoxications, mitral heart defects, renal failure.

In obstetrics, when performing a cesarean section, the technique of hypervolemic hemodilution is used, which consists of preliminary transfusion of solutions with high colloid-osmotic pressure or osmolarity. As a result, microcirculation improves, in particular in the uteroplacental zone, the rheological properties of blood normalize, the risk of thrombotic and purulent-septic complications decreases, and lactation increases. For hypervolemic hemodilution, solutions of albumin, rheopolyglucin, and hydroxyethyl starch are used, which are well tolerated, improve tissue perfusion, circulate in the vascular bed for a long time, and do not pose a risk to the pregnant woman and the fetus. The method is contraindicated in cases of severe anemia, mitral heart defects, renal failure, hypocoagulation, and intrauterine fetal suffering.

The availability of modern Cell-saver equipment from Haemonetics, Althin, and Dideco has made intraoperative blood reinfusion promising and safe. In this case, the blood from the surgical wound is aspirated using a sterile pump into a special container with an anticoagulant, then enters a separator, where during rotation it is washed with physiological solution, hemoconcentration occurs and the final product is an erythrothromene suspension with Ht of about 60%, which is returned to the patient.

Blood reinfusion is used during gynecological operations when the estimated blood loss is more than 500 ml, and is the method of choice in patients with rare group blood burdened with an allergic and blood transfusion history.

The use of reinfusion during surgery is promising C-section, however, it is necessary to remember the presence of thromboplastic substances in amniotic fluid ah and the possibility of their transfer into the patient’s vascular bed. Therefore it is necessary:

1) performing amniotomy before surgery,

2) use of a second pump immediately after extraction to aspirate amniotic fluid, cheese-like lubricant and meconium,

3) use of a special regime of high-quality washing of red blood cells with a large amount of solution.

Availability in abdominal cavity liquids such as furatsilin solution, small amounts of alcohol, iodine, cyst contents are not a contraindication to reinfusion, because these substances will be washed out during high speed rinsing.

Indications for intraoperative reinfusion in obstetrics are repeat cesarean section, cesarean section and conservative myomectomy, cesarean section followed by amputation (extirpation) of the uterus, varicose veins of the uterus, hemangiomas of the pelvic organs.

An absolute contraindication to reinfusion is the presence of intestinal contents and pus in the abdominal cavity. A relative contraindication is the presence of a malignant neoplasm in the patient.

The use of the above methods, taking into account their indications and contraindications, in most cases allows for timely, effective and safe prevention development of hemorrhagic shock. This reduces the use donated blood, i.e. the risk of developing blood transfusion complications, HIV infection and hepatitis is eliminated, maternal morbidity and mortality are reduced (Methodological recommendations No. 96/120 of the Ministry of Health of the Russian Federation “Prevention and treatment of bleeding in obstetrics and gynecology”, 1997).

A feature of obstetric hemorrhages is their acute onset and massive blood loss, therefore important role Implementation of a set of organizational measures plays a role in reducing maternal mortality from bleeding. According to the definition of V.N. Serov (1993), the survival of patients with massive obstetric hemorrhage is determined by assistance started in the first 30 minutes and carried out in the first 3 hours from the onset of obstetric hemorrhage; 75% of the lost blood volume should be replenished in the first 1-2 hours from the start of bleeding.

Organizational activities include the following points (E. N. Zarubina, 1995, I. B. Manukhin et al., 1999):

1. The suddenness of a critical situation and the multifaceted nature of actions at the time of bleeding determine the attitude towards childbirth as a surgical operation. This approach involves a preliminary examination of the woman by an anesthesiologist and her preoperative preparation, including bowel movement, bladder emptying, creating psychological comfort, etc. During childbirth, it is recommended that an anesthesiological team be present to organize pain relief during labor and provide the full volume and quality of infusion therapy in the event of bleeding.

2. An important point is the creation in a maternity institution of reserves of blood components, consisting of FFP, washed red blood cells, erythromass, thrombomass, albumin, plasma-substituting solutions, systems for emergency blood collection.

3. It is necessary to have a 24-hour express laboratory, whose function includes clinical and biochemical examination of blood and the hemostasis system. It should be emphasized the need to determine the initial parameters of hemostasis, monitor them during the occurrence of bleeding and during infusion therapy.

4. For each woman in labor, even before the onset of the active phase of labor, a peripheral vein is catheterized and the ABO and Rh blood group is determined in case of possible blood transfusion.

