Bleeding in the puerperium

Bleeding in the early postpartum period

They include the loss of more than 500 ml of blood in the first 24 hours after childbirth. This complication is observed in 5% of all births.

Most often the cause is atony of the uterus, as well as tissue trauma or hemorrhagic diathesis.

[1], [2], [3]

Factors predisposing to poor uterine contraction

• Atony of the uterus with a bleeding in the postpartum period in the anamnesis.
• Delay of the placenta or its lobules.
• This or that anesthetic, including the use of fluorotan.
• A wide placental area (twins, severe Rh-conflict, large fetus), low location of the placental area, overgrowth of the uterus (polyhydramnios, multiple fetuses).
• Extravasation of blood in myometrium (followed by rupture).
• Neoplasms of the uterus or fibroids.
• Prolonged delivery.
• Poor uterine contraction in the second stage of labor (for example, in multi-mature women of adulthood).
• Injury of the uterus, cervix, vagina or perineum.

Note: coagulation disorders can develop during pregnancy, or may be a complication of premature detachment of a normally located placenta, embolism with amniotic fluid, or long-lived intrauterine fetal death.

[4], [5], [6], [7], [8],

Tactics of management for bleeding in the puerperium

Enter 0.5 mg of ergometrine intravenously. In cases where bleeding occurred outside the hospital, you should call a "flying" brigade of obstetric care. It is necessary to establish a system for intravenous infusion. With the development of hemorrhagic shock, Haemaccel or fresh blood of 1 (0) group is introduced, Rh-negative (in the absence of the same group and Rh-factor). Infusion should be performed rapidly until the systolic blood pressure level exceeds 100 mm Hg. The minimum amount of blood transfused should be 2 bottles (package). The bladder is catheterized to empty it. Determine if the placenta was born. If she has exfoliated, then check whether she completely separated, if this did not happen, examine the uterus. If the placenta has completely separated, put the woman in the lithotomy position and examine it in conditions of adequate analgesia and good lighting to provide a full control study and a good healing of the traumatized sections of the birth canal. If the placenta did not completely separate, but separated, then an attempt is made to manually detach the placenta, while stroking the uterus from outside with cautious finger movements to stimulate its contractions. If these manipulations are unsuccessful, then they resort to the help of an experienced obstetrician for the separation of the placenta under general anesthesia (or in conditions of already functioning epidural anesthesia). It is necessary to be afraid of a possible violation of kidney function (acute renal failure - prerenal form, caused by hemodynamic consequences of shock).

If the bleeding in the puerperium continues, despite all the above manipulations, then inject 10 U of oxytocin in 500 ml of dextrose saline at a rate of 15 drops / min. Bimanual pressure on the uterus can reduce the nearest blood loss. Check whether blood is clotting (blood - 5 ml - should be folded in a standard 10 ml glass tube with a rounded bottom in 6 minutes, formal common tests: platelet count, partial thromboplastin time, kaolin-cephalic clotting time, determination of fibrin degradation products). Examine the uterus for possible rupture. If the atony of the uterus is the cause of the bleeding, and all the above measures are unsuccessful, 250 μg of carboprost (15-methylprostaglandin F2a), for example in the form of Hemabate-1 ml, is injected deep into the muscle. Side effects: nausea, vomiting, diarrhea, fever (less often - asthma, increased blood pressure, pulmonary edema). Injections of the drug can be repeated after 15 minutes - up to a total of 48 doses. This treatment allows you to take control of bleeding in about 88% of cases. Occasionally, a ligation of the internal iliac artery or hysterectomy is required to stop bleeding.

Bleeding in the Late Postpartum Period

This is excessive blood loss from the genital tract, occurring no earlier than 24 hours after delivery. Typically, such bleeding occurs between the 5th and 12th day of the postpartum period. They are caused by a delay in the retreat of the placenta or blood clot. Secondary infection often develops. Postpartum involution of the uterus may be incomplete. If the spotting is minor and there are no signs of infection, the tactics of doing it can be conservative. If the blood loss is more significant, with an ultrasound study, suspicions of a delay in separation from the uterus of fragments of the afterbirth or uterus painful with gaping mouths appear, additional studies and manipulations are needed. If there are signs of infection, antibiotics are prescribed (for example, ampicillin 500 mg every 6 hours intravenously, metronidazole 1 g every 12 h rectal). Carefully produce a curettage of the uterine cavity (it is easy to perforate in the postpartum period).

[9], [10], [11]