Uterine bleeding after childbirth - this “term” puerperal refers to any bleeding from the genital tract after the completion of childbirth. And many of the women who gave birth start to panic, not knowing how much bleeding after delivery should last, what is its intensity and how to distinguish the norm from pathology.
In order to avoid such situations, the obstetrician, on the eve of discharge from the maternity hospital, conducts a conversation with the woman, explaining all the features of the postpartum period, its duration, and appoints attendance at the antenatal clinic (usually 10 days).
How much so-called bleeding lasts after birth, i.e. blood excretion
Normal intense spotting continues no more than 2 - 3 days. This is a natural process and such discharge is called lochia.
As you know, after the birth of the fetus there is a separation or, roughly speaking, the separation of the children's place (placenta) from the inner lining of the uterus. At the same time, a sufficiently large wound surface is formed, which requires time for healing. Lochia is nothing more than a wound secret, which is presented as detachable from the wound surface.
On the first day after delivery, the lochia consists of blood and pieces of the decidual membrane. Then, as the uterus shrinks and returns to its normal “pregenerate” size, blood plasma and tissue fluid, as well as parts of the decidual membrane, which continue to fall off, mucus with leukocytes, join the secretions of the discharge. Therefore, after a couple of days, discharge after birth becomes bloody-serous, and then serous. Their color also varies, from bright red to brown, and at the end yellowish.
Along with the coloring of the secretions, their intensity also changes (decreases). The process of discharge ends by 5-6 weeks. If the discharge is delayed, or become bloody and more intense, you should consult a doctor.
Uterine and cervical changes
The cervix and the uterus itself also undergo a stage of change. In the postpartum period, which lasts on average about 6 to 8 weeks, that is, up to 42 days, the uterus is reduced (reduced) in size, and its “internal wound” heals. In addition, the cervix is formed.
The most pronounced stage of the reverse development or involution of the uterus occurs in the first 14 days after birth. By the end of the first postpartum day, the bottom of the uterus is palpated at the navel site, and then, subject to its normal contraction, the uterus is lowered every day by 2 cm or 1 transverse finger.
As the height of the uterus floor decreases, other uterine sizes also decrease. The uterus becomes flatter and narrower in diameter. At about 10 days after delivery, the bottom of the uterus descends beyond the limits of the pubic bones and is no longer palpable through the anterior abdominal wall. When conducting a gynecological examination, you can determine the uterus in size from 9 to 10 weeks of pregnancy.
In parallel, and formed the cervix. The cervical canal gradually narrows. After 3 days, we pass for 1 finger. First, the internal pharynx closes, and after - the external one. Completely internal pharynx closes by 10 day, while outer by 16 - 20 day.
What is called postpartum bleeding?
Postpartum hemorrhages include intense blood loss of up to 0.5% and more of the puerperal body weight and are directly related to childbirth.
- If the bleeding after childbirth occurred after 2 hours or more (in the next 42 days), it is called late.
- If intense blood loss is recorded immediately after delivery or within two hours, it is called early.
Postpartum hemorrhages are considered a formidable obstetric complication, and can lead to the death of the puerperal.
The severity of bleeding is determined by the volume of blood loss. In a healthy parturient woman, the estimated volume of blood loss during childbirth does not exceed 0.5% of body weight, whereas with gestosis, anemia or coagulopathy, it decreases to 0.3%. If in the early postpartum period a woman has lost more blood than was calculated, then they speak of an early postpartum hemorrhage, which requires taking immediate measures, sometimes even before surgery.
Atonia or hypotonia of the uterus
This is one of the leading factors that contributes to the occurrence of bleeding. Hypotonia of the uterus is called its state, in which both the tone and its contractility are reduced. With uterine atony, the tone and contractile activity are sharply reduced or completely absent, and the uterus is in a “paralyzed” state. Atonia, fortunately, is extremely rare, but is dangerous by massive bleeding that is not amenable to conservative treatment. Bleeding associated with impaired uterine tone, develops in the early postpartum period. The reduction and loss of uterine tone contributes to one of the following factors:
- excessive overstretching of the uterus, which is observed with polyhydramnios, multiple fetuses or large fetus,
- pronounced fatigue of muscle fibers, aided by prolonged labor, irrational use of contraction, rapid or rapid delivery,
- loss of myometrium ability to normally reduce with its cicatricial, inflammatory or degenerative changes.
The following factors predispose to the development of hypo or atony:
- young age
- pathological conditions of the uterus:
- myomatous nodes
- postoperative uterus,
- structural dystrophic changes (inflammation, a large number of genera),
- overstretching of the uterus during gestation (polyhydramnios, multiple fetuses)
- pregnancy complications,
- anomalies of generic forces,
- abnormalities of the placenta (presentation or detachment),
- gestosis, chronic extragenital diseases,
- DIC syndrome of any origin (hemorrhagic shock, anaphylactic shock, amniotic fluid embolism.
Violation of the placenta
After a period of expulsion of the fetus, the third or subsequent period of labor begins, during which the placenta is separated from the uterine wall and excreted. As soon as the placenta is born, the early postpartum period begins (remember that it lasts 2 hours). This period requires the most attention, both the puerperal and the medical staff. After the birth of the placenta, it is examined for integrity, if any lobule remains in the uterus, it can provoke massive blood loss, as a rule, such bleeding begins a month after delivery, against the background of the woman’s full health.
What I want to mention. Unfortunately, such bleeding, which suddenly begins a month later and more after childbirth, is not uncommon. Of course, to blame the doctor who took delivery. I looked that there was not enough lobule on the placenta, but maybe it was an additional lobe (apart from the placenta), and did not take appropriate measures (manual control of the uterus cavity). But, as obstetricians say: "There is no such placenta that cannot be folded." That is, the absence of a lobule, especially the extension, is easy to overlook, and the doctor is a person, not a X-ray. In a good maternity hospital, when the puerperal is discharged, an uterus ultrasound is performed, but, as it is not sad, there is no ultrasound apparatus everywhere. And sooner or later the bleeding in this patient would still begin, only in such a situation he was “spurred” by severe stress.
Trauma to the birth canal
Far from the last role in the onset of postpartum bleeding (usually in the first 2 hours) is obstetric injury. In the event of abundant blood discharge from the genital tract, the obstetrician must, in the first place, exclude damage to the birth canal. Impaired integrity may be at:
Sometimes ruptures of the cervix are so long (3-4 degrees) that they go to the vaults of the vagina and the lower segment of the uterus. Gaps can occur spontaneously, during the expulsion of the fetus (for example, rapid delivery), and due to medical manipulations used in the extraction of the fetus (imposition of obstetric forceps, vacuum escohleator).
After cesarean section, bleeding can be caused by a violation of suturing techniques (for example, a missed, non-sutured vessel and a divergence of sutures in the uterus). In addition, in the postoperative period, it may be triggered by the prescription of antiplatelet agents (blood thinning) and anticoagulants (reduce its clotting).
Predisposing factors contribute to uterine rupture:
- scars on the uterus after previous surgical interventions,
- scraping and abortion,
- use of intrauterine contraceptives,
- obstetric manipulations (external rotation of the fetus or intrauterine rotation),
- birth stimulation
- narrow pelvis.
Various blood diseases associated with impaired blood clotting should also be considered as a factor in possible bleeding. These include:
- von Willebrand disease
- hypofibrinogenemia and others.
The development of bleeding also cannot be ruled out with liver diseases (as is well known, many clotting factors are synthesized in it).
Early postpartum hemorrhage, as already noted, is associated with impaired tonus and contractility of the uterus, so a woman 2 hours after birth remains under the supervision of medical staff in the delivery room. Every woman who has just become a mother must remember that during these 2 hours she cannot sleep. Severe bleeding may open suddenly, and it is likely that there will be no doctor or midwife near the puerperal. Hypo-and atonic bleeding can occur in two ways:
- Bleeding immediately becomes massive, "pouring like a tap." At the same time the uterus is very relaxed and flabby, its borders are not defined. There is no effect from external massage, manual control of the uterus and contraction drugs. In view of the high risk of complications (DIC and hemorrhagic shock), the puerperal woman is immediately operated on.
- Bleeding is wave-like. From time to time the uterus either relaxes or contracts, so the blood is released in portions of 150-300 ml. The positive effect of reducing drugs and external massage of the uterus. But at a certain point the bleeding increases, and the woman’s condition worsens dramatically, the above complications join.
But how to determine the pathology, if the woman is already at home? First of all, it is worth remembering that the total volume of lohium for the entire recovery period (6–8 weeks) is 0.5–1.5 liters. Any abnormalities indicate pathology and require immediate medical attention:
The appearance of such secretions, especially after the lochia has become grayish or yellow, should alert the woman. Bleeding can be simultaneous, or repeated periodically, in the discharge may be present or absent blood clots. The blood itself can change color - from bright scarlet to dark. Suffer and the general condition of the mother. Her pulse and breathing quicken, weakness and dizziness appear, a woman can constantly feel cold. Similar signs speak about the remains of an afterbirth in a uterus.
If the bleeding has started, and it is massive enough, it is urgent to call an ambulance. It is not difficult to determine the intensity of bleeding by a young mother on her own - a change of several pads per hour is required. You should not go to a doctor in such a condition on your own, as there is a high risk of loss of consciousness on the street.
Termination of discharge
Not excluded is such an option as the sudden disappearance of discharge, which is also not the norm and requires the provision of medical care.
Bleeding after childbirth lasts (normally) for no more than 7 days and is similar to heavy menstruation. If the period of bleeding is delayed, it should alert the young mother.
After the birth of the afterbirth, a number of measures are taken to prevent the onset of early postpartum hemorrhage:
The puerperal remains in the delivery room
Finding a woman in the delivery room for the next 2 hours after the end of labor is necessary to take emergency measures in case of possible bleeding. In this period of time, the woman is monitored by the medical staff, who assesses blood pressure and pulse, the color of the skin and the amount of blood secreted. As already mentioned, the permissible blood loss during childbirth should not exceed 0.5% of a woman’s weight (on average, up to 400 ml). Otherwise, blood loss is regarded as early postpartum hemorrhage, and measures are taken to stop it.