5. Therapy for obstetric hemorrhage is carried out in the operating room or in the delivery room, where there is everything necessary to provide intensive treatment and, if necessary, surgical intervention. The time required to set up the operating room should not exceed 5-7 minutes.

6. The duty team must include a specialist who knows all methods of stopping obstetric hemorrhage, including performing hysterectomy and ligation of the internal iliac arteries.

7. When bleeding develops, the main task of the obstetrician is the timely use of the most effective and reliable methods to stop it before hemorrhagic shock occurs. Delay leads to the fact that you have to deal not only with bleeding, but also with multiple organ failure that occurs in the post-resuscitation period. When bleeding, the main task is to stop it. Inspection implied birth canal, elimination of traumatic injuries, the use of mechanical methods to stop bleeding, the introduction of uterotonic agents.

Lysenkov S.P., Myasnikova V.V., Ponomarev V.V.

Bleeding can complicate the course of childbirth, the postpartum period, and lead to severe endocrine pathology. Every year, 140 thousand women die from bleeding during childbirth. Half of them occur against the background of gestosis, a pathology of vital important organs. TO fatal outcome are cited by underestimation of the severity of the patient’s condition, insufficient examination, inadequate and untimely therapy. What are the causes of obstetric bleeding, is there any prevention, what should be the therapy.

What is physiological blood loss

Most cases of pathological blood loss occur in the postpartum period, after the placenta has separated. The volume programmed by nature, up to 0.5% of a woman’s body weight, does not exceed three hundred milliliters. From one hundred to one hundred and fifty of them are spent on the formation of blood clots in the placental area after separation of the placenta. Two hundred milliliters are secreted from the genital tract. This blood loss is called physiological - provided by nature without harm to health.

Why does it occur

Obstetric hemorrhages are usually divided into those that begin with the onset labor activity, in the afterbirth and early postpartum periods. Bleeding in the first stage of labor and in the second can be caused by premature abruption of a normally located placenta. In the third period there are many more reasons.

After the birth of the fetus, during the normal course of labor, the placenta separates and the placenta is released. At this time, an open placental area appears, which contains up to two hundred spiral arteries. The terminal sections of these vessels do not have a muscular membrane; blood loss is prevented only by uterine contractions and activation of the hemostatic system. The following happens:

After expulsion of the fetus, the uterus decreases significantly in size.
A powerful contraction and shortening of muscle fibers occurs, which draw in the spiral arteries, compressing them with the force of myometrial contractions.
At the same time, compression, twisting and bending of the veins occurs, intensive education blood clots.

In the area of the placental platform (the place of former attachment of the placenta) healthy women blood clotting processes are accelerated ten times compared to the time of thrombus formation in vascular bed. During the normal course of the postpartum period, the first thing that occurs is a contraction of the uterus, which triggers a thrombosis mechanism, which requires a decrease in the lumen of blood vessels and a decrease in blood pressure.

It takes about two hours for the final formation of a blood clot, which explains the observation time due to the risk of the described complication. Therefore, the causes of bleeding during childbirth can be:

conditions that impair the contractility of the myometrium;
pathology of the blood coagulation system;
birth canal injuries;
premature, disruption of the processes of its separation and excretion.

Bleeding can begin after the birth of the fetus with a decrease in myometrial tone, abnormalities in the location of the placenta, disruption of its attachment and incomplete separation from the walls in the third stage of labor. The likelihood of pathology occurring is higher with the development of the following complications:

anomalies of labor;
inappropriate use of uterotonics;
rough handling of the third period.

The risk group includes women with previous gynecological diseases, genital surgeries, abortions, infantilism. In the afterbirth period, due to pathologies of the placenta, the force of myometrial contractions may be impaired, and the operation of manual separation of the placenta disrupts the process of thrombus formation in the placental site.

Additional provoking factors are disruption of the integrity of the birth canal. In the first hours after childbirth, bleeding can be caused by low content fibrinogen in the blood, atony and hypotension of the uterus, retention of parts placental tissue, membranes.

How does it manifest

Bleeding is the most severe complication of childbirth. Blood loss of 400-500 milliliters is pathological, and one liter is massive. Pathology accompanies abnormalities of placental attachment, retained placenta, rupture of soft tissue of the genital tract.

Premature detachment normally located placenta

If the measures taken remain ineffective, the issue of applying surgical treatment. When the uterus ruptures, internal bleeding develops. This condition is an indication for urgent extirpation or amputation of the organ.

