Bleeding in the postpartum period

Bleeding in the early postpartum period

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

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

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Factors predisposing to poor uterine contraction

• History of uterine atony with bleeding in the postpartum period.
• Delayed delivery of the placenta or its lobule.
• Some form of anesthesia, including the use of fluorothane.
• Wide placental site (twins, severe Rh-conflict, large fetus), low location of the placental site, overstretched uterus (polyhydramnios, multiple pregnancy).
• Extravasation of blood into the myometrium (with subsequent rupture).
• Uterine neoplasms or fibroids.
• Prolonged labor.
• Poor contraction of the uterus in the second stage of labor (for example, in mature women who have had multiple births).
• Trauma to the uterus, cervix, vagina or perineum.

Note: coagulation disorders can develop during pregnancy or be a complication of premature detachment of a normally located placenta, amniotic fluid embolism, or intrauterine fetal death that occurred long ago.

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Management tactics for bleeding in the postpartum period

Administer 0.5 mg of ergometrine intravenously. If bleeding occurs outside the hospital, a "flying" obstetric care team should be called. It is necessary to set up a system for intravenous infusions. If hemorrhagic shock develops, Haemaccel or fresh blood of group 1 (0), Rh-negative (in the absence of a matching blood group and Rh factor) is administered. The infusion should be carried out quickly until the systolic blood pressure level exceeds 100 mm Hg. The minimum amount of blood transfused should be 2 vials (bags). Catheterize the bladder to empty it. Determine whether the placenta has been born. If it has detached, then check whether it has completely separated; if this has not happened, examine the uterus. If the placenta has separated completely, the woman in labor is placed in the lithotomy position and examined under conditions of adequate analgesia and good lighting to ensure a full control examination and good healing of the injured areas of the birth canal. If the placenta has not separated completely, but has separated, then an attempt is made to manually separate the placenta, while stroking the uterus from the outside with gentle finger movements to stimulate its contractions. If these manipulations are unsuccessful, then resort to the help of an experienced obstetrician to separate the placenta under general anesthesia (or under conditions of already effective epidural anesthesia). One should be wary of possible renal dysfunction (acute renal failure - its prerenal form, caused by the hemodynamic consequences of shock).

If bleeding in the postpartum period continues despite all the above manipulations, then 10 U of oxytocin in 500 ml of saline dextrose solution are administered at a rate of 15 drops/min. Bimanual pressure on the uterus can reduce immediate blood loss. The blood is checked for clotting (blood - 5 ml - should clot in a standard 10 ml glass test tube with a rounded bottom in 6 minutes; formal generally accepted tests: platelet count, partial thromboplastin time, kaolin-cephalin clotting time, determination of fibrin degradation products). The uterus is examined for possible rupture. If the cause of bleeding is uterine atony and all the above measures are unsuccessful, 250 mcg of Carboprost (15-methylprostaglandin F2a) is administered, for example, in the form of Hemabate - 1 ml, deep into the muscle. Side effects: nausea, vomiting, diarrhea, increased body temperature (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 control bleeding in about 88% of cases. Rarely, 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 that occurs no earlier than 24 hours after delivery. Such bleeding usually occurs between the 5th and 12th day of the postpartum period. It is caused by a delay in the discharge of parts of the placenta or a blood clot. A secondary infection often develops. Postpartum involution of the uterus may be incomplete. If the bloody discharge is insignificant and there are no signs of infection, the management tactics can be conservative. If the blood loss is more significant, an ultrasound examination shows suspicions of a delay in the discharge of fragments of the placenta from the uterus or the uterus is painful with a gaping orifice, additional studies and manipulations are necessary. If there are signs of infection, antibiotics are prescribed (for example, ampicillin 500 mg every 6 hours intravenously, metronidazole 1 g every 12 hours rectally). Careful curettage of the uterine cavity is performed (it is easy to perforate in the postpartum period).

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