After the birth of the baby, it is mandatory for the obstetrician together with the midwife to examine it and decide on the integrity of the placenta, the presence / absence of additional lobes, their separation and delay in the uterine cavity. In case of doubts about the integrity of the placenta, a manual examination of the uterus is performed (under general anesthesia). During the examination of the uterus, the doctor produces:
- eliminates uterine trauma (rupture),
- removes remnants of the placenta, membranes and blood clots,
- conducts a manual (with caution) massage of the uterus on the fist.
Inspection of the birth canal
In the recent past, the examination of the birth canal after childbirth was carried out only in primiparas. At the moment, this manipulation is carried out to all puerperas, regardless of the number of births. During the inspection, the integrity of the cervix and vagina, the soft tissues of the perineum and the clitoris is established. If tears are detected, they are sutured (under local anesthesia).
Measures in the development of early postpartum hemorrhage
In the case of increased bleeding in the first 2 hours after the end of labor (500 ml or more), doctors carry out the following activities:
- Emptying the bladder (if it hasn’t been done before).
- The introduction of uterotonics intravenously in high dosage.
- Chill to the underbelly.
- External massage of the uterus
Having set the hand on the bottom of the uterus, gently squeeze and unclench it until the uterus is completely contracted. The procedure for a woman is not very pleasant, but quite tolerable.
It is performed as indicated above under general anesthesia. A hand is inserted into the uterus and, after examination of its walls, the hand is squeezed into a fist. With the other hand, massage the uterus outside.
- Tamponade of the posterior vaginal fornix
A tampon impregnated with ether is injected into the posterior vaginal fornix, which causes a reflex contraction of the uterus.
If all these measures have not had a positive effect, and the bleeding has increased and has reached 1 liter or more, the issue of surgery is resolved. At the same time, intravenous administration of solutions, blood products and plasma is carried out to replace blood loss. From operations apply:
- amputation or extirpation of the uterus (depending on the situation),
- ligation of the arteries of the uterus,
- ligation of ovarian arteries,
- ligation of the iliac artery.
Risk factors for postpartum hemorrhage
There are conditions in which the risk of postpartum bleeding is higher than in their absence. Analysis of statistical information has shown that such bleeding occurs more often in the following situations.
- Postpartum hemorrhages, abortions, miscarriages that were in the past. This means that a woman is prone to bleeding, which means the risk will be higher.
- Late toxicosis. In the case of preeclampsia, high blood pressure and kidney dysfunction are present, as a result, the vessels become more fragile and easily destroyed.
- Big fruit. Due to the pressure of such a fetus during labor, the uterus wall may be injured, which is manifested by bleeding after the birth of a child. In addition, the uterus is overstretched and therefore decreases worse.
- Polyhydramnios (large amounts of amniotic fluid). The mechanism is about the same as with a large fruit.
- Multiple pregnancy. Here is similar.
- Uterine leiomyoma. This is a benign tumor that gives the clinic bleeding. A childbirth can provoke it.
- A scar on the uterus. After operations (most often, caesarean section), a scar remains, which is a weak link in the uterine wall. Therefore, after the birth of a child, a gap may occur in this place.
- DIC syndrome. As a result of this phenomenon, the blood coagulation function is disturbed. After childbirth, there is always trauma and discharge of blood, but with DIC, the bleeding does not stop.
- Thrombocytopathy. These are acquired or congenital diseases, where platelets involved in blood coagulation cannot perform their duties due to the presence of defects in them.
The mechanism of development of postpartum bleeding
After the baby is born, the endometrial pressure drops sharply and the empty uterus also decreases sharply (postpartum contractions). The size of the placenta does not correspond to such a shortened uterus and it begins to separate from the walls.
Then begins the evacuation of the separated parts of the placenta, the compression and twisting of the vessels to stop the blood and the formation of blood clots to seal the damage in the walls of the vessels.
The duration of the separation of the placenta and its release is directly dependent on the contraction of the uterus. Normally, evacuation occurs approximately 30 minutes after birth. Delayed evacuation of the placenta indicates a high chance of postpartum hemorrhage.
При отделении от стенок матки плаценты повреждаются сосуды. Задержка выхода плаценты свидетельствует о слабом сокращении. This means that the vessels can not narrow and the bleeding does not stop. Also, the cause of bleeding can be an incomplete separation of the placenta from the walls due to its accretion or pinching of parts in the uterus.
Postpartum bleeding in the case of soft tissue injury occurs only when they break. In diseases of the blood vessels are not able to withstand even minor damage. And since there is always damage to the blood vessels at birth, the bleeding after birth will continue for a long time, which requires immediate action to stop the blood.
Types of postpartum hemorrhage
In obstetric practice, it is customary to distinguish two main types of bleeding:
- Bleeding in the early postpartum period - this means that blood is released in the first 2 hours after birth. The most dangerous, because here it is difficult to eliminate the cause.
- In the late postpartum period - after 2 hours and up to 1.5-2 months.
Well, since this is bleeding, the separation is due to the appearance. That is, bleeding due to:
- weak uterine contraction,
- delayed separation and excretion of parts of the placenta,
- blood disorders
- trauma to the uterus.
They also determine sharp bleeding, which begins immediately after the birth of a child in large quantities (per minute blood loss reaches more than 1 liter) and pressure drops rapidly. Another type is characterized by the release of blood in small portions with a gradual increase in blood loss. It stops and begins.
Weak uterine contraction
Since the main number of vessels is in the uterus, when it is reduced, the vessels narrow and the blood stops. With insufficient contraction of the uterus vessels do not narrow and the blood continues to be released. This occurs when the uterus is overstretched by a large fetus, in case of high water flow, overworking of a woman, an overflowing bladder, or a fast birth of a child.
When using antispasmodics, long and exhausted childbirth, the muscles of the uterus are overexcited and exhaled, which leads to a drop in its tone.
Various kinds of inflammation of the uterus, cancer and endocrine diseases lead to a deterioration in the ability of the muscles of the uterus to contract effectively.
Mental disorders (extreme excitability, fear of the child’s condition) or severe pain can also lead to insufficient contraction of the uterus.
Delayed separation or excretion of parts of the placenta
The main symptom is the occurrence of bleeding immediately after the start of the evacuation of parts of the placenta. The blood flows either in continuous current, or, more often, in separate portions.
The blood is usually dark in color with admixtures of small clots. Sometimes it happens that the opening of the cervical canal of the uterus closes and, as it were, the bleeding stops. But in reality the situation is the opposite or even worse. The fact is that in this case the blood accumulates inside the uterus. The uterus increases in size, is poorly reduced, and if massaged, then a large blood clot comes out and bleeding resumes.
The general condition of the mother gradually deteriorates. This is manifested by the following features:
- pale skin and visible mucous membranes,
- gradual decrease in blood pressure
- rapid pulse and breathing.
It is also possible to pinch parts of the placenta in the area of the fallopian tube. This can be determined by finger examination, during which protrusion will be felt.
Bleeding due to blood disorders
A characteristic sign of such bleeding is the normal tone of the uterus. This results in blood that is rare without clots, there are no signs of any injury or damage. Another symptom that indicates a blood disorder is the formation of hematomas or hemorrhages at the injection site. The blood that has leaked out does not clot for a long time or does not clot at all, since the necessary substances are missing for this in the right quantity.
Hemorrhages can be not only at the injection sites, but also in the internal organs, stomach, intestines, that is, anywhere. With an increase in blood loss increases the risk of death.
In the case of DIC (depletion of clotting substances), this leads to the formation of blood clots and the blockage of most small vessels in the kidneys, adrenal glands, liver and other organs. If proper medical care is not provided, the tissues and organs will simply begin to collapse and die.
All this is manifested by such symptoms:
- hemorrhages under the skin and mucous membranes,
- excessive bleeding at injection sites, operating wounds, uterus,
- the appearance of dead skin,
- hemorrhages in the internal organs, which manifests itself in violation of their functions,
- signs of damage to the central nervous system (loss, depression of consciousness, etc.).
Bleeding due to injury
Frequent manifestation in such a situation will be a gap in the soft tissues of the genital tract. At the same time characteristic features are observed:
- the onset of bleeding immediately after the baby is born,
- the blood is bright red
- the uterus is thick to the touch
- when viewed visualized the place of the gap.
When the perineal tissue is ruptured, there is a slight blood loss and it does not carry any threat. However, when the cervix or clitoris ruptures, the bleeding can be serious and threaten the life of the woman.
Signs of bleeding in the late period (from 2 hours to 2 months)
Usually such bleeding makes itself felt about 7-12 days after birth.
Blood can be released once and heavily or in small quantities, but several times and bleeding can last a couple of days. The uterus can be soft, and can be dense, painful and not painful. It all depends on the cause.
The delay of parts of the placenta creates a favorable background for the reproduction of bacteria and the development of infection, which later will manifest characteristic symptoms of the inflammatory process.
Diagnosis of postpartum hemorrhage
What is the diagnosis of postpartum hemorrhage? How do doctors determine the type of bleeding? In reality, diagnostics and treatment take place at the same time because this condition is a threat to the patient’s life. Especially when there is heavy bleeding, the diagnosis generally goes by the wayside, as the most important thing is to stop the blood. But now we’ll talk about diagnostics.
Here, the main task is to find the cause of bleeding. The diagnosis is based on the clinical picture, that is, when the bleeding began, what color of blood, the presence of clots, the number, nature, and so on.
The first thing to notice is the time of the bleeding. That is, when it arose: immediately after childbirth, in a few hours or in general, for example, for 10 days. This is an important point. For example, if the bleeding immediately after childbirth, then there may be a problem in the blood disease, tissue rupture or insufficient muscle tone of the uterus. And other options automatically disappear.
The nature and amount of bleeding are the second most important signs. When analyzing these symptoms, one can reason about the possible cause, the extent of the damage, how heavy the bleeding is and how to make predictions.