Manifestations in the early postpartum period

Bleeding in the first two hours after birth occurs in five percent of all births. Predisposing factors may be inflammatory processes against the background of pregnancy, endometritis, abortion, history of miscarriage, presence of a scar on the uterus. The main causes of occurrence are:

retention of parts of the placenta;
violation contractility myometrium;
birth canal injuries;
blood coagulation disorders.

Read more about bleeding after childbirth.

Retention of parts of the placenta, fetal membranes

Prevents contraction, pinching uterine vessels. Pathology may arise due to the acceleration of the birth of the placenta by obstetricians, when its complete separation has not yet occurred, with the true attachment of one or several lobes. They remain on the wall at a time when the main part children's place born from the genital tract.

Pathology is diagnosed by examining the placenta, finding a defect in its lobules and membranes. The presence of defects is an indication for a mandatory inspection of the uterine cavity, during which the retained parts are searched and separated.

Hypotony and atony of the uterus

Damage to the neuromuscular apparatus of the uterus, dysregulation of muscle fiber contractions, malnutrition, oxygen starvation myometrial cells lead to a significant decrease or complete loss (, respectively) of uterine tone. Hypotonic bleeding during childbirth is a reversible condition, the first manifestations of which begin immediately after the separation of the placenta, and can be combined with a violation of the processes of its separation.

The large size of the organ, flabby consistency, unclear contours, profuse bleeding from the birth canal, which is accompanied by additional release of blood and clots during external massage of the uterus, are symptoms of hypotension. This condition direct reading for manual examination of the cavity, fist massage, administration of uterotonics, infusion therapy. If the measures taken are ineffective and blood loss is 1 liter, the issue of organ removal is decided.

There are two development options pathological condition– wavy and massive blood loss. With uterine atony, bleeding is continuous, quickly leading to hemorrhagic shock. In this condition urgent Care It turns out from the first seconds, with simultaneous preparation of the operating room. Consists of several stages:

Restoring the volume of lost blood.
Achieving adequate oxygen levels.
Timely use of maintenance therapy – steroid hormones, cardiovascular drugs.
Correction of biochemical, coagulation, vascular disorders.

The level of organization of the work of the maternity hospital, a clearly developed scheme of staff actions is the basis successful therapy. Prevention of bleeding during childbirth involves early identification of pregnant women in the appropriate risk group.

These measures make it possible to foresee severe complication, prepare for it in advance. Establish with the first contractions intravenous catheter, determine the main indicators of hemostasis, administer Methylergometrine when the fetal head erupts, prepare a supply of medications. All events are held against the background intravenous administration necessary drugs.

The infusion therapy protocol provides for the administration of Infucol in an amount equal to the volume of lost blood. In addition, crystalloids, fresh frozen plasma, erythromass are used.

Indications for the administration of red blood cells may also be a decrease in hemoglobin levels to 80 g/l hematocrit to 25%. Platelet mass is prescribed when the platelet level decreases to seventy. The amount of blood loss recovery is determined by its size.

TO preventive measures include the fight against abortion, compliance with the protocol for managing women at the stage antenatal clinics, in childbirth, the postpartum period. A competent assessment of the obstetric situation, prophylactic administration of uterotonics, and timely surgical delivery make bleeding preventable.

Careful observation in the first two hours after birth, applying ice to the lower abdomen after discharge of the placenta, periodic gentle external massage uterus, accounting for lost blood, assessment general condition women avoid complications.

It is known that normal birth, and postpartum period accompanied by bleeding. The placenta (baby place) is attached to the uterus with the help of villi and is connected to the fetus by the umbilical cord. When she's in labor naturally is rejected, capillaries and blood vessels rupture, which leads to blood loss. If everything is in order, then the volume of lost blood does not exceed 0.5% of body weight, i.e. for example, a woman weighing 60 kg should have no more than 300 ml of blood loss. But in case of deviations from normal course During pregnancy and childbirth, bleeding that is dangerous to the health and even life of a woman may occur, in which the volume of blood loss exceeds allowable norms. Blood loss amounting to 0.5% of body weight or more (this is on average more than 300–400 ml) is considered pathological, and 1% of body weight or more (1000 ml) is already massive.

All obstetric hemorrhages can be divided into two groups. The first combines bleeding that occurs in late dates pregnancy and in the first and second stages of childbirth. The second group includes those bleedings that develop in the third stage of labor (when the placenta leaves) and after the baby is born.