The clinical picture allows only to suspect a possible cause. But in most cases, by experience, doctors can make a diagnosis. In doubtful cases, a gynecological examination is performed to confirm the diagnosis. In this case, you can:
- to assess the tone and ability to reduce the uterus,
- determine the pain, shape and density of the uterus,
- detect the source of bleeding, the place of tissue rupture in case of injury, stuck or attached parts of the placenta.
Usually the afterbirth is always inspected after any birth. Then apply special samples that are necessary to detect defects in the placenta.
If it was revealed that parts of the afterbirth remained in the uterus, a manual examination is carried out. It is carried out in case of suspected violation of the integrity of the placenta, regardless of whether there is bleeding or not. Since it may not be visible excretion of blood. This method is also used to search for possible defects after surgical procedures.
The procedure looks like this:
- One hand is inserted into the uterine cavity, and the other is placed on the stomach outside for control.
- With that hand inside, an inspection and assessment of the state of the walls of the uterus, the mucous membrane for the presence of placenta residues is carried out.
- Next, the soft parts, flat foci of the mucous are removed.
- If scraps of tissues that reach to the wall of the uterus are found, then with the outer hand a massage of that area is done. If these are remnants of the afterbirth, then they are easily separated.
- After the uterus is massaged with two hands clenched into a fist, oxytocin is injected to increase the contraction of the organ, plus antibiotics to prevent infection.
There is damage to the uterus by a large fetus against the background of rapid delivery, the use of obstetric forceps, a narrow pelvis in a pregnant woman or during polyhydramnios. Such injuries include rupture of the uterus, cervical canal, perineum, and the area of the clitoris.
Violation of the discharge of the placenta
The impossibility of complete separation of the placenta from the walls and its release or delay parts (umbilical cord, fetal membranes) of the organ in the uterus.
Treatment of postpartum hemorrhage
What actions are taken by doctors during bleeding? What is the provision of medical care? Excessive bleeding is life threatening. Therefore, everything is done quickly and accurately according to the instructions, and the choice of tactics depends on the cause of the bleeding. The main task is to first stop the bleeding, and then eliminate its causes.
The algorithm of actions looks like this:
- A catheter is placed on one of the veins to quickly administer pharmacological agents. Yet this action is due to the fact that with a large blood loss, blood pressure drops and veins fall down. As a result, it will be hard to get into them.
- The bladder is freed from urine by a urinary catheter. This will remove the pressure on the uterus and improve its contraction.
- Estimated volume of blood lost, blood pressure, the severity of the situation. With a loss of more than 1 l. blood is used to compensate for blood loss using intravenous drip of saline. In the latter case, transfusion of donor blood is resorted, and with low pressure, appropriate drugs are administered.
- Means are introduced to enhance uterine contraction. This will squeeze the blood vessels and slightly stop the secretion of blood. But for the duration of the drug.
- An instrumental examination of the uterus.
- Further, medical assistance depends on the cause and the tactics are selected individually according to the situation.
Treatment of a weak uterine contraction
Treatment of postpartum hemorrhage in this case is based on the fight against hypotension and the prevention of the development of atony. That is, it is necessary to stimulate and resume the normal functioning of the muscles of the uterus. To do this, use 4 ways:
Medication. We have already mentioned it. This is the first and most frequently used method. Intravenously or in the area of the cervix, special medications are injected that reinforce the contraction. Side effects in overdose are worsening of the contraction of the organ, increase or decrease in blood pressure.
Mechanical. Here apply massage. First, they carry out a light massaging from the side of the abdomen for about 60 s until the moment of contraction. Then from above they press with a hand on the area of the uterus to excrete a blood clot. This contributes to a better reduction. If this is not effective, then one hand is inserted into the uterus, the other is on the stomach, and an external internal massage is performed. After impose on the cervical canal sutures to reduce the uterus and stop the blood.
Physical. These include methods that increase the tone of the uterus using an electric current or cold. In the first case, electrodes are placed on the stomach in the pelvic region and a light current is allowed. This procedure is painless. In the second case, put a bag with ice on the lower abdomen for 30-40 minutes. or use a tampon that is wetted with ether for anesthesia. When ether evaporates, the surrounding tissues are cooled rapidly, and the cold causes contraction and constricts the vessels.
Tamponade of the uterus. This method is rarely used in case of inefficiency of the previous ones and in preparation for the operation. Gauze cloths are used here and injected into the uterine cavity to form blood clots. But there is a big risk of an infectious complication.
Even as a temporary way to stop bleeding, pressing the abdominal aorta against the spine with a fist can be used, because uterine vessels move away from the aorta.
When hypotension of the uterus is transferred to atony and it is impossible to stop the bleeding by the above methods, then they turn to surgery. Atonia is when the uterus no longer reacts to any stimuli, and the bleeding can be stopped only by invasive means.
First, the patient is put into general anesthesia. The essence of the operation is based on cutting the abdomen and gaining access to the uterus and vessels that are involved in its blood supply and subsequent removal of the organ. The operation is carried out in 3 stages:
- Pinched vessels. It uses clips on the uterine and ovarian arteries. If the condition of the woman is normalized, then proceed to the next stage.
- Ligation of vessels. The uterus is taken out of the surgical wound, the necessary arteries are found by a characteristic pulsation, tied up with threads and cut off. After that, there is a sharp insufficiency of blood in the uterus, which leads to its reduction. This procedure is used as a temporary event, when the doctor does not know how to extirpate (remove) the uterus. But it is necessary to remove it. The doctor who can do this operation comes to the rescue.
- Extirpation of the uterus. The most radical method of dealing with such bleeding. That is, the organ is completely removed. This is the only way to save a woman’s life.
Blood Disease Treatment
Since in this case more often there are no substances necessary for coagulation, the best way would be the transfusion of donor blood. This is due to the fact that in the donor blood the necessary substances will be.
Direct intravenous administration of fibrinogen, which is involved in the formation of blood clots, is used. Also used a special substance that reduces the work of the anticoagulant system. All these activities most contribute to providing the body with everything necessary to stop the bleeding.
Treatment with delayed parts of the placenta
Remnants of the afterbirth are removed either by hand or using tools. Which method the doctor chooses depends on the period of bleeding.
If blood loss occurs immediately after birth or on the first day, then resort to manual separation. The second method is used in case of bleeding for 5-6 days, since the uterus has already significantly decreased in size.
General anesthesia is required. In the manual mode, the arm enters the uterine cavity and parts of the placenta are separated from its walls. The remains are pulled out with the other hand over the umbilical cord and removed. The inner hand once again checks the wall of the uterus for the presence of the remaining parts of the afterbirth.
When the tool room is essentially the same, only here is the scraping of the uterus. First, the cervix dilates with special mirrors, and then a surgical spoon is inserted, the walls are scraped out and the remnants are removed.
After treatment and elimination of the cause, correction of pathological conditions arising in connection with blood loss is carried out. With a small blood loss (about 500-700 ml), physiological solutions are dripping. If the volume is more than 1 liter, donor blood is transfused. In case of anemia (low hemoglobin level), iron preparations are prescribed, since it is from this that hemoglobin is formed.
Possible complications of postpartum hemorrhage
With severe postpartum hemorrhage and late delivery of proper care, hemorrhagic shock may occur. This is a life-threatening complication when blood pressure drops sharply. The consequence of the body's defensive reaction to a lack of blood.
The remaining blood flows to the main organs (brain, heart, lungs). Because of this, all other organs and tissues suffer from a lack of blood supply. There is a failure of the liver, kidneys and further their failure. The defense mechanism wears out, the blood comes back, which leads to a lack of blood in the brain and, consequently, to death.
With hemorrhagic shock, the countdown goes on for a second, so therapy should be carried out immediately. Immediately stop the bleeding by any means, use artificial respiration. They introduce agents that increase blood pressure, normalize metabolism and transfuse donor blood, since lack of blood is the cause of this condition.
How to prevent the development of postpartum bleeding
Directly involved in the prevention of doctors. Even at the first admission to the antenatal clinic, they conduct a full examination of the pregnant woman for the presence of factors that increase the chance of postpartum hemorrhage and determine the risk of its occurrence.
For example, one of the risks is placenta previa (improper attachment). Therefore, for the prevention of recommended birth of a child through a caesarean section.
After birth, a thorough examination of the genital tract. For a woman for 2 hours actively watching. Если присутствуют факторы риска, то после рождения капают окситоцин, чтобы поддерживать матку в тонусе.
After discharge of the woman from the hospital, and this is not earlier than in 15-20 days, the doctors of the antenatal clinic will be systematically examined. Because sometimes these women have serious complications: disruptions in the hormonal balance (amenorrhea, postpartum dying of the pituitary, atrophy of the genital organs). Detection of early symptoms will enable effective treatment.
Take good care of your health and often come to the consultations to specialists in order to identify the problem in advance and solve it, discussing the appropriate tactics with your doctor.
Causes of bleeding after childbirth
In the last stage of labor, the placenta is rejected from the uterus, and a wound is formed on the surface of the endometrium. It bleeds until it is completely healed, and doctors call these bloody discharges lochia. Often, women take lochia for the first after childbirth menstruation, but this discharge has a different cause and nature.
Lochia does not require any treatment, but during this period special attention should be paid to intimate hygiene. But pathological bleeding should be the reason for immediate treatment to the doctor.
"Good" bleeding after childbirth
Lochia - physiological, normal bleeding, accompanying the postpartum period. However, there may be pathological, dangerous to the health and even life of a woman's condition, when blood loss exceeds acceptable limits. For their prophylaxis, childbirth doctors must impose an ice heater on the abdominal cavity of the puerperal immediately after the childbirth, and take other measures if necessary (make an external massage of the uterus, enter hemostatic drugs).
Until the wound surface of the uterus in the place of the former attachment of the placenta does not heal completely, the lochia will continue. On the first day after birth, they can be very abundant, but gradually their number, nature and color will change. Soon they will become a gray color, then yellow and, eventually, the prenatal normal discharge will return to you.
"Bad" bleeding after childbirth
However, in some cases it is necessary to immediately consult a doctor. The following signs should alert you:
- * Lochia do not change the bright scarlet color for more than 4 days after birth,
- * you have to change sanitary pads every hour,
- * bleeding has an unpleasant smell,
Stop Late Postpartum Bleeding
Later, postpartum hemorrhage, as already mentioned, occurs due to the delay of parts of the placenta and membranes, less often blood clots in the uterine cavity. The scheme of assistance is as follows:
- immediate hospitalization of a woman to the gynecology department,
- preparation for curettage of the uterus (infusion therapy, the introduction of reducing),
- performing emptying (curettage) of the uterine cavity and removal of the remnants of the ovum and clots (under anesthesia),
- bubble with ice for 2 hours on the lower abdomen,
- further infusion therapy, if necessary, blood transfusion,
- prescription of uterotonics, iron preparations and vitamins.
Baby feeding on demand
Frequent attachment of the baby to the breast not only establishes and consolidates the physical and psychological contact between the mother and the baby. Irritation of the nipples causes exogenous (self) oxytocin, which stimulates the contraction of the uterus, and also intensifies the secretions (emptying of the uterus).
"Normal" postpartum bleeding - causes and signs
Lochia continues until the damaged area of the inner surface of the uterus is fully restored. At the same time, in the first days the profusion of blood discharge is high. After a day or two, the amount of discharge begins to noticeably decrease, and their character also changes.
During the first 3-6 weeks after birth, the bleeding is gradually replaced by the nascent, and then by the transparent mucous membranes that the woman observed before pregnancy. Together with normal lochia, a woman can lose up to one and a half liters of blood, but this volume is not critical: during pregnancy, the amount of blood in the mother’s body can be approximately doubled in nature to reduce the risk of excessive blood loss during and after birth.
If during a postpartum blood loss a woman feels normal, does not notice lethargy, weakness, dizziness - vivid signs of anemia - then everything is normal and there is no cause for concern.
Normal duration of postpartum hemorrhage
In the natural postpartum period, the rejection of residues of the placenta and the tightening of wounds occurs simultaneously with a decrease in the size of the uterus, contractions of its muscle walls. This process is hormonally controlled and significantly accelerated with additional stimulation, for example, during massage, physiotherapy, reflexology.
The main stimulator for uterine contraction is a baby that naturally feeds on ore milk. During feeding, especially in the first days after birth, the mother clearly feels how her uterus contracts when the baby is attached to the breast.
In some cases, for example, in the absence of lactation, inability to breastfeed, during uterine ruptures or after cesarean section, the natural process of uterine contraction is depressed. Then the uterus acquires its original size much longer, respectively, and the duration of lohii increases accordingly. In this case, the doctor may recommend intramuscular injection of oxytocin or other similar drugs that stimulate its reduction, or prescribe a course of physiotherapy procedures.
Pathological postpartum discharge
By the nature of postpartum hemorrhage, its duration, and the presence or absence of additional symptoms, it is possible to judge whether the first weeks of motherhood are proceeding normally.
In the first days after giving birth, it is necessary to sound the alarm if:
- bleedings do not become less abundant and do not acquire a brownish color, that is, if only fresh blood is present as part of the discharge, instead of regular blood, released during wound healing,
- body temperature rises, weakness appears, chills,
- even after 4-5 days, the high-absorbing sanitary pad has to be changed more often than every hour,
- discharge has an unpleasant smell.
All this may be due to the absence of a uterus contraction and the healing of its surface, placenta residues in its cavity, the presence of an active infection, as well as some other pathological conditions. Bleeding after childbirth, which is dangerous to the health of the mother, may occur both on the first day and a half to two months after the birth of the baby due to the following conditions:
- The weak contractility of the uterus, which is associated with its weakening, overstretching, rupture and some other circumstances. The resulting bleeding can be abundant and prolonged and requires compulsory medical care, because it can threaten not only the development of anemia, but also death.
- Remains of fetal membranes and particles of the placenta in the uterus. With the complete separation of the placenta, the capillaries, which bound it to the uterus, break off and, as the muscle layer of the uterus contracts, they go deeper into her body and tighten. As a result, the bleeding stops. If the placenta is not completely separated, the contractility of the uterus is disturbed and at the same time the capillaries cannot close and stop bleeding, but on the contrary, new sources of bleeding are constantly being discovered. At the same time, postpartum bleeding gradually subsides and ends, and after a few days, it resumes and proceeds intensively, abundantly, without any pain, but it threatens with severe blood loss.
- Low rate of blood clotting in the woman. Often, on the eve of birth, doctors recommend that you take a blood test to identify this pathology, since its presence can threaten with a lot of blood loss both during and after childbirth, sometimes ending in death. If this condition is acquired when carrying a child, it is in most cases correctable.
- Infection of the birth canal and uterus, the presence of benign or malignant tumors of the body of the uterus or the birth canal.
Diagnosis and treatment of postpartum hemorrhage
The nature of postpartum discharge can serve as an indicator of a normally flowing postpartum period, as well as the presence of a serious threat to the health and life of a young mother. That is why when detecting any warning signs it is necessary to go to a doctor without delay.
To determine the presence of postpartum hemorrhage, as well as its cause, the gynecologist will be able to study the history of the process, as well as the results of some tests. First of all, a woman with suspected postpartum hemorrhage is recommended to undergo a pelvic ultrasound, which with a high degree of accuracy determines the presence in the uterus of the placenta and blood clots. A blood test from a vein for the presence of infections and low blood clotting can also be prescribed. The presence of infections and other pathological processes in the uterus and the birth canal can also show the result of a vaginal smear test.
Treatment of postpartum hemorrhage is determined by its cause. If this is the presence of residues of the placenta in the uterus - the woman can not avoid scraping. If there is an infection, antibacterial or antifungal drug therapy will be prescribed. Plus, these methods are applied physiotherapy and restorative therapy.
How to deal with postpartum bleeding?
The postpartum period is extremely important for the recovery of the mother's body, and at the same time it is in it that most of the complications associated with uterine bleeding occur. Therefore, in the first weeks after childbirth, you should, if possible, ensure yourself a rest and a comfortable environment, do the bare minimum of homework, do not lift any weights - all this can lead to the onset of abnormal postpartum bleeding.
If the bleeding has nevertheless begun, it is necessary to visit a doctor as soon as possible and take measures to eliminate it. In case of breakthrough uterine bleeding after childbirth, it is important to immediately call an ambulance and wait for it lying on your back with a roller under the buttocks. It is impossible to stop such bleeding by yourself and any delay in hospitalization and adequate treatment can lead to the death of a woman due to severe blood loss.
Physiology of blood loss
For each woman entering the hospital, the doctor must calculate the physiologically acceptable blood loss. To do this, mathematically find 0.5% of body weight. For example, for a woman with a weight of 68 kg, this volume will be equal to 340 ml. Pathological blood loss is 0.7-0.8% or more.
At birth, the volume of blood lost is usually calculated by collecting it in a special tray. It is placed under the buttocks of the woman in labor, and the bleeding freely flows into it. Additionally, the weighting of diapers is used.
Other methods for assessing blood loss are also used, but in practice, assessment of the clinical condition and hemodynamic parameters is most often used. There are three severity of the condition:
- 1 degree - weakness is observed, rapid heartbeat to 100 beats per minute. The skin becomes pale, but remains warm. The pressure is low, but not lower than 100 mm Hg. Art. Hemoglobin is not critically reduced, to 90 g / l.
- Grade 2 - weakness increases, severe tachycardia over 100 beats per minute worries. Systolic pressure is reduced to 80 mm Hg. Art. Pale skin becomes moist. Hemoglobin decreases to 80 g / l.
- Grade 3 - shock, skin is pale and cold. The pulse is felt with difficulty, it becomes filiform. The pressure is critically low, the excretion of urine stops.
The state of acute blood loss is very dangerous in the postpartum period. This is due to the peculiarities of hemostasis in a pregnant woman.
Dangerous symptoms in the labor hall
After giving birth, the woman stays in the delivery room for 2 hours under the supervision of the medical staff. During this period, hypotonic bleeding most often occurs. It is characterized by a sudden onset against the background of apparent well-being and a rapid flow: in a short period of time, the puerperal can lose up to a liter of blood. Such a volume can be critical and lead to rapid decompensation, the development of hemorrhagic shock and death.
Therefore, in order to notice the adverse symptoms in time, to have time to react to them and to reduce the time for rendering assistance, the patient is not shifted from chair to couch or gurney: in a gynecological chair, they will provide medical assistance in developing a critical situation.
How long is bleeding after childbirth?
It all depends on the individual characteristics. It continues directly in the delivery room, when transferred to the ward and even during the first day has the appearance of liquid blood. By the second day, it is no longer blood, but lochia, thicker in consistency, containing the slimy component. Over the next four days, the discharge decreases, first becoming dark brown, and then gradually lighten. Lochia continues to stand out for another month.
Signs of bleeding in the early postpartum period are difficult to determine on their own. It is accompanied by a weakness that worries a woman after childbirth. There may be a chill feeling, but it is also a nonspecific symptom. After muscular tension during the laboring period, the puerperal may experience a period of muscle tremors, which are difficult to distinguish from the state of severe blood loss.
While the patient lies motionless, blood can accumulate in the uterus, gradually stretching it. When pressing on the uterus through the abdominal wall, a large amount of blood is released, sometimes with large clots. Gradually, this quantity should normally decrease. But with the development of pathology this does not happen.
Be sure to measure blood pressure. With a significant decrease in it, as well as an increase in signs of tachycardia, it is concluded that there is significant blood loss.
Why the bleeding does not stop
The causes of postpartum hemorrhage are reduced uterine contractility. This is influenced by several risk factors:
Frequent births also increase the risk of excessive postpartum blood loss. If a woman has a break between childbirth does not exceed two years, and there are more than four births, then the prevention of hypotension must be carried out.
The immediate cause most often becomes a delay in the uterine cavity of parts of the placenta or the membranes of the fetus. In order to prevent this state, after the birth of the afterbirth, the midwife gently spreads it on the diaper, dabs from the blood, aligns and aligns the edges. This allows you to assess whether all parts are separated from the walls of the uterus and out.