Causes of bleeding in the first and second stages of labor

It should be remembered that the onset of labor can provoke bleeding, which is by no means normal. The exception is streaks of blood in the mucus plug, which is released from the cervical canal a few days before birth or with the onset of labor. The water that breaks during childbirth should be clear and have a yellowish tint. If they are stained with blood, emergency treatment is necessary. health care!
Why might bleeding start? The causes of blood loss can be different:

Bleeding in the third stage of labor and after it

Bleeding in the third stage of labor(when the placenta separates) and after childbirth arise due to anomalies in the attachment and separation of the placenta, as well as due to disturbances in the functioning of the uterine muscle and the blood coagulation system.

Disorders of placenta separation. Normally, some time (20–60 minutes) after the birth of a child, the placenta and membranes are separated, constituting the baby's place or placenta. In some cases, the process of separation of the placenta is disrupted and it does not come out on its own. This happens due to the fact that the placental villi penetrate too deeply into the thickness of the uterus. There are two forms of pathological placenta attachment: dense attachment and placental accreta. It is possible to understand the cause of violations only by performing manual separation placenta In this case, the doctor general anesthesia inserts his hand into the uterine cavity and tries to manually separate the placenta from the walls. With a tight attachment this can be done. And during accretion, such actions lead to heavy bleeding, the placenta is torn off in pieces, not completely separating from the wall of the uterus. Only immediate surgery will help here. Unfortunately, in such cases the uterus has to be removed.
Ruptures of the soft tissues of the birth canal. After the placenta has separated, the doctor examines the woman to identify ruptures in the cervix, vagina and perineum. Given the abundant blood supply, such ruptures can also cause heavy bleeding in childbirth. Therefore, all suspicious areas are carefully sutured immediately after birth under local or general anesthesia.
Hypotonic bleeding. Bleeding that occurs in the first 2 hours after birth is most often caused by impaired contractility of the uterus, i.e. her hypotonic state. Their frequency is 3–4% of total number childbirth The cause of uterine hypotension may be various diseases of a pregnant woman, difficult labor, weakness of labor, violations of the separation of the placenta, premature detachment of a normally located placenta, malformations and inflammatory diseases uterus. In this condition, most often the uterus periodically loses its tone, and the bleeding either increases or stops. If medical care is provided on time, then the body compensates for such blood loss. Therefore, in the first two hours after childbirth, the newly-made mother is constantly monitored, because in the event of bleeding, you need to act as quickly as possible. Treatment begins with the introduction of contractile medicines and replenishing blood volume using solutions and components of donor blood. Simultaneously released bladder with the help of a catheter, an ice pack is placed on the lower abdomen, an external and internal massage of the uterus is done, etc. These mechanical methods are designed to reflexively “trigger” uterine contractions. If medicinal and mechanical methods of stopping bleeding are ineffective and blood loss increases, an operation is performed, possibly trying to avoid removal of the uterus.
Late postpartum bleeding. It would seem that when everything is in order with a woman and 2 hours after giving birth she is transferred to the postpartum ward, then all the dangers are already behind and you can relax. However, it also happens that bleeding begins in the first few days or even weeks after the baby is born. It may be caused by insufficient contraction of the uterus, inflammation, tissue injuries of the birth canal, and blood diseases. But more often this problem arises due to the remains of parts of the placenta in the uterus, which could not be determined during the examination immediately after birth. If pathology is detected, the uterine cavity is curetted and anti-inflammatory drugs are prescribed.

How to avoid bleeding?

Despite the diversity causes of bleeding, it is still possible to reduce the risk of their occurrence. First of all, of course, you need to regularly visit an obstetrician-gynecologist during pregnancy, who closely monitors the course of pregnancy and, if problems arise, will take measures to avoid complications. If anything worries you about the “female” organs, be sure to notify your doctor, and if you have been prescribed treatment, be sure to follow through with it. It is very important to tell your doctor if you have had any injuries, surgeries, abortions, or venereal diseases. Such information cannot be hidden; it is necessary to prevent the development of bleeding. Do not avoid ultrasound: this study will not cause harm, and the data obtained will help prevent many complications, including bleeding.

Follow the recommendations of doctors, especially if prenatal hospitalization is necessary (for example, with placenta previa), do not decide on a home birth - because in case of bleeding (and many other complications) you need immediate action, and help may simply not arrive in time! Whereas in a hospital setting, doctors will do everything possible to cope with the problem that has arisen.