The delay of any parts in the uterine cavity violates its contractility. Vessels to which the placenta was attached, do not fall down and bleed. Also important is the release from the placenta of active substances that prevent blood clotting.
Sometimes blood loss in the postpartum period is a result of tight attachment or increment of the placenta. In the first case, the villi are woven into the tissues of the uterus and can be separated manually. And in the second case it is impossible to do. The only way to save a woman is through a hysterectomy.
Emergency care for postpartum hemorrhage includes mandatory manual examination of the uterus. The purpose of this manipulation is as follows:
- Determine the presence in the uterus of the placenta or membranes.
- Establish whether the organ has contractile potential.
- Determine if there are any ruptures in the uterine wall.
- The ability to identify organic abnormalities that can cause bleeding, such as myoma node.
The sequence of actions of a doctor during a manual examination includes the following steps:
- The amount of blood loss and the condition of the woman is estimated.
- Antiseptics are treated by external genital organs.
- Anesthesia and reducing drugs are given (or continue with uterotonics).
- The hand is inserted into the vagina and gently into the uterine cavity.
- All clots and parts of pathological tissues are gradually removed.
- Determined by the tone of the uterus. It should be tight.
- The hand is removed, the birth canal is evaluated for lesions, which can also cause bleeding.
- Re-assesses the condition of the woman in labor. Blood loss is reimbursed using crystalloid and colloid solutions. If necessary, perform a transfusion of blood plasma or formed elements.
Additional steps to stop hypotonic bleeding after a manual examination are the following:
- The introduction of additional reducing funds. Usually, a solution of methylergometrine is used for this purpose. It is administered while maintaining the drip of oxytocin.
- You can enter oxytocin in the cervix to improve its contractility.
- Introduce tampons moistened with ether into the posterior vaginal fornix. Bleeding should stop reflexively.
- Оценивают кровопотерю и возмещают ее.
Не всегда матка реагирует на проводимые мероприятия, и ее сократительная способность полностью отсутствует. Такое состояние называют атоническим кровотечением.
If, after a manual examination, the blood loss continues, the following tactics are used:
- On the back lip of the cervix is a lot of receptors that are responsible for contractility. Therefore, suturing with a thick catgut ligature on this area in Lositskaya is used. Bleeding should stop reflexively.
- When inefficiency - on the uterus impose clamps, passing them through the vagina. This is due to the anatomical location of the uterine artery.
But if in this case the deterioration continues, the only way to help is the operation. During it, it is possible to preserve the organ if intervention is carried out in a short time and special intraoperative methods are applied.
Reflexively stop blood loss by ligating vessels according to Tsitsishvili. To do this, they tie up the vessels that pass in the round ligament of the uterus, the own ligaments of the ovary. A more outdated method is electrostimulation. The extreme method is hysterectomy. He is resorted to with the ineffectiveness of previous manipulations, and if the loss is more than 1200-1500 ml.
Bleeding in the chamber ...
The postpartum period may be complicated by bleeding several days after delivery. There are symptoms that should alert the woman. The first sign is a decrease in the number of lohii. They become poor or stop altogether. This must be reported to the doctor.
Previously, postpartum hemorrhage develops when the cervix is blocked with clots that do not allow lochia to flow normally. They stagnate in the uterus, lead to its subinvolution. This symptom is clearly visible on ultrasound.
Diagnosis is necessarily carried out in the postpartum period to all women in order to eliminate this pathology. On ultrasound signs of subinvolution are:
- the expansion of the uterine cavity more than 1 cm,
- discrepancy between the size of the body postpartum,
- the presence of homogeneous content in the cavity.
After a long absence of discharge, sudden bleeding may begin. Therefore, the subinvolution treatment is carried out immediately after diagnosis. For this, it is necessary to remove residues from the uterus that prevent it from contracting. By the third day, the cervix is already beginning to form, so the procedure cannot be performed only with the hands, a surgical instrument is needed.
To remove the remnants of fetal membranes, clots, use a curette. She gently scraping. After the procedure, a solution of oxytocin or methylergometrine is administered intravenously to improve contractility. Be sure to fill the blood loss with special salt solutions.
The duration of discharge in this case should correspond to those during normal delivery.
... and on the operating table
In most cases, there are no emergency situations during a cesarean section. But sometimes the variant anatomy of the location of organs and vessels can lead to the careless injury of one of them, and, as a result, to internal bleeding, which manifest itself already on the operating table.
Very rarely, it is caused by the divergence of stitches in the postoperative period. Then the puerperal woman has all the symptoms of hemorrhagic shock:
- pale skin
- a cold sweat appears
- tachycardia is observed,
- blood pressure drops sharply.
Symptoms of irritation of the peritoneum with drained blood may also appear. The clinical protocol in this case provides the only way to stop the blood - abdominal surgery, which will allow you to find the bleeding vessel and bandage it.
The woman is usually in serious condition. Replenishment of blood loss is possible with blood substitutes, colloidal and crystalloid solutions, plasma, uniform elements. Sometimes they collect their own blood poured into the abdominal cavity and return it back into the bloodstream through a vein.
After discharge home
Bleeding in the late postpartum period occurs after discharge home. Its symptoms are similar to the processes occurring in the subinvolution of the uterus. Suddenly, the release of lochia stops, after a while there is a cramping pain in the abdomen. Blood clots come out of the genital tract, causing retention of blood in the uterus. After that, most often begins heavy bleeding.
If these symptoms appear, you should immediately seek medical attention. The treatment is carried out not in the maternity hospital, but in the conditions of a gynecological hospital. The correct tactic is to cure the uterus. Necessarily prescribed oxytocin drip.
It is very important to preserve lactation. The release of a natural hormone during an act of feeding will improve uterine contractility. While in the hospital, the milk is decanted.
To continue therapy at home prescribed oxytocin tablets.
The development of bleeding in the distant postpartum period, one month or two months after delivery, is an alarming symptom that can be a sign of a placental polyp. This is a tumor that occurs at the site of the remaining villi of the placenta. They are covered with fibrin clots, connective tissue and initially look like a flat formation. Bleeding is the main symptom of this pathology. Its consequence can be severe anemia, endometritis, sepsis and infertility in the long term.
The diagnosis is made on the basis of ultrasound of the pelvic organs. Further tactics include hysteroscopy, during which you can finally verify the presence of a pathological formation and remove it. In some cases, limited to separate diagnostic curettage followed by histological examination of the material obtained.
Normal postpartum discharge
Normally, for six weeks (42 days) a woman has discharge from the genital tract - lochia. Intensity, consistency, color and other parameters undergo significant changes during this time. Approximately it looks like this:
- The first hours after birth. Discharge abundant, often with clots. As a rule, at this time the woman is still lying, resting, and the doctor and the midwife are watching her.
- The first few days. Gradually, the allocation becomes less, clots appear less and less. At this time, the woman can safely use the pads maxi. After breastfeeding, they become larger, since sucking stimulates uterine contraction.
- From about 7 to 10 days, the bleeding is already smearing, with periods increasing.
- From the second week the lochia becomes more mucous with streaks of blood. Also retains a periodic small daub. At this time, even for several days there may be no discharge, and then reappear. This is absolutely normal rhythm up to and including 42 days after delivery.
If discharge continues after six weeks, consult a physician immediately. This is an alarming sign of a possible pathology.
We recommend to read an article about diseases after childbirth. From it you will learn about risk factors, inflammatory and infectious pathologies, methods of treatment.
And here more about herbs with uterine bleeding.
Periods of uterine bleeding after childbirth
Uterine bleeding is an abnormal discharge of blood from the uterus. Particularly relevant issue in the postpartum period. At this time, due to some peculiarities of discharge, a girl cannot always correctly estimate their volume.
Uterine bleeding after childbirth can be divided into the following types:
- early if it occurs within 2 hours after delivery,
- late - up to 42 days inclusive,
- after 42 days.
In the first case, the woman is still in the maternity ward under the close supervision of obstetrician-gynecologists. Bleeding during this period is very massive and can even be life threatening. Only a doctor or midwife assesses the discharge.
Early postpartum hemorrhage
Such complications in case of untimely assistance can lead to the death of a woman. Therefore, all actions of doctors should be sharp, coordinated and fast. The main reasons for bleeding within two hours after delivery are as follows:
In most cases, they are all diagnosed immediately after the birth of the baby. Late detection of tears or poor suturing can cost a woman’s life.
Diagnosis of mom's condition in uterine bleeding
If bleeding occurs, it is necessary to make the most correct reason for it. Only in this case it is possible to take the most correct medical and diagnostic measures.
With early postpartum hemorrhage, there is no time for any additional manipulations. Therefore, everything is immediately executed to stop it. In this case, only the amount of blood that the woman has lost is estimated. This is of fundamental importance for the course of therapeutic measures.
Regarding late postpartum hemorrhage, it is necessary to clarify the reason for its occurrence. The following methods are used:
- Ultrasound examination of the pelvic organs. With it, you can identify signs of inflammation, suspect a placental polyp. It is also important to exclude a new pregnancy, the first monthly and other pathologies.
- Hysteroscopy, which is performed in case of suspected placental polyp or pathology of the uterus.
- RDV in the absence of opportunities in another survey.
- The study of blood coagulation abilities - coagulogram.
All received material is sent for histological examination. According to his conclusion, we can talk about the true cause of bleeding.
Early postpartum bleeding
Based on the possible causes and treatment. The sequence of actions is approximately as follows:
- The introduction of tools that enhance the contractile activity of the uterus, for example, oxytocin.
- Manual examination of the uterus. Allows you to identify parts of the afterbirth, which prevent myometrium from contracting. If necessary, a manual massage is performed to increase the tone of the uterus (with atony).
- Examination of the birth canal for tears and injuries. Suturing if necessary.
- With the ineffectiveness of previous events, a complex of hemostatic actions is carried out: the imposition of clips on the vaults of the vagina, repeated administration of uterotonics and some others.
- If the bleeding continues, the woman is transferred to the operating room. An intervention is being carried out, the volume of which depends on many factors. This may be the imposition of special compression stitches on the uterus for its compression, and other methods. If necessary, the removal of the body, which is the last hope for the salvation of women.
Prevention of postpartum bleeding
No woman can be insured against such bleeding, even if she already had successful uncomplicated childbirth. Therefore, all, without exception, prophylaxis in the early postpartum period. It includes the following:
- Removal of urine by a catheter so that the overflowing bladder does not prevent the uterus from contracting.
- Chill on the lower abdomen for an hour or two for 20 minutes with interruptions.
- At risk groups (large fruit, bleeding in the past, fibroids, etc.), reducing agents, as a rule, oxytocin are administered.
After being discharged from the maternity hospital, the woman should also take good care of her health. The following is recommended for the prevention of bleeding:
- Practice breastfeeding.
- Do not exhaust yourself with physical exertion.
- Observe sexual rest from 2 - 3 weeks to 2 months, depending on the complexity of childbirth.
We recommend reading an article about uterine inflammation after childbirth. From it you will learn about the causes of postpartum inflammation, symptoms and signs of a problem, methods of diagnosis and treatment.
And here more about the pain in the uterus after childbirth.
Bleeding after childbirth is a serious, sometimes life threatening condition for a woman. Only timely and qualified medical assistance will help remove its cause and save the young mother. The task of the woman is to turn in time to the specialists and follow all the advice after giving birth.
Diseases after childbirth. . Herbs help uterine bleeding. Uterine hemorrhages occur in various gynecological pathologies, at the initial stage of using contraceptives.
Complications of childbirth. This can include bleeding in any period, multiple breaks. In addition to inflammatory diseases, after childbirth, women are susceptible to the development of other pathologies, which provoke the following
Ultrasound after birth is one of the most effective methods for early diagnosis of various diseases. diseases such as acute postpartum uterine bleeding, endometriosis and residual effects of the past.
The danger of postpartum bleeding is that it can lead to rapid loss of large amounts of blood and the death of the woman. Abundant blood loss contributes to the presence of intensive uterine blood flow and a large wound surface after childbirth. Normally, a pregnant woman's body is ready for physiologically acceptable blood loss during childbirth (up to 0.5% of body weight) due to an increase in intravascular blood volume. In addition, postpartum bleeding from the uterine wound is prevented by increased contraction of the uterus muscles, contraction and displacement into the deeper muscular layers of the uterine arteries with simultaneous activation of the blood coagulation system and thrombus formation in small vessels.
Early postpartum hemorrhages occur in the first 2 hours after birth, late ones can develop in the period from 2 hours to 6 weeks after the birth of the baby. The outcome of postpartum bleeding depends on the volume of blood lost, bleeding rate, the effectiveness of conservative therapy, the development of DIC. Prevention of postpartum hemorrhage is an important task of obstetrics and gynecology.
Causes of Postpartum Bleeding
Postpartum bleeding often occurs due to a violation of the contractile function of the myometrium: hypotension (reduced tone and insufficient contractile activity of the uterus muscles) or atony (complete loss of uterus tone, its ability to reduce, lack of response to stimulation of the myometrium). The causes of such postpartum hemorrhage are uterine fibroids and fibroids, cicatricial processes in the myometrium, excessive stretching of the uterus during multiple pregnancies, polyhydramnios, prolonged labor of large fetus, the use of drugs that reduce the tone of the uterus.
Postpartum hemorrhage may be caused by a delay in the uterine cavity of residual afterbirth: the lobes of the placenta and parts of the membranes. This prevents normal uterine contraction, provokes the development of inflammation and sudden postpartum hemorrhage. Partial increment of the placenta, incorrect management of the third stage of labor, discoordinated labor activity, cervical spasm leads to a violation of the placenta.
Factors provoking postpartum hemorrhage can be hypotrophy or atrophy of the endometrium due to previous surgical interventions - cesarean section, abortion, conservative myomectomy, uterine curettage. The emergence of postpartum hemorrhage can contribute to the violation of blood coagulation in the mother, due to congenital anomalies, taking anticoagulants, the development of DIC.
Often, postpartum bleeding develops with injuries (tears) or dissection of the genital tract during childbirth. There is a high risk of postpartum hemorrhage with preeclampsia, presentation and premature detachment of the placenta, threatened abortion, fetoplacental insufficiency, pelvic presentation of the fetus, mother’s presence of endometritis or cervicitis, chronic diseases of the cardiovascular and CNS, kidneys, and liver.
Symptoms of postpartum bleeding
The clinical manifestations of postpartum hemorrhage are due to the amount and intensity of blood loss. With an atonic uterus that does not respond to external therapeutic manipulations, postpartum hemorrhage is usually abundant, but may also have a wave-like character, sometimes subsiding under the influence of drugs that reduce the uterus. Objectively determined arterial hypotension, tachycardia, pallor of the skin.
The volume of blood loss of up to 0.5% of the woman's body mass is regarded as physiologically permissible, with an increase in the volume of blood lost, they speak of pathological postpartum hemorrhage. The amount of blood loss exceeding 1% of body weight is considered massive, more than this - critical. With critical blood loss, hemorrhagic shock and DIC with irreversible changes in vital organs can develop.
In the late postpartum period, a woman should be alerted by intense and prolonged lochia, bright red discharge with large blood clots, unpleasant smell, and pulling pains in the lower abdomen.
Treatment of postpartum hemorrhage
In case of postpartum hemorrhage, it is of primary importance to establish its cause, to stop it extremely quickly and to prevent acute blood loss, to restore circulating blood volume and to stabilize blood pressure. В борьбе с послеродовым кровотечением важен комплексный подход с применением как консервативных (медикаментозных, механических), так и хирургических методов лечения.
To stimulate the contractile activity of the uterus muscles, catheterization and emptying of the bladder, local hypothermia (ice on the lower abdomen), sparing external uterine massage are performed, and if there is no result, intravenous administration of uterotonic agents (usually methylergometrine with oxytocin), injection of prostaglandins into the cervix. To restore the BCC and eliminate the effects of acute blood loss in postpartum hemorrhage, infusion-transfusion therapy with blood components and plasma-substituting drugs is performed.
When ruptures of the cervix, vaginal walls and perineum are detected during examination of the birth canal in the mirrors, they are sutured under local anesthesia. In case of violation of the integrity of the placenta (even in the absence of bleeding), as well as hypotonic postpartum hemorrhage, an urgent manual examination of the uterine cavity under general anesthesia is carried out. During the revision of the walls of the uterus perform manual separation of residues of the placenta and membranes, removal of blood clots, determine the presence of ruptures of the uterus.
In case of rupture of the uterus, an emergency laparotomy is performed, wound closure or removal of the uterus. If there are signs of an increment in the placenta, as well as in intractable massive postpartum hemorrhage, Subtotal hysterectomy (supravaginal amputation of the uterus) is shown, if necessary, it is accompanied by ligation of the internal iliac arteries or embolization of the uterine vessels.
Surgery for postpartum hemorrhage is carried out simultaneously with resuscitation: blood loss compensation, stabilization of hemodynamics and blood pressure. Their timely conduct before the development of thrombohemorrhagic syndrome saves the woman in childbirth from death.
Prevention of postpartum bleeding
Women with an adverse obstetric and gynecological history, coagulation disorders, taking anticoagulants, have a high risk of postpartum hemorrhage, so they are under special medical supervision during pregnancy and are sent to specialized maternity hospitals.
In order to prevent postpartum hemorrhage, women are given drugs that promote adequate uterine contraction. The first 2 hours after birth, all parturient women spend in the maternity ward under the dynamic supervision of medical personnel to assess the amount of blood loss in the early postpartum period.
Preventing is easier than curing
Prevention of bleeding in the postpartum period is the proper management of pregnancy and childbirth. Anamnestic and clinical data of a specific pregnant woman is assessed and the risk group for the development of bleeding is determined. Such women need special attention. Already at birth, they are prescribed oxytocin, but not with the aim of enhancing labor, but to reduce the risk of massive blood loss. Measures of prevention include the inspection of the children's site, a thorough revision of the birth canal and the closure of existing gaps.
Recovery of the menstrual cycle
Sometimes menstruation begins during breastfeeding.
How after birth to distinguish menstruation from bleeding?
It is necessary to focus on the normal blood volume lost during menstruation. On average for all days, it should not exceed 100 ml. At the same time, menstrual blood can come out in small mucous clots - rejected endometrium. In the first, second, and sometimes the third, the intensity of discharge is slightly higher, but gradually this process should decline.
The duration of menstruation after childbirth may differ from that before pregnancy. Normally, it is 3-7 days. At prolongation of this period, and also at plentiful allocations which does not decrease according to days of a cycle, it is necessary to see a doctor.
The problem of bleeding in the postpartum period does not lose its relevance, regardless of the level of development of medicine. Sometimes it is impossible to predict how the uterus will contract, how firmly the placenta is attached, and whether it will be able to completely stand out on its own. Therefore, women who decide to experiment with childbirth should be aware of the risk for their own lives, in which minutes are set aside for medical assistance.
How long is bleeding after childbirth, and how long should the discharge last? Such questions are often addressed to women by a gynecologist. It is considered normal if blood loss lasts no more than 6 weeks. On average, blood can stand out about 1.5 liters.
How long postpartum bleeding lasts depends on how you feed the baby. During lactation, the uterus contracts much faster, and the recovery of its size is accelerated. This contributes to the rapid cessation of secretions.
The duration of bleeding in the postpartum period is influenced by such features:
- transferred cesarean section
- excessive exercise
- weak contractility of the uterus,
- the presence of gynecological diseases
- inflammation caused by remnants of the placenta,
- internal suturing
- bleeding during childbirth,
- poor blood clotting,
- taking anticoagulants
- the birth of a large child
- extensive injuries to the birth canal,
- placental polyp.
The first 2–3 days after birth, the discharge is bright red with clots, rather intense. This is a sign of lochia, which are detachable wound secretion of the uterus. Gradually, the intensity of discharge decreases, tissue fluid, decidual membrane cells and mucus are added to the secretion.
From about 4 days old, the blood goes less strongly, its color changes to red-yellow, later the substance takes on a brown tint. By the end of week 5–6, a transparent, blood-secret is highlighted.