First aid for blood loss

If you notice the appearance bloody discharge(most often this happens when visiting the toilet) - do not panic. Fear increases uterine contractions, increasing the risk of miscarriage. To assess the amount of discharge, thoroughly blot the perineal area, change a disposable pad, or put a handkerchief in your panties. Lie down with your feet up or sit with your feet on a chair. Call ambulance. Try not to move until the doctors arrive. It is also better to ride in a car lying down with your legs elevated. At heavy bleeding(when completely wet underwear and clothes) something cold should be placed on the lower abdomen - for example, a bottle of cold water or something from the freezer (a piece of meat, frozen vegetables, ice cubes wrapped in plastic bag and a towel).

Etiology.

Decreased tone, disturbance contractile activity uterus, abnormalities of attachment and location of the placenta. Contractile function myometrium is disturbed with irrational management of childbirth, polyhydramnios, multiple pregnancies, late toxicosis, large fruit, pathological change the walls of the uterus after inflammation, submucous or interstitially located myomatous node, etc. Incomplete presentation of the child's place, its low attachment or location in one of the tubal corners of the uterus, where the myometrium cannot develop full contractions, are the cause of bleeding in the afterbirth period. Irrational management afterbirth(iatrogeny) often leads to bleeding, massaging the uterus, pressing on its bottom, pulling on the umbilical cord, unreasonable use of uterotonics is completely unacceptable.

Classification of obstetric hemorrhage during childbirth and the postpartum period.

1.Bleeding during the first stage of labor:

Placenta previa.

Premature abruption of a normally located placenta.

Soft tissue injuries.

2.Bleeding during the second stage of labor:

Placenta previa.

Premature abruption of a normally located placenta.

Injuries of the soft birth canal.

Spontaneous and violent uterine rupture.

H. Bleeding during the third stage of labor:

Intimate (excessively tight) attachment of the placenta.

True placenta accreta.

4.Bleeding during the postpartum period

Obstetric traumatism.

Retained parts of the placenta (placental defect).

Hypotony and atony of the uterus

Failure of the hemostatic system (coagulopathic bleeding).

Retention of the placenta or its parts in the uterus (placenta defect).

The main symptom of retained placenta is bleeding from the genital tract.

If in the afterbirth period bleeding exceeded 0.5% of the mother’s body weight (reached 300 ml), then this abnormal bleeding. If, after the birth of the placenta, an unseparated lobule or part of the lobule of the placenta remains in the uterine cavity, then bleeding can be profuse.

Sometimes symptoms appear internal bleeding: paleness skin, increased heart rate and respiration, drop in blood pressure, etc. There is no external bleeding. The uterus increases in volume, accepts spherical shape and sharply tense. This situation occurs when a completely or partially detached placenta closes the internal os or a spasm occurs. internal pharynx and the outflow of blood from the uterus to the outside stops. Blood accumulates in the uterine cavity.

Diagnosis

diagnosed based on examination of the placenta and membranes after birth. If irregularities, roughness and depressions are found on the smooth, shiny maternal surface of the placenta, then this is a sign of an afterbirth defect. Detection during examination of the membranes of the breaking umbilical vessels indicates the presence of an additional lobule that remained in the uterus. If, when examining a child's place, ambiguities arise in its integrity, then a diagnosis of "doubt in integrity" is made.

obstetric tactics.

The operation of manual separation of the placenta (retained lobule), as well as blood clots that prevent uterine contraction. If, after manual separation of the placenta or its parts on the placental site, small pieces of the placenta are determined that do not separate during manual examination, then they are removed instrumentally in the absence of signs of a true increase in the share, i.e., by scraping the walls of the uterine cavity with a large blunt curette. After complete emptying the uterus is injected with substances that reduce the uterus, put cold on the lower abdomen and periodically control palpation through the anterior abdominal wall condition of the uterus.

To prevent postpartum infection in all cases surgical intervention Antibiotics are prescribed in the afterbirth period. When blood loss reaches 500 ml or more, blood transfusion is performed.

BLEEDING DURING LATE PREGNANCY AND DURING CHILDREN

The main causes of bleeding in the second half of pregnancy are placenta previa and PONRP. Along with the above-mentioned pathology, the causes of bleeding can be disorders that occur at any stage of gestation: rupture of the umbilical cord vessels during their membrane attachment, erosion, polyp, cervical cancer and vagina.

ALGORITHM FOR EXAMINATION OF PREGNANT WOMEN ENTERING THE HOSPITAL WITH BLOOD DISCHARGE

Due to the variety of causes of bleeding, patients entering a maternity facility must be examined in accordance with a certain algorithm:
· external obstetric examination;
· listening to fetal heart sounds, cardiac monitoring;
· examination of the external genitalia and determination of the nature of blood discharge;
· Ultrasound (in case of massive blood loss in the operating room).