Symptoms of early menorrhagia
Postpartum hemorrhage is a profuse loss of blood, which is 0.5% of the body weight of the woman who gave birth. Severe blood loss, which began immediately after the afterbirth or within the first 2 hours, is called early. This condition refers to postpartum complications and can lead to serious consequences.
Why does bleeding develop in the early postpartum period? The reasons are as follows:
- decreased tone, uterine paralysis,
- taking anti-coagulants, antiplatelet agents,
- birth injuries of the vagina, body and cervix, of the joints of the pelvis,
- uterine rupture
- increment or incorrectly located placenta,
- incorrect suturing
- blood diseases.
With hypotension, atony, the neuromuscular apparatus of the uterus is paralyzed, the organ loses its ability to contract, and as a result strong uterine bleeding develops after delivery. Pathology is observed with a large weight of the fetus, fast delivery, inflammatory processes of the myometrium. Most often, this complication occurs in young women, in women with congenital anomalies of the reproductive organs.
Bleeding after childbirth, the causes of which: hypotension and impaired contractility of the uterus - can proceed in different ways. In one case, the blood goes in waves. This is caused by a periodic contraction of the uterus, which is accompanied by more abundant blood loss (150-300 ml).
Intensive menorrhagia is characterized by abundant loss of a large volume of blood (up to 1 l), while the walls of the uterus are completely relaxed.
When bleeding of a wave-like nature, contraction preparations are prescribed, external massage of the uterus is performed, and manual control of the organ cavity for the presence of placenta is also necessary. With breakthrough bleeding, many measures are ineffective, so an urgent surgical intervention is indicated. Otherwise, anemia, hemorrhagic shock and death may occur.
Why late bleeding develops
Postpartum hemorrhage, which began after 2 hours or in the period up to one month after the birth of the child, is called late. After the placenta leaves, the obstetrician examines it and assesses its integrity. The rest of the afterbirth in the uterus can be the main cause of heavy bleeding. Pathology most often develops within a month. However, a woman may not have symptoms of general malaise.
Postpartum bleeding causes:
- inflammatory disease of the uterus.
- remnants of the afterbirth,
- weakening the body
- the onset of menstruation,
- endocrine diseases
- hormonal imbalance.
Severe bleeding after childbirth, which began in the late period, is a doctor's mistake. Before discharge of the patient, an ultrasound scan of the uterus must be performed, if residual afterbirth is detected, instrumental curettage is performed.
How to distinguish menstruation from bleeding after childbirth? When menorrhagia appears the following symptom complex:
- bright scarlet color can go more than 7 days,
- body temperature rises
- blood goes in clots, has an unpleasant smell,
- menstruation should not begin if the mother gives birth to breastfeed,
- one laying is not enough for 2 hours.
Menstruation may begin a month after the woman left the hospital if the baby is on artificial feeding. The beginning of critical days can be recognized by the characteristic symptoms: aching pain in the abdomen, swelling of the mammary glands, a small amount of discharge (up to 150 ml). The duration of menstruation may be slightly longer than usual, but it should be no more than 7 days to bleed. How long the critical days will last depends on the complexity of the transferred birth.
Dysfunctional uterine bleeding of the reproductive period are caused by impaired hormone production by the ovaries, endured stress, taking certain medications, lack of vitamins, infectious diseases of the genitourinary system. Late treatment of DMK can lead to infertility.
Methods of prevention and treatment
A woman should not leave the delivery room for 2 hours; it is during this period that bleeding may develop. Medical workers monitor the patient's condition and, if necessary, provide emergency assistance. That the uterus was well reduced, carry out emptying of a bladder by means of a catheter.
After the placenta leaves, the obstetrician examines its integrity, and if in doubt, conducts a manual control of the uterine cavity for the presence of residues. Checks if there are tears that occurred during childbirth and can cause uterine bleeding. If necessary, the woman is given an external massage of the uterus, applied cold.
If there are injuries, tears, stitches are performed under local anesthesia, it helps to stop the blood. To increase the contractility of the uterus and prevent hypotension, Oxytocin is administered intravenously.
To stop the blood, spend tamponade. A tampon impregnated with ether is inserted into the posterior vaginal fornix; this stimulates the uterus to strengthened contractions. If remedies for uterine bleeding do not give results, decide on surgical intervention.
If symptoms of pathology appear, urgently need urgent medical attention! Stopping late bleeding should be carried out in a hospital. In the department of gynecology, the uterus is scraped, then antibiotics are prescribed, drugs that stop blood are shown (Vikasol, Ditsinon).
In some cases, women need plasma transfusions. To maintain the body take vitamins, and iron supplements are necessary for the symptoms of anemia. It is important to compensate for the loss of fluid, you need plenty of drink.
First aid for the development of menorrhagia
If bleeding started a month after delivery, when the woman is at home, the following procedures should be performed before the ambulance arrives:
- take a horizontal position so that the legs are above the level of the head,
- apply cold to the groin area (ice, frozen foods),
- drink hemostatic agent.
Measures to prevent uterine bleeding include feeding a baby on demand. During lactation, the hormone oxytocin is produced, causing uterine contractions. Cannot be tolerated when the bladder is full. A toilet is recommended every 3 hours, especially in the first weeks after birth.
Folk remedies for uterine bleeding can be taken only after consulting a doctor. From the recipes of herbal medicine can be distinguished tincture of water pepper, yarrow, shepherd's bag, horsetail, nettle and viburnum bark. Herbs have a hemostatic, vasoconstrictor, analgesic effect. Stimulate uterine contraction, accelerate tissue healing.
If therapy does not produce results, surgical treatment is necessary. Removal of the epithelial layer of the uterus (ablation) is carried out in several ways:
- laser technology
- instrumental curettage of the uterus and cervical canal.
In some cases, if after delivery it is not possible to stop the early bleeding, the uterus is removed (hysterectomy). Endometriosis, fibroma, prolapse of the uterus are also indications for surgery. Removal is performed by vaginal or abdominal. Excised only the uterus or spend a total hysterectomy with resection of the uterus and vagina.
Primary bleeding in the postpartum period
Due to the subjectivity of diagnosis, the frequency of this pathology varies from 2 to 10%. In general, the following trend is observed: medical personnel underestimate blood loss, and patients overestimate it. For example, if a doctor evaluates blood loss as “exceeding 500 ml, then the real blood loss is usually around 1000 ml. In addition, it should be remembered that the BCC correlates with the weight of the patient. Accordingly, a thin, anemic patient will not tolerate even a small blood loss.
Physiology of the third stage of labor
Before discussing the causes and tactics of treatment of the primary CPR, it is necessary to consider the physiology of the third stage of labor. This is the shortest period of childbirth, which, however, poses a great danger to the mother.
During pregnancy, myocytes are very stretched, respectively, the uterus can accommodate the increasing volume. After the birth of the fetus, the uterus continues to contract, which leads to a pronounced shortening of the long fibers. This process is provided by retraction - a unique property that does not require energy expenditure and is characteristic only of the myometrium.
The separation of the placenta occurs due to contraction and retraction of the myometrium fibers, which leads to a significant decrease in the surface of attachment of the placenta. It is separated from the wall of the uterus, as a postage stamp is separated from the surface of the balloon from which the air has been released. After separation of the placenta from the place of attachment due to uterine contractions, it migrates to the lower uterine segment, and then through the cervix into the vagina.
Clinical signs of separation of the placenta
The separation of the placenta correspond to three clinical signs.
- After separation of the placenta and moving it to the lower uterine segment by palpation, it is possible to determine the change in the shape of the uterus - its body becomes narrow and elongated (it is wide and flattened before the placenta separates). Changing the shape of the bottom of the uterus is clinically difficult to determine, with the exception of only very thin patients. However, the uterus becomes harder due to the contraction and is easily dislodged.
- Blood secretions accompany the separation of the placenta from the uterine wall. This symptom has less clinical significance, because bleeding can occur with partial separation of the placenta. Hidden bleeding is possible when blood accumulates between the membranes and therefore is not visualized.
- After separation of the placenta and moving it to the lower uterine segment and cervix, the visible part of the umbilical cord increases by 8-15 cm. This is the most reliable sign of the separation of the placenta.
The mechanism of hemostasis at the place of placentation is one of the anatomical and physiological wonders of nature. Myometrial fibers are rearranged and intersected with each other, forming a lattice through which the vessels feed the placental bed. With the contraction of the uterine wall, such a structure ensures reliable compression of the vessels. This architecture of the myometrium is sometimes called a living ligature or physiological sutures of the uterus.
Tactics of conducting the third period of labor
After the birth of the fetus, the umbilical cord is clamped and crossed, and if necessary, cord blood is collected. Pull the umbilical cord gently towards yourself to make sure that there are no loops in the vagina. Then, at the introitus level, a cord is placed on the umbilical cord, this facilitates visualization of its elongation after the placenta is removed. One hand palpate the bottom of the uterus to determine changes characteristic of the separation of the placenta, or to identify atonic uterus, expanded by blood. The hand, located on the bottom of the uterus, is forbidden to carry out any massaging movements, because this contributes to partial premature separation of the placenta, increased blood loss, the formation of a contraction ring and delayed parts of the placenta. After the appearance of signs of separation of the placenta, it is isolated, gently sipping the umbilical cord. Вторую руку перемещают ниже, непосредственно над лобковым симфизом, и попеременно смещают матку кверху и книзу, а другой рукой постоянно подтягивают пуповину. Необходимо, чтобы между двумя руками было достаточное расстояние, которое позволит избежать выворота матки.
There are two tactics of the third stage of labor.
- Expectant tactics involve waiting for the placenta to separate. This usually occurs within 10-20 minutes. This tactic is chosen by those who prefer minimal intervention in the process of childbirth. Some experts recommend attachment to the chest immediately after childbirth to stimulate the physiological release of oxytocin. Unfortunately, this tactic does not reduce the likelihood of CPR compared with active drug.