If necessary:
· examination of the cervix and vagina using mirrors;
· two-manual vaginal examination.

Due to the widespread introduction of ultrasound into the practice of antenatal clinics, the diagnosis of placenta previa is known
in advance. At established diagnosis placenta previa and bleeding after admission to the patient
transferred to the operating room. In other situations with massive bleeding, first of all it is necessary
exclude PONRP.

If the diagnosis of PONRP is not confirmed by external obstetric and ultrasound examination, it is necessary to examine the cervix and vaginal wall using speculum. In this case, the diagnosis is excluded or confirmed (erosion or cervical cancer, uterine polyps, rupture of varicose veins, trauma). If this pathology is detected, treatment measures are carried out in accordance with the identified diseases.

Vaginal examination during childbirth is performed in the following cases:
· amniotomy during vaginal delivery;
· determination of the degree of cervical dilatation;
detection of blood clots in the vagina, posterior fornix(definition of true blood loss).

A vaginal examination is performed with the operating room open; If bleeding increases, an emergency transection and CS are performed. Be sure to determine the amount of blood loss (weighing diapers, sheets) taking into account the blood clots located in the vagina.

PLACENTA PREVIA

Placenta previa (placenta praevia) is the location of the placenta in the lower segment of the uterus in the area of the internal os or 3 cm above (according to ultrasound). In case of previa, the placenta is in the path of the newborn fetus (“prae” - “in front”, “via” - “on the way”).

ICD-10 CODE
O44 Placenta previa.
O44.0 Placenta previa, specified as without bleeding. Low attachment placenta, specified as non-bleeding.
O44.1 Placenta previa with bleeding. Low attachment of the placenta without additional instructions or bleeding. Placenta previa (marginal, partial, complete) without additional instructions or bleeding.

PREMATURE DETACHMENT OF NORMALLY POSITIONED PLACENTA

Premature abruption of a normally located placenta - placental abruption before the birth of the fetus (during pregnancy, in the first and second stages of labor).

ICD-10 CODE
O45 Premature placental abruption (abruption placentae).
O45.0 Premature placental abruption with blood clotting disorders.
O45.8 Other premature placental abruption.
O45.9 Premature placental abruption, unspecified.

BLEEDING IN THE POSTPARTUM AND EARLY POSTPARTUM PERIOD

BLEEDING DURING THE FOLLOW-UP PERIOD

Bleeding is the most dangerous complication afterbirth period. Blood loss of 0.5% of body weight or more (300–400 ml) is considered pathological, and 1% of body weight or more (1000 ml) is considered massive.

Causes of bleeding in the third stage of labor:
· violation of the separation of the placenta and the discharge of the placenta (partial tight attachment or placenta accreta, infringement of the separated placenta in the uterus);
· soft tissue injuries of the birth canal;
· hereditary and acquired hemostasis defects.

VIOLATION OF SEPARATION OF PLACENTA AND DISCHARGE OF AFTERMISSION

Dense attachment - attachment of the placenta to the basal layer of the uterine mucosa. Placenta accreta is the accretion of the placenta into muscle layer uterus.

SOFT TISSUE INJURIES OF THE BIRTH CHANNEL

See the chapter “Birth Trauma”.

BLEEDING IN THE EARLY POSTPARTUM PERIOD

Bleeding within 2 hours after birth occurs due to the following reasons:
· retention of parts of the placenta in the uterine cavity;
hypotension and atony of the uterus;
· rupture of the uterus and soft tissues of the birth canal;
· hereditary or acquired defects of hemostasis.
Abroad, to determine the etiology of bleeding, they offer the “4 T” scheme:
· “Tone” - decreased tone of the uterus;
· “Tissue” - the presence of placental remains in the uterus;
· “Trauma” - ruptures of the soft birth canal and uterus;
· “Thrombi” - impaired hemostasis.
ICD-10 CODE
O72 Postpartum hemorrhage.
O72.1 Other bleeding in the early postpartum period. Bleeding after delivery of the placenta. Postpartum
bleeding (atonic). neuromuscular apparatus of the uterus.

HEMORRHAGIC SHOCK

Hemorrhagic shock develops as a result of a decrease in blood volume during bleeding, which leads to a critical decrease in tissue blood flow and the development of tissue hypoxia.