- Active tactics include prescribing oxytocin drugs at the end of the second or beginning of the third stage of labor in order to speed up the uterine contraction, which promotes the separation of the placenta. Active tactics of labor management introduced in practice in the last 50 years. During this period, it was shown that an active tactic compared with the waiting one is characterized by a 50-70% reduction in blood loss, the frequency of prescribing therapeutic doses of oxytocin, the frequency of CPR and the need for transfusion of blood products. Evidence-based medicine data and accumulated experience have contributed to the fact that such tactics have now become the standard of care. Expectant tactics are followed only on the urgent demand of the patient and with her written informed consent.
The choice of a drug for active management of the third stage of labor is usually carried out between low-cost injectables, oxytocin and ergometrine, or a combination of them (sintometrin). Among these drugs, oxytocin is the cheapest, in addition, it has the lowest percentage of side effects, in particular, it does not cause a delay in parts of the placenta. Nevertheless, it is a short-acting drug (15-30 minutes). Ergometrine is an effective drug, the duration of which is longer (60-120 min), but it has more side effects (see below), including a slight increase in the frequency of retention of parts of the placenta.
The duration of action of ergometrine or oxytocin is usually sufficient for the specified period. In patients with a high risk of atonic CPR (for example, multiple pregnancies), the recommended prophylaxis is to administer oxytocin for a long time intravenously or, in some cases, prostaglandins.
One should know the characteristics and possible side effects of the available oxytocin preparations, each of which has specific indications for administration in different clinical situations.
Oxytocin is the cheapest and safest uterotonic drug. It acts quickly enough, causes strong and rhythmic contractions of the uterus within 15-30 minutes. Oxytocin acts mainly on the upper uterine segment, and also has a short-term relaxing effect on vascular smooth muscle, which can cause minor hypotension due to a decrease in total peripheral resistance.
Ergometrine is the first uterotonic preparation for intramuscular administration, which has been used for more than 70 years. It causes prolonged contractions (60-120 min), acting on the upper and lower uterine segments. Ergometrine affects all smooth muscles, affecting the bloodstream. Peripheral vasoconstriction, which normally has no clinical significance, can cause a significant increase in blood pressure in patients with hypertensive disorders and preeclampsia. For such patients, ergometrine is contraindicated. At the same time, the drug spasms coronary arteries, which in rare cases causes myocardial infarction in patients with predisposing factors. Therapy for endometrine-associated vasospasm consists of administering nitroglycerin.
Due to the duration of the effect, ergometrine may cause the infringement of the detached placenta in the lower uterine segment. When appointing ergometrine sometimes requires manual selection of the afterbirth (1: 200 kind).
Nausea and / or vomiting occurs in 20-25% of patients. Ergometrine prescribed intramuscularly. Given the pronounced vasopressor effect, the drug is not recommended to be administered intravenously (with the exception of emergency cases in which it is possible to administer 0.2 mg bolus slowly). The initial dose should not be increased to 0.5 mg, since at the same time, side effects are extremely pronounced, and there is no expected enhancement of the uterotonic effect.
Analogue of PGE1 Misoprostol is a cheap uterotonic agent and the only drug in this series that can be administered non-parenterally. In these cases, misoprostol is prescribed "outside the instructions", i.e. according to indications not listed in the official registration forms, but used by obstetricians and gynecologists at CPR in most countries. The drug has a long shelf life, it is stable in a large temperature range, which distinguishes it from oxytocin and ergometrine, which must be stored in the dark at a temperature of 0-8 ° C. Depending on the clinical situation, misoprostol can be administered orally, under the tongue, vaginally or rectally. Side effects include chills, mild hyperthermia and diarrhea (develop gradually). Studies have shown that misoprostol is more effective than placebo in the prevention of CAT, but less effective than parenterally administered uterotonics. However, the previously mentioned properties make misoprostol an extremely convenient drug for use in developing countries, given the limited availability of obstetric services. Prophylactically, the drug is prescribed in a dose of 400-600 µg orally or sublingually, in the case of bleeding - 800-1000 µg rectally. Duration of action is about 2 hours.
Usually prescribed in a dose of 100 mg intramuscularly or intravenously. The side effects are similar to those of oxytocin: a sensation of hot flashes and slight hypotension. The most important property of the drug is its long-term uterotonic effect, comparable to that of oxytocin, while there is no need for long-term intravenous infusion. The drug is more expensive than oxytocin, but cheaper than 15-methyl PGF2α.
Atonia of the uterus
Causes of atony - any process or phenomenon that violates the ability of the uterus to contraction and retraction and found in most (80-85%) cases of CPR. Atonia can also develop in patients without predisposing factors. Violation of contraction and retraction contributes to a number of clinical situations:
- high parity
- prolonged first or second stage of labor, especially in the presence of chorioamnionitis. A “depleted” infected uterus is prone to atony and often does not respond to the introduction of uterotonics,
- fast delivery This situation is the clinical opposite of the previous one, but is also characterized by an increase in the frequency of CAT,
- overstretching of the uterus: multiple pregnancy, macrosomia, polyhydramnios,
- delay of parts of the afterbirth,
- the presence of blood clots in the uterus. After the birth of the afterbirth, it is necessary to massage the bottom of the uterus, in the presence of signs of atony - to administer oxytocin within 2-3 hours. Otherwise, even a small bleeding from the placental site promotes the accumulation of blood clots in the uterine cavity. This process can break the contraction and retraction, which, in turn, will start the pathological circle,
- the use of tocolytics, such as nitroglycerin or terbutaline, deep anesthesia, especially fluorinated hydrocarbons,
- anatomical features of the uterus, including malformations and uterine myoma,
- placenta previa: implantation of the placenta in the region of the lower uterine segment, which has a reduced ability to contraction and retraction,
- incorrect tactics of conducting the third period of labor, especially premature massage: the bottom of the uterus and cord traction, which leads to the late partial separation of the placenta and an increase in blood loss.
Prevention of primary bleeding in the postpartum period
All patients with risk factors for the development of primary CPR should be delivered in a hospital equipped with appropriate anesthetic, obstetric and transfusiological services, and be under the supervision of medical personnel. It is necessary to properly conduct the third stage of labor:
- administer oxytocin at the birth of the front shoulder or as soon as possible
- eliminate unnecessary manipulation of the uterus and / or traction for the umbilical cord until clear signs of separation of the placenta appear,
- assess the integrity of the placenta after its birth,
- conduct a thorough massage of the uterus to eliminate all clots from the uterus,
- maintain uterine tone by administering oxytocin for 2 hours, and at high risk of developing PPC, a longer period,
- constantly monitor the woman in labor for 2–3 hours after delivery, including emptying the bladder.
It should be remembered that the administration of oxytocin has a negative effect on its receptors. Thus, if in the first or second period of labor, roactivation was performed by oxytocin, its receptors would be less sensitive. At physiological birth, the release of oxytocin in the third period does not increase, but an increase in the concentration of endogenous prostaglandins is noted. Myometrium contains different receptors for each of the uterotonic drugs, so if one fails, one should immediately switch to another. It is recommended to adhere to the following uterotonic prescription sequence:
- intravenous 5 IU of oxytocin, then 40 IU in 500 ml of crystalloids, the rate of administration should be sufficient to ensure good contraction,
- with inefficiency - ergometrine 0.2 mg intravenously (it is necessary to determine in advance the absence of contraindications),
- oxytocin and ergometrine can be re-administered in the same doses. With the ineffectiveness of oxytocin and ergometrine immediately proceed to the introduction of prostaglandins,
- 0.25 mg of 15-methyl P1T2a can be administered intramuscularly, but the method of introduction to the myometrium is preferred. If necessary, you can enter up to 4 doses. The alternative is intravenous administration of 0.25 mg in 500 ml of crystalloids,
- in the presence of bleeding, oral and vaginal methods of administering misoprostol are not very suitable, the latter is due to the fact that the drug is simply washed away with blood secretions. The preferred route of administration is rectal, the dose is 1000 μg. Since the drug is inexpensive and easy to use, many experts prescribe it immediately in the absence of the effect of oxytocin,
- Treatment of hypovolemia should be carried out by intravenous administration of colloids, crystalloids, blood products.
With the ineffectiveness of drug treatment, various surgical methods are used, including uterine tamponade, implantation of compression stitches on the uterus, ligation and pelvic embolism, and hysterectomy.
During preparation for any of the surgical interventions, a bimanual compression of the uterus, or massage of the uterus on the fist, can be performed. A hand inserted into the anterior vaginal fornix is squeezed into a fist, the uterus is displaced toward the first hand with a second hand. Due to the hand inserted into the vagina, the uterus rises somewhat, the vessels pinch a little and the bleeding decreases. Hands should perform rotating movements that can stimulate the contraction of the uterus.
In difficult cases, while waiting for preparation for surgery, external aortic compression can be applied. With both hands, the bottom of the uterus is displaced upward, then one hand is placed on the region of the lower uterine segment, and the other is pressed against the bottom of the uterus to the aorta. If the uterus is atonic, the effectiveness of the procedure is low, because the aorta is pressed against a loose object. An alternative method involves pressing the aorta with a fist, which is placed above the navel.
Secondary bleeding in the postpartum period
Secondary CAT is defined as abnormal bleeding from the genital tract, which occurred from 24 hours to 6 weeks. after childbirth. This type of bleeding is less common than primary - in about 1% of births. The most common secondary transmissions occur within 3 weeks. after childbirth.
- Delay of parts of the placenta occurs in about 30% of cases.
- Endo (mio) metritis often accompanies a delay in parts of the placenta. Patients with a history of, as a rule, were primary CPR.
- Extremely rare causes, which, however, must be excluded, are trophoblastic disease, chronic uterine reversal, the formation of a false aneurysm or arteriovenous malformation at the site of the scar on the uterus after cesarean section.
Treatment of severe bleeding after childbirth
Doctors can take various measures to stop bleeding, including massage of the uterus. You may be given intravenous fluids and oxytocin. Oxytocin is a hormone that stimulates uterine contraction. Another treatment may consist in the use of drugs that stimulate the reduction of the uterus, surgery and blood transfusion. Treatment depends on the cause and severity of the problem. Even in the most severe cases, removal of the uterus is not inevitable.